bluuebunny/crossref_metadata_2025 huggingface dataset:
WE6.9 Enoxaparin venous thromboembolism prophylaxis in bariatric surgery: A best evidence topic update
Authors: Pathmaraj Bavin , Parmar Chetan , Sufi Pratik
Published: November 2022

Aim

To examine the literature and identify the best dosing regimen of enoxaparin for perioperative venous thromboembolism (VTE) prophylaxis in patients undergoing bariatric surgery. This presentation reviewed publications from 2015 to 2021 to determine whether previous recommendations based on a similar examination of evidence conducted in 2015 needed to be updated, considering new evidence.

Method

A literature search was conducted in accordance with a structured format. One hundred and one papers were identified using a standardised literature search from 2015 to 2021 on Medline and EMBASE using the same search terms “bariatric surgery” AND “venous thromboembolism” AND “enoxaparin”. The author, date and country of publication, patient groups and VTE prophylaxis strategy, level of evidence, outcomes, key results and study weaknesses were tabulated.

Results

Three studies were selected as the best available evidence to answer the question. All three articles were non-randomised cohort studies analysing VTE and major bleeding rates following different bariatric thromboprophylaxis regimens. There was still no level 1 evidence available to answer this question.

Conclusion

Enoxaparin 40mg/day starting 12 hours after the operation, continuing for at least one week post-discharge may be the best enoxaparin dosing regimen for VTE prophylaxis in bariatric surgery patients based on the best evidence available to 2021. New evidence suggests that the previously recommended 40mg enoxaparin twice daily for in-hospital patients may increase major bleeding risk. A Randomised Controlled Trial would probably require 3500 patients in each arm to identify the best enoxaparin dosing regimen.
WE6.10 Gender Balance at Surgical Meetings in Ireland
Authors: Aketch Martin Safari , Leon Ryan , Qaoud Yazan , McGuire Andrew , Hill Arnold D K
Published: November 2022

Aim

To assess the genders of lead authors and primary investigators in major surgical research meetings over a 10-year period in Ireland.

Method

We gathered data from the 3 main surgical conferences in Ireland. We looked at the abstracts of each of the plenary sessions over the last 10 year. We used the Irish Medical Council, previous published research from these authors and ResearchGate to help identify the gender of the author. We complied and analysed the data using Excel.

Results

We analysed 306 papers over the last 10 years. We found that the primary investigator was male in 78% of the papers and female in 20%. The primary author was male in 52% and was female in 46% of the papers. There has been little change over each 5-year interval for who was the primary investigator. In 2010–2015, it was 77% male and 23% female while from 2016–2020, it was 82% male and 18% female.

Furthermore, in relation to the primary author, it has shifted from being relatively equal to becoming more male dominant. In 2010–2015, it was 52% female and 48% female while from 2016–2020, it was 57% male and 43% female.

Conclusion

The gender gap has appeared to have widened at the non-consultant hospital doctor level and it is very apparent that there is a large inequality at consultant level regarding surgical research in Ireland.
WE7.1 Getting it right first time: a standardised approach to closure of trauma laparotomy
Authors: Allan Jennifer , McGuinness Etain , Yoong Susan
Published: November 2022

Aims

Surgical site infection (SSI) has been reported between 12–14% following trauma laparotomy. It became apparent in a regional trauma center that 25% of trauma patients required an MRI within 10 days of admission and point of potential trauma laparotomy leading to the morbidity of non-MRI compatible clip removal and reclosure of the wound. The aim was to ensure all trauma laparotomies underwent closure with MRI compatible clips.

Methods

A retrospective data collection was performed of patients undergoing trauma laparotomies between July and December 2021. Data was collected on wound morbidity, if an MRI was required and if patients required clip removal.

Results

16 patients underwent trauma laparotomy between July-December 2021. 25% of these patients had an MRI performed within 10 days of their laparotomy, (median 3days), 3 of these required removal of clips. 1 of these patients developed a SSI requiring negative pressure therapy.

Conclusion

This QI project led to the introduction of a unit approved damage control laparotomy trolley with all potential essential equipment to allow instant availability including only MRI compatible clips. The project also led to a qualitative improvement of improved team morale due to teaching sessions for theatre nursing staff on importance and use of all these instruments. Outcome measure data is currently being collected to ensure compliance with trolley usage and MRI compatible clips negating the morbidity of reclosure of wound as well as the process measure of staff satisfaction of equipment knowledge and availability during a trauma laparotomy.
WE7.2 The development of a rib fracture pathway in a district general hospital to improve patient care
Authors: Collis Justin , Farquharson Barnaby , Dickson-Lowe Richard , Chan Shirley
Published: November 2022

Our aim was to evaluate the management of rib fractures under the general surgical team over a 1-year period. To compare our practice against a standard we reviewed rib fracture pathways from several NHS teaching hospitals. In doing so develop a rib fracture pathway that addressed the needs of our hospital.

A retrospective review of paper notes and electronic databases of patients with a recorded diagnosis of ‘rib fractures’. We collected data points on; mechanism of injury, analgesia strategy, pain team review, dietician review, whether a nerve block was used and baseline characteristics. Our project used the rib fracture STUMBL to determine prognosis and collected the relevant data for this score.

