bluuebunny/crossref_metadata_2025 huggingface dataset:
451 Metastatic Cervical Cancer to the Duodenum: A Learning Point
Authors: Ash J , Tsai A
Published: October 2021

Background

Carcinoma of the Cervix is the second most common gynaecological malignancy. It usually spreads in a predictable manner with most via direct extension to surrounding structures. When distant metastases present, they usually spread haematogenously and via the lymphatics to the liver, lung and bone marrow. Metastatic spread to the duodenum is rare with only 15 reported cases identifying spread to the bowel.

Case Presentation

An 81-year-old lady presented with signs and symptoms consistent with bowel obstruction with a background of renal cell carcinoma and cervical cancer. Investigations identified gastric outlet obstruction. Subsequent oesophago-gastroduodenoscopy showed structuring at D1/D2 and a enteric stent was inserted. Biopsies taken at the time showed lymphovascular permeation of the mucosa and submucosa by nests of tumour cells resembling squamous cells. The cells were P16 and P63 positive and FISH analysis detected Human papilloma virus 16. The tissue was identified as metastatic cervical cancer. The patient subsequently did not want further interventions and was referred to palliative care and subsequently passed away due to her illness.

Conclusions

Few reported cases of metastatic cervical cancer to the bowel have been reported. Of these, most commonly they have presented with obstructive bowel symptoms and metastasised to the duodenum such as in this case. The pathophysiology for this manner of transmission is poorly understood in literature. Obstructive bowel symptoms on the background of cervical cancer should raise the possibility of metastases in future practice.
595 Penetrating Pelvic Trauma from a Crossbow Bolt: An Unusual Choice of Weapon
Authors: Ting A , Barnetson C , Joegi A , Gibbs R
Published: October 2021

Introduction

The crossbow was a popular weapon in medieval times due to their relative ease of use and accuracy but was superseded by firearms around the 16th century. Today, it is legal for adults in the UK to own a crossbow without a licence.

Case Report

A young adult male victim was brought to a Major Trauma Centre with a single lower left quadrant penetrating wound caused a crossbow bolt that was self-removed immediately after the injury. A 2.5cm entry wound was present with no exit wound. The patient was haemodynamically unstable on arrival and was transferred to theatre without imaging within 16 minutes of arrival. The main operative findings were multiple small bowel serosal tears, a full thickness small bowel injury with no contamination and a left external iliac artery injury with active bleeding which were all repaired primarily. The post-operative recovery course included occlusive left cephalic and antecubital vein thrombi and an extensive non-occlusive left common femoral vein thrombus treated with anticoagulant therapy but was otherwise unremarkable. He was discharged 10 days later with no lasting sequelae at 6-week follow up.

Discussion

This case highlights a rare but important and likely underreported modality of penetrating injury. Crossbow bolts have low kinetic energy compared to bullets but high penetrative force, thus little energy is transferred to surrounding tissues. Hence the main injuries caused by crossbow bolts are due to direct damage to structures they come into contact with. Although rare, trauma surgeons should be aware of the pattern of injury caused by crossbows.
675 ICA Ligation and Malignant MCA Syndrome Secondary to A Gunshot Wound: A Case Presentation
Authors: Cairns G , Belshaw A
Published: October 2021

Penetrating carotid injuries occur infrequently in the UK. Without surgical intervention, mortality rates are close to 100%. Whilst vessel repair is the optimal surgical choice, zone III neck injuries or haemodynamic instability in particular often require vessel ligation, which carries higher mortality rates, increased risk of stroke and poorer outcomes overall.

We present a young patient who sustained a gunshot wound to the neck. Emergency exploration revealed a penetrating injury to zone III of the left side of the neck and a complete transection of the left internal carotid artery. Due to haemodynamic instability, damage control surgery was mandated, and the internal carotid artery was ligated. The patient was admitted to ITU but had a severe acute neurological deterioration post-operation. CT head imaging revealed a large left frontal-parietal infarct with rightward midline shift, in keeping with malignant MCA syndrome. He underwent an emergency decompressive craniectomy, with resolution of the midline shift seen on subsequent imaging. At 3 months, the patient walked independently out of hospital, with a reduction in his modified Rankin Scale score from 5 to 2 following intensive therapies input.

Whilst rare, the importance of timely recognition and intervention of an infrequent complication of carotid ligation is paramount. Decompressive craniectomy is the mainstay of treatment for malignant MCA syndrome, yet outcomes remain poor in all ages, highlighting the patient’s noteworthy recovery. Though emerging evidence suggests novel endovascular repair techniques may provide favourable outcomes and reduced complications in carotid injuries, open surgery remains the treatment of choice.
770 Mondor's Disease: A Rare Presentation of Inflammatory Bowel Disease
Authors: Armstrong L , Lockhart J , Mathers H
Published: October 2021

Introduction

Mondor's Disease (MD) is a rare condition characterised by thrombophlebitis of the superficial veins of the breast and anterior chest wall. Cases associated with inflammatory bowel disease are rare.

Case

A 54-year-old male presented to the symptomatic breast clinic with a 6-week history of a painful linear area on the anterolateral aspect of his left chest wall. There was no history of trauma or underlying coagulopathy. He also described increased stool frequency and crampy abdominal pain. On clinical examination, superficial thrombophlebitis with cording was noted along the outer upper quadrant of the chest wall. His past medical history included a previous diagnosis of ulcerative colitis, with no pharmacological treatment. He was subsequently referred to a gastroenterologist and all symptoms resolved following management of his underlying colitis.

