bluuebunny/crossref_metadata_2025 huggingface dataset:
ThTP8.6 A novel method for stoma isolation in a complex abdominal wound treated with vacuum assisted closure
Authors: Browning Nick , Thornton James , Smith Andrew
Published: August 2023

Introduction

Vacuum assisted closure (VAC) is a well established method in the treatment of abdominal wounds where the fascia is intact. The presence of one or multiple intestinal stomas or fistulae may present challenges in successful application of VAC therapy. Key concerns with the presence of intestinal stomas alongside open abdominal wounds is the risk of contamination with stoma effluent or the potential for the negative pressure to create enterocutaneous fistulae. Here we describe a novel method for isolating a small bowel stoma existing within a large abdominal wound, allowing successful resolution having failed conventional management.

Method

No device currently exists to allow a functioning stoma to be isolated within an abdominal wound requiring VAC therapy. This method relies on modification of a standard silicone fistula crown, this is then integrated into the standard VAC dressing, using stoma seals to provide successful vacuum. Stoma output is then successfully isolated, protecting surrounding tissue and supporting wound granulation without concern of wound effluent contamination.

Discussion

Of key importance in this case is the proximity of clean wounds with skin grafts done by plastic surgeons also being managed with VAC therapy and the importance of preventing contamination to allow successful granulation without further debridement of an already large wound.

Conclusion

Although this situation is rare with the increasing use of vacuum assisted closure devices for the management of wounds across many specialities this scenario is certainly not unprecedented. The technique described allowed successful treatment of a complex wound with significant existing comorbidities allowing resolution of a very challenging situation.
FTP1.2 Delay in ankle fracture fixation against BOAST guidelines for ankle fractures
Authors: Hassan Rawan , Divekar Manish
Published: August 2023

Aim

Ankle fractures are common, and the majority are the result of low energy torsional trauma. The aim of treatment is to restore and maintain stability and alignment of the joint, ideally with normal anatomy of the ankle mortise. According to BOAST guidelines for ankle fractures, Early fixation within 24-48 hours is recommended in the majority of patients under 60 years when the ankle mortise is unstable. This study aimed at assessing our practice in managing ankle fractures against BOAST guidelines and infection rate assessment.

Methods

Data was collected respectively from electronic patient records for three months period and entered excel. First cycle results were presented in a departmental audit meeting and recommendations to improve practice were acted upon. Second cycle data was collected three months later and for three months period. Final re-audited results were presented in a departmental audit meeting.

Results

First cycle results: only 11% of patients had their ankle fractures fixed within 48 hours and none of them had surgical site infection. 65.2 % of patients had their operations over a week with an Infection rate of 10.6%.

Second cycle results: 19% of patients had their ankle fractures fixed within 48 hours and none had surgical site infection. 47.6 % of patients had their operations over a week with an Infection rate of 4.8%.

Conclusions

Second cycle results showed improvement in operative timing and surgical site infections rate against BOAST guidelines compared to initial first cycle results. Early fixation for ankle fractures is associated with lower infection rates.
FTP1.3 Woodcast is Ecologically Sound and Tolerated by Majority of Patients
Authors: Hassan Rawan , Darke Emma , Duncombe Justin , Dias Ana , Anderson Kerry , Middleton Rory
Published: August 2023

Aim

NHS England has set itself the task of delivering a “Net Zero” National Health service by 2040. It is incumbent upon all health care practitioners to work towards this goal. Orthopaedic surgeons are no exception. Distal radial fractures are the most common fractures sustained by the adult population. However, studies are shortcoming on individual patient experience. The aim of this study was to assess the patient’s satisfaction and outcomes with woodcast in the conservative management of distal radius fractures compared to the standard synthetic cast.

Methods

For all patients managed with woodcast in our unit, we undertook a structured questionnaire that included the The Oxford cast experience score, the numerical pain scale and qualitative open-ended questions about individual patient experience at the time of injury and six weeks after.

Results

30 patients were initially managed with woodcast. 80% of patients tolerated woodcast for the full duration of their treatment. Of these, 20% didn’t tolerate woodcast and had their casts removed within 48 hours. Of the remaining, 79.1% were satisfied about woodcast comfort, 66% were very satisfied about woodcast weight, 70% were satisfied with temperature and sweatiness, 62.5% were very satisfied about the smell/odour, and 75% were satisfied about the level of support woodcast provided. During their treatment, 83.3% of patients rated their pain as five or less.

Conclusions

For those who completed their treatment in woodcast, none required any further intervention or utilised the open appointment because of ongoing wrist problems. In conclusion, when woodcast is tolerated, patients’ satisfaction and outcome levels were good.
FTP1.6 Epidemiology of Medial Tibial Plateau Fractures and Factors Associated with its Outcomes
Authors: Sanmugam Kischentaran , Keating John
Published: August 2023

Background

Medial tibial plateau fractures (TPFs) are reported to be difficult to treat and are subject to higher levels of postoperative complications. The aim of the study was to evaluate the results of management of medial and bicondylar TPFs and determine the factors influencing its outcomes.

Method

143 patients with TPFs were included in this study during a total period of 6 years. The groups were divided into medial TPFs (B-type) and bicondylar TPFs (Ctype), according to the AO/OTA Classification and Schatzker Type IV, V and VI classification. Patient information including basic demographics, duration of followup, mechanism of injury, comorbidities, management, and post-operative complications were included in this study. Analysis of this data was done to determine a correlation between the outcomes of both fracture groups.

