bluuebunny/crossref_metadata_2025 huggingface dataset:
507 Total Lower Lip Reconstruction: A Systematic Review and Treatment Algorithm
Authors: Ang K K , Jones C D
Published: May 2021

Introduction

To critically appraise the outcomes of different techniques described for total lower lip reconstruction in a retrospective study, where these factors were specifically documented.

Method

A comprehensive literature review was conducted over a 20-year period using Pudmed and EMBASE using the search terms “local”, “regional”, “functional”, “total lip reconstruction”. Data collected included: patient demographics, aetiology for lip reconstruction, reconstruction methods and outcomes (functional, aesthetic, complications).

Results

204 patients from 28 studies were included. Squamous cell carcinoma of the lower lip (93.1%) was the most common cause for reconstruction. Of all the flaps, 67% were local flaps, 8.5% were regional flaps and 24.6% were free flaps. Most studies used a wide variety of objective and subjective outcome measures whereas only 4 used validated scoring systems to determine functional and aesthetic outcomes.

Conclusions

Despite a myriad of different techniques described, we are currently unable to determine a superior technique. Given the ultimate goal of reconstruction is to restore form and function, we recommend the use of a standardised recording of functional and aesthetic outcome measure to allow comparison and identification of best technique for lower lip reconstruction to optimise patients' outcomes.
510 Case Series: Four cases of Orbital Extension of Cutaneous Squamous Cell Carcinoma and Their Management
Authors: Gaston-Grubb M , Boylan C
Published: May 2021

Introduction

Cutaneous squamous cell carcinoma (cSCC) invading the orbit is exceedingly rare. Understanding its presentation and management is of great value to the plastic surgeon.

Method

Retrospective case series of four patients aged 54 to 88 years. All patients presented with cSCC of the face or scalp which infiltrated the orbit. All underwent tumour excision and appropriate reconstruction.

Results

Case 1 and 2 involved cSCC originating from the right temporal and medial maxilla region, respectively. Case 1 posed the further challenge of irreversible blindness in the other eye, making exenteration very undesirable. In Case 2 the tumour extended along the infraorbital nerve and required several reconstructions of the eyelid to improve functionality and aesthetics.

Cases 3 and 4 involved cSCC originating from the forehead and temporal region, respectively. Both required burring of the bony outer table and soft tissue reconstruction. Case 4 presented with the additional challenge of perineural spread to the cavernous sinus.

Conclusions

This case series provides an insight into a rare, advanced presentation of cSCC. Eyeball exenteration has significant physical, aesthetic, and psychological impacts and therefore should be avoided if possible, particularly if the tumour has not breached the orbital septum.
637 Enterolith Ileus Secondary to Small Bowel Diverticulum: A Rare Cause of Small Bowel Obstruction
Authors: Elmasry M , Dey A , Marshall R
Published: May 2021

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

An elderly man, with no history of abdominal surgery, presented with 10 days of colicky right iliac fossa pain and recurrent episodes of bilious vomiting. He initially reported diarrhoea but complained of eventual absolute constipation for last 5 days. Physical examination revealed distended abdomen with right-sided tenderness and no mass or faeces on rectal examination. Abdominal CT revealed a 3.5 cm calculus in the distal ileum causing obstruction initially flagged as gallstone ileus. No gallstones or pneumobilia were identified although some intrahepatic duct dilatation was noted. An emergency laparotomy was conducted, where the radiological findings were reinforced, and the calculus was extracted via enterotomy. There were no abnormal communications between gallbladder and intestinal tract. The small bowel traced from duodenojejunal flexure to terminal ileum did not reveal any further calculi or diverticula. FTIR spectrum analysis of the extracted specimen indicated similarities to enterolith. Retrospective analysis of radiological images revealed a possible duodenal diverticulum. The case highlights the diagnostic conundrum and therapeutic challenges of small bowel diverticular enterolith.
692 Does Sleep Laterality Influence Kidney Stone Formation and Clearance? – A Review of The Current Literature
Authors: Yun J W , Saada L
Published: May 2021

Introduction

Stone disease is a common urological presentation that carries significant morbidity. Patients with renal calculi often experience ipsilateral recurrences. Sleep posture has been implicated in conditions ranging from heart failure to glaucoma. We seek a consensus view on the association between sleep laterality and stone disease and discuss its possible clinical implications.

Method

A literature search was conducted on the PubMed database from its inception through to September 2020. Publications assessing the correlation between sleep laterality and unilateral stone formation or clearance were included. 19 results were identified, of which 13 were excluded due to irrelevance.

Results

A review of the literature suggests that sleep laterality is positively correlated with ipsilateral stone formation. Interestingly, a study examining the interaction between sleep laterality and stone clearance following shock wave lithotripsy showed greater clearance of stones in patients who slept on the ipsilateral side.

Conclusions

Sleep laterality may positively influence both the formation and clearance of unilateral kidney stones. The mechanism for this remains unclear. However, sleep posture aids may prove to be a low-cost intervention with potential for both preventative and therapeutic benefit. This would be of particular value in patients with recurrent unilateral stone disease as well as those with a single-functioning kidney.
697 An Evaluation of Patient Outcomes Following Percutaneous Cholecystostomy (PC) For Acute Cholecystitis (AC) At Our Health Board Between 2011-2020
Authors: Maharaj G , Haider S A , De Silva K G
Published: May 2021

Introduction

PC is a radiological intervention used in the management of high-risk patients with AC.