Discussion

This gentleman’s thrombophlebitis followed the course of the thoracoepigastric vein. The occurrence of thromboembolic events has been documented in association with an exacerbation of ulcerative colitis; however, literature describing MD is scarce. The underlying aetiology is reportedly due to the hypercoagulable state identified in ulcerative colitis. There is a lack of consensus on the treatment of MD, however cases have responded well to the management of the precipitating colitis. Low molecular weight heparin can be used if chronicity ensues. Surgical management is not recommended.

Conclusions

MD is a rare presentation of ulcerative colitis. Clinicians should be aware of underlying aetiologies and a potential hypercoagulable state. Such cases in relation to UC require early diagnosis and treatment of underlying colitis.
794 Diagnostic Pitfall in Atypical Presentation of Malignant Gastric Ulcer Perforation
Authors: Oo M K , Tun T N , Aung M
Published: October 2021

Background

Peptic ulcer perforation is one of the most common surgical problems in daily practice. Although it can be easily diagnosed clinically, the clinical presentation can be less obvious in some cases leading to diagnostic pitfalls and mortality. This case report aims to highlight an atypical presentation of malignant gastric ulcer perforation in a patient with chronic abdominal pain.

Case presentation

A 78-year-old lady presented with chronic abdominal pain for 3 months. Investigations and imaging revealed T2N1M0 malignant gastric ulcer which was confirmed by endoscopy. Due to her low body mass index and underlying comorbidities, she was admitted for pre-operative optimization. However, she was a good 78 with the clinical frailty scale 4 and the National Early Warning Score 0 throughout the stay. On the night before the operation, she suddenly developed delirium. Further history revealed marked oliguria for 12 hours. There was mild abdominal distension without peritonism. She was catheterized and treated with fluids and antibiotics. X-ray suggested massive pneumoperitonium. Subsequently, she developed full-blown septic shock with rapid clinical deterioration within 3 hours. With the estimated Boey scoring of 3 and rapid clinical deterioration, the symptom control approach was decided. A palliative bedside ascitic tap was performed to relieve the discomfort. Four hours after the onset, unfortunately, the patient passed away.

Conclusions

Although gastric ulcer perforation usually presents with obvious symptoms, extra precaution should be exercised in elderly patients with chronic abdominal pain and comorbidities. We could learn that routine monitoring of urine output might aid in the early diagnosis of sepsis.
830 A Case of Colo-Colonic Intussusception Secondary to A Large Lipoma in An Adult
Authors: Koronfel M , Jamal A , Edmonds R
Published: October 2021

Colonic lipomas are benign tumours, most commonly in the right colon or caecum, usually detected incidentally at colonoscopy and are often asymptomatic not requiring treatment. Lipomas leading to intussusception have previously been described in case reports, but it remains a rare occurrence, no specific incidence data has been documented. We present the case of a patient with a 7cm colonic lipoma that developed an intussusception.

This patient suffered non-specific pulling pain along the right and upper abdomen for many years. A distal ascending colonic lipoma was identified, on repeated imaging and colonoscopy and biopsied. It was concluded that the abdominal pain was due to gallstones, diverticulitis and adhesions from previous pelvic surgery. In early December 2020, the patient was reviewed and listed for elective cholecystectomy. Later the same month, the patient was admitted with severe abdominal pain, watery and bloody diarrhoea. CT scan showed the colonic lipoma had acted as the lead point for an intussusception, with the lipoma and surrounding colon having intussuscepted into the transverse colon. Patient had an open right hemicolectomy and anastomosis for colo-colic intussusception secondary to the lipoma. Subsequently, the patient developed anastomotic breakdown requiring relook laparotomy with resection of ileo-colic anastomosis and end ileostomy formation.

Adults presenting with intussusception is rare and associated with nonspecific signs and symptoms. Variability in clinical presentation highlights the need for a low index of suspicion in people with known colonic masses. In addition, early surgical intervention should be considered in masses >4cm as previously suggested in the literature.
952 When A Surgeon Was Called to The Obstetric Unit: A Rare Case of Gonococcal Peritonitis in A 12-Week Pregnancy
Authors: Ann Jacob P , Jacob L
Published: October 2021

Background

Primary bacterial peritonitis presenting as septic shock is infrequently seen in clinical practice. This is a case of gonococcal peritonitis presenting as septic shock in a pregnant lady needing emergency laparotomy, drainage of purulent fluid and abdominal lavage.

Case Presentation

A 35-year-old woman presented with severe generalised abdominal pain. No history of fever, vomiting, urinary or bowel complaints. She was in her 4th pregnancy, at 12-weeks gestation. She was afebrile but tachycardic and hypotensive. Abdomen was tender and there was no vaginal bleeding. Ultrasound scan showed minimal fluid in hepatorenal area and a viable intrauterine pregnancy. Differential diagnosis were ruptured appendix, ectopic pregnancy, acute abdomen and shock. Exploratory laparotomy was done. Moderate amount of purulent fluid was noted within the abdominal cavity and no bleeding was seen. General surgeon was called for assistance by the Obstetrician as no foci of infection was found. The uterus, fallopian tubes, ovaries, appendix, bowel and upper abdominal organs were found to be intact. Peritoneal fluid culture was taken. Drainage of purulent fluid and peritoneal wash was done. She was nursed in ICU because of peritonitis with septic shock and AKI. Peritoneal fluid culture showed Neisseria gonorrhoea and IV ceftriaxone was given for 7 days. Postoperatively she recovered well but needed evacuation of uterus for a missed miscarriage. She was screened for other STIs and were negative.