A total of 42 were included in our statistical analysis. Of the patients analysed 44% were older than 65 years old. The average length of stay for each patient was 5 days. For analgesia 89% received regular paracetamol, 41% received regular NSAIDS and 69% received regular opioids. Advanced analgesia such as PCA and nerve blocks were poorly used, for instance a PCA was used in only 13% of cases. Only 6% of patient received daily pain team review and 44% of patients were seen by physiotherapist within the first 24hours. Additionally 93% of patients that were admitted under general surgery had a STUMBL score >11.

We attributed areas of poor compliance to certain areas of best practice as a lack of awareness on how to access resources within our hospital. As a result we developed a pathway outlined best practice.
WE7.4 A Systematic Review of Splenic Viability Following Arterial Embolisation in Trauma
Authors: Dhital Ketan
Published: November 2022

The spleen is the most commonly injured organ in blunt abdominal trauma. Patients with these injuries are increasingly being managed nonoperatively, with use of Splenic Artery Embolisation (SAE). Many of these patients receive lifelong prophylactic antibiotics as though they were asplenic.

The aim is to seek robust evidence of splenic vascular integrity and immunocompetence following SAE, and consider whether lifelong antibiotic prophylaxis is necessary for trauma patients managed in this way.

2 separate literature reviews were carried out using the Medline database. One to assess literature pertaining to splenic tissue viability following embolisation, the other to find literature reviewing splenic immune function after embolisation.

In the vascular viability arm, 21 articles were reviewed. 12 studies observed no splenic infarcts at all. 18 of the studies noted <10% splenic infarcts in their populations. Distal embolisation resulted in more infarcted areas of splenic tissue than proximal. 9 studies performed follow-up imaging and confirmed splenic tissue viability post-procedure.

For the review of immunocompetence, the literature search resulted in 13 full text articles. There was no consistency of the immunologic marker used to test splenic immunocompetence post-SAE, but 11 of 13 studies confirmed preserved immunocompetence by their respective markers.

The data do suggest preserved tissue viability and immunocompetence. Agreement is yet to be reached as to which immune marker definitively assesses immunocompetence, and the length of follow-up needed to investigate it. More research is required to confirm the suggestion from these data that lifelong antibiotic prophylaxis is unnecessary for trauma patients treated with SAE.
WE7.7 Bone transport using the Monorail External Fixator over an Intramedullary Nail for Post-Traumatic Femoral Defects
Authors: Lu Victor , Zhang James , Zhou Andrew , Krkovic Matija
Published: November 2022

Aim

The management of limb-length discrepancy secondary to traumatic bone loss poses an unique challenge for surgeons. The Ilizarov technique is popular, but is associated with long external fixator time and many complications. This retrospective study assessed outcomes of post-traumatic femoral defects managed by monorail external fixation over an intramedullary nail.

Method

Eight patients were included from over a four-year period with post-traumatic femoral defects, that underwent treatment with monorail fixator-assisted intramedullary nailing. Mean follow-up time was 232.83 weeks. Five were open fractures (Gustilo-Anderson type 3A:n=4, 3B:n=1), one had closed fracture. Average bone defect size was 8cm. Primary outcomes were lengthening index, consolidation time and index, external fixator index. Secondary outcomes were time to full weight bearing (FWB), time to union, complications. Patient reported outcome measures including EQ-5D-5L, SF-36, Oxford knee scores (OKS), Oxford hip scores (OHS) were recorded after recovery.

Results

Average consolidation time and index were 11.35months and 1.24months/cm, respectively. Mean lengthening and external fixator index were 20.2days/cm and 23.88days/cm, respectively. On average, patients achieved FWB and bone union 56.25 weeks and 68.83 weeks after bone transport initiation, respectively. Two patients had docking site non-union, treated by reamed intramedullary exchange nailing. Two patients had osteomyelitis. EQ-5D-5L and EQ-VAS scores were compared to UK population norms (p=0.104, p=0.238, respectively). Average OKS was 32.17 and OHS was 34.00.

Conclusions

Monorail external fixation over an intramedullary nail is an effective option for post-traumatic femoral defects, reducing external fixator time, lowering complication rate, returning patients’ quality of life to a level comparable with the normal population.
WE7.10 Traumatic abdominal wall hernia and CT missed severe intra-abdominal injuries
Authors: Afonso Matias Mariana Rita , Hunt Leslie
Published: November 2022

Despite traumatic abdominal wall hernia (TAWH) being a rare entity, the incidence of associated intra-abdominal injuries is extremely common. With only few cases published, TAWH remains a diagnostic as well as a therapeutic challenge.

We present an obese 47-year-old female, front seat passenger, that was transferred to our hospital from a neighbouring DGH with a diagnosis of TAWH after a 30mph road traffic collision. On arrival, she was haemodynamically stable, abdominal examination showed a large hernia, extensive bruising but the abdomen was otherwise unremarkable. The CT performed before transfer showed a large hernia but no obvious other injury, no free fluid or gas was identified. Hernia repair was planned for the following day. Overnight there was a transient period of hypotension responsive to transfusion of multiple RBC units. The surgical approach was over the hernia site. Within the sac a transected end of small bowel was found and so laparotomy was undertaken, which demonstrated a bucket handle mesenteric tear of terminal ileal mesentery with infarction of 20 cm of small bowel and a complete transverse tear of mid sigmoid colon and its mesentery. Remarkably there was no intraperitoneal contamination from either injury.