Results

The mechanism of injury profile showed no significant difference with high energy trauma seen in 48% of B-type and 59% in C-type fractures. Age has no influence on the fracture outcomes. Most patients in both groups were mainly treated with ORIF. The incidence of infection, compartment syndrome and post-traumatic arthritis are higher in bicondylar TPFs compared to medial TPFs, with a similar number of patients with CPN Palsy in both groups. No significant difference was found between both fracture types in every aspect of patient information that was compared in this study.

Conclusion

The outcomes of medial TPFs are similar to bicondylar TPFs in terms of complication rates, even though one would generally assume medial TPFs to be less severe than bicondylar TPFs
FTP1.9 Two-Stage flexor tendon repair versus Primary repair: An evaluation of subjective and functional outcomes at a Regional Centre for Plastic Surgery
Authors: Mitchell Robert , Jones Rowan Pritchard
Published: August 2023

Aims

The hand, as the primary executing organ, is at the centre of nearly all daily activities. In the anatomical extremity, the hand is frequently exposed to the potential risk of injury. If a flexor tendon is injured and recognized as needing surgical intervention, two main options are available; Two-stage Flexor Tendon (TSFT) repair or Primary repair. We evaluated the subjective and functional outcomes of the two surgical methods described above in patients presenting with flexor tendon injury in Zone I or II over a 5-year period.

Methodology

A retrospective study employing 35 patients (and a total of 42 tendon injuries) requiring TSFT repair over a 5-year period and 190 patients requiring primary flexor tendon repair between 2012-2014. Data collected included patient demographics, injury details, intraoperative findings and post-operative outcomes.

Results

Of the 35 digital injuries assessed, 15.8% had a good outcome, 21.1% with a fair outcome and 63.2% with a poor outcome, based upon the Strickland grading system. In comparison, of those undergoing primary flexor tendon repair, 51.5% had a good / Excellent outcome, leaving 48.5% with a poor outcome. Rupture rates post-surgery were higher in those undergoing TSFT repair than primary repair; 23.8% versus 12.0% respectively.

Conclusion

A damaged flexor tendon requiring surgery should ideally be repaired within 72 hours of initial insult via primary repair. Delayed presentation and subsequent scar formation with proximal stump retraction warrants a two-stage approach. It is widely accepted that a reconstruction in two-stages can yield effective results in restoring digital function, but these results are often superseded by a primary repair.
FTP1.11 Retroperitoneal injury is associated with anastomotic leak after colonic injury
Authors: Sullivan Thomas , Marsden Max , Devenport Ross , Hancorn Kate
Published: August 2023

Background

The aim of this retrospective observational study was to investigate the association between concomitant retroperitoneal injury and colonic repair failure. Operative repair of perforating colonic injury should ideally maintain bowel continuity. Diversion may be preferable where the repair is likely to fail. To make this decision surgeons must be aware of factors associated with risk of operative failure. Concomitant retroperitoneal injury (RPI) may represent an occult risk factor for post-operative colonic complications.

Methods

Single-centre study of adult patients admitted to a Level 1 trauma centre between June 2015 and July 2020. Trauma patients with full thickness perforation of either the colon or intraperitoneal rectum were included. We compared clinical outcomes and specifically the incidence of colonic repair leak in patients with or without retroperitoneal injury (RPI).

Results

Seventy-seven patients met inclusion criteria, of whom 33/77 (43%) had RPI. Mechanism of injury was penetrating in 61/77 (79%) and 49/77 (64%) had isolated abdominal injuries. Patients with RPI had significantly more leaks compared to patients without (9/33 [27%] versus 3/44 [7%], RR 2.0, 95%CI 1.2 to 3.1 p=0.024). Post-operative leak was higher in shocked patients (shock 3/11 [27%] versus not-shocked 9/65 [14%], p=0.37) or those requiring damage control surgery (DCS) (DCS 6/23 [26%] versus non-DCS 6/54 [11%], p=0.17) but neither reached statistical significance.

Conclusions

RPI is associated with an increased incidence of complications after colonic repair. When selecting operative strategy for perforating colonic injury, surgeons should be aware of increased risk of operative failure in the presence of concomitant RPI.
FTP2.1 Management settings and follow-up of acute diverticulitis
Authors: Albendary Mohamed , Yiannikouride Maria , Tuttle Christopher , Al-Aghbari Maram , Deeknah Abdulqudus , Bhandari Santosh , Besali Mina
Published: August 2023

Aims

This audit evaluated our management of acute diverticulitis against the NICE and ACPGBI guidelines. We explored follow-up luminal investigations to ensure patients safety, and practicality of ambulatory management to potentially improve bed capacity and reduce costs.

Method

Retrospective data of patients presented acutely with CT-proven diverticulitis from 01/06/2021 to 31/10/2021 was collected. We focused on clinical, biochemical and radiological severity, management, and follow-up investigations.

Results

Records of 142 patients were evaluated, most of them had mild clinical disease with significant qSOFA score in only 8 patients. Most of patients had WCC of less than 15 and CRP of less than 100. Even in radiological severity, class 1a of modified Hinchey classification (uncomplicated disease) dominated with 96 patients.

Interestingly, only 22 patients were treated via ambulatory care, while the remaining 120 received inpatient care. 10 of the inpatient treated patients required HDU/ ITU support and most of the hospital stays were 7 days or less. The treatment was predominantly non-operative, with only 4 patients required surgery and 6 others required radiological drainage. The 1-year follow-up showed only 16 readmissions.