Discussion

Gonorrhoea is the second most common reported STI. It can present as acute peritonitis when the infection has spread beyond upper reproductive tract organs.
956 Retained Appendiceal Tip and Abdominal Wall Appendicolith - A Rare Combination of Post Appendicectomy Complications
Authors: Dey A , Symons N
Published: October 2021

Appendicitis involving the appendix stump is a recognised post appendicectomy complication but the same involving the appendiceal tip is rare. Similarly, abdominal wall abscess secondary to retained appendicolith is also infrequently encountered. Our case highlights a rare combination of both complications arising separately.

A 29-year-old man presented with 3 days of generalised malaise and progressively worsening right iliac fossa pain some ten months after a laparoscopic appendicectomy. This had been complicated by residual right iliac fossa inflammation that was treated conservatively and serial scans demonstrated gradually resolving inflammation. He also had well controlled ulcerative colitis.

On examination, he was noted to be pyrexial with a tender fluctuant mass in the right flank. An ultrasound scan demonstrated inflammatory changes in the abdominal wall with no intra-abdominal collections. A diagnostic laparoscopy found an inflamed appendix tip, attached to the residual mesoappendix and embedded in the abdominal wall behind the mid-ascending colon. A completion appendicectomy was performed.

The patient recovered well but returned 4 months later with persistent pain and a fluctuant mass over the right iliac fossa. Radiological investigation revealed an abdominal wall collection containing a calcified appendicolith. The collection was refractory to ultrasound guided drainage and an exploration of the abdominal wall allowed extraction of the appendicolith followed by symptomatic relief.

This case emphasizes the importance of complete excision of the appendix and extraction of debris, which can be challenging when the appendix lies in a retro-colic position.
983 Digital Angioleiomyoma: A Rare Tumour Of the Hand
Authors: Motiwala F , Jivan S
Published: October 2021

Introduction

Angioleiomyoma is an unusual, benign tumour originating from the tunica media of blood vessels. They commonly occur in the face, neck and lower limb. It is rarely found in the hand and is not considered in the differential diagnoses of painful subcutaneous hand tumours.

Case Report

We present a case of a 40-year-old man with a several month history of a slow growing lump on his right middle finger. He complained of pain and difficulty flexing his finger. On examination, he had a solid tumour with normal overlying skin, on the volar ulnar border of middle phalanx with altered sensation and a positive Tinel’s along the ulnar digital nerve. Ultrasound and MRI reported a highly vascular subcutaneous tumour measuring 26x14x22mm with differential diagnoses of giant cell or peripheral nerve tumour. Intra-operatively the tumour was in continuity with the ulnar digital artery and solid in consistency. Tumour excision and microsurgical repair of the digital artery was required. Histology confirmed a well-defined nodule, composed of bundles of smooth muscle surrounding ectatic blood vessels, consistent with angioleiomyoma. On follow-up the patient reported return of full range of movement without hypersensitivity or evidence of recurrence.

Conclusions

Angioleiomyomas in the hand are rare. It should be considered in the differential diagnoses of painful subcutaneous tumours. Ultrasound and MRI are non-specific. Treatment is successful with excision biopsy and microsurgical repair of digital artery. Microvascular instruments should be available, and the patient consented for vein graft.
1067 Neoplasia in Association with a Congenital Anomaly: Wilms Tumor in a Horseshoe Kidney
Authors: Mubarak M , Alhamdan O , Alaradi H , Alhindi S
Published: October 2021

Introduction

Horseshoe malformation is the most common form of fusion defects involving the kidney, whereas Wilm's tumor is the most common primary malignant renal tumor in children. The co-incidence of these two pathologies gives off an incidence rate of 0.48%.

Case Report

This is a case of a two-year-old female who presented early in life with multiple congenital anomalies including congenital heart disease, bilateral aniridia, persistent thrombocytopenia, and sickle cell trait in association with a painless abdominal mass. A CT scan showed a horseshoe kidney. The patient was lost for follow up until the age of two years, in which another CT scan revealed a left lower pole focal cystic mass measuring 5.1x5.3x6.3cm. WAGR syndrome was suspected and confirmed through genetic testing. A multidisciplinary approach was necessary to manage her efficiently due to the numerous co-existing congenital pathologies. The patient underwent six cycles of chemotherapy leading to a 35% reduction in tumor size and a left nephrectomy. She was admitted to the pediatric ICU post-operatively for observation. Histopathological analysis revealed features of stage two stromal type nephroblastoma. Her renal function and urine output were satisfactory throughout the duration of her admission as well as on follow up.

