bluuebunny/crossref_metadata_2025 huggingface dataset:
EP.TU.581Cholecysto-colonic fistula – A rare complication of gallstone
Authors: Loganathan Santhosh , Singh Amal , O'Connor Adam , Antony Martin
Published: October 2021

We present a 90year old male patient presenting to the emergency department with complaints of PR bleed for a month with no associated abdominal pain. He described that the blood was mixed with stools and dark in colour. He has a significant past medical history with multiple comorbidities. The patient is known to have gallstones and had ERCP with sphincterotomy in 2017 as a definitive treatment, as he wasn’t a fit candidate for surgical intervention. On clinical examination, his abdomen was soft and non-tender and per rectal examination showed stools mixed with the blood but no active bleeding or fresh blood.

His haemoglobin was 72 g/L, inflammatory markers were significantly elevated with deranged liver enzymes and normal bilirubin. The medical team were involved in the management of this patient because of pneumonia and extensive medical issues. A gastroscopy was performed as there was a suspicion of UGI bleed, which was normal. Given a deranged liver function and there was a suspicion of biliary sepsis patient had MRCP and Computed tomography of the abdomen which confirmed that there is haematoma in the gallbladder with gas in the biliary tree, with possible cholecysto-colonic fistula, with a large gall stone (2.7cm lamellated structure within rectum) in the rectum.

As the patient was not a surgical candidate decision was made to manage him conservatively with antibiotics under medical care. The cholecysto-colonic fistula is a rare complication of gallstone disease, and very few cases have been reported in the literature.
EP.TU.601Improving extended venous thromboembolism prophylaxis prescription compliance at discharge for colorectal cancer resection patients
Authors: Lewis-Lloyd Christopher , Brewer Hilary , Hall Craig , Adiamah Alfred , Humes David
Published: October 2021

Aims

Extended venous thromboembolism prophylaxis (exVTEp) is used to reduce venous thromboembolism (VTE) incidence following colorectal cancer (CRC) resection. Within our tertiary care centre patients undergoing CRC resection should receive an electronic VTE risk assessment (eVTE) within 24 hours and exVTEp at discharge, compliance targets set at 95%. Our aim was to improve absolute compliance rates of exVTEp prescription at discharge following CRC surgery.

Methods

Data were collected prospectively on CRC resection patients pre and post an educational intervention for doctors during surgical induction, with posters placed in key areas highlighting discharge exVTEp importance. Patients discharged between August-December 2019 served as pre-intervention and those between December 2019-March 2020 as post-intervention cohorts. Time periods reflected junior doctor rotating periods within the country’s healthcare system thus providing more comparable data sets. The service evaluation was registered within the Trust (19-562Q)

Results

Of 80 pre-intervention and 40 post-intervention eligible patients: 81.25% vs. 92.68% received exVTEp at discharge, 70.19% vs. 72.34% had a valid eVTE and 32.50% vs. 36.59% had exVTEp recorded in the post-operative note. Those missing exVTEp documentation in the post-operative plan were significantly less likely to receive exVTEp at discharge with an 80% decrease in exVTEp prescription compared to patients with exVTEp documented within the post-operative note (unadjusted-OR 0.2051, 95%CI 0.0431-0.9773; p = 0.0276).

Conclusions

Educational and visual interventions have shown improvement in exVTEp prescription at discharge. Despite suboptimal eVTE scores true service quality in delivering exVTEp is high. The relationship between exVTEp post-operative instruction and exVTEp prescription needs further investigation.
EP.TU.682Antibiotic Stewardship Within A General Surgery Department – A Quality Improvement Project
Authors: Fadipe Toks
Published: October 2021

Background

Antimicrobial stewardship involves a coherent set of actions geared towards responsible use of antimicrobials. NICE antimicrobial stewardship guidance forms the basis for trust wide standards; the surgical department inconsistently complies to these standards.

Aims

Use of PDSA framework to improve departmental antibiotic prescribing practices.

Methods

Data collection via Meditech™ prescribing records and documentation. ‘Snapshots’ of antibiotic prescriptions for surgical inpatients taken collecting the following data:

Cycle 1 data collection in August/September 2020, followed by a presentation distributed to junior doctors detailing importance of accurate prescribing. Cycle 2 data collection in October/November 2020 was followed by a summary of documentation/prescribing guidelines being circulated to surgical juniors. The final data collection period took place in November 2020. Analysis via Chi-Squared test.

Results

Interventions improved prescribing of correct antibiotics (75 to 89.3%), and documentation of IV antibiotic prescriptions with courses longer than 72 hours (p < 0.05). Similar insigificant improvements observed with reviewing prescriptions within 72 hours and samples sent to microbiology.

Discussion

Low frequency of samples sent to microbiology as antibiotics often used for surgical prophylaxis and continued post-operatively without prior cultures. Brief documentation on the ward round, accentuated by constraints enforced by Covid-19 pandemic.