As for the follow-up investigations, 45 did not have any follow-up investigations or clinic reviews, 14 of them had complicated diverticulitis. Of the 97 patients who were followed up, 88 patients had endoscopic evaluation and 8 underwent CT colonography.

Conclusion

Since most patients of acute diverticulitis present with clinically, biochemically, and radiologically mild and uncomplicated disease, ambulatory management should be encouraged where possible. While 1-year readmissions remain low, it is crucial that patients, especially those with complicated disease, receive luminal investigations.
FTP2.4 Colorectal Resections at an Elective Hub; A service evaluation
Authors: Shukla Yash , Blacker Sarah , Trivedi Prateesh , Trickett Jonathan , Nisar Pasha
Published: August 2023

Aim

Rising acute hospital bed pressures that have persisted post-pandemic have led to increased surgical cancellations and growing waiting lists. Ashford and St Peters Hospital Trust set up a unique elective surgical hub at Ashford Hospital to ensure the continued provision of surgical services, unaffected by the capacity pressures of an acute hospital site. The introduction of a level 1.5 Enhanced Care Unit (ECU) has enabled many colorectal resections to be performed at the elective hub. We aim to evaluate elective colorectal resections at this hub since the introduction of ECU.

Methods

Evaluated all elective colorectal resections in the 12 month period since the introduction of ECU (1st April 2021 - 31st March 2022). Procedure, surgical approach, histology, length of stay, post-operative complications and inter-hospital transfers were recorded for each case. Statistical analysis was performed on the data collected.

Results

In 12 months,169 and 36 colorectal resections took place at the acute site versus the elective respectively. At the elective hub, 50% of patients were male, the median age was 62.5 yrs, 89% were ASA 2. Right hemicolectomy was the most common procedure (50%) followed by high anterior resection (36%). The open conversion rate was 8%. Three patients (8%) required transfer to St Peter’s, 2 of which had an anastomotic leak.

Conclusions

An elective hub provides a safe location for colorectal resections. Appropriate case selection involving consultant surgeons and anaesthetists ensures low transfer rates. Expanding this service will relieve bed pressures at St Peters and reduce waiting lists.
FTP3.2 Differences in the Acute Phase Response in Right-Sided Colorectal Surgery: Evaluation of the Kono-S Anastomosis
Authors: Kapur Ajay , Hassan Sarah , Malcomson Lee , George Bruce
Published: August 2023

Aims

CRP monitoring has become routine post-operative practice in resectional colorectal surgery and is useful as a predictive tool for identification of anastomotic leak. Day 3 CRP > 150 has been shown to be highly predictive of anastomotic leak. The acute phase response observed in surgery for Crohn’s disease (CD) is often more pronounced compared to malignancy and this is not accounted for in post-operative monitoring. This study looks at the difference in CRP in patients undergoing right hemicolectomy for cancer versus CD and evaluates any difference in CD patients who have conventional versus Kono-S anastomosis.

Methods

A single-center retrospective analysis of patients undergoing right hemicolectomy for malignancy and CD was undertaken, including CD patients with conventional and Kono-S anastomosis. Primary outcomes included CRP on Day 1 and 3 post-surgery. Length of stay, leak rate and post-operative infections were recorded. Analyses were carried out including and excluding patients with post-operative leak and infection.

Results

Day 1 CRP was significantly higher in patients undergoing surgery undergoing surgery for CD compared to malignancy (p <0.001). Day 3 CRP was significantly higher in patients undergoing surgery for CD compared to malignancy (p = 0.017). There was no significant difference between CD patients undergoing surgery with Kono-S anastomosis compared to conventional anastomosis. Kono-S anastomosis was not associated with any difference in leak, infection, or length of stay.

Conclusions

The rise in post-operative CRP is more pronounced in CD patients compared to cancer patients. CD patients with Kono-S anastomosis do not have significantly different post-operative CRP from patients with conventional anastomoses.
FTP3.8 Are we doing enough to get patients moving after colorectal cancer surgery?
Authors: Paul Melanie , Lund Jon , Phillips Bethan
Published: August 2023

Background

Enhanced recovery after surgery (ERAS) is a widely implemented, multi-disciplinary pathway designed to reduce perioperative stress, maintain postoperative physiological function and accelerate recovery after surgery. Postoperative movement, as advocated by ERAS, reduces postoperative muscle wasting and the risk of complications such as chest infections and ileus and should be encouraged in all colorectal cancer patients.

Methods

Nine adult patients undergoing elective colorectal cancer resection had their physical activity assessed using an ActivPAL™ accelerometer applied to the anterior right thigh from the first postoperative day for 7 days or until discharge (if sooner). Time in bed and step count was collected.

Results

Patient age ranged from 54-87 years (median = 71). Mode of access included laparoscopy (n=7), robotic (n=1) and open (n=1), and no patients required intensive care postoperatively. The median length of hospital stay was 6 days (interquartile range (IQR): 3 days) and patients wore the accelerometer for a median time of 6 days (IQR: 2 days). The median step count on postoperative days 1, 3 and 5 was 128 (IQR: 236), 506 (IQR: 532) and 438 (IQR: 1256) steps/day, respectively. The median time spent in bed was 10 (IQR: 2.2), 10 (IQR: 8.5) and 9 (3.4) hours, respectively.

