bluuebunny/crossref_metadata_2025 huggingface dataset:
2 Medical student learning in the operating room: Through the lens of the surgical teacher
Authors: El-hassan Mohammed
Published: August 2023

Aims and Objectives

The aims were to deduce surgeons' experiences and challenges of teaching medical students in the operating room and solutions to overcome them. The objectives to achieve this was using pre-existing published and grey literature relating to surgeons' experiences teaching medical students in the operating room.

Methods

A systematised literature review based on a comprehensive search strategy, including quality assessment, was conducted. Two databases, MEDLINE and EMBASE, were searched since inception until March 2022. Grey literature was searched for in The Royal College of Surgeons in Ireland (RCSI) bulletin, as they publish relevant manuscripts related to surgical education. Title and abstract review was performed by two reviewers on 220 papers. The identified studies were then assessed against the eligibility criteria.

Results

A total of 8 papers were included in this review. Following the analysis of the literature, the commonalities captured were categorised into themes for thematic analysis. Themes included student preparation and organisational aspects, attitudes towards active participation of learner, student learning priorities, undergraduate curricula awareness and learning objectives, educational environment of the operating room and teaching techniques and engagement in the operating room.

Conclusion

Numerous commonalities were captured in the literature, replicable in multiple countries, highlighting the need for a standardised undergraduate surgical curriculum. Many of the challenges of teaching identified by surgeons are modifiable, therefore more initiatives need to be in place to extract the educational potential in the operating room.
60 Mesenteric defect closure and the rate of internal hernia in laparoscopic Roux-en-Y gastric bypass: A systematic review and meta-analysis
Authors: Muir Duncan , Choi Byung , Clements Caterina , Ratnasingham Kumaran , Irukulla Shashi , Humadi Samer
Published: August 2023

Introduction

Laparoscopic Roux-en-Y gastric bypass (LRGB) is an increasingly popular operation as rates of obesity rise. Internal hernias pose a worrying complication. This meta-analysis aimed to determine if internal hernia rates were reduced by closure of the mesenteric defects at primary operation.

Method

A systematic review was performed identifying all observational and randomised studies comparing internal hernia rates in patients whose mesenteric defects were closed vs not closed during LRGB.

Results

14 studies were included, totalling 20,553 patients undergoing LRGB. There was a significant reduction in internal hernia rate at both Petersen’s and the Jejunojejunostomy (J-J) defect when closed at operation. The rate of re-operation for suspected small bowel obstruction was also lower in the closure cohort. There was no difference in anastomotic leak or perioperative bleeding between closure and non-closure patients. Similar efficiency was observed when sutures were used to close the defects compared to clips and staples.

Conclusion

Mesenteric defect closure is reducing internal hernia rate as well as re-operation for suspected small bowel obstruction. The closure method of choice remains debatable, and further studies are required to determine this.
118 Bouveret Syndrome: A Rare Case of a Huge Gallstone causing Gastric Outlet Obstruction
Authors: Sabir Alifa , Mushtaq Ruqia , Arshad Rabia , Khalid Noor , Khan Aurangzeb , Hanif Muhammad
Published: August 2023

Introduction

Bouveret syndrome is a rare case of gallstone ileus resulting from an acquired fistula connecting the gallbladder and either the stomach or duodenum and cause intestinal obstruction.

Case Summary

A 85-year-old female presented with epigastric pain non-bilious vomiting and absolute constipation for five days. She patient was tachycardiac and was dehydrated. Abdomen was distended. Bowel sounds were absent. Digital rectal examination was unremarkable.

Abdominal radiography did not demonstrate pathological air-fluid levels, rather revealed a dilated gastric shadow, suggestive of gastric outlet obstruction. The patient was immediately managed with nasogastric intubation and intravenous hydration. Subsequent esophagogastroduodenoscopy (EGD) was planned to rule out carcinoma owing to the age of the patient.

EGD revealed a dilated stomach and a hard, golf-ball-sized gallstone in the third part of the duodenum. The scope could not be passed beyond the impacted stone, nor could it be extracted endoscopically. CT tomography revealed a distended stomach with a large gallstone obstructing duodenum and pneumobilia . One-stage surgical procedure was planned. Intraoperative findings included a thick-walled gallbladder with surrounding inflammation and a fistulous tract connecting the gallbladder with the duodenum. A gallstone measuring 3.7cm in diameter was retrieved from the third part of duodenum via enterotomy. The fistulous tract was closed, and cholecystectomy was performed and drain was placed. Patient was discharged on 4th postop day.

Conclusion

Bouveret syndrome is an infrequent presentation causing gastric outlet obstruction and is often overlooked owing to its rarity. High index of suspicion is necessary when patients present with bowel obstruction and a history of gallstones to prevent morbidity and mortality from Bouveret syndrome.
131 Cholecystectomy operation notes - a review and core trainee survey
Authors: Kho Jason , Kuan Jen Yee , Shetty Vinutha , Date Ravindra , Rajendra Ilayaraja
Published: August 2023

Aim

The “Good Surgical Practice” document by Royal College of Surgeons (RCS) England, in line with GMC’s “Good Medical Practice” emphasises the importance of “clear operative notes for every procedure”. The importance of clear documentation is well-established, facilitates effective handover and represents a legal document. A study was conducted to assess current documentation standards, including a survey amongst core surgical trainees on the use of a proforma for documenting cholecystectomies.