Our clinical case highlights that although the CT scan is the gold standard for initial diagnosis of intra-abdominal injuries in TAWH, these can still be missed. To note that failure to make a timely diagnosis can result in delayed complications with significant morbidity and mortality. Therefore, a high clinical suspicion, despite of negative imaging, is crucial to provide appropriate management.
WE7.11 Robotic-assisted versus conventional total knee arthroplasty: A Systematic Review and Meta-analysis
Authors: Qayum Kaif , Kar Irfan , Nawaz Ghulam
Published: November 2022

Aim

To compare robotic-assisted total knee arthroplasty (TKA) and conventional TKA on both long-term and short-term follow-up.

Methods

For conducting this study, we searched four electronic databases. The outcomes were pooled as mean difference (MD) or risk ratio (RR), and 95% confidence interval. We used RevMan for performing the analysis.

Results

We included nine studies. The data showed a significant favoring of robotic-assisted TKA than the conventional one in mechanical alignment, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and femoral coronal outliers (MD= -1.10, 95% CI [-1.51, -0.69], p<0.00001), (MD= -1.19, 95% CI [-2.35, -0.03], p=0.04), and (RR= 0.49, 95% CI [0.30, 0.80], p=0.004) respectively. On the other hand, the conventional TKA was better in range of motion-flexion (long-term) than the robotic-assisted one (MD= -3.02, 95% CI [-3.68, -2.37], p<0.00001). However, there were no significant differences between them in knee society score-knee score, knee society score-function score, change in hospital for special surgery, and change in range of motion-extension (MD= -0.36, 95% CI [-2.43, 1.70], p=0.73), (MD= -0.34, 95% CI [-2.36, 1.68], p=0.74), (MD=0.78, 95% CI [-0.84, 2.40], p=0.34), and (MD=0.16, 95% [-1.32, 1.64], p=0.83) respectively.

Conclusion

Robotic-assisted TKA had better outcomes than conventional TKA regarding mechanical alignment and WOMAC. However, the conventional approach showed a better range of motion-flexion in the long term. More data is needed for the long-term outcomes.
WE7.12 The changing management of penetrating liver trauma at a tertiary referral centre in the North West of England over a 20-year period
Authors: Reader Harriet , Lunevicius Raimundas
Published: November 2022

Background

In the context of penetrating liver trauma (PLT), the liver is the second most commonly injured intra-abdominal organ. Our institution has served as a regional Major Trauma Centre (MTC) since 2012. This study aims to review trends in PLT presenting to our institution and how management has changed over time.

Methods

This was a single-centre, retrospective cohort study using data obtained from the Trauma Audit and Research Network (TARN) database across a 20-year period (2000–2020).

Results

77 patients presented with PLT; 21 prior to MTC status in 2012 and 56 after. Median age was 26.8, M:F ratio was 6.9:1 and median Injury severity score (ISS) was 14. Stabbing was the most common mechanism of injury (n=53, 68.8%), followed by shooting (n=22, 28.6%). 24 patients were managed conservatively (31.2%) and 5 patients underwent angioembolisation. Prior to becoming an MTC in 2012, 19% of patients (4/21) were managed non-operatively and this increased to 50% (28/56) when the MTC was established (P < 0.05). Understandably, there was a significant increase in injury severity in the post-MTC era (mean ISS 11.75 with SD=2.8 vs 17.9 with SD=2.1). The mortality in the conservative group was 20.7% (n=6) vs 8.3% in the operative group. Overall mortality from PLT was 11.7%.

Conclusion

There was a statistically significant increase in non-operative management of PLT since the MTC was established, there has been no observed increase in mortality during this period.
WE8.3 Pandemic Priorities: The Impact of COVID 19 Pandemic on Ethical Leadership in the Healthcare Profession
Authors: Wright Holly , Musbahi Aya
Published: November 2022

Leadership priorities within the healthcare setting have been brought into sharp focus by the Covid 19 pandemic, coinciding with the Black Lives Matter movement, Me Too movement, PPE shortages and staffing crises. Appropriately championing the rights of such staff is imperative. The pandemic necessitates a period of rigorous self-analysis, recognising past failures, oversights and discriminations. Utilising a modified ethical leadership questionnaire, comparing pre- and post-pandemic views of healthcare leaders on their own ethical leadership values, this study demonstrates a novel research into the effects of the pandemic on this topic. Our study has found significant changes in attitudes of healthcare leaders with regards to the ethics of justice; fewer leaders were likely to hold formal investigations and more leaders would follow unwritten rules relating to an ethical dilemma. They also would pay more attention to individuals. In addition, in terms of critique, leaders were more likely post-pandemic to speak out against injustice and unfair practices although whether this is due to the pandemic solely, or social movements such as Black Lives Matter and Me Too is yet unknown.
WE8.4 Acute Pancreatitis during COVID-19 Pandemic: An Overview of Patient Demographics, Disease Severity, Management and Outcomes in Western Health and Social Care Trust (Altnagelvin Area Hospital)
Authors: Yawar Bakhat , Marzouk Ahmed , Ali Heba , Asim Ayeisha , Ghorab Tamer , Bahli Zahid , Asim Asim
Published: November 2022

Background

Acute pancreatitis is a common disease requiring admissions under surgical and critical care units. The two most common causes are alcohol and gallstones. COVID-19 pandemic had a significant impact on service delivery and patient management throughout all surgical specialties. In this study, primary aim was to ascertain incidence of COVID-19 in acute pancreatitis patients.