Conclusions

Even in those patients engaged in an ERAS programme, time spent performing physical activity is variable and does not appear to increase during the postoperative inpatient period. Step count targets may be a useful goal setting, patient-led directive to improve the consistency of postoperative mobilisation.
FTP3.10 Does Anti-Thrombotic Medication affect the PPV of the Feacal Immunochemical Test: A Single Centre Retrospective Study
Authors: Peters Paul , Manu Nichola , Butler Rebecca , Zardab Mohamed , Magee Connor , Wilson Jeremy , Digne-Malcolm Holly
Published: August 2023

Aims

Our aim of this study was to determine whether anti-thrombotic medication (i.e. anit-coagulative's such as DOACS and anti-platelets) had a causal relationship to the outcome of the FIT score by looking at the PPV in its detection for malignancy and significant neoplasm.

Methods

We analysed records of 500 patients over 2 years (June 2020 - June 2022) from a single centre database of patients who are FIT positive and we reviewed all their endoscopy and CT images to determine the proportion of patients with a diagnosis of Colorectal Malignancy and advanced colorectal neoplasm.

Results

The key finding from our data we discovered that the PPV of having a Colorectal Malignancy/Advanced Neoplasm was significantly lower for patients who were on anti-thrombotic medication (33.1%) when compared to patients who were not on any anti-thrombotic medication (48.8%).

Conclusion

Our findings display that the use of anti-thrombotic medication lowered the incidence of significant colorectal neoplasms and malignancies detected on colonoscopy or CT imaging for patients who are FIT positive in our local population. It is the first out of the United Kingdom to demonstrate data that is consistent with current literature, thus we can suggest that these medications increase the number of False Positives from the FIT (with a FIT cut-off score of >10ugHb/g). From further analysis we will look to answer to the question. ‘Whether having anti-thrombotic medication can increase the likelihood of smaller cancers bleeding?'
FTP3.13 Patients undergoing major abdominal cancer surgery should receive 28 days of VTE prophylaxis: a single-centre audit of patients treated surgically for colorectal cancer
Authors: Epanomeritakis Ilias , Radhakrishnan Ramila , Bevan Katharine
Published: August 2023

Aims

The incidence of venous thromboembolism (VTE) following major abdominal cancer surgery is reduced by extended post-operative VTE prophylaxis using low molecular weight heparin, without an associated increase in bleeding risk. The National Institute for Health and Care Excellence (NICE) issued guidance in 2018, recommending 28 days of post-operative VTE prophylaxis for these patients. We audited local compliance for patients undergoing major surgery for colorectal cancer.

Methods

Clinical records of patients with colorectal cancer were retrieved from a local registry. 104 patients treated surgically between 01/08/2021–24/01/2023 were included in the first audit cycle. Retrospective analysis investigated the nature of operations (elective or emergency) and whether extended VTE prophylaxis was prescribed. Records were examined for documented plans for prophylaxis post-discharge. Data was presented locally and strategies to increase compliance were implemented. Second cycle data is being collected prospectively from 25/01/2023 until the presentation date.

Results

Of the included patients, 89% underwent elective operations and 11% required emergency surgery. Our first cycle demonstrated 84% compliance with guidance across all patients (88% for elective and 55% for emergency procedures, respectively). An explicitly documented plan for extended prophylaxis was observed for 82% of recipients and 12% of those who did not receive it.

Conclusions

Compliance to guidance was particularly high for electively treated patients. This should not differ between elective and emergency cases. Documenting post-discharge anticoagulation plans may act as a simple quality improvement measure. We plan to re-audit and present second cycle results following implementation of interventions, including education, posters, and improving electronic discharge processes.
FTP6.1 A little respect! A closed-loop audit increasing awareness of ReSPECT forms in a busy general surgical department
Authors: Bruno Paris , McKinlay Ailsa , Eva Charlotte , Roe Thomas
Published: August 2023

Aims

ReSPECT forms have been introduced by Resuscitation Council UK to provide recommendations for patients’ emergency care. The primary aim of the audit was to assess the completion rate of ReSPECT forms on a busy surgical ward. Secondly, the audit aimed to both increase the awareness and the completion rate of ReSPECT forms.

Methods

Data was collected in the form of random spot-checks of completed ReSPECT forms for all general surgical inpatients at our general hospital. The first intervention involved the addition of a column to the surgical ‘take’ list to highlight the presence or absence of ReSPECT forms. Team education using a novel poster, prioritising the urgency of completion of ReSPECT forms dependent on patient’s co-morbidities, and a teaching session was the intervention for the second cycle.

Results

The initial completion rate of accurate ReSPECT forms was 31%. Following the first intervention the ‘ReSPECT column’ on the list had been completed for 15% of inpatients and the overall completion rate of ReSPECT forms was 35%. After the ReSPECT poster and teaching the usage of the ‘ReSPECT column’ increased to 39% and overall completion rate was 33%.

Conclusions

The addition of a column to the acute, surgical list was a simple and effective way of increasing awareness of completed ReSPECT forms. Increased compliance may be achieved by finding more efficient methods of monitoring completion. Overall completion of ReSPECT forms had improved with the interventions, however, due to the high turnover of surgical patients, there are still further improvements possible.
FTP6.4 Management and Outcomes of Acute Diverticulitis in Immunosuppressed Patients
Authors: Farrow Emily , Dean Harry , Britton Emily , Abdel-Khaleq Sameerah , Bennett Joanne , Cook Tim
Published: August 2023

Aims

Previous studies have suggested that immunosuppressed patients with acute diverticulitis are at high risk of failing conservative management and many will require urgent surgical intervention. Some series have shown mortality rates as high as 39% and 56% with medical and surgical management respectively. The aim of this study was to analyse the management and outcomes of immunosuppressed patients presenting with acute diverticulitis.