Conclusions

Keeping a high index of suspicion is imperative; individuals with renal anomalies, namely horseshoe kidney in the context of WAGR syndrome, mandate a comprehensive assessment through clinical examination, laboratory workup, and imaging. Though different approaches to standard Wilm's tumor cases have been explored thoroughly, it is crucial to keep in mind the need for multidisciplinary involvement in patients with multiple congenital anomalies.
1094 Diagnosis of Diabetic Ketoacidosis Delayed Due to Concomitant Acute-On-Chronic Pancreatitis
Authors: Lung N
Published: October 2021

The objective of this clinical case is to highlight the importance of recognition and prompt management of diabetic ketoacidosis (DKA) in older patients with comorbidities such as acute pancreatitis.

A 61-year-old gentleman initially presented to the hospital with severe left upper quadrant/epigastric pain and vomiting. He had a background of chronic pancreatitis, diabetes secondary to pancreatitis and alcohol excess. Based on his raised inflammatory markers and CT findings which showed pancreatic pseudocyst compressing on the spleen, a diagnosis of acute-on-chronic pancreatitis and possible intra-abdominal sepsis was made. He was subsequently commenced on piperacillin with tazobactam and given fluids.

His abdominal pain persisted despite initial treatment. His blood glucose levels were within normal range, but his ketone levels were found to be consistently high since admission. Two days later, he presented with reduced consciousness and generalised abdominal tenderness; his arterial blood gas showed a very severe metabolic acidosis. A diagnosis of DKA was then made – he was commenced on the DKA treatment protocol and was transferred to the Intensive Care Unit for stabilisation. He gradually made a recovery and was later transferred from the ICU to the endocrinology ward.

DKA usually presents in younger patients with type 1 diabetes. Given the background of this patient, his presentation was largely attributed to a surgical cause. Clinicians must remain alert to the possibility of dual diagnoses relating to abdominal pain, which in this case were a surgical cause (pancreatitis) and a medical cause (DKA).
1150 A Painless Anterior Chest Wall Mass Post Coronary Artery Bypass Grafting Surgery
Authors: Reid R , Alakhras Aljanadi F , Beattie R , Graham A
Published: October 2021

Aim

We aim to present here a case of a painless anterior chest wall mass which was first noted during routine follow up post coronary artery bypass graft surgery

Case presentation

An 80-year-old male developed an asymptomatic slow growing pronounced swelling over the right anterior chest wall post CABG. His other past medical history includes chronic obstructive pulmonary disease, pulmonary fibrosis, ischaemic heart disease, an AICD for complete heart block, hypertension, hyperlipidaemia and osteoarthritis. A CT scan demonstrated a 10 x 12 x 6.5 cm subcutaneous lesion at the mid-line of the lower chest wall adjacent to the xiphisternum and the previous sternotomy site. On clinical examination there was a large non-tender cystic swelling with peripheral calcifications, but overlying skin was normal. Fluid was aspirated from the lesion and cytology showed a paucicellular specimen with features in keeping with seroma. Due to the progressive increase in size patient underwent surgical resection. A gelatinous bloody fluid was aspirated from the lesion and it was then resected enbloc. The tumour base appeared to arise from 6/7th costal cartilage and tumour was shaved away. The mass was confirmed histologically to be chondrosarcoma.

Conclusions

Given the uncommon prevalence of malignant primary chest wall tumours this case highlights the importance of high clinical suspicion even after developing post CABG.
1399 Anorectal Melanoma: Can Be an Unexpected Diagnosis - A Case Report
Authors: Hagiga A , Shaaban M , Gultiaeva M
Published: October 2021

Anorectal melanoma is a rare tumour. Few cases are reported in the literature. We report a case of 51 years old male complained of anal induration, itching and bloody and suppurative discharge. Patient had symptoms for 2 years. However, patient expected his symptoms are due to recurrence of haemorrhoids. Therefore, he presented late. Then, he had noticed a progressive increase in size, discharge and two opposing ulcers. Patient had no history of abdominal pain, change in bowel habits, bleeding per rectum, history of groin lumps, incontinence nor erectile dysfunction. Patient underwent haemorrhoidectomy about 11 years ago. On examination, there was a circumferential single ulcer eroding the anus extending deep to the dentate line reaching the rectum on digital rectal examination. Also, there was no inguinal lymphadenopathy detected on exam. Incisional biopsy of the ulcer showed anorectal melanoma. Patient had abdominoperineal resection (APR) with adjuvant radiotherapy. At 12 months follow up, there were no signs of recurrence.
1590 Reconstructing Periorbital Necrotising Fasciitis - A Case Report
Authors: Li Z , Filobbos G
Published: October 2021

Periorbital necrotising fasciitis is a rare life-threatening presentation. We present a case of an 87-year-old patient with periorbital necrotising fasciitis. The patient was successfully managed by prompt diagnosis, debridement and reconstruction with a thick split thickness skin graft harvested from the scalp. To the best of our knowledge, this is the first case report in literature suggesting the use of sheet skin grafts from the scalp in reconstruction of necrotising fasciitis. The patient was discharged after 20 days and has no residual corneal or scleral show despite losing bilateral upper and lower eyelid skin. We present the case with photographs of initial presentation, debridement, and final reconstruction.