Methods

A retrospective observational review of all patients admitted under General Surgical team from March 2020 till September 2020 was performed. Information regarding demographics, severity of acute pancreatitis (using Glasgow score, Atlanta classification and CT severity index score), ICU admission and organ support, treatment modalities and follow-up data for outcomes was collected.

Results

Forty four (44) patients were admitted with acute pancreatitis. Only one patient (2.3%) was diagnosed with COVID-19 at time of pancreatitis. Aetiology of pancreatitis was found comparable to aetiology reported by large scale studies (2). Mortality was 7% (3 patients). Five patients (11%) needed ICU admission due to organ dysfunction. Three patients (7%) developed ARDS.

Conclusions

The overall incidence of COVID-19 in pancreatitis in our population of study was low. Therefore, results were compared to patients who were COVID-19 negative in COVID-PAN study. Patients with acute pancreatitis in our target population were mostly elderly, about one in five had moderate to severe or severe pancreatitis and in 16.3% the aetiology could not be identified. As has been observed in other centres globally, urgent for gallstone pancreatitis faced significant delays with no patients being offered index cholecystectomy and only 4/19 patients having undergone interval cholecystectomy.
WE8.5 Can self-estimated BMI be used for pre-operative planning in elective general surgery?
Authors: Burford Charlotte , Ainger Ellen , Chowdhury Ashim , Fernandes Roland
Published: November 2022

Aims

Telemedicine is being increasingly used in outpatient settings following the COVID-19 pandemic. This study aimed to determine if self-estimated body mass index (BMI), from telephone consultation, was accurate and useful for planning prior to elective general surgery.

Methods

Age, gender and estimated BMI were collected from consecutive patients attending a pre-operative telephone clinic under a single surgeon at a district general hospital in the South of England between April and October 2021. Actual BMI was measured on the day of surgery and compared.

Results

124 patients were included (median age 59 years, 49.2% male). BMI was accurately estimated by 38, under-estimated by 33 and over-estimated by 53 participants. Overall, there was a significant difference in the pre-operative and post-operative BMI (p = 0.003). This was significant for females (median change 0.1, IQR 0.0–0.7, p = 0.002) but not for males (median change 0.0, IQR -0.1, 0.2, p = 0.479). Those with an actual BMI >29.9 had a significantly higher median change (0.2 (0.0, 1.1) compared to those with BMI ≤29.9 (0.0 (-0.2, 0.1); p <0.001). Only 2 patients could have required a change in surgeon on the day of the procedure (p = 0.500).

Conclusions

Self-estimated BMI is a suitable method for assessing patients for planning in elective general surgical procedures, particularly for males. However, it is important to be aware of those with higher BMIs, particularly females, who may underestimate their BMI.
WE8.6 Paediatric inflammatory multisystem syndrome presenting as acute appendicitis: a case report and literature review
Authors: Catana Sabina , Burford Charlotte , Pangemi Anang , Shrestha Ashish
Published: November 2022

Aims

Paediatric inflammatory multisystem syndrome– temporally associated with SARS-CoV-2 (PIMS-TS) is a novel hyperinflammatory condition that most commonly presents with an acute abdomen. Here we present a case of PIMS-TS mimicking appendicitis and a review of the literature with a proposed protocol for managing abdominal pain in patients with recent SARS-CoV-2 infection.

Results

An 8-year old girl presented with suspected appendicitis. She underwent a day case open appendicectomy with normal appendix confirmed on histology. Unfortunately, she re-presented the following day with persistently high fever and was investigated for post-appendicectomy complication. She was started on intravenous antibiotics. MRI of abdomen and pelvis showed no collection but evidence of lymphadenopathy. On post-operative day four she was transferred to the tertiary centre PICU for specialist management of suspected severe PIMS-TS.

Common abdominal radiological findings in PIMS-TS include ascites, bowel wall thickening and mesenteric inflammation. In addition, CRP and ferritin have been found to be significantly higher in PIMS-TS. White cells may be raised with neutrophilia and lymphopaenia. In addition, highly deranged inflammatory markers in the context of a normal abdominal imaging are more consistent with PIMS-TS than appendicitis. We propose anyone with these findings is considered as having PIMS-TS and requires urgent imaging including combined senior surgical and paediatrician review.

Conclusion

PIMS-TS may present mimicking acute appendicitis and given the severe cardiac compromise that can develop in patients with PIMS-TS is it important to avoid unnecessary general anaesthetic and abdominal surgery where possible. Our proposed protocol could help reduce unnecessary abdominal surgery in these patients.
WE8.7 Are Virtual Clinics for General Surgery Here to Stay? – A Single Centre Analysis
Authors: Leigh Charlotte , Deb Rita , Sheth Hemant , Raje Durgesh , Pore Naresh , Soggiu Fiammetta
Published: November 2022

Aim

Virtual clinics were rapidly established during the COVID-19 pandemic to maintain outpatient surgical care.