Methods

Data were collected on patients admitted as an emergency with acute diverticulitis over a 2-year period (1st January 2018 to 31st December 2019). Immunosuppressed patients were identified and divided into 5 groups according to the cause: group 1, chronic corticosteroid use; group 2, transplant patients; group 3, malignant neoplasm; group 4 chronic kidney disease; group 5, other immunosuppressant treatments. Outcomes were recorded.

Results

Sixty-one patients with immunosuppression were admitted with acute diverticulitis. The number of patients in groups 1-5 were 23, 2, 11, 16 and 9 respectively. Fifty-one patients (83.6%) had a CT during their admission and thirteen (21.3%) presented with complicated diverticulitis. Two patients (3.3%) underwent emergency surgery, both of whom were on chronic corticosteroid therapy and were alive at 1-year post-op. All fifty-nine patients (96.7%) managed conservatively survived admission.

Conclusions

This study has shown a lower rate of emergency surgery than previously observed and lower mortality with both medical and surgical management. Conservative management appears to be safe for the majority of immunosuppressed patients with acute diverticulitis.
FTP6.5 A review of a District General Hospital's performance in meeting Emergency Cholecystectomy guidelines
Authors: Gallagher Charles , Dwebi Mohammed , McAree Barry
Published: August 2023

Aims

Due the Covid pandemic and resultant decrease in elective cholecystectomies there has been an increase in the emergency presentation of gallstone disease to our DGH. The NICE guidelines recommend >25% of Acute Cholecystitis (AC) should receive emergency cholecystectomy on admission and the AUGIS Commissioning Guide: Gallstone Disease 2016 recommends all patients with mild Gallstone Pancreatitis should have an emergency cholecystectomy on admission or within two weeks of discharge. We wanted to see was our department meeting these guidelines.

Methods

187 patients identified with AC and pancreatitis from admission records over a three month period. Review of online records narrowed this down to 53 patients with AC (without secondary complications i.e. perforation, Mirizzi) and 18 with Gallstone Pancreatitis. We followed these patients up over a six month period.

Results

AC patients: 28% (15) were deemed high risk or not suitable (13: >75yo), 26% (14) emergency cholecystectomy on admission, 23% (12) awaiting clinic/ pre-assessment, 7.5% (4) Elective surgery (3 had readmissions pre elective surgery), 7.5% (4) surgery on readmission, 7.5% (4) opted out of surgery. Separately, 24.5% (13) readmitted with gallstone disease.

Gallstone Pancreatitis

44% (8) deemed not suitable (4: >85yo, 4: multiple co-morbidities), 33.3% (6) emergency cholecystectomy on admission and 1 each: severe pancreatitis/ opted out/ done on readmission (2.5months later)/ done privately.

Conclusions

Our DGH is hitting the target for emergency cholecystectomies although the majority of patients presenting with AC are not suitable for surgery and there is a high readmission rate for gallstone disease. Improvement required in following up patients with gallstone pancreatitis not receiving surgery on admission.
FTP6.6 Same Day Emergency Care Satisfaction Survey, Patients and Staff Respond
Authors: Gurung Ganga , Ullah Muhammad Fahad , Oo Myo Kyaw , Chituku Tsitsi , Rao Milind
Published: August 2023

Surgical Same Day Emergency Care (SDEC) Satisfaction Survey - SDEC was introduced to the hospital in 2021.

Aims

Methodology

Results

Conclusion

Abstract presented at World Society of Emergency Surgery, 2022.
FTP6.8 Impact of frailty on patients undergoing emergency surgeries under general anaesthesia in a district general hospital
Authors: Jalali Uzma , Turi Mubasher , Irfan Sana
Published: August 2023

Aims

To assess the impact of frailty on the outcome of elderly patients underwent emergency surgical procedures in a district general hospital.

Methods

All patients above 65 years who underwent moderate/ major risk emergency surgical procedures from 1st of January 2022 to 31st of Dec 2022 were included in retrospective study. Data was collected from on call hand over and hospital electronic patients record system. Their ASA (American society of anaesthesiologist physical status classification) and P-POSSUM (Portsmouth- Physiological and operative severity score for the enumeration of mortality and morbidity) was calculated.

Results

Eighty-five patients (males:47, females:38) underwent emergency procedures in one year period. Age range was 65 to 90 years with mean age was 80.6 years. We performed 57 laparotomies, seven had laparoscopic bowel surgery. Other procedures were incarcerated hernias repair, appendectomies, lap/ open cholecystectomy/ cholecystostomy, debridement of necrotising fasciitis. Twenty-eight patients were frail (CFS 5-7) with mean ASA 3.4 and mean P-POSSUM mortality was 14.89. Fifty-seven patients were non frail with mean ASA 2.59 and P-POSSUM mortality was 16.12. Length of hospital stay was from 1 to 106 days, average being 13.7 days. Average length of stay for frail patients was 15.8 days and for non-frail was 12.9 days. Twelve patients died within 30 days of surgery or during the same admission, among them 54% were frail. Seventy five percent of mortalities were after bowel surgeries, mainly after stoma formation (both open and laparoscopic approach).