Method

A retrospective study of outcomes following PC, including success rates, complications, AC resolution, readmissions, and subsequent cholecystectomy.

Results

Our database identified 28 patients (14M:14F), median age 73 (range 40-93). 82% were ASA III/IV. Median follow-up was 2 (range 0-8) years. Imaging suggested AC in 61% and empyema in 39%. 86% were calculous. All procedures were USS-guided with 100% success. AC resolution occurred in 89.3%. Of three unresolved, there was 1 death day-1 post-PC (non-procedure related), 1 index cholecystectomy, 1 chronic complicated cholecystitis. 28.6% developed complications, 2 major (1 late biliary peritonitis and 1 cholecystocutaneous fistula with abdominal wall abscess), 17.9% dislodged drain, 10.7% other. 20 patients had bile cultures (70% positive, mainly gram-negative). 17.9% patients were readmitted with AC, 1 had repeat PC. 21.4% had subsequent ERCP. 32.1% underwent subsequent cholecystectomy, 1 laparoscopic cholecystectomy(LC) index, 4 elective (3 LC, 1 open), 4 emergency (2 LC, 1 LC subtotal, 1 failed open with drain insertion).

Conclusions

PC is both safe and effective with significant procedural success rates and resolution rates. There are few major complications but significant morbidities, mainly dislodged drains. One-third of patients have subsequent cholecystectomy.
760 Unilateral Isolated Hypoglossal Nerve Palsy After Shoulder Surgery: A Case Report
Authors: Wei R , Karunaratne D , Sivaji C
Published: May 2021

Aim

Hypoglossal nerve injury is a rare complication in anaesthetic and surgical practice with only a few cases worldwide. This report describes the pathophysiology of this condition and highlights the key managements steps and expected outcomes for clinicians and patients.

Case

An open reduction and internal fixation of a left humeral fracture was performed on a healthy female patient in her mid-fifties under general anaesthesia. Two hours post-operatively, she developed left sided tongue swelling and deviation with dysphagia and dysarthria. Urgent CT head and MRA scans showed no abnormalities, leading to a diagnosis of isolated left hypoglossal nerve injury. Neurology and SALT were both involved in her care, but she ultimately made a full functional recovery after six months without any specific intervention.

Conclusions

A clear history, examination and high index of suspicion are crucial in the diagnosis of a hypoglossal nerve palsy. Cross sectional imaging is necessary to exclude any intracranial lesions, but intervention is rarely required, and patients should expect a slow but complete recovery over a period of months.
766 Endoscopic Surgery for Sporadic Vestibular Schwannoma Resection: A Systematic Review of Surgical Outcomes
Authors: Chiuta S , Raza-Knight S , Alalade A
Published: May 2021

Introduction

Vestibular schwannomas (VS) are benign intracranial tumours originating from the vestibular division of the eighth cranial nerve. The mainstay of their surgical management is microsurgery, other options are radiotherapy or radiological monitoring. Endoscopy (ES) is becoming widely used in neurosurgery and may have a role in improving visualisation and outcomes by enhancing extent of resection, facial nerve, and hearing preservation in VS resection and describe the postoperative outcomes.

Method

The review was conducted according to the PRISMA guidelines and yielded 31 studies for inclusion. Systematic searches of literature databases were done for studies where endoscopic-assisted and/or endoscopic resection of VS were reported.

Results

ES facial nerve preservation rates (median 91.3%, range 39.0 - 100%) were comparable to microsurgical treatment. Hearing outcomes were more variable in ES series and were under-reported. A median gross total resection rate of 97.4% (61.0 - 100%) was achieved in the ES series.

Conclusions

Current data suggest that ES-assisted resection of sporadic VS is not inferior to microsurgical resection with respect to facial nerve outcomes and extent of resection. However, some ES series report poor hearing outcomes, which are under-reported in the literature.
810 Ischaemic Gallbladder Volvulus Within a Parastomal Hernia: Case Report and Literature Review
Authors: Wilkins A , Ikram H
Published: May 2021

Case presentation

An 87-year-old female presented with 24 hours of severe central abdominal pain, preceded by five months of intermittent pain, and weight loss. Surgical history subtotal: colectomy and end ileostomy for ischaemia. Examination demonstrated generalised tenderness and longstanding parastomal hernia.

Abdominal CT demonstrated an oedematous gallbladder contained within the parastomal hernia and emergency laparotomy was performed. The gallbladder was twisted 360 degrees within the hernia and cholecystectomy and suture repair of parastomal hernia were performed.

Literature review: A 2013 review found most cases were diagnosed intra-operatively. Subsequent case reports were reviewed to identify contemporary practice.

Method

A pubmed search for “gallbladder volvulus”, 2012-2019 was performed. Articles meeting the inclusion criteria (gallbladder volvulus, english language, >18 years old, documented preoperative assessment and management) were analysed. Non-human and duplicate cases were excluded.

Results

24/43 screened cases met the criteria, including one within a parastomal hernia. 79% (19/24) were female, 50% (12/24) age >80. Although 96% (23/24) underwent imaging, only 38% (9/24) were diagnosed pre-operatively. One death was reported after non-operative management. 21 cases reported an operative approach with 48% (10/21) completed laparoscopically.