To evaluate their use, we analysed telephone clinic outcomes and their compliance with the NHS Referral to Treatment (RTT) guidelines.

Method

Data was collected for patients booked into Upper GI Surgery clinics between September – December 2020 (n = 622). This included details of referral, appointments (first to most recent), patient attendance, and clinic outcomes (active monitoring, offered surgery, discharge, other). We compared first appointment management decisions between telephone and face-to-face clinics.

Results

317 patients had their first appointment via telephone; 179 patients were seen initially face-to-face.

For first appointments, non-attendance rate was 9.8% (31/317) in telephone clinics versus 3.9% (7/181) in face-to-face clinics.

At first appointment, 8.5% (27/317) of patients consulted via telephone were offered surgery compared to 20.1% (36/179) seen face-to-face.

22.4% (71/317) of telephone clinic patients were started on active monitoring at first appointment, compared to 31.3% (56/179) of patients assessed face-to-face.

31.3% (155/496) of all patients analysed were compliant with RTT guidelines – 57.4% initiated on active monitoring; 11.6% underwent surgery.

Conclusion

Patients are less likely to be listed for surgery after their first assessment if this was via telephone appointment compared to face-to-face. Delays in physical examination, and clinician and/or patient hesitancy may contribute to this; higher non-attendance rates would further postpone outcomes. However, telemedicine does allow effective active monitoring.

To better evaluate telemedicine's efficacy in sustaining timely patient care, comparison of compliance with the RTT guidelines for cases managed solely face-to-face pre-COVID-19 is warranted.
WE8.9 Do Telephone Clinics Lead to Greater Patient Satisfaction in General Surgical Outpatients?
Authors: McCance Angus , Ainger Ellen , Black Rebecca , Fernandes Roland
Published: November 2022

Aims

To limit exposure risk in view of the current COVID-19 pandemic, telephone clinics have become the mainstay of outpatient assessment. Although there is data from primary care, there is little evidence for the suitability of telemedicine within General Surgery. The lack of clinical examination can be dissatisfying for both patient and surgeon. The aim of this study was to explore patient satisfaction from telephone clinics in a General Surgery setting.

Methods

Data was collected prospectively from general surgery clinic appointments by a single surgeon in a District General Hospital from September 2021. Demographic data was obtained in addition to a short questionnaire at the end of their consultation. Patients were asked to score their experience out of 5 (5 being most favourable) and their preference in comparison to face to face appointments.

Results

156 patients were included in the study, of which 95% of patients were contactable. 98% of patients gave the experience a satisfaction score of 3 or more out of 5. The median satisfaction score was 5. 97% expressed a preference over a Face-to-Face appointment. 7% of patients required a further Face-to-Face consultation and this group were more likely to have a lower patient satisfaction score.

Conclusion

Telephone clinics within general surgery achieve excellent satisfaction for the majority of patients. The patient experience could be further optimised by careful selection of patient suitability for the service. The data provides supportive evidence to the NHS Long Term Plan to reduce Face-to Face outpatient appointments by one third before 2024.
WE8.11 How has the management of acute biliary pathology changed as a result of the SARS CoV2 pandemic?
Authors: Mukherjee Arnab , Robertson Sarah , Carden Claire
Published: November 2022

Aims

Gallbladder pathology is a common cause of emergency admission under general surgery - however management had to be drastically changed given the unexpected pressures of the SARS-CoV-2 pandemic. This study aimed to compare management strategies in patients presenting with biliary pathology pre and intra-SARS-CoV-2 pandemic in one NHS trust.

Methods

A database of patients admitted to the acute surgical admissions ward in the months of November 2019 and 2021 was accessed, patients with biliary presentations were isolated and information about these admissions analysed.

Results

In 2019 4 of 57 (8.7%) of patients admitted with biliary pathology had a laparoscopic cholecystectomy during that acute admission, compared to 8 of 65 (12.3%) in 2021. For all interventions (including ERCP and cholecystostomy) these values were 14 of 57 (25%) in 2019 and 24 of 65 (37%) in 2021. Of 54 patients in 2019 who did not have laparoscopic cholecystectomy on index admission, 9 were readmitted (16.7%).

The median duration of admission for all biliary patients on index admission was 4 days in 2019 compared to 5.9 days in 2021.

Conclusions

SARS CoV2 has precipitated a change in management of acute biliary patients. There is now an increased rate of intervention during the index admission and subsequent increase in admission duration. This is seen as an improvement in the pathway for patients in the long term, reducing the burden on the elective waiting list and reducing re-admission which will offset the modest increase in length of stay on the index admission.
WE8.12 Improvement of the Laparoscopic Cholecystectomy Service at a District General Hospital During the COVID-19 Pandemic
Authors: Patel Shivam , Dickson-Lowe Richard , Qureshi Nabeel , Lascelles Simon
Published: November 2022

Background

British Association of Day Surgery and Royal College of Anaesthetists guidelines specify that 75% of elective surgery should be done as a day-case. Our Trust reported a laparoscopic cholecystectomy day-case rate of 25% pre-pandemic. Following the first wave of the pandemic our waiting list increased significantly. Therefore, to address this, we aimed to improve the day-case rate by developing the booking pathway, such as introducing the Cholecystectomy As A Day-case (CAAD) score.