Conclusions

Clinical frailty scale is one of the predictors of prognosis along with other parameters and must be calculated at the time of admission.
FTP6.9 Death is not the worst that can happen: exploring extreme-risk in the National Emergency Laparotomy Audit
Authors: Javanmard-Emamghissi Hannah , Doleman Brett , Hare Sarah , Lund Jon , Moug Susan , Tierney Gillian
Published: August 2023

Background

A National Emergency Laparotomy Audit (NELA) mortality risk score of >5% is considered high-risk. A threshold for very high-risk or extreme-risk has not been defined, and the outcomes of these patients are unknown.

Method

All adult patients enrolled in the NELA database December 2012-2020 were included. Patients were categorised into groups based on predicted mortality score; 50-59% (Group A), 60-69% (Group B), 70-79% (Group C) and >80% (Group D). These groups were compared for demographics and outcomes such as length of hospital stay (LOS), rates of unplanned return to theatre and 90-day survival rates.

Results

Of 161,337 patients, 5196 had a predicted mortality of ≥50% (3.2%). Group A accounted for 2437 (47%) of patients, Group B 1484 (29%), Group C 843 (16%) and Group D 432 (8%). Patient age decreased with increasing predicted mortality, with a median age of 77 in Group A and 75 in Group D (p<0.05). LOS increased from 26 [16-44] days in Group A to 35 [20-54] days in Group D, compared to the NELA median of 15 days. Rates of unplanned return to theatre were double in all extreme-risk groups when compared to the NELA average (11.3% vs 4.8%). The ninety-day survival was 43% in Group A, 34% in Group B, 27% in Group C and 17% in Group D.

Conclusion

The NELA score accurately predicted mortality in the extreme-risk group. In addition, for those that survive, they experience double the rate of unplanned theatre returns and double the LOS than the average NELA patient.
FTP7.5 Accuracy of the END-PAC model in predicting the risk of developing pancreatic cancer in patients with new-onset diabetes: a systematic review and meta-analysis
Authors: Carrington-Windo Eliot , Hajibandeh Shahab , Intrator Christina , James Rhodri , Hughes Ioan , Hajibandeh Shahin
Published: August 2023

Objectives

to evaluate the accuracy of END-PAC model in predicting the risk of pancreatic cancer in patients with new-onset diabetes (NOD).

Methods

A systematic review in accordance with PRISMA statement standards was conducted to identify all studies evaluating the accuracy of END-PAC model in predicting the risk of pancreatic cancer in patients with NOD. The number of true positives, false negatives, true negatives, and false positives were used to construct two-by-two tables, coupled forest plots and the summary receiver operating characteristic plots. We estimated summary sensitivity and specificity points using diagnostic random effects model.

Results

We analysed 26752 patients from four studies. The pooled risk of pancreatic cancer was 0.8% (95% CI 0.6%-1.0%) with median follow-up of 3 years. END-PAC score ≥3 [sensitivity: 55.8% (43.9%-67%); specificity: 82.0% (76.4%-86.5%)] which classifies the patients as high risk was associated with better predictive performance than END-PAC score 1–2 [sensitivity: 22.2% (16.6%-29.2%); specificity: 69.9% (67.3%-72.4%)] and END-PAC score <1 [sensitivity: 18.0% (12.8%-24.6%); specificity: 50.9% (48.6%-53.2%)] which classify the patients as intermediate and low risks, respectively. The quality of the available evidence was moderate to high.

Conclusions

END-PAC model is promising in predicting the risk of pancreatic cancer in patients with new-onset diabetes. END-PAC score ≥3, which classifies the patients as high risk, has the best predictive performance and should be considered as optimum cut-off value. Future comparative studies are required to evaluate whether application of END-PAC model could improve pancreatic cancer early detection rate, pancreatic cancer resection rate, and pancreatic cancer treatment outcomes.
FTP7.9 Not all necrotising pancreatitis are the same: does aetiology affect the extent pancreatic necrosis? A single-centre retrospective study
Authors: Di Mauro Davide , Njere Ikechukwu , Shams Ola , Wajed Shahjehan , Reece-Smith Alex , Manzelli Antonio
Published: August 2023

Aim

To assess the extent of pancreatic necrosis (PN) on abdominal computed tomography (CT) in patients with acute gallstone pancreatitis (GP) and alcohol-induced pancreatitis (AIP).

Methods

Patients ≥ 18-year-old with first-time onset of GP, AIP and PN on CT scan, from January 2010 to September 2018, were included. Extent of PN on CT, organ failure rate, admission to the intensive care unit (ICU), were compared between GP (group 1) and AIP (group 2). PN extent was described as: localised – right or left of the midline; diffuse – across the midline; more/less than 50% of the pancreas.

Analysis of continuous and categorical data and multiple logistic regression were conducted. Significance was set at p<0.05.

Results

One hundred-two consecutive patients, 66 in group 1, 36 in group 2, were included. Overall, diffuse PN occurred in 34.3% of cases, more frequently in group 1 (42.4% vs 19.4%, p=0.03). Single/multiorgan failure developed in 50 patients, 57.6% belonged to group 1 (p=0.03). Predictors of organ failure were diffuse pattern of PN (OR 2.70, 95% CI 1.03 to 7.03, p=0.004) and PN ≥50% (OR 5.50, 95% CI 1.39 to 21.6, p=0.01). Admission to ICU was required in 27 subjects; PN ≥50% predicted ICU admission (OR 8.93, 95% CI 2.68 to 29.73, p=0.0004). The median hospital stay was 12 days (range 1-265), longer in group 1 (12.5 vs 10.5, p=0.02).