Conclusions

Gallbladder volvulus remains rare and difficult to identify on imaging.
866 A Lateral Approach Is More Likely to Be Successful Than A Posterior Approach for An Injection to Reach the Subacromial Space
Authors: Cheyne N , Jeelani A , Zeiton M , Tablot C , Holt E , Jain N
Published: May 2021

Background

Subacromial injections are common for diagnosis and therapy of shoulder impingement secondary to subacromial bursitis. We evaluated the likelihood of a successful subacromial injection from both the posterior and lateral injection sites.

Method

We reviewed 100 MRI scans of the shoulder and recorded measurements in both the sagittal (representative of posterior injection) and coronal (representative of lateral injection) orientations. We compared these to the lengths of standard needles.

Multiple measurements were taken:

Results

Measuring along the angle of the acromion demonstrated shorter mean distances from the lateral injection site. The distance from skin to mid-point of the acromion) provided mean values of 51.4mm for posterior and 40.1mm for lateral. A standard 40mm (green) needle would reach the midpoint of the acromion in 58% of lateral measurements and 23% from posterior.

Conclusions

Injections are more likely to enter the subacromial space from a lateral rather than a posterior entry point.
953 Role of Routine Preoperative Echocardiograms in Adolescent Idiopathic Scoliosis Patients undergoing Deformity Correction Surgery
Authors: Hassan A , Shah S , Patel M
Published: May 2021

Introduction

Patients with Adolescent Idiopathic Scoliosis (AIS) are often noted to have routine preoperative Echocardiograms (ECHO). The prevalence of ECHO abnormalities and their impact on perioperative outcome is not clear, especially balancing against its costs. The study aims at identifying the significance of routine preoperative ECHO for AIS patients.

Methodology

Clinical records of 295 adolescent AIS patients, >10years age (mean 15.64years), who underwent primary posterior corrective surgery in a tertiary spinal centre, between 2015-2020, were reviewed. Patients with revision surgery, anterior correction, syndromic/neuromuscular scoliosis and/or pre-existent known cardiac comorbidities were excluded.

Results

139(47%) patients had preoperative ECHO. 21(15%) patients showed echocardiographic abnormalities (11 trivial valvular abnormalities, 5 mild root dilatation, 3 mild pericardial effusion and 2 septal defects). None of these patients showed any clinical symptoms/signs or required Cardiology assessment; and none had perioperative cardiovascular complications. Conversely, four(1.36%) patients demonstrated auscultatory murmurs on preoperative clinical assessment. None reported any perioperative complication. The average known cost of an echocardiogram was noted to be £363.

Conclusions

Routine preoperative Echocardiogram for all AIS patients is not recommended or deemed cost-effective. Positive clinical assessment finding could be used as a screening tool for performing ECHO in AIS patients.
978 Acute Appendicitis in The Age of COVID-19 – How Changing Standards Affect Patient Outcomes
Authors: Karagiannidis G , Toma Omar
Published: May 2021

Introduction

The COVID-19 -19 pandemic has forced changes in the management of Acute Appendicitis (AA), such as prioritising conservative management and avoiding laparoscopic procedures. We aim to assess how these changes affected patient outcomes in comparison to routine practice during the same time frame in 2019.

The primary study outcomes are operative intervention, length of stay and hospital re-admission within 30 days.

Method

Retrospective data collection for all patients admitted to Ipswich Hospital with suspicion of AA since lockdown came into effect in England on March 23 up to May 10th, 2020 and the same time frame in 2019.

Results

23 patients were admitted during the lockdown period. 39%(N = 9) were treated conservatively.14 (61%) operatively, of which 71% (N = 10) had open appendicectomy while 29% (N = 4) underwent laparoscopic appendicectomies. The mean Length of Stay(LOS) was 3.83 days. In 2019,21 patients were admitted. 33%(N = 7) were treated conservatively. All appendicectomies were laparoscopic. Mean LOS was 2 days.

Re-admission rates were similar in both groups.

Conclusions

Due to Covid19 a majority of patients requiring surgery underwent open appendicectomies. We noted a significant increase in both length of stay and progression from non-operative to operative intervention rates compared to 2019. The general case load was similar.
71 Electronic Prescribing Promotes Antimicrobial Stewardship In Surgery: A Closed-Loop Audit
Authors: Lee A , Kelly M , Maden C , McHardy J , Elfadl D
Published: May 2021

Introduction

Antimicrobial resistance is increasing globally. Surgical inpatients are more likely to receive inappropriately broad-spectrum and prolonged antimicrobial treatment, against local policy. Electronic prescribing (e-prescribing) has the potential to promote antimicrobial stewardship. We conducted a closed-loop audit to assess the impact of e-prescribing on surgical inpatient prescriptions.

Method

Audit standards (from Public Health England) included: (1) documentation of allergy status, prescriber contact information, antimicrobial indication and review/stop dates; and (2) prescription of appropriate antimicrobials for appropriate durations (IV and total). Prospective data collection occurred over 1-week. The interventions included an educational session, a once weekly microbiology round of surgical inpatients and the introduction of e-prescribing (Cerner©).