Reconstruction of post-debridement necrotising fasciitis offers a challenge to the plastic surgeon. The wound bed is not ideal and commonly colonised. We suggest the use of thick split thickness skin grafts harvested from the scalp. Despite their utility in burns surgery, the use of scalp split thickness skin is not documented in literature for reconstruction of necrotising fasciitis. We believe this type of skin graft offers multiple advantages: higher rate of graft takes, less contracture and inconspicuous donor site morbidity. Time to reconstruction is particularly important in patients with eye lid skin loss and we believe this type of skin graft offers a versatile solution when graft take is essential.
1678 A Rare Example of a Simple Bone Cyst of The Ascending Ramus in A Paediatric Patient
Authors: Aruede G , Carey E , Bhatia K , Smart K
Published: October 2021

A simple bone cyst is described as an intra-osseous pseudocyst, devoid of an epithelial lining and either empty of filled with serous or sanguineous fluid. This case presents a rare example of a simple bone cyst of the ascending ramus of the mandible in a paediatric patient. Studies have shown that less than 5% of simple bone cysts of the jaw bones are located within the mandibular ramus, with the most common site being the premolar-molar region (75%). The 14-year-old female was referred by her orthodontist to the local Oral and Maxillofacial department, for an incidental finding on her pre-orthodontic OPT of a radiolucency in the left ascending ramus. Her medical history was clear, she was asymptomatic and had no sensory deficit. A CT scan demonstrated a 22mm multilocular radiolucency centred on the left ascending ramus, extending superiorly up to the base of the coronoid process and condylar neck. Inferiorly, the radiolucency abutted but did not involve the unerupted third molar. The scan highlighted thinning of the buccal and lingual cortices putting the patient at risk of pathological fracture. The inferior alveolar nerve canal passed through the lingual aspect of the radiolucency. The patient underwent exploration of the left mandible which revealed an empty bony cavity, with no cystic lining or contents. The definitive diagnosis of a simple bone cyst was established. She experienced satisfactory healing by her review appointment 4 weeks post-surgery. Combined radiographic and clinical assessment is important in the diagnosis of simple bone cysts.
663 A Multi-centre National Study of the Effectiveness of Virtual Fracture Clinic Management of Orthopaedic Trauma during the COVID-19 Pandemic (MAVCOV): A Cross-sectional Study Protocol
Authors: Ng Z H , Downie S , Makaram N , Kolhe S , Mackenzie S , Clement N , Duckworth A , White T
Published: October 2021

Aim

Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on demographics of injuries presenting to the VFC and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines.

Method

This is a national cross-sectional cohort study comprising centres with VFC services across the United Kingdom. All consecutive adult patients assessed at VFC pre-lockdown (6 May 2019 to 19 May 2019) and at the peak of the first lockdown (4 May 2020 to 17 May 2020), and a randomly selected sample during the second wave (October 2020) will be eligible for the study. Data comprising local VFC practice, patient and injury characteristics, unplanned re-attendances, and complications will be collected. A telephone questionnaire will be used to determine patient satisfaction and patient-reported outcomes for patients who were discharged following VFC assessment without face-to-face consultation.

Results

As of 31 October 2020, 51 hospitals with VFC services have been recruited to participate in this study.

Conclusions

The study results will identify changes in case-mix and numbers of patients managed through VFCs, due to urgent necessity, and whether this is safe and is associated with patient satisfaction to inform future clinical practice.
1277 A Closed-Loop Audit of the use of qFIT in Symptomatic “Two Week Wait” referrals in Somerset Foundation Trust
Authors: Cullen J , Chambers A , Smyth E , Mackey P l , Hunt L , Bamford R
Published: October 2021

Introduction

Quantitative faecal immunochemical test (qFIT) is recommended as the replacement test for faecal occult blood testing by NICE. We audited qFIT use in two week-wait (2WW) referrals in Somerset Foundation Trust (SFT) following its introduction in 2019.

Method

Following qFIT being made available to general practitioners, all 2WW referrals received before (July 2019) and after (December 2019) the introduction of the new 2WW referral form were reviewed. Electronic patient records were analysed to determine investigations performed and if a diagnosis of cancer was made.

Results

July 2019: 288 2WW referrals with 74 patients eligible for qFIT – only 7 of these underwent qFIT; total of 93 qFIT performed by GPs with 11 positive tests. December 2019: 222 2WW referrals with 18 patients eligible for qFIT – all of whom underwent qFIT; total of 155 qFIT performed by GPs with 18 positive (and 137 negative) tests. 1 patient with a positive qFIT was found to have colorectal malignancy (qFIT = 267 g/dL, investigation showed benign TVA). An increase in qFIT was observed over time, coinciding with a reduction in 2WW referrals, including reduction in patients who were qFIT eligible. The 2WW service identified 11 (3.8%) cases of colorectal cancer in July 2019 compared to 12 (5.4%) cases in December 2019, showing an increased pickup rate.

Conclusions

High proportions of 2WW referrals undergo investigation. The results of this audit highlight the utility of qFIT in screening 2WW referrals and reducing burden on the service, particularly where access to investigations is severely restricted due to coronavirus.
387 Plastics Surgery and the COVID-19 Pandemic: How Our Practice Has Improved as A Consequence
Authors: Yeoh T , Tan A , Ahmed F
Published: October 2021

Aim

Plastic trauma cases were impacted by the COVID-19 pandemic. Multiple plastic trauma theatres were lost due to redeployment and redistribution of staff and resources. Plastic surgery was essentially left with an emergency list to manage trauma cases. This retrospective study aims to highlight the pitfalls and solutions realised during COVID times and how different strategies can be implemented should a third national lock down occur.