Conclusion

Positive changes can be achieved from simple interventions. Sustainable changes in prescribing practices require engagement of entire clinical team and amendments to electronic prescribing.
EP.TU.688The fate of the rectal stump following subtotal colectomy for acute colitis
Authors: Lucocq James , Porter Darren , Muthukumarasamy Girivasan
Published: October 2021

Aims

Acute severe colitis requires surgery in approximately thirty percent of cases. Subtotal colectomy with end ileostomy is the standard procedure with distinct advantages to a laparoscopic approach. Controversy surrounds the optimal short and long-term management of the distal rectal stump. This study reviews the clinical outcomes and the fate of the rectal stump in this patient cohort.

Methods

Analysis of prospective data of patients who underwent emergency subtotal colectomy for severe acute colitis between 2010 and 2020 in a tertiary referral centre.

Results

Sixty-six patients underwent subtotal colectomy (median age, 40years; M:F, 1.3:1). Subtotal colectomy was performed for failure of medical therapy during an acute episode of severe colitis (56%), for fulminant colitis (40%), or for colonic strictures (4%). In 98% percent of patients the rectal stump was closed at the level of the recto-sigmoid junction and in 2% a mucous fistula was formed. 73% of patients opted for no further surgery, but 27% underwent a completion proctectomy, most commonly performed because of rectal stump bleeding. The median follow-up was 6.25years, during which 17% of those with a completion proctectomy underwent an ileo-pouch anal anastomosis (IPAA).

Conclusions

Subtotal colectomy with closed rectal intra-peritoneal stump and end ileostomy is the procedure of choice in severe acute colitis refractory to maximal medical therapy or fulminant colitis. Given the patient dissatisfaction and morbidity associated with mucous fistula, this procedure should be abandoned. Pelvic dissection should not be performed at the time of the emergency subtotal colectomy given the risk of morbidity.
EP.TU.713A review of mobile device stands to facilitate virtual surgical skills teaching
Authors: Measuria Radheswari , Yau Jih Dar , Loubani Professor Mahmoud
Published: October 2021

Aims

To assess optimal overhead video camera stand for virtual surgical skills teaching.

Methodology

Based on the assumption that most surgical trainees have an internet-enabled mobile device with a camera, an overhead device mounted on a phone stand is a ubiquitous set-up for trainers and trainees to demonstrate surgical skills to each other virtually.

On 4th December 2020, to reflect affordability and accessibility, phone stands under £15 were purchased from an online retailer, Amazon. Data regarding their design characteristics were collected and studied. Each product was independently reviewed in a simulated setting by two investigators.

Results

11 stands were identified with prices ranging from £5.99 to £14.99, with an average of £9.20.

Clamp phone holders were the most secure in camera stability but were less adaptable to a variety of device sizes. Table-clamp and broad-based phone stands were sturdier than tripod-based holders.

Fit-for-purpose phone stand designs were linked with smaller space occupied at set-up, greater maximum height for camera and more intuitive set-up. Products with smaller box dimensions, which were associated with storability, allowed them to be portable and have lower costs of delivery.

Conclusion

The ideal features for a phone stand are a clamp or stand for the base and a clamp phone holder, with reasonable cost and storability.

Phone stand 4 was the most favourable candidate based on this review; however, further user feedback is required from trainees and trainers to select an ideal design suited for virtual surgical skills teaching.
EP.TU.838Educating the ITU Nursing Staff during the COVID-19 Pandemic: A Quality Improvement Project
Authors: Devarakonda Sreekar , Korula Pritish John
Published: October 2021

Aims

The nursing staff always plays a crucial role in the management of patients. This pandemic had put the ITUs under an undue burden, and the nurses faced an altogether new challenge. There was extensive use of various oxygen delivery systems and fastly emerging guidelines. So, there is an increased demand for the nursing staff to stay abreast with the situation. Hence a teaching program was organized for the ITU nurses.

Methods

Five academic sessions were conducted as a part of the first cycle of QIP in November 2020 under the guidance of nursing tutors and ITU consultants. These topics covered the respiratory system, including Severe Acute Respiratory Illness, Non-invasive and Invasive ventilation techniques, and ARDS. Feedback forms were collected and analysed after each session, which focused on the usefulness and relevance of content, teaching style, and the overall confidence in the topics.

Results

Audit of the feedback forms showed globally positive feedback and improvement in understanding amongst the nursing staff. Also, the confidence of nurses in these topics increased abundantly. Many of them expressed interest in attending similar sessions in the future.

Conclusions

Keeping the nursing staff up-to-date with the latest management guidelines is quintessential for patient safety. More so during this pandemic, where academic activities are becoming scarce, and protocols are rapidly changing. Further sessions on relevant topics will continue to enhance learning.
EP.TU.888Aortic dissection: Causes of delay in diagnosis and transfer, implications for patients, and how to improve
Authors: Blakley Megan , Poots Catherine , Ahmed Alsir , Joseph Jijin
Published: October 2021

Background

Aortic dissection is a common differential in patients presenting with chest pain. In Northern Ireland, there is one hospital with a cardiac surgical unit. Therefore, patients are diagnosed in district general hospitals and then transferred for intervention.

Over the past number of years it has been noted that there can be delays in the diagnosis and transfer of patients with aortic dissection to the cardiac surgery service. This study aims to identify any common reasons for this and develop a way to improve.

Methods

Patients operated on for aortic dissection from 2014-2019 in the Royal Victoria Hospital Belfast were included. Their notes and electronic care records were analysed, looking at time of initial presentation, time of diagnosis, and time of arrival to theatre.