Results

Compliance improved significantly between cycle 1 (n = 54 prescriptions) and 2 (n = 59 prescriptions), for: documentation of prescriber contact details (69 vs 100%) and appropriate antimicrobial review/stop dates (17 vs 100%), indications (78 vs 96%), selection (76 vs 90%) and IV and total antibiotic duration (63 vs 93% and 87 vs 100%, respectively); p < 0.05 throughout.

Conclusions

Audit compliance improved significantly, partly because Cerner© prompts clinicians to input contact details, review dates and indications before prescribing. E-prescribing in combination with appropriate education is likely to promote antimicrobial stewardship and should be considered by other Trusts using paper prescriptions.
106 A Retrospective Study Comparing Histopathology Proformas For Anterior Resections Against the Royal College of Pathology (RCPath) Guidelines
Authors: Dardak S , Gooneratne S , Butterworth W
Published: May 2021

Introduction

Royal College of Pathologists (RCPath) published guidance on clinical information needed on histopathology forms accompanying colorectal cancer specimens. Inadequate information can significantly impact the ability of histopathologists to accurately interpret specimens; in turn correctly diagnose and stage cancers. The primary aim of our audit was to evaluate local compliance with the RCPath guidelines.

Method

Histopathology request forms of 50 patients undergoing anterior resections between January 2018-19 were retrospectively evaluated against the RCPath guidelines, ‘Standards and datasets for reporting cancers’ published in December 2017.

Results

Of the 50 patients, the site and type of tumour resection were documented in 94% and 56% of cases, respectively. 48% of cases specified whether the surgery was open or laparoscopic. However only 4% mentioned the preoperative tumour stage, and only 10% recorded whether any pre-operative therapy had been given. Furthermore, no cases reported whether there was a family history of bowel cancer or inflammatory bowel disease.

Conclusions

Information on colorectal histopathology forms is failing to meet RCPath guidelines. Significant information regarding preoperative treatment, associated malignancy risk factors and resection type is absent in over half of cases. This will have detrimental effects on the ability of histopathologists to accurately assess and interpret cancer specimens.
201 Reducing Noise Pollution on a Surgical Ward
Authors: Shah S
Published: May 2021

Noise pollution in surgical wards negatively influence the wellbeing of patients and healthcare professionals. In addition to disrupting sleep and impairing communication, recognised patient consequences include increased pain, increased re-admission rates and post-ICU psychosis. Ambient white-noise machines, sound-absorbing ceilings and retractable screens are purported as noise pollution reducing strategies (NPRS). These are expensive and impractical. We investigated the capacity of various low resource NPRSs.

Noise was measured using “Sound Meter” app at four sites on two identical surgical wards. Ward A and B were designated as study and control ward, respectively. Measurements were taken at three time points (9am, 11am, 3pm) every day during a week. NPRSs were then implemented in ward A and data collection repeated.

Prior to intervention there was no difference in noise between ward A and ward B (83dB and 87dB respectively, p > 0.05). After intervention, ward A was significantly quieter than ward B (64dB and 85dB respectively, p < 0.05).

Restructuring ward environments presents several challenges. However, low resource interventions can have a positive role in reducing noise pollution. As hospitals become busier with resumption of normal services post-COVID-19, staff should be considerate of noise pollution in order to create an environment conducive to high quality patient care.
235 An Audit of The Post-Op Day One (Pod1) Discharge After Bariatric Surgery – The Effect on Length of Hospital Stay And 30-Day Re-Admission Rate
Authors: Sam M
Published: May 2021

Introduction

Discharge protocols after bariatric surgery are multi modal. At the Sunderland Royal Hospital, the standard protocol is POD 2 as long as patient satisfies the entire requirements. With the recent drive towards enhanced recovery after surgery, some consultants introduced the POD 1 discharge protocol.

Method

Using our prospectively maintained bariatric data set POD 1 and POD 2 groups were identified. The length of stay (LOS) and 30-day re- admission was analyzed.

Results

The average LOS was 2 days for POD 2 group. 19 % of patients were discharged on POD 1, 69% on POD 2 and 6% on POD 3 and 4 each. There were no 30-day re- admissions. In the POD 1 group, the average LOS was 1.4 days. 69% were discharged on POD 1, 25% on POD 2 and 6% on POD 4 with no 30-day re-admission.

Conclusions

There was significant decrease in LOS with POD 1 discharge with no difference in 30-day re- admission. Therefore, patients could be potentially discharged safely on POD 1 after bariatric surgery.
415 Improving Preoperative Computed Tomography Staging for Men with Suspected Testicular Cancer
Authors: Stanley S A , Berridge C T , Griffiths T R L
Published: May 2021

Introduction

Neo-adjuvant chemotherapy may be considered for suspected testicular malignancy if widespread life-threatening metastases are identified on computed tomography (CT) imaging. Staging preoperatively enables this and may prevent delays in ongoing oncological care. This project aimed to increase the proportion of staging scans performed preoperatively in the University Hospitals of Leicester NHS trust.

Method

All referrals between 01/01/2016 and 31/12/2018 to the urology multidisciplinary team for suspected testicular cancer were reviewed. Exclusion criteria were applied prior to collecting treatment pathway data for each patient.

Based on initial audit findings, clinicians were advised to request staging CT scans at the first urology clinic appointment. Re-audit was between 01/01/2019 and 31/12/2019.