Methods

A retrospective review of cholecystectomy operation notes collected from hospital database was performed between February 2022 and July 2022. Operative documentation was compared to the guideline published by RCS England. Specific information relevant to cholecystectomy operation were reviewed; critical view of safety/Calot’s triangle, number and type of clips, gallbladder dissection difficulty and spillage of bile/stones. Compliance to RCS standards was considered satisfactory at ≥80%.

Results

109 typed operation notes were reviewed. Majority of information including date and time (100%), procedure name (99%), name of surgeon and assistant (100%), operative findings (100%) and post-operative care instructions including VTE prophylaxis (92%) were clearly documented. Shortfalls in documentation included priority of operation (63%), intraoperative complications (66%), gallbladder dissection difficulty (53%), anaesthetist name (52%), removal of ports under vision (33%) and local anaesthetic details (70%). Survey of eight core surgical trainees found a consensus that a proforma would improve understanding and documentation of the procedure.

Conclusion

The use of an operation note proforma in cholecystectomies could improve patient care and compliance with RCS guideline, and act as a learning modality for surgical trainees.
133 A review of analgesia prescription in patients admitted with Neck of Femur Fractures
Authors: Kukreja Madhav , Satar Zabina , Jalal Seyed Ramin , Makki Daoud
Published: August 2023

Background

Analgesics are amongst the most commonly prescribed drugs within a hospital setting. Often prescribed based on clinical judgement and perceived pain, without formal evaluation. They are integral to patients comfort and experience. A study in 2008 showed that when patients had moderate to severe pain, they had only about a 50 percent chance of obtaining adequate pain relief, while another study in 2010 showed that the average cost per patient for readmission due to pain was $1,869 (≈£1,571) per visit.

Aim

Methods

Review of drug charts of all the neck of femur patients admitted from 04/10/2022 to 22/10/2022 (30 in total). Recorded patient pain score extracted from admission clerking.

Results

Conclusion

Pain score tends not to be recorded at the time of admission and analgesia is prescribed based on clinical judgement. Therefore, a poster of new Trust guidelines for patients admitted with Neck of Femur Fractures (NOF) was circulated amongst Orthopaedics department and A&E in Watford General Hospital, United Kingdom.
138 Overview of the management of acute uncomplicated diverticulitis in a District General Hospital
Authors: Chu Ee Earn , Thomas Kerushan , Mostafa Mohamed , Robertson-Jones Beatrice , Rahman Atiqur , Alkhusheh Moutaz
Published: August 2023

Aims

Acute diverticulitis is a condition where diverticula, which is the outpouching of the large intestinal mucosa; becomes inflamed or infected. We took recommendations from ACPGBI, WSES and NICE guidelines on the management of acute uncomplicated diverticulitis and compared our practice with them in a district general hospital.

Methods

Retrospective data collection of 50 consecutive patients presented to A&E with CT-proven acute uncomplicated diverticulitis was performed. Data included demographic distribution, clinical, laboratory and radiological features on presentation, treatment history and follow-up plans.

Results

All 30 patients being admitted with antibiotics, had modified Hinchey type 1a or 1b diverticulitis. However, 12 of these patients were over the age of 65 and another four had CRP >150. In the discharged group, all 20 patients had type 1a or 1b diverticulitis and almost all were discharged with antibiotics. However, 2 of these patients had CRP >150 and another five of them were over the age of 65. A request for the endoscopic procedure was placed for all 50 patients however 36 of them are still on the waiting list. Almost half of these patients were discharged without any written advice on discharge about the diverticular disease.

Conclusions

After analysing the data, more than half of these admitted patients could have been managed in ambulatory care without antibiotics. Conservatively managed diverticulitis patient doesn’t need routine endoscopic evaluation. All patients should have written advice given about their condition. We are in the process of making a pathway to ensure safe and cost-effective management for patients with acute diverticulitis.
193 A rare cause of small bowel obstruction- Obturator Hernia
Authors: Loganathan Santhosh , Gul Rahman , Ahmed Tarig
Published: August 2023

Obturator hernias are clinically challenging to diagnose, and the incidence reported in the medical literature is between 0.05% to 2.2%. This is commonly seen in thin, elderly female patients. Computed tomography is the gold standard for diagnosis. The mortality has been reported as 12-70%. Here, we present a 90-year-old female with complaints of abdomen pain, distention, vomiting and bowels not opening for a few days. She had a background of severe frailty, poor mobility and comorbidities such as hyperlipidaemia and mild cognitive disorder. On clinical examination, her abdomen was distended on examination with diffuse tenderness. Her blood investigations were normal, apart from CRP 26mg/L. Her abdominal X-Ray showed dilated loops of small bowel in the central abdomen. Computed tomography of the abdomen and pelvis showed high-grade mechanical distal small bowel obstruction with a transition point to probably in the right iliac fossa. She had an emergency laparotomy and was found to have an obturator hernia with bruised but viable small bowel. Hernial contents reduced. Postoperatively she developed hospital-acquired pneumonia, for which she was treated with antibiotics and later discharged. It is a rare case with a high chance of getting missed on clinical examination. In case of diagnostic uncertainty, CT should be promptly performed. Knowledge about this rare acute surgical condition is required for clinical suspicion, appropriate investigation and diagnosis, as the mortality is high.
195 Small bowel obstruction through peritoneal defect herniation after a totally extraperitoneal hernia repair- A unusual complication case series
Authors: Loganathan Santhosh , Chapman Stephen , Whittaker Laura , Newman Chris
Published: August 2023

The rates of major complications associated with totally extraperitoneal (TEP) inguinal hernia repair are reportedly low, and intra-abdominal complications are rare. However, here we present a case series with small bowel obstruction through herniation of the small bowel into the peritoneal defect after a TEP, which is a rare complication.