Method

Plastic surgery data (trauma, elective) was analysed from the first national lockdown due to COVID-19 in 2020. This data was compared against plastic surgery trauma data from 2019. Theatre time, the number of trauma surgeries, anaesthetic used and delay to theatre were all analysed.

Results

There was a 47% reduction in plastic surgery trauma cases and a 42% reduction in delay to surgery during the national lockdown (2020) when compared with data from 2019. A significant increase in the use of Local Anaesthetic (LA) and Regional Anaesthetic (RA) during COVID times with a decrease in General Anaesthetic when compared with pre-COVID data of 2019 was also identified.

Conclusions

This study identified that the majority of plastic cases could be performed under RA/LA. This would lead to decreased aerosol generating procedures (GA) thus limiting the transmission of COVID, and decreased delay to surgery and theatre time. As a third national lockdown may be on the horizon, it would be prudent to implement these strategies into current practice and by doing so optimising theatre usage and assisting in curtailing the COVID-19 transmission rate.
423 Patient Perspective on the Use of the Independent Sector to Maintain Elective NHS Services During the COVID-19 Pandemic
Authors: Clough O , Lee G , Walker J
Published: October 2021

Introduction

COVID-19 resulted in the suspension of planned treatments for patients worldwide leaving millions suffering the physical and mental effects of delay. Reports indicate that when services have been re-established, patients have been afraid to take up appointments. Hospitals put processes in place to counter this, notably separating emergency and elective patient cohorts. Most notably seen by the co-operation between the NHS and independent private healthcare providers in March 2020 at the height of the pandemic. We undertook a study to ascertain the perceptions of NHS patients who underwent elective treatment at independent ‘cold’ sites during the COVID-19 pandemic.

Method

A cross-sectional study with structured telephone interviews of patients who had planned elective treatments at ‘cold’ independent hospitals between March and September 2020. 1150 patients were identified, and a 20% sample formed a 230 patient study group, with 158 (70%) agreeing to participate.

Results

30% of patients delayed their treatment due to COVID related concerns, with 76% of these only accepting treatment because this was at a ‘cold’ site. 46% of patients perceived treatment at a ‘cold’ site as the most important factor contributing to their safety. 153 patients (97%) supported the paid arrangement between the NHS and the independent sector to provide separate ‘cold’ sites for elective treatments.

Discussion

Safely restarting elective services to allow important planned treatments to take place, as was the pandemic continues, is a priority. Our study indicates that physical separation of patient pathways impacted most on patient confidence, and that the use of ‘cold’ sites is a viable option.
454 Impact Of COVID-19 Pandemic on Elective Theatre Productivity in Otolaryngology
Authors: Lam C M , Owens D
Published: October 2021

Aim

COVID-19 has had a significant impact on otolaryngology surgery. There are new requirements to prepare patients for theatre however the impact on theatre productivity is unknown. This study aims to evaluate the impact of COVID-19 on elective theatre productivity.

Method

We conducted a retrospective evaluation of elective otolaryngology theatre lists. Ten consecutive theatre lists beginning on the final week of November 2019 and November 2020 were analysed. Dedicated emergency operation lists were excluded.

Results

There were fewer operating lists per working day in 2020 (0.9) compared to 2019 (2.0) and a higher percentage of operations cancelled (2020: 15.4%, 2019: 8.6%). Theatre lists finished significantly earlier in 2020 than in 2019 (2020 median: 97.5 minutes, 2019 median: 15.5 minutes; p = 0.00018). The percentage of theatre lists finishing over 60 minutes early was substantially greater than the national average of 23% (2020: 75%, 2019: 30%). The median pre-list delay was higher in 2020 than 2019 (2019: 20.5 minutes, 2020: 31.5 minutes; p = 0.14) whilst the median total delay was higher in 2019 compared to 2020 (2019: 20.5 minutes, 2020: 18 minutes; p = 0.21). Both results were not statistically significant. The commonest reason for delay in 2020 were COVID-19 related reasons such as awaiting test results, in 2019 the commonest reason was patient not being ready for theatre such as consent not completed.

Conclusions

COVID-19 has had a significant impact on theatre productivity and is currently the commonest cause of theatre list delay. The early theatre finishing time suggest that improvements can be made to improve theatre productivity.
460 Remote Orthopaedic Clinics during COVID-19: Lessons for a Sustainable Future
Authors: Curtis A , Parwaiz H , Winkworth C , Sweeting L , Pallant L , Davoudi K , Smith E , Chin K , Kelsey M , Brankin-Frisby T , Stevenson A
Published: October 2021

Aim

The COVID-19 pandemic has led to a focus on non-face to face (NF2F) orthopaedic clinics. Our aim was to establish whether NF2F clinics were sustainable according to the ‘Triple Bottom Line’ framework by taking account of the impact on patients, the planet and financial cost.

Method

This retrospective cohort study was carried out at a large DGH with 261 patients identified as having undergone F2F or NF2F orthopaedic consultations (April 2020). These patients were contacted by telephone to establish their experience, mode of transport and preference for future consultations. Data was also collected relating to environmental and financial costs to the patient and trust.