Results

Initial audit included 95 patients and re-audit included 23 patients. The proportion of preoperative scans increased from 28.4% to 82.6% following intervention. Median time from first ultrasound to CT was reduced from 44 days to 17 days without affecting median time to orchidectomy (27 to 23 days) or oncology appointment (61 days).

Conclusions

Requesting a staging CT scan as part of the first clinic assessment improved the proportion of preoperative scans without affecting time to surgery or oncology appointment.
462 Empirical Antibiotic Prescribing in General Surgical Patients
Authors: Rokkas S , Wells L
Published: May 2021

Introduction

Prescribing antibiotics is common practice on a standard general surgical take, however incorrect prescribing can result in sub-standard care or even patient harm. This audit loop was conducted to assess the adherence to local antibiotic prescribing guidelines to evaluate and improve practice.

Method

Data was collected prospectively against a pre-designed proforma over a 2-week period. Inclusion criteria were patients admitted on the general surgical take and were prescribed empirical antibiotics. This process was repeated after the first audit and a) a questionnaire on prescribing behaviours b) An educational presentation.

Results

Antibiotic indication and bleep number were generally well documented, above 86% and 77% respectively in both audit cycles. Duration of antibiotic was poorly documented overall and requires further improvement. The most significant improvement was in documentation of signature and a printed name. The questionnaire revealed that 70% of doctors were unaware of the importance of printing name as well as a signature on prescription, after educational intervention the rate of printed and signed scripts improved from 23% to 70%.

Conclusions

Significant improvement was noted in doctors printing their name compared to the initial cycle. These results highlight the importance of informing the junior doctors of the benefits of printing their name on prescriptions.
493 Evaluation of Patient Waiting Times for Plain Radiographs Whilst Attending Outpatient Clinics in A Tertiary Orthopaedic Centre
Authors: Hayat Z , Kinene E , Molloy S
Published: May 2021

Introduction

Reduction of waiting times is key to delivering high quality, efficient health care. Delays experienced by patients requiring radiographs in orthopaedic outpatient clinics are well recognised.

Method

To establish current patient and staff satisfaction, questionnaires were circulated over a two-week period. Waiting time data was retrospectively collected including appointment time, arrival time and the time at which radiographs were taken.

Results

84% (n = 16) of radiographers believed patients would be dissatisfied. However, of the 296 patients questioned, 56% (n = 165) were satisfied. Most patients (89%) felt the waiting time should be under 30 minutes. Only 36% were seen in this time frame. There was moderate negative correlation (R=-0.5); higher waiting times led to increased dissatisfaction. Mean waiting time was 00:37 and the maximum 02:48. Key contributing factors included volume of patients, staff shortages (73.7%), equipment shortages (57.9%) and incorrectly filled request forms. Eight (42.1%) had felt unwell from work related stress.

Conclusions

A concerted effort is needed to improve staff and patient opinion. There is scope for change post COVID. Additional training and exploring ways to avoid overburdening the department would benefit. Numerous patients were open to different days or alternative sites. Funding requirements make updating equipment, expanding the department and recruiting more staff challenging.
497 Targeting Improvements in The Elective Aneurysm Pathway in The Dorset and Wiltshire Vascular Network (DWVN)
Authors: Cruikshank N , Harris L , Richards S , Metcalfe J , Page B , Watson A , Wijesinghe L
Published: May 2021

Introduction

Two consecutive NVR reports identified the DWVN as the 7th slowest network to treat patients with AAAs. We aimed to detect if there were any significant delays in our pathway.

Method

We performed a retrospective audit of patients having elective open and endovascular repair. 144 patients who had AAA repair between 30/06/2016-01/08/2018 were included. Data were collected on the following stages: the date the AAA reached ≥55mm, referral date, date clinician reviewed, CT scan date, CPET testing date, MDT date and operation date. The time in days between each stage was recorded and any delays documented.

Results

At RBH the longest delay was between MDT and surgery (median 73 days, IQR 32 days-130 days). At DCH the major delay was between CPET and MDT (median 28.5 days, IQR 10 days-31 days). At SDH the longest stage was between MDT and operation (median of 88 days, IQR 37 days-154 days).

Examples of reasons for delays across the three hospitals included awaiting specialist opinions, patient being unwell and no ITU beds available.

Conclusions

The pathway for elective AAA treatment in the DWVN is slow across all three hospitals. The greatest delay is often between MDT and surgery. Targeting this stage could significantly shorten the pathway.
527 Selective Approach to Gallbladder Histopathological Examination Following Cholecystectomy. Would Incidental Gallbladder Cancers Be Missed?
Authors: Ryska O , Atwan M , Nowinka Z
Published: May 2021

Background

The incidental finding of gallbladder carcinoma on histopathological examination following cholecystectomy is rare and thus, a selective approach should be evaluated as it could be more cost-efficient.

The primary aim of this retrospective study was to assess the incidence of gallbladder cancer in a single hospital trust. The secondary aim was to evaluate the predictive value of macroscopic changes.

Method

A retrospective analysis of all cholecystectomies performed at a hospital trust between November 2017-November 2019. Discharge notes, operation notes, histopathology reports were evaluated.

Results

In total, 966 patients were included. All gallbladder specimens had been sent for histopathological examination. The histology was normal in 21 patients (2.1%) and inflammatory changes reported in 930 cases (96.3%). Gallbladder dysplasia was found in 14 specimens (1.5%) and macroscopic abnormalities were seen in 11 of those. One case (0.1%) was reported as incidental gallbladder carcinoma and macroscopic abnormalities were observed intra-operatively.

