bluuebunny/crossref_metadata_2025 huggingface dataset:
EP.FRI.332 Impact of Nutritional Deficit in Emergency Surgery (INDIcatES): A cohort study
Authors: O'Connor Tim , Mackenzie Laura , Clarke Rory , Wilson Timothy , Lee Matthew
Published: October 2021

Background

Emergency laparotomy is associated with significant morbidity. Nutritional status is an important factor that can influence outcomes, particularly in this setting where temporary gastrointestinal failure can occur. This study aims to compare the performance of three nutrition risk tools in predicting time without enteral nutrition. 

Methods

A prospective cohort study was conducted across two sites (NCT04696367). Patients undergoing NELA eligible procedures were invited to participate. Data collected included demographics, surgical diagnosis, surgical procedure, and surgical outcomes. Nutrition risk was assessed using three tools: MUST score, the Nutritional Risk Index (NRI), and Nutritional Risk Score 2002 (NRS). 

Results

In total, 56 patients were recruited of whom 21 had small bowel obstruction. Median age was 69 years and 23 participants were female. Overall, 23 participants (41.8%) were identified as high risk using the MUST score, compared to 11 (20.0%) using NRS and 4 (8.9%) using NRI. Median time to return to normal enteral intake was 10 days (IQR 7-14). 91%, 90%, and 95% of those identified as low risk according to MUST, NRS, and NRI respectively were without enteral intake for 5 days or more. The median complication index score was 15 (IQR 0-34). There was no significant difference in duration of time without intake or complications seen in any of the nutritional risk groups. 

Discussion

This study shows that patients undergoing emergency laparotomy spend a prolonged time without enteral intake. Current tools do not adequately stratify the likelihood of prolonged starvation at baseline, or in light of surgical findings.
EP.FRI.374 Characteristics of Emergency General Surgery Operations at Night. An Avoidable Issue?
Authors: Quah Samantha , Cheah Hock Ping , Wong Kenneth
Published: October 2021

Aim

Most hospitals mandate afterhours operations to permit only cases that are life or limb-threatening. This is in the interests of promoting patient safety and reducing surgical errors. The incidence and caseload of night-time operations has not been well defined in Australia. This study aims to investigate the characteristics emergency operations involving consultant general surgeons between 10pm to 7am in regional and rural hospitals.

Methods

A multicentre, prospectively collected health service database of all emergency general surgery operations performed over a 12-month period was reviewed. In particular, patient demographics, type of operation, primary surgeon and time of operation were analysed.

Results

There were a total of 2059 emergency operations performed with 1344 cases performed in the regional hospital and 715 performed in the rural hospital within the area health network. Consultant surgeons were involved in 62 cases at night beyond 10.00pm, of which majority were laparotomies (n = 26/62, 42%), appendicectomies (n = 21/62, 34%), and hernia repair ((n = 4/62, 6.5%). In comparison, surgeons in the rural hospital performed seven emergency cases at night comprising of 6 laparotomies and one abscess drainage.

Conclusion

Larger hospitals have higher volumes of emergency cases, which increases the likelihood of afterhours operating. The rural hospital does not have other subspecialty cover competing for emergency operating time. This allows most emergency cases to be performed in the evening. In order to promote safe working hours and improved patient safety, theatre availability and staffing could be increased in the evening to diminish necessity for midnight to morning consultant operations.
EP.FRI.376 Early Routine CT Scans for All Surgical Admissions for Abdominal Pain May Improve Patient Outcomes
Authors: Quah Samantha , Cheah Hock Ping , Wong Kenneth
Published: October 2021

Aim

Acute abdominal pain remains a diagnostic challenge in the Emergency Department (ED) as pathologies can involve various surgical craft groups. Computed tomography (CT) enables accurate diagnosis of abdominal pathologies. However, with pressures on ED such as the “4 hour rule” established by the Australian NSW Health Emergency Performance Plan, there may be resistance or omission of early CT in ED. We hypothesise that early, routine CT in adult patients presenting with acute abdominal pain requiring hospital admission improves patient outcomes by increasing diagnostic and referral accuracy. This study compares the proportion of correct ED diagnosis of abdominal pain presentations with and without formal imaging reports.

Methods

Data from 118 patients presenting with abdominal pain are collected prospectively in a regional hospital and analysed. Patient demographics, imaging results, initial ED diagnosis and final discharge diagnosis are further examined.

Results

Out of the 118 patients who had abdominal pain, 32 patients obtained complete imaging with a radiology report whilst 86 patients either did not have any imaging performed or was referred to a general surgical unit prior to obtaining a formal report. Among the patients who had imaging reported, 78% (n = 25/32) had the correct diagnosis, whilst those without a radiology report had a 52% (n = 45/86) diagnostic accuracy. This demonstrates an improved accuracy of diagnosis or reduced error rate of 26% when a scan report is available (p = 0.01).

Conclusion

Early, routine CT with formal reporting significantly reduces diagnostic error rates and increases accurate referral. This allows accurate diagnosis and improves patient outcomes.
EP.FRI.390 Improving care for patients with acute bowel obstruction: A closed loop audit
Authors: Clayphan Benjamin , Fairclough Anna , Lim Jeff , Alexander Roderick
Published: October 2021

Aims

Acute Bowel Obstruction (ABO) accounts for 10% of emergency surgical admissions and when surgery is required mortality can exceed 10%. Early diagnosis is associated with improved patient outcomes and timely acquisition of abdominal CT scans can help prevent delays. The NCEPOD 2020 report on ABO identified ‘delays in imaging’ as a key area for improvement in the care of these patients, with these delays being exacerbated if an abdominal X-ray (AXR) was performed as well as an abdominal CT. This study looks at ways to expedite the diagnosis of patients presenting with ABO.  