Conclusions

Diffuse PN occurred more frequently in patients with GP. A larger extent of PN predicted the onset of single/multiorgan failure and admission to the ICU.
FTP7.12 Percutaneous Cholecystostomy use at ESHT
Authors: White Annabelle , Ahmed Elmurtada , Al-Robaie Basim , Klimovskij Michail
Published: August 2023

Aim

Percutaneous Cholecystostomy is a well-recognised adjunct to antibiotic therapy in management of acute calculous cholecystitis – often as a temporising measure to definitive surgery. Multiple guidelines exist advising on patient selection and timing of insertion, however little evidence exists on managing these following insertion, timing of interval cholecystectomy, and investigations prior to removal.

Method

A closed-loop retrospective review of all patients undergoing radiologically guided PC insertion between 01/06/2015-31/05/2017 (Cycle 1) and 01/11/2021-01/12/2022 (Cycle 2) at ESHT. Data collected included patient demographics, time from diagnosis to PC, duration of admission and PC in situ and investigations prior to removal.

Results

43 patients across both cycles, with average age 72, (median 74, range 50-92). Cycle 1 consisted of 26 patients, whereas Cycle 2 had 17 patients. Duration of admission was longer in Cycle 1 (Average: 10 vs 8.5, Median: 9.5 vs 6, Range: 3-21 vs. 1-26 days). Time from admission to PC insertion was similar (Average: 2.7 vs. 3, Median: 2 vs. 1, Range: 0-12 vs 0-25 days). Duration of cholecystostomy in situ was longer in Cycle 2 (Average: 26 vs. 41, Median: 21 vs. 32, Range: 7-95 vs 1-196 days). 53% (n=17) of patients in Cycle 2 underwent a cholecystogram prior to removal vs. 12% (n=3) in Cycle 1.

Conclusions

We identified considerable heterogeneity within practice surrounding the insertion and removal of PC at ESHT. Considering this we are introducing a trust-wide “Cholecystostomy Management” Pathway to standardise our practice, and “Cholecystostomy Passport” for patients outlining this and providing safety netting information and emergency contact details.
FTP7.13 Do additional preoperative investigations delay the time to resection in patients with pancreatic cancer? Results from the Recurrence After Whipple’s (RAW) study
Authors: Russell Thomas , Labib Peter ,   RAW Study Collaborators, Aroori Somaiah
Published: August 2023

Aims

Suitable patients with a resectable pancreatic cancer should undergo timely pancreatoduodenectomy (PD) as the disease is aggressive and recurrence rates are high. This study aimed to investigate whether selected preoperative investigations resulted in a delay to surgery.

Methods

Data were extracted from the Recurrence After Whipple’s (RAW) study, a retrospective study of PD outcomes (29 centres from eight countries, n=1484). Patients were excluded if: they had staging data missing, they underwent neoadjuvant chemo-/radiotherapy, or if radiological staging was performed for another malignancy. The median time from radiological staging to PD was calculated in patients who underwent selected preoperative investigations and compared to those who did not undergo the investigation.

Results

In the 595 included patients, the median time from (most recent) preoperative computed tomography (CT) to PD was 32 days (IQR: 32) and 25%, 5%, 34%, 10% and 60% underwent preoperative magnetic resonance imaging (MRI), positron emission tomography (PET)-CT, endoscopic ultrasound (EUS), staging laparoscopy and/or biliary stenting (PBS), respectively. MRI (32 vs 31 days, p=0.55), PET-CT (40 vs 31 days, p=0.08) and EUS (28 vs 32 days, p=0.99) were not associated with an increased median time to PD. However, staging laparoscopy (43 vs 29.5 days, p=0.009) and PBS (39 vs 20 days, p<0.0001) were.

Conclusions

In our multicentre study of PD outcomes, preoperative MRI, PET-CT and EUS did not delay the time to resection. However, staging laparoscopy (median difference: 13.5 days) and PBS (median difference: 19 days) did, so these investigations/interventions should only be performed when there is a strong indication.
FTP7.14 A systematic review and meta-analysis evaluating the role of single-dose preoperative versus extended use of antibiotics therapy following acute cholecystectomy
Authors: Kaur Mandeep , Singh Anurag , Sains Parv , Singh Krishna , Sajid Muhammad
Published: August 2023

Laparoscopic cholecystectomy (LC) during index admission for acute cholecystitis is considered a preferred mode of treating gallstone disease. The objective of this study is to evaluate the role of single dose pre-operative prophylactic antibiotics versus extended antibiotics therapy up to 5th post-operative days in these patients undergoing acute cholecystectomy for mild to moderate acute cholecystitis.

Materials and methods

RCTs reporting the use of single dose pre-operative prophylactic antibiotics versus extended antibiotics therapy up to 5th post-operative days following acute cholecystectomy were retrieved from the search of standard medical electronic databases and analysis was conducted by using the principles of meta-analysis on the statistical software RevMan version 5.

Results

The search of medical databases yielded 4 RCTs on 949 patients undergoing acute cholecystectomy. There were 481 patients in in single dose pre-operative antibiotics group whereas 468 patients received extended doses antibiotics therapy. In the random effects model analysis, the extended use of post-operative antibiotics in patients undergoing acute cholecystectomy for mild to moderate acute cholecystitis does not confer any extra benefit [risk ratio 1.05, 95%, CI (0.73, 1.51), Z = 0.25, P=0.80] in terms of reducing the infective complications. There was no heterogeneity (Tau2 = 0; Chi2 = 0.40, df = 3; (P = 0.94; I2 = 0 %) among included studies.