Conclusions

Gallbladder carcinoma detected incidentally after cholecystectomy is rare. Gallbladder dysplasia and cancer are associated with macroscopic abnormalities and thus selective approach could potentially replace routine histopathological examination - provided all gallbladders are dissected and inspected at the time of surgery.
746 COVID-19: Changing the Future of Emergency Epistaxis Management
Authors: Devabalan Y
Published: May 2021

Introduction

Acute epistaxis can be a life-threatening airway emergency. Therefore, the majority of patients in whom conservative management (including cautery) has failed are admitted. However, due to the COVID-19 pandemic, our management has shifted towards a more outpatient centred approach.

Method

A single centre retrospective study was undertaken of all epistaxis patients managed by the ENT team at our centre over a five-month period from 1st January to 31st May 2020. The first 10 weeks (Pre-COVID-19) were managed using pre-existing guidelines. The following 10 weeks (COVID-19) were managed using the new COVID-19 standard operating procedures which aimed to minimise inpatient admissions.

Results

142 patients, with similar demographic data, were seen across the 5-month period. There were significantly more patients aged over 65 presenting in the COVID-19 group (p = 0.04). There was a significantly increased use of local haemostatic agents (Nasopore ® and Surgiflo ®) and decreased use of nasal packing in the COVID-19 group. There were significantly fewer admissions (p < 0.0005) in the COVID-19 group, but similar rates of representation, length of stay and morbidity.

Conclusions

The COVID-19 pandemic has accelerated the shift towards the use of local haemostatic agents and outpatient management of epistaxis, which is as safe and effective as previously well-established epistaxis management.
893 Intestinal Stoma - A challenge for the Patient
Authors: Bhatia M , Hafeez R , Smedley F , Read L , Abbas W , Ahmed R
Published: May 2021

Introduction

Formation of intestinal stoma is a widely performed surgical procedure worldwide. It is associated with variable complications which can impact physical and mental health of the patient. The purpose of this study is to study the aspects (indications, complications, change in quality-of-life etc) and make necessary recommendations for quality improvement and to make patient experience better.

Method

study included 150 patients with stoma formation. Data categorised according to indications, complications, based on their response to change to quality of life.

Results

A total of 150 patients were included in this study. There were 89 male (59.3%), female (40.6%). 63 patients (42%) had loop ileostomy;38 patients (25.3%) had transverse colostomy. 77 patients (51.3%) had bowel malignancy, diverticular perforation in 19.3%. 21 patients (14%) mentioned change into their self-esteem following the surgery, 14% patients reported decline in their sexual life.

Conclusions

Pre & postoperative assessments should be carried out in detail with the patient to help them understand the implications of having a “stoma”. Stoma nurse involvement helps the patient to accept the changes to their life after the surgery. Psychological &sexual consultation helps in improving patient’s response to the challenge it may impose.
900 An Audit of Effectiveness of Inhaled Methoxyflurane (Penthrox) Use for Reduction of Shoulder Dislocation
Authors: Adewusi M , Richards O , Hickey B , Barlow D
Published: May 2021

Introduction

Shoulder dislocation is a painful injury best treated by early closed reduction. Patients often require intravenous sedation, with airway monitoring in a safe setting. We implemented methoxyflurane inhalational analgesia (Penthrox) to aid shoulder dislocation reduction without the need for sedation and evaluated the effectiveness and adverse events.

Method

Patients presenting to the minor injury’s unit at Wrexham Maelor Hospital between 01/04/2020 and 26/05/2020 with only shoulder dislocation were included. Patients had Penthrox and underwent closed reduction. Pre and post reduction shoulder radiographs were reviewed to determine reduction success and time between radiographs was evaluated. Adverse events were recorded. Reduction success and times between radiographs were compared to a consecutive retrospective cohort of patients who underwent closed shoulder dislocation reduction with sedation before implementing Penthrox.

Results

22 patients were included. Mean patient age was 44.6 years. Majority were male (72%). Penthrox was used in 11 patients. All patients had their shoulder dislocation reduced successfully. Mean time between reduction radiographs for the Penthrox group was 40.8 min (95%CI 27.4 to 54.3). This was shorter than the intravenous sedation group mean 157.7 minutes (95%CI 92.3 to 223.2, p = 0.0026). No documented adverse events with Penthrox.

Conclusions

Simple shoulder dislocations can be reduced safely, quickly, and effectively using Penthrox.
921 Audit of Pre-Radiation Therapy Extractions at Dublin Dental University Hospital
Authors: Fahy E , Pierse D
Published: May 2021

Introduction

The time between diagnosis of head and neck cancer and commencing treatment involves multi – disciplinary input from several specialities. Dental assessments are carried out prior to radiotherapy in order to instigate preventive care and remove all unrestorable teeth. Post – radiation dental extractions have been shown to increase the risk of osteoradionecrosis (ORN).

Method

Our hospital handles the majority of the pre - radiotherapy dental assessments in the east of Ireland. We examined the patient records of all patients attending the radiotherapy clinics between January 2018 and December 2019, assessing the time interval between the removal of teeth prior to radiotherapy and the start of radiotherapy. A secondary aim was to determine from the patient records whether any diagnosis of ORN was established post – radiation.