Results

Final analysis included 180 patients (69%): 42% had a F2F consultation and 58% a NF2F consultation. There was no significant difference between each group in terms of convenience, ease of communication, subjective patient safety, or overall satisfaction rating (p>0.05). 80% of NF2F patients would be happy with virtual consultations in future. Mean journey distance was 18.6 miles leading to a reduction in total carbon emissions of 563.9kg CO2e (66%), equating to 2106 miles in a medium sized car. The hospital visit carbon cost (heating, lighting, and waste generation) was reduced by 3,967kg CO2e (58%). The financial cost (petrol and parking) was also reduced by an average of £8.96 per person.

Conclusions

NF2F consultations are aligned to the NHS ‘Long Term Plan’. They (i) deliver high patient satisfaction with equivalent outcomes to F2F consultations; (ii) have reduced carbon emissions from transportation and hospital running; and (iii) are cheaper.
615 Evening Emergency Theatre Usage Analysis Pre And Post COVID-19: Are We Making the Cut?
Authors: Barzilai L , McArthur G
Published: October 2021

Introduction

Emergency theatre is a 24/7 service. We aim to assess a large UK hospital’s utilisation of theatre time in the evening.

Method

Electronic records of all evening (6pm-9pm) operations between January-February 2020 (pre COVID-19) and July-August 2020 (post COVID-19) assessed for start and finish times, send for times and booking times. Existence of pending cases during downtime noted as well as any delay reasons.

Results

Time between out of room and send for times (when cases pending) average 59 minutes pre COVID-19 vs. 78 minutes post COVID-19 (median 35 minutes vs. 59 minutes, respectively). Time between surgical end and send for times (when cases pending) average 83 minutes pre COVID-19 vs. 96 minutes post COVID-19 (median 64 minutes vs. 81 minutes, respectively). Time between out of room and anaesthetic start average 84 minutes pre COVID-19 vs. 101 minutes post COVID-19 (median 58 minutes vs. 80 minutes, respectively). Send for times post booking for new evening bookings average 80mins pre COVID-19 vs. 57 minutes post COVID-19 (63 minutes vs. 38 minutes, respectively). 20.45% of cases did not have a computer booking for surgery pre COVID-19 vs. 25.92% post COVID-19. Pre COVID-19, theatre overrunning contributed to delays, whereas post COVID-19, delays also due to repeat COVID-19 swabs, repeat group & saves and delays in bed availability.

Conclusions

Lingering effects of COVID-19 have caused further delays to a service already in need of implementation of changes to improve utilisation. Surgical, anaesthetic, nursing and executive teams must work together to improve efficiency.
793 Orthopaedic Surgical Training in The Independent Sector During the COVID 19 Pandemic
Authors: O'Callaghan J , Lochab S , Stanier P , Woods D
Published: October 2021

Introduction

The COVID pandemic had led to the cancellation of elective Orthopaedics in the NHS. The aim of this study was to investigate the effect of the independent sector on orthopaedic training and the effect of the COVID pandemic on training locally.

Method

A retrospective review of trauma and elective operations was made between April and September of 2019 and 2020 to compare the effects of COVID on training opportunities and the additional capacity provided by the private sector.

Results

The impact of COVID on Surgical training at GWH has been no decrease in trauma operating experience, but a 53% decrease in elective operating experience and a 74% decrease in joint replacement operative experience during an equivalent six-month period. Use of the independent hospital has enabled 6% of the total elective surgery experience, and 11% of the joint replacement surgery experience.

Discussion

The private sector has provided additional capacity but a productivity of 66 cases from 48 half day lists is low (1.4 cases per list) has proved disappointing. There has been a low impact on elective training. The challenges have been faced on the elective side as trauma cases have remained consistent during the pandemic.

Conclusions

Use of the alliance between the private sector and NHS as a resource to provide additional training opportunities needs to be developed further in the future with incentivised guidance. Orthopaedic training will inevitably adapt to the challenges presented for the next generations of surgeons.
1222 Improving Consenting for Emergency General Surgery During The COVID-19 Pandemic
Authors: Oyewole B , Sandhya A , Tawfik A , Elzaafarany A , Ma J , Jethwa P
Published: October 2021

Aim

Patients undergoing surgery during the Covid pandemic are exposed to increased risks of pulmonary complications and mortality. These novel risks need to be documented on the consent form. We carried out various interventions to ensure appropriate consenting and documentation following an initial audit that revealed poor compliance with published guidelines.

Method

The initial audit reviewed consent forms of patients undergoing emergency surgery over two-weeks in May 2020 while the re-audit was over a two-week period in June 2020 following implementation of interventions. Inclusion Criteria: Age >18-years, urgent or emergency laparoscopic surgery Exclusion criteria: Age <18-years, Open surgery, ‘Covid-light’ areas, NELA.