Results

61 cases were analysed. Among those with delays in diagnosis, many were initially admitted medically or to cardiology wards for work up of their chest pain. When a medical cause was not found, scans were performed demonstrating aortic dissection. Some patients were discharged from ED after initial presentation and the diagnosis was found on re-presentation. There were delays in reports of some scans. Delay in diagnosis was a more common feature than delay in transfer.

Implications

Delay in diagnosis or transfer of these patients affects their prognosis. As a result of this study a pathway has been developed regarding diagnosis, initial medical management, and transfer of these patients and it is hoped this will be implemented in hospital departments in Northern Ireland in the future.
EP.TU.972Torsion of the gallbladder: a rare disease
Authors: Taylor Roland , Reid David
Published: October 2021

Gallbladder torsion was first described as early as in the 19th century but there are only about five hundred cases reported in literature. This rare disease predominantly affects elderly women with a median age of 77 years.The female to male ratio is 4:1. Though the exact etiology is unknown, certain anatomical variants of the gallbladder are thought to increase one's predisposition to the condition. Gallbladder torsion is very difficult to diagnose preoperatively and even with all the advancements in imaging techniques, only about a quarter of cases are diagnosed preoperatively. Most cases like the index case are diagnosed during surgery

Aim

To review the diagnosis and management of gallbladder torsion in 78 year old female patient who presented acutely to our unit.

Method

Discussion on the presentation, assessment, imaging and preoperative findings to as well as the management plan adopted.

Results

A review of intraoperative findings, postoperative recovery of the patient and literature on gallbladder torsion.

Conclusion

Since the first case of laparoscopic cholecystectomy for torsion in 1994, 105 further cases have been reported. Of this, 28% were managed by laparoscopic surgery whilst 8% resulted in a laparoscopy converted to open procedure. one case of ERCP detorsion has been reported. A high index of suspicion together with improved imaging techniques can help to significantly improve the preoperative diagnosis of gallbladder torsion. Early operative management usually results in a good prognosis. Innovations imaging techniques to help improve preoperative diagnosis will be discussed.
EP.FRI.5 Defining measurable data points for Emergency Surgical care
Authors: Pearson Katherine , Kowalska Aleksandra , Jannoo Shalaina , Bailey Ian , Elberm Hassan , Berry David
Published: October 2021

Aims

Service provision and assessing the impact of future innovations can best be assessed by accurate data collection.

Methods

We have devised a simple dataset and implemented prospective data collection detailing patient referral source and outcome (consecutive days from 19.08.20 to 06.01.21) of Acute Surgical admissions.

Results

2706 patient episodes.

Conclusions

These baseline figures demonstrate referral source and outcomes. Traditional Emergency Department referrals via the Surgical Registrar result in a noticeable difference in admission rates compared with novel pathways such as ASU Direct which allows admission from ED without discussion. These data are essential to facilitate proper evaluation of service delivery, the impact of novel pathways and would allow units to compare / combine results.
EP.FRI.48 Right iliac fossa pain in females: more than appendixes and ovarian cysts; Haemorrhagic Cyst in the Canal of Nuck: A Case Report
Authors: Davis Heather , Marshall Caitlin , Nahid Md Abu Kamal , Shah Ankur
Published: October 2021

Case report

A 43-year-old woman presented with acute onset migratory right iliac fossa pain, on a background of intermittently painful right groin swelling. CT demonstrated differential diagnosis of appendicitis besides an ovarian cyst. Diagnostic laparoscopy was undertaken with a view to diagnosis and treat possible appendicitis, ovarian cyst and inguinal hernia. To our surprise, a haemorrhagic nuchal cyst was seen intraoperatively, and duly aspirated. Post-operatively she recovered well and was discharged the same day.

Introduction

The Canal of Nuck is a small evagination of parietal peritoneum which accompanies the round ligament through the inguinal canal, in females. It is obliterated in the first year of life. When this remains patent, it can fill with fluid and result in the formation of cysts (akin to hydroceles in patent processus vaginalis).

In current literature there are only sixteen case reports of Nuck hydroceles in adults, with only one haemorrhagic cyst reported.

These are typically diagnosed in children, but occasionally present in women (aged 35.18 ± 3.27) with groin swelling and are frequently misdiagnosed as hernias. It is only when these woman are taken to theatre, that the correct diagnosis is discovered.

Conclusion

This case highlights the importance of considering Canal of Nuck cysts when women present with groin swellings, to ensure quick diagnosis and appropriate management is delivered under the correct speciality.
EP.FRI.101 Paediatric Appendicitis Score (PAS): A local trial of a risk prediction pathway
Authors: Lim Jie , Darwich Ayman , Paul Saati , Malik Afaq , Verma Keshav
Published: October 2021

Introduction

Right iliac fossa (RIF) pain remains the commonest acute general surgical presentation in children. Our centre had been an outlier compared with the national average in terms of negative appendicectomy rates. Thus, we designed and implemented a local pathway for risk stratification and management of children with RIF pain.