Results

15 out of 147 patients had extractions less than 2 weeks prior to radiotherapy. In total, three patients developed ORN. One had extractions less than 2 weeks prior to radiotherapy, one had post radiotherapy extractions, while the other’s timing was unknown.

Conclusions

Most patients received timely care. A referral for dental assessment early in treatment planning is desirable. Despite the small sample size, an association between ORN and extractions just before and following radiotherapy was found.
958 Pre-operative Pregnancy Testing in Paediatric Patients
Authors: Ashraf S , Bogden M
Published: May 2021

Introduction

NICE emphasises the importance of pregnancy testing before surgical procedures as a patient safety precaution, especially in 13-16-year-olds. This is because, in the UK, a third of females will have been sexually active by the age of 16, meanwhile, in England there are 67,000 operations involving females aged 12-15 annually.

Method

Guidance from NICE and RCPCH was used to create standards to compare against current practice. Surgical admissions involving females aged 13-16 were retrospectively analysed over a one-year period and compared to these standards. Changes, including creation of a protocol, revision of the clerking proforma and staff education, were implemented to improve compliance and patient data was re-audited following this.

Results

Initially, 27% of patients did not have pregnancy testing before their procedure and consent for pregnancy testing was not documented. However, when pregnancy tests were performed, the result was documented 100% of the time. After implementing changes, 100% of patients had pregnancy testing before their procedure and documentation of consent had improved.

Conclusions

Initial practice showed poor compliance with NICE and RCPCH standards. Changes implemented have shown increased compliance to NICE and RCPCH standards and these changes could be used as a model to improve clinical compliance in further areas.
966 Implementation of Regional Scalp Blockade for Painless Removal of ICP Bolts: A Quality Improvement Project
Authors: de Gouveia M , Craven C L , Goel A , Asif H , Das P , Thorne L , Watkins L , Toms A
Published: May 2021

Introduction

Intracranial pressure (ICP) monitoring through insertion of a bolt is a common neurosurgical procedure for diagnosing cerebrospinal fluid disorders. The first step of our quality improvement project identified ICP bolt removal the most painful part of the procedure. We implemented and tested the efficacy of a scalp nerve block for bolt removal.

Method

Two groups were identified: (A) receiving oral analgesia only and (B) receiving ipsilateral supraorbital and supratrochlear nerve blocks. We then retrospectively compared satisfaction ratings of insertion versus removal process for the two bolt types using a telephonic questionnaire

Results

Eighty-five patients had ICP bolts (32M:53F, mean age 42.7±16.0 SD). Fifty-four were removed with oral analgesia (A) and 31 with oral and regional anaesthesia (B). Removal experience was reported as worse for group A than for group B (p < 0.01). Most patients (66%) reported would have preferred local anesthetic during removal. No complications occurred from the block.

Conclusions

Regional nerve blocks are a safe and effective adjuvant for the painless removal of frontal ICP monitoring bolts. The final stage of the project was to implement nerve blocks as standard practice for bolt removal, to improve patient experience.
977 The Role of Group and Save Samples in Perioperative Management of Laparoscopic Appendicectomies: A 2-Cycle Quality Improvement Project (QIP)
Authors: Afshari S J , Toi T H H , Chicken W
Published: May 2021

Introduction

Group and Save samples (G&S) are routinely performed before laparoscopic appendectomies (LA). Cycle-1 of this QIP showed <1% of patients required blood products perioperatively. We recommended and implemented that a G&S request should be at the clinician’s discretion and not routinely performed. Cycle-2 assesses the impact of our recommendation.

Method

In Cycle-1 patients who had undergone LA and laparoscopic conversion to open appendicectomies between January - December 2018 were identified using Operating Room Management Information System. Patients who had G&S performed and patients receiving blood products were identified using the hospital’s electronic patient records and online pathology reporting service. Patients from December 2019 to June 2020 formed Cycle-2 of this QIP.

Results

124 patients were included in Cycle-2 (versus 263 in Cycle-1). 58% of patients had G&S taken (versus 99.6% in Cycle-1). 0.81% required a transfusion post-operatively (versus 0.76% in Cycle-1). The average number of G&S per patient was reduced by 1.19, saving the Trust £23.80 per patient.

Conclusions

Blood products are not routinely required peri-operatively, therefore G&S should be ordered at the clinician’s discretion. This safely saves the Trust significant cost and improves patient experience by eliminating the discomfort of unnecessary blood tests.
22 Volumetric MRI; A Potential Outcome Measure of Muscle Reinnervation
Authors: Wilcox M , Canas L D S , Hargunani R , Tidswell T , Phillips J , Modat M , Ourselin S , Quick T
Published: May 2021

Introduction

Improved outcome measures of muscle reinnervation would facilitate clinical translation of new therapies which hope to enhance human peripheral nerve repair. Valid outcome measures should be receptive to the biological process of muscle reinnervation and correlate with clinical assessments of muscular function. This study investigated the responsiveness of volumetric MRI to the biological process of muscle reinnervation and its relationship with clinical indices of muscular function.