The first case, a 71year old male two weeks post-TEP left inguinal hernia repair, presented with abdomen pain, vomiting, distension, and bowels not opened for three days with elevated inflammatory markers. Computed Tomography of the abdomen and pelvis (CTAP) demonstrated small bowel obstruction secondary to a loop of inflamed small bowel adherent to the anterior abdominal wall in the left inguinal region. During emergency diagnostic laparoscopy found to have a small bowel loop passing through a peritoneal defect just lateral to the medial umbilical ligament, converted to laparotomy, and small bowel resection was performed. In the second case, a 61-year-old male presented with similar complaints and elevated inflammatory markers two days post bilateral TEP. The CTAP showed dilated small bowel with a transition point in the left iliac fossa. Emergency diagnostic laparoscopy found a peritoneal defect on the left groin with small bowel herniation. The bowel-reduced back and the defect was closed with sutures.

Small bowel obstruction due to a peritoneal defect after TEP is a rare but potentially fatal complication. Therefore, the clinician should have a low threshold for surgery, as it is unlikely to resolve with conservative treatment like the adhesional bowel obstruction.
196 Long-term mortality after emergency laparotomy for malignancy – a single centre, retrospective study
Authors: Leung Chee Sian , Ng Jene , Clark Maggie , Moug Susan , MacDonald Scott
Published: August 2023

Emergency laparotomy (EmLap) has a variable 30-day mortality rate (8.7-14%) but less is known about the long-term outcomes. We aim to describe long-term mortality in those undergoing EmLap for malignancy, and also to explore whether those who undergo EmLap have an increased incidence of new malignancy.

A retrospective single-centre review of a prospectively maintained database of patients undergoing EmLap in 2018 at a district general hospital was performed. Inclusion criteria was per NELA guidelines. Clinical data was assessed from electronic records until December ’22.

n=86 patients were identified (Mean age-65.9years) with 33.7% having malignancy at EmLap (n=17 pre-existing, n=12 new diagnoses).

30 day, 90 day and 1 year mortality rates were 10.5%,15.1% and 23.3% respectively, and by time of follow-up, almost half died (48.8%). There was no significant difference in the 30 or 90 day mortality between malignant and benign pathologies, however, the long-term mortality was higher in the malignancy group (1 year-41.4%v12.5%, p=0.002; By-time-of-follow-up -69.0%v27.8%, p<0.0001). The long-term mortality of those with new malignancy at EmLap was higher than those with pre-exisiting malignancy (83.3%v58.8%, p<0.005), with no differences in short term-mortality.

n=3 patients developed a new primary malignancy by time of follow-up, including 2 females in their 70s who developed primary lung cancer, which is higher than normal expected rates for this cohort.

EmLap for malignancy has higher long-term mortality rates than for benign disease, but there is no difference in short-term mortality. There may be an association between EmLap and developing new malignancy, potentially due to the induced inflammatory response, but larger scale research with an appropriate control group is required.
226 The Liberal Use of Magnetic Resonance Cholangiopancreatography (MRCP) can be switched over to its Selective use to detect choledocholithiasis
Authors: Elhassan Ali Mohamed
Published: August 2023

Gallstone disease is known in 10-15% of adults in Western populations. Cholangiopancreatography (MRCP) is the investigation of choice for choledocholithiasis; however, its use is varied, and guidelines are not well defined. The National Institute for Health and Care (NICE) guidelines recommends MRCP to be done when common bile duct (CBD) dilatation ≥ 8mm or liver function tests (LFTs) are abnormal but do not quantify this further. The liberal use of magnetic resonance cholangiopancreatography (MRCP) is gaining popularity as a roadmap prior to cholecystectomy, aiming to assess primarily for the presence of migrated gallstones within the cystic duct or common bile duct, as well as providing information regarding the anatomical features of the extrahepatic biliary tree on an individualised basis .Due to these reasons MRCP’s at times are done unnecessarily which creates economic burden and restricts access to patients in real need of imaging slots

The aim of this retrospective study was to identify whether magnetic resonance cholangiopancreatography (MRCP) can be used selectively in patients with deranged liver enzymes with gallstone disease to detect choledocholithiasis, based on liver function tests (LFTs) and ultrasonography appearance.
284 Quality improvement in venous thromboembolism (VTE) risk assessment
Authors: Hammett Felix , Wilkins Alexander , Menon Rohan , Shah Murium , Chang Lydia
Published: August 2023

Aims

To improve the rates of venous thromboembolism (VTE) risk assessment on the elective Upper GI surgery ward in a tertiary hospital.