Methods

The first phase was a retrospective analysis of all appendicectomies performed between April 2018 and March 2019, in children aged five to seventeen years old. Pre-operative inflammatory markers, clinical signs, and histology findings were analyzed. Second phase involved designing a pathway utilizing Paediatric Appendicitis Score (PAS), a ten-point scoring system when assessing children with RIF pain. The final phase was a prospective analysis of appendicectomy results performed between August and November 2019, after implementing PAS pathway.

Results

92 cases were recruited in the first phase (mean age 12.3). 22 cases were analyzed in the final phase after implementing PAS pathway (mean age 10.9).  Our negative appendicectomy rates had reduced from 25% to 15.4%. In addition, we found that 96% of positive appendicectomies had either raised inflammatory markers (WCC or CRP), raised PAS (Score of ≥ 4), or both. 

Conclusion

There is noticeable difference in our negative appendicectomy rates since the introduction of PAS pathway. A diagnosis of appendicitis in a child with normal inflammatory markers and PAS score seemed unlikely. Our goal is to continue utilizing the PAS pathway in our department in order to reduce unnecessary surgeries in children.
EP.FRI.121 Unusual sites of colorectal cancer metastases – A complete systematic review
Authors: Alfred Joshua , Altaf Kiran , Titley-Wilson Gabriella , Shah Maya , Williams Ruby , Ahmed Shakil
Published: October 2021

Background

While colorectal cancer (CRC) usually metastasizes to liver, lungs and central nervous system, spread to more unusual sites is rarely reported in literature. We aimed to investigate unusual colorectal metastases (UCRM), their clinical course and disease progression.

Methods

MEDLINE, EMBASE and Cochrane Library were searched by independent reviewers to identify clinical studies to date that reported UCRM and relevant demographic/clinical data were extracted.

Results

We identified 349 patients, involving 28 sites (bone, musculo-skeletal, skin, brain/spinal cord, head, eye, oral mucosa, thyroid, mediastinum, heart, bronchus, breast, biliary/GI tract, stomach, pancreas, spleen, adrenal, urinary tract, inguinal canal, ovaries, vagina, vulva, testes, spermatic cord, prostate, penis) with male preponderance and median age of 59 years (IQR=54.5-65). These were diagnosed at a median interval of 18 months (IQR=6-36)) after a median follow-up of 12 months (IQR=6-22.5). More were metachronous (n = 210) with recurrence rate of 15.75%. Primary CRC staging revealed T3 in 61% (28%-T4), equal distribution of N0/N1 (38%/37%) and M0 in 85%. 74% of primaries were surgically resected (96%=adenocarcinomas) and 54% underwent adjuvant therapy. UCRM were resected in 45% of cases and showed same histology as primary. 30% had chemotherapy. Only 8% were palliated. Overall morality was 35.24%.

Conclusion

This is the first comprehensive review looking at clinical course and outcomes of patients with UCRM. Most of these developed in patients with primary T3/N0 staging. Outlook of these patients is comparable to those with usual metastatic disease. Judicious and rigorous surveillance is the key to early detection and timely management.
EP.FRI.181 Beyond the adenoma- carcinoma sequence. A review of the morphogenetic basis of colorectal cancer
Authors: Daniel Sudin , Patil Sangram , Iype Satheesh
Published: October 2021

Introduction

Looking beyond the adenoma carcinoma sequence researchers have discovered alternate morpho-genetic routes, and tumour biomarkers in colorectal cancer. This has caused a paradigm shift in the management, resulting in improved diagnosis, prevention, and delivery of tailored treatment aiming at specific molecular pathways.    

Aims, Methods

This review summarises

Methods

PubMed, Google Scholar, NLM searches based on aims and key words were conducted. Further, academically and clinically relevant searches were made if more information was required. When required, references of articles were also retrieved.       

Results

The two main theories regarding the morphological origins of colorectal cancer are the adenoma carcinoma sequence and the De-novo origins. The underlying genetic models are the (i) chromosomal instability pathway (CIN), (ii) the microsatellite instability pathway (MSI) and (iii) the CpG Island methylator phenotype (CIMP) pathways. Though unique, the pathways communicate with each other. The genetic fingerprinting of colorectal cancers has an impact on their tailored management and consequently a through grounding in the basics are essential for those in gastrointestinal subspecialties. 

Conclusions

Two morphologically distinct pathways and three unique genetic mechanisms have been described. There are significant interactions between them. Behaviours of sporadic and inherited colorectal cancer, their treatment and prognosis depend on our understanding of these mechanisms and the availability of targeted therapies to assist surgical resection.
EP.FRI.277 A Young Lady with Lower Abdominal Pain. Eosinophillic Enteritis; an uncommon cause for a common symptom
Authors: Lefroy Rebecca , Kalatzis V , Brookes Alastair
Published: October 2021

Aims

Abdominal pain presents frequently to the acute general surgical take with a huge variation in nature and, most importantly, in cause. The large number of common diagnoses are frequently discussed however, we present the case of a young lady with the uncommon diagnosis of eosinophilic enteritis as a primary presentation of lower abdominal pain. Here we present her case and review the current literature surrounding this condition and the group of conditions causing eosinophilia in the gastrointestinal tract.