Conclusion

Post-operative extended use of antibiotics in patients undergoing acute cholecystectomy for mild to moderate acute cholecystitis does not demonstrate extra benefit to reduce infective complications.
27 Neuroendocrine tumour of the breast: A case report & Literature review
Authors: Shafique Muhammad Salman , Bhatti Hamza Waqar , Hazma Muhammad , Farooqui Marryam Riaz , Chaudhary Noman Ahmed , Rauf Fatima
Published: August 2023

Introduction

Neuroendocrine differentiation in breast carcinomas was first described by Feyrter and Hartmann in 1963, based on positive silver staining in mucinous carcinomas of the breast. NEBC are heterogeneous group of rare breast tumours which account for < 0.1 % of breast tumour and < 1% of neuroendocrine tumours.

Case

A 65-year-old female presented with a 12 x 10 cm non-tender hard globular slightly mobile mass in upper medial /inner quadrant of right breast with overlying 2 cm scar mark and bilateral axillary lymphadenopathy. Mammography revealed a BIRADS-4 lesion and FNAC showed atypical cells. Octreotide Scan showed that the mass was neuroendocrine in origin. Further CT imaging showed no other site for metastasis. She was managed with a Right sided modified radical mastectomy (MRM) after multidisciplinary team (MDT) decision. Biopsy of the Lesion showed ER, PR receptor & synaptophysin receptor positivity, negative Her 2-neu status, ki-67 proliferation index of 10% & grade II NET.

Conclusion

Primary neuroendocrine tumours of the breast are infrequent tumours that appear in women aged 60–70 years. Their diagnosis is complex as they lack defining clinical and radiological characteristics. Their low incidence makes it impossible to establish an optimal treatment protocol.
56 Epidermoid cyst mimicking appendiceal mucocoele
Authors: Silvestre Stefania , Bose Sayantan
Published: August 2023

Background

Congenital epidermoid cysts found in internal organs are thought to arise from displaced or implanted ectoderm during embryonic development. Their histogenesis differs from that of acquired cysts which are associated with trauma or iatrogenic implantation. Epidermoid cysts related to caecum or appendix are rare. The present case describes the largest caecal epidermoid cyst reported in the English literature so far in a patient with no previous history of surgery or trauma.

Case report

A man in his late thirties presented with a three-week history of dull right-sided abdominal pain. Physical examination revealed right flank fullness and subsequent CT scan showed a large right-sided cystic mass adjacent to caecum. The appendix could not be visualised separately and the mass was thought to be either an appendiceal mucocoele or an inclusion cyst. Cryptorchidism was excluded. Due to concerns of possible mucocoele that could lead to pseudomyxoma peritonei, laparotomy was performed and the cyst was excised intact with an ileocaecectomy. The specimen weighed 1.8kg and was 120 x 105 x 95mm in size. Histological findings were consistent with an epidermoid cyst inseparable from caecum and appendix, visibly distinct from the appendiceal wall stretching over it.

Conclusion

Epidermoid cysts related to caecum or appendix are rare benign lesions. In the present case, the cyst was safely excised via an open ileocaecetomy, based on its location and concern for an appendiceal mucocoele. Ileocaecectomy or segmental colectomy with primary anastomosis can be safe surgical management options for caecal cysts in an otherwise healthy patient.
117 Double Trouble: Rapunzel Syndrome Presenting with Closed-Loop Intestinal Obstruction Between Two Synchronous Trichobezoars
Authors: Arshad Rabia , Arshad Daneyal , Aamir Suman , Basharat Fauzia , Khan Huma , Hanif Muhammad
Published: August 2023

Background

Trichobezoar formation is a rare phenomenon associated with certain psychiatric conditions like trichophagia and is more frequent in young women. Rapunzel Syndrome denotes a gastric trichobezoar which extends into the duodenum. We report a rare case of dual isolated trichobezoars, a gastric and an ileal trichobezoar, causing sub-acute closed-loop intestinal obstruction between the two bezoars.

Case presentation

A 15-years old girl presented to the emergency department with history of generalized abdominal pain and distention for two days. She had nausea, loss of appetite, absolute constipation followed by vomiting.She was tachycardiac, had abdominal distention with an ill-defined upper abdominal mass and absent bowel sounds. CT-scan abdomen revealed a giant trichobezor in stomach tailing into duodenum and a separate small rounded mass in ileum with dilated bowel loops. Mid-line laparotomy was done. Per-operatively a giant gastric trichobezoar(22x8cms) was extracted after gastrostomy, which completely occupied the stomach and extended into the duodenum. Another large ileal trichobezoar(6x5cms) was also removed via enterotomy at 2 feet proximal to the ileo-cecal junction. Hence a markedly distended closed loop was formed between the two obstructing trichobezoars. Enterotomies were closed using vicyrl2.0. Feeding was started on post-operative day-3 & she was discharged on day-5. She developed complete wound dehiscence after 2 weeks which was surgically closed. Patient was consulted for nutritional and psychiatric evaluation and for management of trichophagia.

Conclusion

Trichobezoars usually present with vague abdominal symptoms and can rarely cause intestinal obstruction. Invasive intervention such as laparoscopy or laparotomy becomes necessary for such large obstructing trichobezoars. Psychiatric follow-up and management are crucial to prevent its recurrence.