Methods

A standard of 95% completion of VTE risk assessment within 24 hours of admission was set, in line with our trust policy and NICE guidance. Initial data collection for one month was followed by implementation of measures to improve rates of assessment: raising the issue in our departmental governance meeting, allocation of responsibility to ward based junior doctors for daily checking and completion of assessments and prescriptions, and fortnightly snap audits to check progress. Data was collected from electronic patient records to evaluate the impact of these measures in the subsequent two months.

Results

Initially, only 75% of VTE assessments were completed. Following the interventions, compliance increased to 89% and subsequently to 98.5%.

Conclusion

VTE assessment is a mandatory requirement for all admissions with the potential for serious harm if the risk is not assessed and managed appropriately. Compliance was initially poor, falling well below our standard. Following simple interventions and active engagement from junior doctors, this was greatly improved and sustained over two months. Moving forward, we anticipate the main issue to be longevity as junior doctors rotate through the department. We recommend highlighting the issue in departmental induction and allocation of responsibility for ongoing quality improvement to rotating juniors in the role of a ‘VTE champion’. In future work we aim to assess the correlation between improved compliance with risk assessment and incidence of VTE.
320 Surgical Site Infections (SSIs)- Are you doing your part to prevent them?
Authors: Agbedare Oluwabukola , Lingam Gita , Kirmani Naveed
Published: August 2023

Aims

(1) To evaluate the current literature regarding prevention of surgical site infections (SSIs). (2) To assess our General Surgery department SSI rate. (3) To implement changes within the department that are reflective of current evidence/guidance. (4) To re-audit our SSI rate post implementation of changes.

Methods

Evaluated and summarised 3 studies published in 2022 relating to the use of surgical care bundles to reduce SSIs. Collected post- operative laparotomy data within 2022; primary outcome SSI prior to discharge. Secondary outcomes: organism grown on wound culture, prolongation of hospital stay and other hospital acquired infections. Trust data and literature review presented a local department meeting. Consultant Surgeon cohort concluded which changes were to be implemented (pre-closure glove change, new closure equipment set, wound irrigation, anti-microbial sutures, use of wound retractors and negative pressure wound therapy). Post-operative laparotomy wound data recollected after changes.

Results

Clear literature evidence in support of surgical care bundles. Pre-closure glove change, new closure equipment set, wound irrigation, anti-microbial sutures, use of wound retractors and negative pressure wound therapy all found to contribute to a statistically significant reduction in SSIs. Implementation of these changes led to a reduction of SSIs within the department.

Conclusions

SSIs are the most common surgical complication worldwide. They lead to increase morbidity/mortality, prolonged hospital stays and increase economic burden. Recent literature has highlighted simple measures to reduce SSIs. Implementation of these measures has led to a department wide reduction in SSIs.
359 Confidence levels in junior doctors managing paediatric surgical patients in a busy district general hospital
Authors: Leeman Charlie , George Jayan , Wafai Ahmad Hisham , Durham-Hall Antonia
Published: August 2023

Aims

Methods

Doctors were surveyed in December 2022. Eight questions used Likert scales (1 to 5: not at all confident to very confident) to assess general surgical patient management. Five closed questions were asked, and one question focused on education methods. Data was initially inputted using Google Docs and analysed in Microsoft Excel.

Results

7 FY1 doctors (7/10) and 4 SHO doctors (4/11) completed the questionnaire.

2/11 have had to clerk or create a management plan for a paediatric patient.

8/11 would use guidance to prescribe for a paediatric patient.

2/11 have had teaching or e-learning to support prescribing.

3/11 have had to prescribe for a paediatric patient.

Confidence levels were low for prescribing at the start of the rotation but increased by the end of the rotation. The highest confidence modal values were 3. Confidence levels of diagnosing and managing appendicitis were higher than mesenteric adenitis.

Most doctors felt that group teaching would be the preferred educational method to increase understanding.

Conclusions

Most doctors did not receive teaching in managing paediatric patients. The highest modal value for confidence was 3. Further targeted group teaching may support increasing confidence levels.
386 MINT: Minimising Ileus through sham NuTrition
Authors: Mactier Mhairi , Parajuli Arun , Kemp Olivia , Tom Tanyaradzwa , Nicholson Gary
Published: August 2023

Background

Post-operative ileus is a common post-operative complication, leading to prolonged hospital stay and associated costs. Evidence suggests use of chewing gum after abdominal surgery is a safe, effective intervention to encourage gastrointestinal function and reduce post-operative ileus. The Enhanced Recovery After Surgery (ERAS) Society supports this as part of the multimodal post-operative recovery pathway.

Aim

To improve post-operative sham feeding in a tertiary colorectal unit.

Methods

Retrospective analysis of clinical notes and prescription charts was carried out between 17.4.2022-24.4.2022. Education was provided to all medical and nursing staff; posters were disseminated around relevant wards and stickers were placed at each computer base (accommodating for electronic prescribing). Prescription of chewing gum was also including in the day one post-operative checklist within the departmental ERAS booklet. Further data was collected between 3.10.2022-14.10.2022 to assess for improvement.

Results

Between 17.4.22-24.4.22, 11 patients underwent major abdominal surgery [n=11]. 0 patients were prescribed chewing gum.

Between 3.10.22-14.10.22, 17 patients underwent major abdominal surgery [n=17]. 16 were eligible for our study [n=16]. 19% patients had chewing gum prescribed [n=3]; none of which developed post-operative ileus, and all were discharged by post-operative day 9. 13% patients demonstrated evidence of post-operative ileus [n=2]; both remained inpatients at post-operative day 35.