Methods

A search of PubMed was performed, looking for research published within the last 50 years, regarding human subjects and published in English. This identified 16 review papers and 18 case reports. From these, current recommendations regarding investigation, diagnosis, management and follow up was assessed. We reviewed our case using clinical notes, clinic letters and investigations to evaluate our management of this case. 

Results

Our case represents an unusual case where not only did our patient suffer eosinophilic enteritis (the least reported of these group of conditions) but they also underwent surgery to reach diagnosis. Our review of the literature revealed that although our lady presented in an unusual fashion, this may well have prevented months of investigation. 

Conclusions

Eosinophilic enteritis is a rare condition, unusually seen or managed by surgeons. An awareness of this diagnosis and group of conditions is useful in the acute surgical setting as another differential for a common presentation. In our presented case, multidisciplinary management resulted in a swift diagnosis and favourable outcome for this patient.
Ep.Fri.329 Severe Acute Pancreatitis in Pregnancy Secondary to Hypertriglyceridemia – A Case Report and Literature Review
Authors: Fadipe Toks , Narayanasamy Sangara Narayanan , Thomas Pradeep
Published: October 2021

Background

Hypertriglyceridemia is a common and well characterized physiological phenomenon in pregnancy. Rarely does it complicate the pregnancy causing acute pancreatitis (APIP).  The majority of APIP cases arise secondary to gallstones. Hyperlipidaemia induced pancreatitis is a rarer cause with relatively worse outcomes with increased incidences of preterm delivery and pseudocyst formation.

Case Report

A 38-years-old woman at 29 weeks gestation presented with epigastric pain. The initial investigations revealed raised inflammatory markers, elevated amylase and hypertriglyceridemia. A diagnosis of APIP was made, prompting transfer to ITU. Foetal compromise necessitated an emergency Caesarean delivery. Post-partum, her clinical condition improved with NG feeding, bezafibrates and IV antibiotics. Her baby was transferred to a nearby tertiary neonatal unit with no immediate complications.

Discussion

Hyperlipidemia induced APIP requires intensive treatment. Various medical treatments for hypertriglyceridemia, such as fibrates and insulin infusions, have been described. Plasmapheresis in severe cases may benefit reducing the triglycerides level. Considering maternal and foetal morbidity and mortality, early diagnosis and multidisciplinary input is required to treat and reduce complications.

Conclusion

APIP is a serious and rare complication of pregnancy. The current lack of consensus on treatment of APIP warrants further inquiry, to minimise poor neonatal outcomes.  The merits of routine screening for gestational hypertriglyceridemia are yet to be elucidated; the morbidity associated with APIP, coupled with its rising incidence justify a targeted screening programme.

Keywords

Pancreatitis, Pregnancy, Hypertriglyceridemia.
EP.FRI.422 Over 100,000 COVID-19 deaths calls for a radical reform of health and care system in the UK
Authors: Bodapati Shruti , Gambhir Raghvinder
Published: October 2021

Aim

With over 100,000 deaths due to COVID 19 and still counting, is it a wake-up call to overhaul our health and care system.

Methods

Review of NHS England, Office of National Statistics (ONS) and Public Health England (PHE) data to determine where the deaths occurred and what role did the primary care, secondary care, play in delivering the service.

Results

The data shows that it took 40 weeks to get to the first 50,000 deaths and just another 10 weeks to add another 50,000 deaths. Among the OECD UK ranked number 1 for deaths due to COVID 19.  69.9%   of deaths occurred in hospitals, 24.1% in care homes, while 4.9% occurred at homes. The primary care effectively remained shut for face to face consultation, effectively leaving people to manage themselves at home on their own or reach A & E when things got worse. The hospitals where overwhelmed and coped by shutting out all elective work and converting normal wards to COVID wards and that is where the maximum deaths occurred. There were over 80000 excess deaths above the five-year average.

Conclusion

We may have been underprepared for the first wave but had the PPE and plans to battle the second wave yet we had the highest mortality in Europe. Is it a price we paid for our disjointed health and care system. There is a need for radical changes to prepare for future disasters.
EP.FRI.477 Neutrophil-To-Lymphocyte Ratio (NLR) as a Predictor of Acute Appendicitis
Authors: Tasleem Sadia , Gulnaz Nadia
Published: October 2021

The most common reason for an acute surgical assessment of the abdomen is acute appendicitis with a rate as high as 30 %There is a   lifetime risk of 8.6% and 6.7% in men and women respectively. The common age for presentation is between that of 5 and 4.4 while 28 is the median age.

The objective of this study was to determine   the diagnostic accuracy   of (NLR) neutrophil-to-lymphocyte ratio to prognosticate severe/ complicated appendicitis by taking histopathology of the appendix as a gold standard.

Methodology

This cross-sectional validation study was conducted at the department of surgery and western vascular institute, University College Hospital Galway, Ireland retrospectively for a period of 6 months in 2016 And approximately 186 cases with appendicitis were enrolled in the study.

Results

The mean age of patients in this study was 29.15±9.54 years, the ratio of male to female was 1:1.7.   The sensitivity, Specificity was 97.1% and   25.2% respectively and the diagnostic accuracy of NLR was 38.7% taking histopathology as the gold standard.