Results

57 consent forms were assessed during the audit loop: 22 laparoscopic appendicectomies and diagnostic laparoscopies, 14 incision and drainage, 8 laparoscopic cholecystectomies, 4 hernia repairs, and 9 other procedures. Consenting for covid pneumonia increased from 70% to 89%, potential ITU admission 56% from 25% and the risk of death 63% from 21%

Conclusions

The covid pandemic changed our surgical practice. There are many unknowns regarding the risks to surgical patients, however, evidence shows increased risks of covid pneumonia, ITU admission and death in the perioperative period. Our consenting and the documentation of such conversations with patients must reflect our new reality.
1291 COVID-19 And Skin Cancer Mohs Service: Are We on The Line?
Authors: Cooper K , Kloecker D , Labib A , Odili J
Published: October 2021

Introduction

Mohs surgery is a technique of surgical excision indicated for high-risk basal cell carcinomas involving contemporaneous histopathological assessment to ensure clear margins at the time of excision. Post-Mohs excision, patients should undergo reconstruction by plastic surgeons.

Aim

To explore the impact of the COVID-19 pandemic on a post-Mohs plastic surgery reconstructive service.

Method

A single-centre, retrospective analysis of patient undergoing post-Mohs reconstruction between March and September 2020 – including the first national lockdown period. This was compared with the same period in 2019. Key outcome measures included:

Results

In 2019, between March and September, 12 patients were referred for Mohs surgery and reconstruction versus 23 in 2020. In 2019, patients referred for Mohs waited a mean of 101 days between their clinic appointment and surgery, versus 97 days in 2020. No Mohs surgery was performed during the first lockdown and patients referred during this period waited a mean of 150 days for surgery versus 81 days in this period in 2019. The proportion of patient undergoing direct closure or full thickness skin grafting to post-Mohs defects increased by 20% while the number undergoing local flap reconstruction decreased by 12% in 2020 compared to 2019.

Conclusions

While overall waiting times improved in 2020, those patients referred during the lockdown experienced longer waits for Mohs surgery. The increased proportion of patients undergoing simpler reconstructive techniques in 2020 may reflect pressure on operating time due to the period of inactivity during the lockdown.
1595 Instituting Rapid and Semi-rapid COVID-19 Testing Pathways to Facilitate Emergency Surgery
Authors: Berezowska A , Cross A , Hunt E , Price J , Mirfenderesky M
Published: October 2021

Aim

Defining a patient’s COVID-19 status on admission is essential for optimised patient management, safe bed-placement, and flow across the hospital. Perioperative COVID-19 infection is associated with significantly poorer outcomes and may influence a patient's and/or surgeon's decision to proceed. Rapid PCR tests (1-2 hours) for COVID-19 remain the gold-standard, however most NHS Trust’s either do not have, or have severely limited access to such testing modalities. Our aim was to introduce a surgical triaging algorithm to conserve rapid testing for immediate surgery, whilst developing a semi-rapid pathway with results available in 12-15 hours for surgery within 24-48 hours.

Method

Using quality improvement methodology, based on a ‘PDSA’ model we introduced a surgical triaging algorithm. Testing options were categorised into rapid, semi-rapid or routine (24 hours). Defined outcomes, as well as primary and secondary drivers were identified. Both the pre-analytical and post-analytical testing pathways were characterised, concentrating on electronic requesting, laboratory transportation and reporting. Five ‘PDSA’ cycles were performed with immediate audit and feed-back to surgeons after each round. A vetting procedure was also introduced to improve compliance with requesting.

Results

Turn-around-times for COVID-19 PCR swabs at our institution improved from 23 hrs:13 minutes at baseline, to 9 hrs:38 minutes for semi-rapids, to < 2 hours for rapid swabs.

Conclusions

Adoption of a surgical triaging algorithm ensured prioritisation of rapid and semi-rapid COVID testing based on clinical need. This ensured optimised patient care, safe theatre and anaesthetic Infection Prevention and Control practices, as well as correct post-operative placement.
189 Outcomes in Appendicitis During The COVID-19 Pandemic: A Single Center Report Of 36 Cases
Authors: Angamuthu N , Mirnezami R , Knowles J
Published: October 2021

Introduction

Surgical management of acute appendicitis(AA) during the first peak of COVID-19 was modified somewhat in order to mitigate concurrent infection. Early in the pandemic an open approach was preferable. The management of AA at a single surgical unit over three months during the COVID-19 outbreak is presented.

Method

Data on patients diagnosed with AA (3rd March 2020 to 4th May 2020) were analysed. Management strategies, morbidity, length of stay and readmissions were evaluated.

Results

Median age was 45 years (range 6-75) with a male: female ratio of 2.7:1. The mean white cell count and CRP were 14.7(5.4-25) and 121.6(1- 545), respectively. Appendicectomy (28/36;77.8%) was performed laparoscopically in 23(82.1%) and open in 4(14.3%); 13.9%(5/36) of AA, were managed conservatively. Among the COVID-19 positive patients(5/36), 4 were managed laparoscopically, one needed a laparotomy. Considering COVID-19 positive vs negative/not done status, conversion was seen 50%(2/4) and 5.3%(1/19) respectively. A difference in mean length of stay was noted (positive vs negative/not done = 10.4 days vs 3.43 days). Morbidity was 16.7%(6/36) with a re-admission rate of 11%(4/36).

Conclusions

Surgical units need to be flexible to modify their management plans as the COVID-19 pandemic evolves. Awaiting USS/CECT, wait and watch policy related delays should be avoided when possible. A higher conversion rate, morbidity and readmission rate were noted in this cohort of patients, potentially the result of more complicated inflammation, as patients may present late owing to apprehensions regarding their safety while attending hospital.