Conclusion

Use of chewing gum is a cheap and effective way to reduce post-operative ileus and prolonged hospital stay. We wish to pursue this as routine practice in our tertiary unit. There is more work to do but this a fresh idea which deserves to be showcased.
414 Renal artery aneurysm after blunt trauma in a pediatric patient- A case report
Authors: Sabir Alifa , Rasul Laraib , Iftikhar Usama , Shahwar Ameena , Rauf Fatima , Gondal Mudassar
Published: August 2023

Introduction

Renal artery aneurysm is a rare complication after renal trauma. Most patients are managed with minimally invasive techniques. However, in case of risk of expansion or rupture, surgical exploration may be warranted.

Here we present a case of a 10 year old girl who presented with renal artery aneurysm after blunt trauma.

Case report

A 10 year old girl presented in ER with sudden onset abdominal pain after history of fall. Fast scan showed free fluid in abdomen and right kidney injury. CT scan of abdomen showed grade V kidney injury and right renal artery aneurysm compressing inferior vena cava anteriorly and ascending colon laterally. CT angiogram was done which confirmed a ruptured renal artery aneurysm.

Patient was initially being managed conservatively and angiography was planned. She, however, became vitally unstable and her haemoglobin level dropped. Patient was taken to operation theatre urgently. Per- operatively, a ruptured right renal artery aneurysm was found, 2cm from aorta, causing a large hematoma compressing surrounding structures and dilated renal vein. Right nephrectomy was done. Patient remained stable and was discharged with an uneventful recovery.

Discussion

Renal artery aneurysm is an extremely rare complication following blunt trauma in paediatric population. Diagnosis is difficult, hence requires high level of clinical suspicion. Angiography is the standard tool for diagnosis and management. However, in case of hemodynamic instability, operative management may be warranted.

Conclusion

Despite its rarity, renal artery aneurysm may occur in children after blunt trauma. Hence, high suspicion should be kept by the clinicians in these cases.
464 Incidence of recurrent inguinal hernias and their repairs at a large DGH
Authors: Alkaissy Riem , Tahir Muhammad-Javid
Published: August 2023

In the UK 100,000 hernia operations are performed annually – this includes umbilical/epigastric/incisional etc. Options of inguinal repair are either open or laparoscopic (TAPP vs TEP). Recurrence rates for Liechtenstein repairs are quoted as 5.6%. Median recurrence rates for TAPP repair are quoted as 2.3% and for TEP 0.6%. However, several meta-analyses comparing TEP/TAPP to open repairs found no significant difference in recurrence rates. At our trust, 331 inguinal hernia operations were performed between August 2021- August 2022 (post-COVID). The aim of this project was to look at the incidence of recurrent hernias and their initial repairs at our trust.

We obtained a list of all inguinal hernia repairs in our trust (across all sites) between August 2021- August 2022. We looked at the number of patients that underwent an operation for a recurrent hernia and whether that patient’s primary repair was done laparoscopically or open.

76% of total inguinal hernia repairs were performed open, compared to 24% laparoscopic repairs (72% TEP repairs). About 10% of total repairs were for recurrent hernias. 56% of those had a primary open repair and 44% had a primary laparoscopic repair. 75% of the recurrent hernias underwent a second open repair and 25% underwent a second laparoscopic repair.

We aim to repeat this study with more data (i.e. looking at pre-COVID years) and encourage our laparoscopic hernia surgeons to look into their own practice.
480 Clinical outcome of patients underwent cholecystostomies for acute gall-bladder related pathologies
Authors: Zheng Jennifer , Burford Charlotte , Gardner Alvin , Adeshina Oyinade , Whiteway James , Shah Ankur
Published: August 2023

Percutaneous cholecystostomy is an important and effective temporising procedure in patients with acute cholecystitis who are too unwell to undergo early cholecystectomy. We are seeing a rising number of cholecystostomies performed during the pandemic due to various reasons. However, evidence regarding drain indication, timing and management is lacking with varied practice within and between trusts. We have conducted this study to understand current practice employed at our unit and associated patient outcomes. In this retrospective study, we identified 138 patients who underwent image-guided percutaneous cholecystostomy between 1st January 2020 and 31st July 2022 in all hospitals within our trust. Data was collected from electronic records including drain details, immediate and late complications, biliary-related morbidity and mortality, subsequent re-admissions and definitive management. This is one of the largest studies ever conducted on cholecystostomies. Median length of time with a drain in situ was 35 days (IQR 28 days). 13 (9.8%) experienced minor immediate complications including pain during and after insertion, 51 (3.8%) experienced late complications including formation of cholecysto-cutaneous fistulous tracts and drain site infections. Hospital mortality secondary to biliary pathology was 6.8%. 28.6% had undergone definitive treatment at time of writing (median wait-time 23.5 weeks) and 25.6% were still awaiting a procedure. 29 (21.8%) patients had at least one re-admission related to their gallbladder pathology, with an average admission length of 15 days. No association was found between length of drain in situ and rates of complication and readmissions. The substantial mortality and readmission rates warrant a greater need for early/extra cholecystectomy lists in this era of gall-bladder pathologies.
517 A retrospective audit into the implementation of CT as the recommended first-line imaging in the investigation of suspected Acute Bowel Obstruction in a Tertiary General Surgical Unit
Authors: Solkar Maseera , Jamal Mehvish , Roy Pratik , Riyad Kallingal
Published: August 2023

Introduction

The NCEPOD ‘delay in transit’ report 2020 explored the management of patients presenting with Acute Bowel Obstruction (ABO), highlighting delays at all stages of patient care from presentation to management. CT scan as the first definitive imaging was a key recommendation to prevent delay in decision making. The Aim of this audit was to investigate compliance with this key recommendation and consequential delay in decision making and treatment.