We observed that the sensitivity, specificity, and diagnostic accuracy of NLR   changes with the duration of symptoms in days, the sensitivity, specificity, and diagnostic accuracy of NLR was 100%, 17.0%, and 28.7%    respectively for <3days   and 92.3%, 93.75% and93.1% respectively for >3 days.

Conclusion

According to our study results the (NLR) neutrophil-to-lymphocyte ratio is a highly sensitive tool to predict severe/   complicated appendicitis by taking histopathology as the gold standard, but with the low value of diagnostic accuracy in terms of specificity.
EP.FRI.479 Clinical accuracy of u/sound combined with inflammatory markers in Acute Appendicitis
Authors: Gulnaz Nadia , Tasleem Sadia , Abdullah Farooq
Published: October 2021

Traditionally acute appendicitis has been a clinical diagnosis based on patients' history and physical examination, but the accuracy of clinical diagnosis ranges from 70-95%. Pre-operative diagnosis of acute appendicitis still remains an enigmatic challenge, because no single test alone can reduce the rate of negative appendectomy. Hence some authors have recommended a combination of two or more investigations to increase accuracy and therefore the use of imaging is gaining support.

The objective of the study was to determine the clinical accuracy of ultrasound, combined with inflammatory markers such as CRP, WBC, and neutrophilia keeping histopathology as the gold standard.

Methods

The study was conducted in a Tertiary care hospital in Peshawar from September 2014 to March 2015 on 250 patients who were clinically diagnosed with acute appendicitis. All these patients underwent u/sound scanning in addition to blood tests.

Findings

In this study, WBC had the highest sensitivity (77.68%) followed by neutrophil% (69.96%), CRP(67.10%), and U/Sound (62.96%) respectively. While U/Sound had the highest specificity (70.59%) followed by CRP and TLC (64.71% each) and neutrophil% (58.82%) respectively. When all the four tests were combined the sensitivity, specificity, (99.17% and 98.45%) increased significantly. When all four tests were negative, appendicitis could be safely ruled out.

Conclusion

Acute appendicitis is very unlikely and surgery can be safely deferred in these patients when all tests are negative thereby reducing the negative appendicectomy rates.
EP.FRI.495 A retrospective audit of electronic venous thromboembolism risk assessment compliance across three surgical wards in a district general hospital
Authors: Banwaith Tavlene , Qayum Mohammed Kaif , Arun Chokkalingam , Nawaz Ghulam
Published: October 2021

Aims

Venous thromboembolism (VTE) is the leading cause of preventable hospital deaths; with hospital-acquired VTEs accounting for 50% to 60% of all VTEs seen. This project aims to review and improve the number of VTE risk assessments completed for surgical in-patients.

Methods

This retrospective, cross-sectional study involved data collection from surgical in-patients (n = 648) over three consecutive months, using an electronic VTE risk assessment tool. Data was categorised into ‘First VTE prophylaxis risk assessment completed within 24 hours of admission’ and ‘Second VTE prophylaxis risk assessment completed within 48 hours of admission’. This was further sub-categorised into surgical specialties. Results were presented in departmental meetings and educational posters were displayed. The study was re-audited using the same method over one month (n = 216).

Results

Results demonstrated improvement from the initial audit cycle, particularly in relation to the mean number of VTE risk assessments completed for patients undergoing breast surgery (100% from 95.3%), colorectal surgery (93.3% from 90%) and general surgery (88.0% from 86.6%). The mean number of first VTE risk assessments completed in 24 hours across all surgical wards remained above 65%, whilst the mean number of second VTE risk assessments completed in 48 hours improved from 36.1% to 47.6%.

Conclusions

Variation in compliance is still evident across the surgical in-patient wards. Going forward, responsibility to complete outstanding VTE risk assessments will be handed to the FY1 on the late shift. Following this intervention, a further audit cycle will be performed, with the aim of 100% compliance in VTE risk assessment completion.
EP.FRI.510 The Management of Hyperkalaemia in Acute General Surgical Inpatients
Authors: Karadaghi Rezhaw , Sagar Joseph , Bullingham Roberta , Mathur Pawan
Published: October 2021

Aims

Hyperkalaemia is very common in hospitalised patients especially in peri-operative settings. It is associated with increased length of stay, morbidity and mortality. Here we review the management of hyperkalaemia in emergency surgery inpatients compared to the recommended national guidelines. With the identification of any gaps, we will introduce a new protocol to standardize practice as the basis of our educational intervention.

Methods

A retrospective observational study of adult surgical inpatients between July and December 2020. 20 patients with a K+ >5.5 during their inpatient stay were identified. Data on their clinical management was extracted from their electronic data record and handover database and analysed.

Results

Of the 20 patients identified, 13 had mild (5.5-6), 3 moderate (6-6.5) and 4 severe (>6.5) hyperkalaemia. Mortality was 0 and 100% of patients with K + ≥6.5 received timely emergency treatment in line with guidelines. However, there was a wide variation in the type of treatment given with 100% of cases not aligning with current guidelines. Additionally, in only 40% of cases was the hyperkalaemia documented and only 20% of patients received an ECG; a recommendation even in mild cases. 