Method

Twenty-five patients who underwent nerve transfer to reinnervate elbow flexor muscles were followed-up at a median time of 258 days (-86 to 1698 days) post-operatively for a mean of two (one to three) volumetric MRI assessments. Medical Research Council (MRC) grade, peak volitional force (PVF), muscular fatigue, co-contraction and Stanmore Percentage of Normal Elbow Assessment (SPONEA) was also measured at each appointment. The responsiveness of each parameter was compared using Pearson or Spearman correlation as appropriate.

Results

Elbow flexor muscle volume per unit BMI demonstrated responsiveness to the biological process of muscle reinnervation (R2=0.73, p < 0.001) and correlated with patient reported impairments of reinnervated muscle; co-contraction (R2=0.63, p = 0.02) and muscle fatigue (R2=0.64, p = 0.04).

Conclusions

Volumetric MRI may is an excellent candidate as an outcome measure of muscle reinnervation.
186 Acute Kidney Injury in Skeletal Trauma Admissions to Intensive Care: An Under-Estimated Complication
Authors: Brown O , Crisp T , Flatman M , Hing C
Published: May 2021

Introduction

Acute kidney injury (AKI) is associated with prolonged admission and 3.5 times increased mortality for trauma patients requiring intensive care (ICU) treatment. Blunt trauma confers greater risk of AKI than penetrating trauma, potentially related to long bone fracture. The relationship between skeletal trauma and AKI in ICU has not previously been investigated.

Method

Retrospective data was analysed from 202 consecutive adult patients admitted to ICU with skeletal trauma from 01/06/2018 to 01/06/2019. AKI was defined by creatinine rise >1.5 times baseline.

Results

AKI was found in 70/202 (34.65%) patients aged 16-99 years, 138 males and 64 females. Mean limb Abbreviated Injury Scale (AIS) was significantly higher in AKI (AIS= 2.57 (SD 0.53) versus non-AKI AIS=2.38 (SD 0.61), p = 0.027). Other body regions and total Injury Severity Score (ISS) were non-significant.

AKI was associated with a significantly worse Glasgow Outcome Score (AKI 3.28 (SD 1.52) versus 4.02 (SD 1.08) p < 0.001), increased intensive care stay (AKI 7.03 (SD 8.30) days versus non-AKI 3.8 (SD 4.1) days p < 0.001) and increased 30-day mortality (AKI 18/70 (25.71%) versus non-AKI 10/132 (7.58%) p < 0.001)

Conclusions

Skeletal trauma patients have a high incidence of AKI, which was significantly correlated with severity of skeletal limb trauma but not overall ISS.
240 Aetiology and Outcomes of Head and Neck Free Flaps in Patients Aged ≥ 65 Years: The Cambridge Experience
Authors: Hjalmarsson C , Chan T , Chawla R , Patel A
Published: May 2021

Introduction

Elderly patients often present to the Head & Neck Plastic Surgery department with complex reconstructive needs, for which free flaps are the gold-standard management. In order to provide appropriate, patient-centred care, it is imperative to understand how increasing age and related factors affect long-term free flap outcomes.

Method

The authors carried out a retrospective review of all patients 65+ years who underwent free flap surgery at Addenbrooke’s Hospital from 2008-2019. Patient, operative, and flap characteristics, and outcomes, were analysed using Excel and RStudio.

Results

163 patients were identified (54F, 109M). The majority were ALT (n = 74), radial forearm (n = 35), and fibula flaps (n = 23).

Of pre-operative comorbidities, only neurological comorbidities (n = 16), were significantly associated with long-term flap failure (p = 0.016). There was no significant association between number of comorbidities and flap outcome. There was no association between age group and length of stay.

Flap site complications, and particularly venous complications, were significantly associated with later failure (p = 0.001). No other complications were statistically associated with flap failure.

Conclusions

The high success rate supports the use of free flaps in the 65+ population. This data supports a case-by-case approach to assessing fitness for free flap surgery rather than excluding patients on the basis of age or specific comorbidities.
268 Efficacy and Safety Profiles of Surgical Resection in Patients with Metastatic Gynecologic Melanoma on Immune Checkpoint Inhibitors: A Retrospective Cohort Study
Authors: Naderi-Azad S
Published: May 2021

Introduction

Malignant vulvovaginal melanoma is a rare, aggressive malignancy with poor prognosis and no consensus regarding treatment. Few studies to date have comprehensively examined the efficacy and safety of surgical procedures alongside immunotherapy in their treatment.

Method

We retrospectively analyzed 169 patients with advanced-stage metastatic melanoma who received at least one dose of immunotherapy between June 2012 to December 2018. Descriptive statistics were used, as well as Chi-square statistical analysis to examine associations between immune-related adverse events (irAEs) and treatment response. P-values <0.05 were statistically significant.

Results

Surgical resection was performed in 63.6% of patients with vulvovaginal melanoma, which was comparable to other melanoma subtypes. From patients with vulvovaginal melanoma who received prior surgery, 80% had progressive disease and 20% response to treatment, compared with 100% progression in patients without prior surgery. Furthermore, patients with vulvovaginal melanoma developed irAEs in 53.8% of the cases. Cutaneous adverse events were overall the most common irAEs and were significantly associated with patient response to ICIs (p = 0.01).

Conclusions

The majority of patients received surgery prior to immunotherapy. Those who received prior surgery had greater response to immunotherapy compared to those without prior surgery. Surgery and immunotherapy is a unique therapeutic regime to control metastatic vulvovaginal melanoma.