Methods

Data from imaging requests for patients above the age of 16, with a provisional diagnosis of ABO from March-September 2022 was included in the study and analysed. Data analysed included: times of admission, X-ray of abdomen, CT, and time of decision to treat (TDT). The hypothetical time to decision to treat (TDT) was calculated if CT was the first investigation instead of X-Ray; the time of X-ray being performed as the potential time of performance of CT. Delays at each stage of care were calculated.

Results

Between March 2022 and September 2022, 37 patients were admitted under surgery and diagnosed with ABO. The median TDT when X-ray was done prior to CT was 7 hours 3 minutes (IQR 4 hours 32 minutes to 16 hours 42 minutes). 82% of patients required a CT after X-Ray for definitive decision making.

Conclusion

Our surgical service is yet to achieve compliance to this NCEPOD recommendation, with consequential delay in decision making. Further education and change of practice are necessary to implement this key recommendation for raising physician awareness and improve care.
564 Tackling tobacco dependency in surgical patients
Authors: Songra Lalana , Pratheepan Ponnuthurai
Published: August 2023

Aims

Smoking is associated with an increased risk of developing post-operative complications and is a risk factor for abscess development. We aimed to audit our performance in delivering very brief advice (VBA) to surgical patients, and establish a smoking cessation pathway to promote smoking cessation particularly within elective and ambulatory care patients.

Methods

A retrospective audit was undertaken to identify whether smoking status was documented for all surgical inpatients on admission over a 24 hour period, and those attending the surgical ambulatory care unit with an abscess over a 3 week period. Data was collected on whether very brief advice and referral to smoking cessation service or nicotine replacement therapy was offered.

Results

In total, 36 inpatients were identified. 4 reported smoking (11.1%), 26 (72.2%) reported no smoking and 6 had no documentation (16.7%). Of those identified as smokers, 50% had documented VBA and 75% were offered NRT. Of the 51 ambulatory patients attending with abscesses, 13 (25.4%) reported smoking, 10 (19.6%) reported no smoking and 28 had no documented smoking status (54.5%). Only 1/13 had VBA documented (7.7%)

Conclusions

Smoking status is poorly documented in surgical patients presenting to ambulatory care in particular, and there is a high rate of smoking in patients presenting with abscesses. Ambulatory care represents a good opportunity to deliver VBA and direct patients to smoking cessation services. A combined effort between the surgical department and the tobacco dependency service that is present in many hospitals represents a good opportunity to advocate for smoking cessation, primarily in pre operative assessment clinic or surgical ambulatory care.
587 #ILookLikeASurgeon: How Social Media Can Help Change the Face of Surgery
Authors: Lowe Chloe
Published: August 2023

Aim

This study was conducted to assess the benefit of using Twitter hashtags in campaigns that promote diversity and inclusivity amongst the medical workforce, specifically the surgical gender disparity discourse. Hashtags were assessed by their ability to establish the main issues faced by current female-identifying trainees and in promoting engagement with the movement.

Method

Five Twitter hashtags, specific to the surgical gender inclusivity discourse were examined: #ILookLikeASurgeon, #MedBikini, #WomenInSurgery, #OperateWithRespect, and #HammerItOut. Phase One involved the manual collection and thematic analysis of tweets to identify the main areas of gender disparity affecting trainees. Phase Two consulted TweetBinder to yield analytical information on hashtag engagement.

Results

Three-hundred-and-fifteen tweets were collected, with five main themes of gender-based disparity identified: sexism, bullying, sexual harassment, patients’ perceptions, and pay and job disparity. Female-identifying students and trainees describe experiencing exclusionary microaggressions, whilst bullying practices, and incidences of sexual harassment, have made surgery a hostile work environment for some. Structurally, the surgical curriculum remains limited in the support of non-clinical caring responsibilities, resulting in great pay disparity and global under-representation in the field. Hashtags increased the scale of the online discourse and outreach of the tweets, helping to promote the movement and increase engagement.

Conclusion

Following topical hashtags, thematic analysis of tweets can establish the main areas of gender disparity in surgery. Hashtags promote engagement from users globally and outside of the field, generating an impactful online discourse. The findings of this study reflect contemporary literature but personalise the statistics reported to further drive cultural change.
Transcatheter thrombectomy of acute pulmonary embolism in an adult Fontan patient: a case report
Authors: Benjamin Christina , Franklin Wayne J , Garn Byron , Awerbach Jordan D
Published: August 2023

Background

The Fontan operation is a well-described palliative procedure for functional single-ventricle patients. This population has an increased risk of thrombo-embolic events. Adequate imaging, and therefore diagnosis, requires an understanding of the unique anatomy and physiology of a Fontan. Optimal strategies for the prevention and treatment of thrombo-embolic complications in the Fontan population are poorly defined.