Methods

Retrospective data for laparoscopic cholecystectomy were reviewed between 19th March and 9th July 2021. Specific documents reviewed were the operation booking forms, hospital-specific ‘boarding cards’ for booking and CAAD score completion, and a day-case rate was calculated.

Results

A total of 86 procedures were performed. There was an overall day-case rate of 54.7%. Of those booked to be day-cases (n=39), 61.5% remained day-case post-operatively and 28.2% were discharged the next day. Of the patients that were not discharged the same day (n=39), 18 cases had no documented reason for the additional stay. Incomplete booking forms (n=42) demonstrated a day-case rate of 50% versus 60.5% with complete forms (n=38).

Conclusions

Overall, the day-case rate has improved. We believe this is from adhering to the boarding card and introduction of the CAAD score to guide appropriate booking. However, for further improvement we are going to revise the booking form and create a Standard Operating Procedure (SOP) for the booking of these operations. Together with CAAD scoring, this should improve day-case rates further to reach the nationally accepted standard.
WE8.13 Hospital consultant remote consultations during COVID 19 - experiences at a large NHS trust
Authors: Ahmed Humairaa , Oni Georgette
Published: November 2022

Aim

COVID-19 has intensified the need for the NHS to almost overnight utilise remote consulting technology, with clinicians under increasing pressure to provide virtual services preferentially, in line with the NHS digital ideals. This study explores the clinician experience of virtual working during the pandemic in a large acute NHS Teaching Trust, and to identify the facilitators and barriers to remote consultations (RC).

Method

A multi-format online questionnaire was constructed and emailed to all 816 consultants across the trust. The survey was open for one month and during that time two reminders were sent. The data was tabulated and analysed using Microsoft excel.

Results

270 consultants responded to the questionnaire, giving a response rate of 33%, with 208 (77%) performing RCs. 92.8% of these (N=193) have increased the number of RC during the pandemic. 45.9% did not have their own office (N=124), with over half of those (N=63) sharing an office with 3 or more people. The majority of remote consultations were over telephone (82%) with only 54.4% feeling they had the right equipment for video consultations. The biggest barriers were patient related issues (technical, poor environment or not available at scheduled time).

Conclusion

The main challenges facing consultants, in the provision of virtual services were: lack of appropriate hardware, an absence of a suitable environment, the prevalence of technical complications, and difficulties experienced by their patients. It is therefore, important to recognise, both at an organisational level, and nationally, that virtual consultations may play a role in the worsening of health inequalities.
TH1.3 Initial experience - Magseed for impalpable breast lesion localisation
Authors: Harris Grant , Saafan Tamer , Quigley Katie , Bristow Gary , Townend Alice , Youssef Magdi
Published: November 2022

Aims

Impalpable breast lesions can be localised intraoperatively with Magseed and the Sentimag probe. Advantages over traditional wire localisation include reduced displacement, flexible insertion timescales, reduced patient anxiety and no requirement for radiation governance compared with radio-iodine seeds. We assess outcomes following introduction of Magseed localisation for impalpable breast lesions.

Methods

The first consecutive Magseeds inserted into breast lesions were identified from radiology records in a UK non-screening breast unit from July 2020 to March 2021. Indication for seed, intra-operative complications, margin involvement and re-excision rates were ascertained from electronic patient records. Caldicott / audit department approval was obtained.

Results

63 Magseeds were inserted in 59 patients. Indications for seed localisation were invasive disease 81% (51/63), DCIS 8% (5/63) and B3 lesions 11% (7/63). 21% (10/47) of patients with invasive disease had received neoadjuvant chemotherapy. The median seed insertion to surgery time was 13 days. All patients underwent standard wide local excision or therapeutic mammoplasty. The lesion localisation rate and seed retrieval rate was 100%, however 2 magseeds (3%) were displaced during dissection. The margin re-excision rate was 15.3% (8/52) in patients with invasive and preinvasive disease. The upgrade rate for B3 lesions was 16.6% (1/6).

Conclusions

Magseed can be used to accurately localise impalpable breast lesions with acceptable margin re-excision rates. These findings during the learning curve would imply that this technique is easy to adopt. Insertion of seeds within 2 weeks of the operation is feasible and should improve radiologist's efficiency by avoiding on the day wire insertion.
TH1.4 Indication for clinical biopsy in symptomatic breast disease- A closed loop audit
Authors: Ning Lee Rachel Xue , John Avinesh , Fabelurin Christiana , Zheng Chia Zoe Ying , Goyal Amit
Published: November 2022

Aims

Royal College of Radiologists states core biopsy is indicated where imaging is normal, but clinical assessment is P3 and above. However, many clinicians opt for clinical biopsy following normal imaging results despite clinical assessment under P3. We recommended: reserving clinical biopsies following normal imaging for women >50 year; performing ultrasound and mammogram in women <40 years with clinically (P3-P5) or ultrasonically (U3-U5) findings. Here we look at the impact of our recommendations on clinical practice and patient diagnosis.

Methods

All patients who had clinical biopsies were analysed within a six-month time period in 2019 and 2020. 43 patients were included in 2019. 78 patients were identified in 2020. 14 were excluded as they had history of breast malignancy, or a biopsy diagnosis of non-breast malignancy.