Conclusions

There is a need to standardise practice in the clinical management of hyperkalaemia and align with recent, validated guidance. A clear and easily accessible algorithm reinforced by an educational intervention to junior doctors may improve the management of high potassium in surgical inpatients and improve outcomes. Following this intervention, the standard will be re-audited.
EP.FRI.583 Re-Audit of the Quality of Operation Notes
Authors: McAuliffe Orlaith , Aboulela Ahmed , Mohamed Mohamed
Published: October 2021

Aims

High quality operation notes are crucial for the safe management of surgical patients. The Royal College of Surgeons Good Surgical Practice (2014) describes eighteen separate pieces of information that should be included in operation notes. Our aim was to determine whether the quality of operation notes have improved since the introduction in our hospital in 2015 of an electronic proforma to record these notes.

Methods

We conducted a retrospective audit of operation notes between 28th October and 19th November 2020 based on the RCS guidelines. These results were compared to those of our 2015 audit.

Results

Of the seventy eight operation notes analysed in this re-audit, twenty eight percent were produced using the electronic proforma compared to forty five percent in 2015. In our re-audit a significantly higher proportion of notes had records of whether operations were elective or emergency (p < 0.01), intraoperative diagnosis (p < 0.01) and estimated blood loss (p < 0.05).Compared to the 2015 audit data there was a significant improvement in recording whether or not the surgery was elective or emergency (p < 0.0001).

Conclusion

In this audit we noted a disappointing decrease in proportion of operation notes that were produced using the electronic proforma. We also noted that operation notes produced using the electronic proforma were of higher quality compared to those that were not. We need to increase awareness amongst surgeons in our hospital of the benefits of using the electronic proforma to improve the quality of operation notes.
EP.FRI.614 An Atypical Case of Small Bowel Obstruction in the Virgin Abdomen: Case Presentation and Literature Review
Authors: Chouari Tarak , Khan Hamza , Gala Tanzeela , Ceraldi Serena
Published: October 2021

Aims

The management of post-operative adhesional small bowel obstruction (SBO) has shifted from the historical motto of “the sun should never rise and set on a complete SBO” to a non operative approach in selected patients. Despite this shift, the operative management of patients with SBO with a virgin abdomen is still encouraged. 

Methods

We present an atypical case of SBO managed conservatively with resolution, without surgical intervention. A literature review is conducted and our case compared with the current literature. A treatment algorithm is presented. 

Results

A 57 year old with a virgin abdomen presented with vomiting and abdominal pain. Computed tomography was consistent with mid to distal SBO proximal to the terminal ileum, in the context of a high riding caecum. He was managed conservatively. Symptoms resolved within 12 hours without gastrograffin. Gastrograffin was subsequently given to ensure contrast was present in the large bowel. At 6 month follow up he remains symptom free.

Discussion

Many advocate surgery is the cornerstone of the management of SBO in the virgin abdomen. There is little evidence to support this. Recent emerging evidence challenges this view. Ultimately the clinical evaluation of the patient is paramount in selecting which patients can be managed conservatively. A longer interval to operation may carry greater risk of ischaemia and bowel resection. Therefore careful patient selection and serial examination is vital and one should have a low threshold for early operative intervention in the patient which isn't settling. Follow up should be tailored to each patient.
EP.FRI.668 Surgical Clinicians’ Views on the Current Admission Booklet in NHS Fife
Authors: Chan Deona Mei Lam , Yalamarthi Satheesh
Published: October 2021

Aim

The use of an admission booklet for hospital admission has become a standardised practice. This survey reflects on the surgical clinicians’ views on the use of our hospital admission booklet in NHS Fife for surgical admissions. 

Methods

An online questionnaire was sent to the clinicians (Advanced Nurse Practitioners, junior doctors to consultants) of the surgical department via Google Questionnaire. The clinician’s views on the use of the admission booklet and VTE prophylaxis were surveyed. Data from the responses were collated.

Results

23 clinicians took part in the survey, with an average 18.30 months worked in the department. 77.3% indicated if given a choice they would use the admission booklet. 63.6% prefer the booklet due to familiarity, 54.3% feel the laid out is good and 31.8% prefer it due to the ease of completion. Although a majority of clinicians prefers the use of the booklet, 59.1% indicates they would like the booklet to be changed, in general to a shorter booklet, with more space for relevant past medical history and social circumstances. 68.2% indicated VTE prophylaxis assessment make an influence to their prescribing of VTE prophylaxis. 

Conclusion

This survey identified most clinicians are in favour of the use of the admission booklet and VTE prescribing are influenced by the VTE assessment in the admission booklet, although they would welcome some changes to a shorter booklet with more space. We recommend some updates to the admission booklet more tailored to the use for the surgical department.
EP.FRI.700 NCEPOD Acute Bowel Obstruction Report 2019: A pilot study for review of quality of care provided to patients with acute bowel obstruction in a Surgical Emergency Unit
Authors: Dey Abhishek , Rudzats Antons , Gilmour Jeffrey
Published: October 2021

Aims

Acute bowel obstruction is one of the commonest surgical emergencies posing various diagnostic and therapeutic challenges. A review of care titled ‘Delay in Transit’ by NCEPOD delineated inadequacies in the pathway of care for patients with acute bowel obstruction nationwide, highlighting areas of improvement. This audit aims to assess key elements of management pathway in our centre and compare it to national statistics. 