Case summary

A 28-year-old female with a history of Ebstein anomaly of the tricuspid valve status post-Fontan presented with chest pain and acute hypoxia. Computed tomographic angiography (CTA) reported a submassive pulmonary embolism (PE). She was initiated on a heparin drip. Catheterization demonstrated elevated Fontan pressures and a large thrombus in the right lower pulmonary artery that was removed with an aspiration device. The patient was transitioned to a direct oral anticoagulant (DOAC) following the procedure.

Discussion

Thrombotic complications are common in the adult Fontan population. Given the morbidity and mortality associated with this complication, the use of proper imaging techniques is imperative. Traditional CTA imaging for PE in Fontan patients often has contrast filling defects related to their anatomy and physiology. Utilization of adequate imaging techniques helps decrease cost and additional radiation exposure. In addition, it avoids inappropriate hospitalization, need for anticoagulation, and potential need for catheterization toconfirm or exclude the presence of PE. For Fontan patients with a thrombus, prior event, and no contraindications, current guidelines recommend oral anticoagulation with a vitamin K antagonist; however, there are increasing data on the use of DOACs in this population.
Economic evaluation of self-help group interventions for health in LMICs: a scoping review
Authors: Ochalek Jessica , Gibbs Naomi K , Faria Rita , Darlong Joydeepa , Govindasamy Karthikeyan , Harden Melissa , Meka Anthony , Shrestha Dilip , Napit Indra Bahadur , Lilford Richard J , Sculpher Mark
Published: August 2023

This scoping review aims to identify and critically appraise published economic evaluations of self-help group (SHG) interventions in low- and middle-income countries (LMICs) that seek to improve health and potentially also non-health outcomes. Through a systematic search of MEDLINE ALL (Ovid), EMBASE Ovid, PsychINFO, EconLit (Ovid) and Global Index Medicus, we identified studies published between 2014 and 2020 that were based in LMICs, included at least a health outcome, estimated intervention costs and reported the methods used. We critically analysed whether the methods employed can meaningfully inform decisions by ministries of health and other sectors, including donors, regarding whether to fund such interventions, and prioritized the aspects of evaluations that support decision-making and cross-sectoral decision-making especially. Nine studies met our inclusion criteria. Randomized controlled trials were the most commonly used vehicle to collect data and to establish a causal effect across studies. While all studies clearly stated one or more perspectives justifying the costs and effects that are reported, few papers clearly laid out the decision context or the decision maker(s) informed by the study. The latter is required to inform which costs, effects and opportunity costs are relevant to the decision and should be included in the analysis. Costs were typically reported from the provider or health-care sector perspective although other perspectives were also employed. Four papers reported outcomes in terms of a generic measure of health. Contrary to expectation, no studies reported outcomes beyond health. Our findings suggest limitations in the extent to which published studies are able to inform decision makers around the value of implementing SHG interventions in their particular context. Funders can make better informed decisions when evidence is presented using a cross-sectoral framework.
Can a private sector engagement intervention that prioritizes pro-poor strategies improve healthcare access and quality? A randomized field experiment in Kenya
Authors: Boone Claire E , Gertler Paul J , Barasa Grace Makana , Gruber Joshua , Kwan Ada
Published: August 2023

Private sector engagement in health reform has been suggested to help reduce healthcare inequities in sub-Saharan Africa, where populations with the most need seek the least care. We study the effects of African Health Markets for Equity (AHME), a cluster randomized controlled trial carried out in Kenya from 2012 to 2020 at 199 private health clinics. AHME included four clinic-level interventions: social health insurance, social franchising, SafeCare quality-of-care certification programme and business support. This paper evaluates whether AHME increased the capacity of private health clinics to serve poor clients while maintaining or enhancing the quality of care provided. At endline, clinics that received AHME were 14.5 percentage points (pp) more likely to be empanelled with the National Health Insurance Fund (NHIF), served 51% more NHIF clients and served more clients from the middle three quintiles of the wealth distribution compared to control clinics. Comparing individuals living in households near AHME treatment and control clinics (N = 8241), AHME led to a 6.7-pp increase in the probability of holding any health insurance on average. We did not find any additional effect of AHME on insurance holding among poor households. We measured quality of care using a standardized patient (SP) experiment (N = 596 SP–provider interactions) where recruited and trained SPs were randomized to present as either ‘not poor’, and able to afford all services provided, or ‘poor’ by telling the provider they could only afford ∼300 Kenyan Shillings (US$3) in fees. We found that poor SPs received lower levels of both correct and unnecessary services, and AHME did not affect this. More work must be done to ensure that clients of all wealth levels receive high-quality care.
Implication of Inflammatory Bowel Disease Diagnosed Before the Age of 18 for Achieving an Upper Secondary Education: A Nationwide Population-Based Cohort Study
Authors: Rasmussen Julie , Nørgård Bente Mertz , Nielsen Rasmus Gaardskær , Bøggild Henrik , Qvist Niels , Brund René Børge Korsgaard , Bruun Niels Henrik , Fonager Kirsten
Published: August 2023

Background

Educational achievement may be adversely affected by chronic conditions in childhood and adolescence. This study aimed to examine the effect of being diagnosed with IBD on achievement of an upper secondary education and the influence of disease severity and psychiatric comorbidity.