Results

64 patients were included in our analysis. Improvements in the 2020 audit cycle compared to 2019 included: Lesser women <40 years with P3/U3 not getting MMG prior to clinical breast biopsy (15.4% compared to 80.0%); higher rates of both MMG and targeted US were performed in women 340 years with score 3U3 (86.8% compared to 41.9%). Only 6 (9.4%) patients returned with malignant biopsy results. No patients (compared to 1) who underwent clinical biopsy for symptomatic breast disease following normal imaging showed malignant biopsy results.

Conclusion

Our findings indicate a low test positivity rate for clinical biopsies performed following normal imaging. Being prudent and selective in the type of patients clinical biopsies are carried out have a positive impact on clinical practice and patient diagnosis.
TH1.5 A Novel Method Breast Lesions Localisation: Using Scout System
Authors: Lefroy Rebecca , Kaur Jaspreet , Karategos Athanasios , Bowen Natasha , Tapan Sircar , Raghavan Vidya
Published: November 2022

Aims

The advent of screening along with increased patient awareness means that approximately 30–50% of breast lesions are impalpable at diagnosis. SAVI SCOUT is a reflector guided system using an implanted device within the breast to guide excision. A probe is then used, in a similar fashion to sentinel node localisation, to target and excise the lesion. As it lacks an external component, it can be placed days prior to surgery, one of a number of advantages it has over our current standard; wire guided excision.

Methods

Our unit aimed to review the implementation of the SAVI SCOUT system into our practice, looking at the excision and re-excision rates as well as evaluating the advantages or drawbacks we found during our learning curve with this device.

Results

18 patients underwent 19 SCOUT guided excisions, over a nine month period. Average age was 62 (range 50–81) and modal length of hospital stay was 0 days (range 0–1). All 18 patients were female and 79% (n-15) underwent wide local excision with 21% (n-4) undergoing quadrantectomy with mammoplasty. 100% of patients (n-19) had the lesion successfully removed. 10% (n-2) of patient underwent re-excision due to close or positive margins.

Conclusion

Our study has small numbers so far but represents successful use of this technology with good outcomes. We have also found its use acceptable to both surgeons and radiographers. In our experience we have found that diathermy can prevent the reflector from sending or receiving signals if used too close to the device.
TH1.7 Patterns of care of male breast cancer in clinical practice: A five-year single institution experience
Authors: Troy Amanda , Jaffer Alisha , Julius Barbara , Tormey Shona
Published: November 2022

Aims

Only 1% of all diagnosed breast cancers are in male patients. Overwhelmingly, current literature addresses breast cancer in female patients. This study aims to analyse the investigation and management of male breast cancers in a busy Symptomatic Breast Unit.

Methods

We conducted a single-centre review of male breast cancers diagnosed in our institution between January 2016 and December 2020. Initial presenting symptoms, imaging findings, histology and follow-up data were collected via a prospectively maintained database.

Results

The most common presenting symptom was a palpable breast lump (69%). Other symptoms included nipple bleeding/discharge (15%) and skin ulceration (8%). 62% of cases were located centrally behind, or involved, the nipple. The most common pathology was invasive ductal carcinoma (77%). One patient was diagnosed with invasive papillary carcinoma, while two patients were diagnosed with different cancers (spindle cell sarcoma and metastasis of medullary carcinoma of the thyroid). 77% of patients were managed operatively, with all undergoing a simple mastectomy. A sentinel lymph node biopsy or axillary clearance was performed in 62% and 8% of cases respectively. Several patients underwent adjuvant radiotherapy (62%) and chemotherapy (54%). 77% of patients were ER/PR positive, with 15% HER2+ positive. 100% of these patients received appropriate endocrine therapy.

Conclusions

Although female breast cancer commonly presents in the upper outer quadrant of the breast this study found that more male breast cancers occur centrally and involved the nipple. As breast cancer in male patients is rare, larger cohorts are required to confirm the findings of this study.
TH1.8 Changes In the Operative Management of Breast Cancer During The COVID Pandemic -- Single Institution Experience
Authors: Khun Ng James Chean , Muhibullah Nazli , Cuffolo Giulio , Whisker Lisa
Published: November 2022

Aims

COVID has had a wide ranging impact on surgical practice; including staffing issues, procedural prioritisation and changes to perioperative practice. We aim to compare the operative management of breast cancer before and during year 1 of the pandemic.

Methods

A retrospective review of primary breast cancer surgery in women between 23/3/2020–23/3/2021 with sub-analysis looking at wave 1 of COVID (23/3/2020–23/7/2020), compared to pre-COVID (1/1/2018–31/12/2018). Data collected include type and complexity of surgery, re-operations and complications.

Results

Pre-COVID, 606 cancers were included, with 217 (35.8%) simple BCS, 241(39.8%) oncoplastic BCS, 88 (14.5%) simple mastectomies and 60 (9.9%) mastectomies with immediate reconstruction. During COVID study period, a total of 398 cancers were included, with operative number (percentages) being 104(26.1%), 176(44.2%), 83(20.9%) and 35(8.8%) respectively. During wave 1, 47 cancers were diagnosed and operated on. The operative numbers (percentages) during initial wave COVID pandemic were 9 (19.1%), 25(53.2%), 12(25.5%) and 1(2.1%) respectively.