Methods

A retrospective case note analysis was conducted for 24 randomly selected patients, aged above 15 years, admitted with a clinical diagnosis of acute bowel obstruction between December, 2018-December, 2019.

Results

Summary of some of NCEPOD recommendations, national and local performance

The mean time to diagnosis was 8.5±6.6 hours, which was delayed if abdominal X-ray preceded the CT. Poor consultant review times may reflect failure to capture on records.

Conclusion

The management pathway, although faring well in some criteria, has scope for further improvement. Plans for an audit with a larger sample size will be implemented along with an enhanced pathway.
EP.FRI.763 Impact of COVID-19 on the rates of emergency laparotomies at an acute general hospital in the United Kingdom
Authors: Wright Curtis , Kirkham Simon , Millward Alex , MacAdam Robert
Published: October 2021

Aims

The aim of this study was to analyse if the COVID-19 pandemic had any effect on the number of emergency laparotomies performed each month at a single NHS Foundation Trust.

Methods

This single-centre retrospective observational study included all patients that underwent an emergency laparotomy that was registered as part of the National Emergency Laparotomy Audit (NELA) at Whiston Hospital in Merseyside, UK, between January 2019 and October 2020. The rates recorded throughout March and April 2020 (COVID) were then compared to the preceding 12 months until the first COVID death was recorded in the UK on March 5th, and the 6 months following the initial national lockdown.

Results

The number of emergency laparotomies performed each month declined from an average of 14.7 (95% CI 13.2 – 16.1) in the preceding 12 months to 5 during COVID (95% CI 5 – 5); a decrease of 65.9%. Following the easing of lockdown rules in early May, this decline was partly reversed with an average of 9.7 (95% CI 8.9 – 10.5) performed each month until October 2020, reflecting a 34.1% reduction from the pre-COVID baseline. The percentage of patients that achieved the NELA best practice tariffs also fell during COVID to 71% from an average of 79.3% (95% CI 76.0 – 82.7) due to fewer high risk laparotomies being admitted to Critical Care post-operatively.

Conclusions

During the COVID-19 pandemic, emergency laparotomy rates fell and have only partially recovered to pre-pandemic rates. Post-operative admission to critical care for high risk laparotomies also declined during this period.
EP.FRI.771 National audit on VTE prophylaxis for lower limb injuries treated in a plaster cast
Authors: Karagiannidis Georgios , Toma Omar
Published: October 2021

Aims

Audit to assess Orthopaedic departments’ compliance with NICE guidelines on Venous thromboembolism (VTE) prophylaxis published in 2010, specifically looking at VTE practices for patients with lower limb injuries treated in a plaster cast.

Methods

A telephonic survey was carried out on junior doctors within orthopaedic departments of 66 hospitals across all regions of England. A questionnaire was completed regarding VTE risk assessment, prophylaxis and hospital guidelines etc. Data collected from August 2016 till February 2017.

Results

83% (n = 55) of trusts routinely give VTE prophylaxis to these patients. 96% (n = 64) give Chemoprophylaxis of some sort. Formal VTE assessments are performed in 81% (n = 54) and 77% (n = 51) have a local VTE prophylaxis policy.

Conclusions

We conclude that Orthopaedic departments across England have increased compliance with NICE guidelines for VTE prophylaxis. However there is considerable variation in practice, especially in duration and chemoprophylaxis agent. We attribute this to the lack of specific NICE guidelines for this cohort of patients. We aim that this study can influence NICE to introduce added guidance that will standardise practice.
EP.FRI.798 Emergency surgery: Acute intestinal obstruction – how are we doing three years post NASBO guidelines?
Authors: Lafaurie Guillaume , Butterwoh James , Iakovou Angeliki , Engeldow Alec
Published: October 2021

Aims

10% of emergency surgical admissions are due to acute intestinal obstruction. If surgery is required, the mortality is raised to 10%. The latest 2017 National Audit of Small Bowel Obstruction (NASBO) has identified several key investigative and therapeutic targets. Our aim is to look into our clinical practice and compare it to the NASBO standards. 

Methods

In a district general hospital (DGH), we prospectively collected data of 30 patients coming consecutively with acute small bowel obstruction looking into imaging, conservative management, surgical management and outcomes. 

Results

30 patients were included in this study with mean age of 69 years (24-88 years old), with an average hospital stay of 7 days (1 - 46 days). Bowel obstruction aetiology included: 15 secondary to adhesions, 5 hernias, 4 crohns strictures and others. 28 patients had AXR on admission as well as CT with average time to CT of 13.4 hours from admission. A third received water soluble contrast, on average 32.9 hours after admission. A third patients required surgery, undertaken on average 60 hours from admission. The outcomes showed 25 recovering well and going home and a 30-day mortality of 13% (4/30). Seven patients received dietician input, two patients were reviewed by geriatricians before surgery and none post-operatively. 

Conclusion

From a previous review of our practice we improved in terms of instigating timely investigations and prompt decision to surgery. However, we need to clearly work towards a more holistic approach including dietician and geriatrician input within the complex post-operative management of these patients.