Methods

This cohort study was based on nationwide Danish administrative registries. We compared a cohort of patients with IBD with a matched population-based cohort. The IBD cohort included patients born between 1970 and 1994 who were diagnosed with IBD (age <18 years). The outcome was achieving an upper secondary education and was analyzed using Cox regression. The impact of disease severity (expressed by surgery or corticosteroid prescriptions) or psychiatric comorbidity within the IBD cohort was assessed using Poisson regression.

Results

We identified 3178 patients with IBD (Crohn’s disease [CD] n = 1344, ulcerative colitis [UC] n = 1834) and matched them with 28 204 references. The hazard ratio of achieving an upper secondary education was 1.14 (95% confidence interval, 1.07-1.21) for CD and 1.16 (95% confidence interval, 1.10-1.23) for UC. In the IBD cohort, having surgery, a steroid prescription, or a comorbid psychiatric condition was associated with a lower chance of achieving an upper secondary education.

Conclusion

Being diagnosed with IBD before 18 years of age increased the chance of achieving an upper secondary education. However, patients with more severe disease or psychiatric comorbidity were at higher risk of not achieving an upper secondary education than patients with milder disease.
Children and Young Adults With Inflammatory Bowel Disease Have an Increased Incidence and Risk of Developing Mental Health Conditions: A UK Population-Based Cohort Study
Authors: Cooney Rachel , Tang Daniel , Barrett Kevin , Russell Richard K
Published: August 2023

Background

The burden of mental health conditions in children and young adults with inflammatory bowel disease remains unclear. We assessed this using a primary care database in the United Kingdom.

Methods

A retrospective, observational study compared children and young adults with incident inflammatory bowel disease 5 to 25 years of age (2010-2020) against population control subjects. Outcomes comprised incident depression, anxiety disorder, eating disorders, body image disorders, attention-deficit disorders, behavioral disorders, adjustment disorders, acute stress disorder, schizophrenia, bipolar disorder, posttraumatic stress disorder, self-harm, parasuicide (including suicide), and sleep disturbance. The any mental health condition category comprised any of these conditions.

Results

A total of 3898 young patients with incident inflammatory bowel disease were matched to 15 571 control subjects. Inflammatory bowel disease patients were significantly more likely to develop new posttraumatic stress disorder (adjusted hazard ratio [aHR], 2.47; 95% confidence interval [CI], 1.23-4.94), eating disorders (aHR, 1.85; 95% CI, 1.05-3.26), self-harm (aHR, 1.49; 95% CI, 1.00-2.21), sleep disturbance (aHR, 1.40; 95% CI, 1.15-1.71), depression (aHR, 1.34; 95% CI, 1.16- 1.56), anxiety (aHR, 1.25; 95% CI, 1.06-1.48), and any mental health condition (aHR, 1.28; 95% CI, 1.12-1.46). Male inflammatory bowel disease patients aged 12 to 17 years, and patients with Crohn’s disease appear to have the highest risk for developing new mental health conditions.

Conclusions

Young inflammatory bowel disease patients have a significantly higher incidence and risk of new mental health conditions. Mental health remains a critically overlooked aspect of inflammatory bowel disease patient management. Further research into identifying optimal monitoring tools and support for these patients is required to improve patient care. The study protocol was specified and registered a priori.

ClinicalTrials.gov study identifier: NCT05206734.
A Treat-to-Target Strategy Guided by Pan-Enteric Evaluation in Children With Crohn’s Disease Improves Outcomes at 2 Years
Authors: D’Arcangelo Giulia , Russo Giusy , Aloi Marina , Ruggiero Cosimo , Maccioni Francesca , Hassan Cesare , Papoff Paola , Cohen Stanley Allen , Oliva Salvatore
Published: August 2023

Background and Aims

It is uncertain whether a treat-to-target approach could be an effective strategy for improving outcomes in children with Crohn’s disease (CD). Previously, we reported mucosal healing (MH) and deep remission rates throughout the intestinal tract by performing 3 pan-enteric capsule assessments and using a treat-to-target strategy over 52 weeks in children with CD. This report describes the outcomes of this approach at 104 weeks.

Methods

Children with known CD who completed the 52-week protocol repeated pan-enteric capsule endoscopy (PCE) at 104 weeks. Results at weeks 52 and 104 were compared, and long-term outcomes between patients, with and without MH, were calculated using an intention-to-treat analysis of clinical relapse, need for steroids, treatment escalation, hospitalization, and surgery.

Results

Of the previous study cohort of 48 patients, 46 (96%) were available for this extension study (28 [61%] of 46 with MH and 18 [39%] of 46 without MH at 52 weeks). When evaluated at 104 weeks, MH was maintained in 93% of patients with MH at 52 weeks. In the intention-to-treat analysis, complete MH at 52 weeks was associated with reduced risk of steroid use (log-rank P < .0001), treatment escalation (log-rank P < .0001), hospitalization (log-rank P < .0001), and clinical relapse (log-rank P < .0001).

Conclusions

When a PCE-based, treat-to-target strategy is employed, MH is sustainable (93%) over a 1-year period and is correlated with improved patient outcomes, including reduced need for steroids, treatment escalation, hospitalization, and clinical relapses at 104 weeks.

ClinicalTrials.gov number: NCT03161886.