Conclusions

In our unit COVID led to a shift of breast cancer operative management to more BCS and simple mastectomies. As a unit, we were able to maintain good oncoplastic BCS service, however, reconstruction options were limited.
TH1.9 Clinical relevance of postoperative elevated thyroglobulin antibodies in patients with differentiated thyroid cancer
Authors: Anderson Hannah , Gull Sadaf , Lim Kah , Oprean Raluca , Spence Kirsty , Cvasciuc Titus
Published: November 2022

Aims

20%–25% of patients with differentiated thyroid cancer (DTC) can have elevated thyroglobulin antibodies (TgAb). The study aimed to find any prognostic significance of elevated TgAb during follow-up.

Methods

10-year retrospective study from a tertiary centre including 79 patients with raised TgAb after total/staged thyroidectomy for DTC. We identified patients with stable (7.6%), increasing (15%) and decreasing levels of TgAb (77.2%); groups 1, 2 and 3 respectively. During follow-up we analysed TgAb in subcategories by TgAb trend (>50% increase, <50% increase, >50% decrease, <50% decrease, positive to negative, negative to positive and stable levels), gender, age, surgery, autoimmune disease, histology, RAI uptake, distant metastasis, and recurrence.

Results

The incidence of raised TgAb levels was 33.2%, with female predominance. No connection was identified regarding other parameters; 11.4% had distant metastasis. The highest mean level of TgAb was in group 2 (1918.75IU/mL) and the lowest in group 3 (412.70IU/mL). The recurrence rate changed significantly between the 3 groups: 50% in group 1, 75% in group 2, and 25% in group 3 (p=0.002). Recurrence rates decreased to 15% in the subcategory where TgAb become undetectable from positive (p=00001). In patients with negative to positive trend or >50% increase, recurrence rates were 100% (p=0.041) and 70% (p=0.012) respectively.

Conclusions

Patients with increasing TgAb levels during follow up have a higher rate of recurrence distinctly for those with negative to positive and >50% increase. These categories of patients need closer follow-up.
TH1.11 Outcomes of Sublay Mesh repair in Ventral Abdominal hernia; retrospective study
Authors: Noureldin Khaled , Issa Mohamed , Badawi Marwa , Darwish Mariam , Abdelaziz Ayyat , Makram Mahmoud
Published: November 2022

Introduction

Ventral hernia repair is one of the challenging surgical operations over time. It is suggested that sublay mesh repair has the lowest recurrence and surgical site infection in open anterior abdominal hernia repair. This study aimed to analyse the pros and cons of sublay mesh in ventral hernia repair to evaluate the significance of this technique as a treatment modality. Hospital stay, acute postoperative complications, and the recurrence rate were the main areas of investigation.

Methods

A retrospective study on 79 Patients with ventral hernias were operated on (electively) with sublay mesh repair over 3 years. Fit patients with first-time ventral hernias (primary and incisional) were included. Recurrent hernia, associated decompensated cardiopulmonary disorders, and bleeding disorders were excluded. The project Performa includes; patient's demographics, operative details, length of stay, postoperative complications, and follow-up, up to 12 months.

Results

All patients underwent open mesh repair using the sublay technique. Ventral hernia was five times more common in females than males. Mean age of presentation was at 44.8 years old. Mean operating time was 67 minutes and a 1-day hospital stay. Para-umbilical and incisional hernias represented the majority of cases. Component separation approach was added in three cases (3.7%). Simultaneous cholecystectomy was performed in 2 cases (2.5%). Only 6 cases (6.3%) developed wound-related complications, while 2 cases (2.5%) had a recurrence.

Conclusion

Sublay mesh repair is favourable for ventral abdominal hernia reconstruction. It is associated with a smooth and short hospital stay and the least incidence of complications and recurrence.
TH1.12 Merkel Cell Carcinoma in the Breast: A rare Case Presentation
Authors: Rezkallah Emad , Elsaify Wael
Published: November 2022

Background

Merkel cell carcinoma (MCC) is a rare neuroendocrine tumor of the skin. The annual incidence is 0.13–1.6 per 100.000. MCC arise from Merkel cells in the basal layer of the epidermis and hair follicles. It is characterized by poor prognosis and rapid progress with a mortality rate about 30%. Most patients are over 65 years. We represent a rare case of MCC in the breast and axilla.

Case presentation

A 71-years old lady initially presented with loss of weight. A CT scan reported a 45.97 mm malignant mass in the right axilla with no identified primary origin. No obvious tumors were detected in the breast on mammogram and ultrasound scans. Core biopsy eventually confirmed a metastatic Merkel cell tumor. The patient had neo-adjuvant chemotherapy followed by right axillary nodal dissection (level III). Post-operative radiotherapy was given. Six months later, the patient represented with two tumor foci in the right breast. The patient underwent right mastectomy. Two foci of Merkel cell carcinoma, 28 mm and 10 mm, were found.

Discussion

MCC is a rare highly aggressive cutaneous neoplasm. It affects primarily the sun exposed areas of the skin. 5-year survival in patient with MCC is 50–68%. Treatment options vary according to the disease stage. Surgical excision provides the best treatment for localized diseases. Radiotherapy and chemotherapy are provided for high stage MCC and/or lymph node involvement.

Conclusion

Treatment of MCC should be multidisciplinary. Early diagnosis and proper surgical resection provide the best management option. Long term follow-up is recommended.