Methods

A retrospective audit of 77 patients admitted from A&E or SAU with ABO from April 2019 to February 2020 was conducted. Imaging modality, time-to-CT scan and time-to-diagnosis was recorded. Results and recommendations were presented locally and an evidence based ABO care pathway was implemented and publicised. 20 patients were audited prospectively, post care pathway implementation. 

Results

70.1% of patients from the initial audit received a CT-scan and 42% of these patients received an AXR before their eventual CT-scan. The average wait for a definitive radiological diagnosis was 27.8hr. After implementation of the pathway only 18% of patients audited received both modes of imaging and the average time to diagnosis has been reduced to 10.7hr. 

Conclusions

Raising awareness of the appropriate and timely use of CT-scans in the diagnosis of ABO has reduced the number of concomitant AXR for these patients, expediting the making of a definitive diagnosis and improving patient outcomes.
EP.FRI.451 Laparotomy rates and factors influencing treatment modality for diverticulitis during the COVID-19 lockdown
Authors: Yiasemidou Marina , Guadalajara Hector , Lockwood Sonia , Maslekar Sushil , Olmo Damian Garcia , Chetter Ian
Published: October 2021

Background

Infection control measures during the COVID-19 crisis modified diverticulitis treatment. Here we present the treatment applied in three large UK centres compared to the same timeframe in 2019. 

Methods

This was a multicentre, comparative study, whereby diverticulitis cases from March 23rdto May 11th2019 acted as historical controls for cases during lockdown. Severity at presentation (SD), comorbidities, treatment modality, Length of Stay (LOS), complications and COVID-19 status (CS) were recorded. Chi-squared, ANOVA, Mann-Whitney test and linear regression were used for analyses. 

Results

59 patients presented with diverticulitis in 2020 compared to 130 in 2019 (M:F 27/32, 56/74 and 64vs.62 y.o.). Laparotomy was performed in 6/59 and 12/130 respectively. Comparing 2019 to 2020, there was no statistical difference for severity (p = 0.643), treatment modality (0.946), comorbidities (0.313), LOS (0.602). Linear regression demonstrated statistically significant association between treatment employed (p < 0.001) and SD, while there was no association with age, comorbidities or CS. LOS was associated with severity only (p < 0.001), whilst CS, treatment, age and comorbidities yielded no statistical difference. 

Conclusion

Diverticulitis cases during 2020 lockdown reduced noticeably (59vs.130). There was no difference in severity, treatment, comorbidities or LOS between 2019 and 2020. Laparotomy was performed in 6/59 and 12/130 respectively. Decision about treatment and LOS in 2020 was associated with severity of disease only. There was no association with COVID status. These findings should be interpreted with caution due to small COVID positive numbers and not including ambulatory units, however, they are consistent with findings from our sister Spanish group.
EP.FRI.454 National Emergency Laparotomy Audit: are we compliant with pre-operative mortality risk documentation?
Authors: Lam Mark , Ng Sherwin
Published: October 2021

The National Emergency Laparotomy Audit (NELA) set out key performance indicators in patients undergoing emergency laparotomy, one of which is the assessment of individuals pre-operative risk of mortality. This should be made explicit to the patient and recorded clearly on the consent form and in the medical record.1 Pre-operative mortality risk can be calculated through clinical assessment or using the NELA risk scoring tool. Omission of a this can lead to patients missing out on accepted standards of care and belies gaining informed consent. A snapshot audit of patients added to the NELA database was performed between 01/08/2020 and 31/10/2020. Data collected included the pre-operative mortality risk percentage (if calculated) and whether the patient was taken to theatre. This figure was correlated against the patient's physical notes or scanned copies on Medway. A target level of ≥ 85% of patients having their pre-operative mortality risk calculated and the this figure being documented appropriately. 

49 patients were uploaded to the NELA database and 80% (n = 39) had a calculated risk. 55% of these patients (n = 27) proceeded to theatre, however correlation with physical notes and scanned documents on Medway revealed none had the correct documentation as per NELA standards. A questionnaire circulated to trainees and consultants exploring their understanding of pre-operative mortality risk documentation. Of the 7 respondents, 4 stated they rarely or never documented the pre-operative mortality risk as per NELA guidance. Ideas for improving the documentation process included a NELA pathway document, visual aids (e.g. poster) and a pre-operative mortality risk sticker.
EP.FRI.466 Indications and Outcome of Abdominal Re-exploration in the Pediatric Population. A Single Centre Experience
Authors: Abdullah Farooq , Gulnaz Nadia
Published: October 2021

Abdominal exploration (ARE) is an important complication of abdominal surgery and has an effect on morbidity and mortality. ARE refers to exploration performed within 60 days following initial surgery.

The purpose of this study is to know the grounds for performing re-exploration and its effects on the outcome.

Methods

This retrospective study was carried out in the pediatric surgery unit of Khyber teaching hospital from May 2017 to May 2019. All patients under the age of 16 years who underwent abdominal re-exploration within 60 days of the initial procedure were included in the study.

Results

A total of 55 re-exploration were done in the study duration of 2 years. The mean age of patients was 41 months (range of 0.06 to 168 months) male patients were 64%. On initial presentation, 56% of cases were emergency cases and 44% were elective. Common indications for re-exploration were, intestinal obstruction 29.1%, peritonitis 16.4%, complications of stoma 16.4%, burst abdomen 10.9%. The mean interval from initial surgery was 12.5±13.7 days. Common operative findings of re-exploration were inter-loop adhesions, anastomotic disruption, burst abdomen, anastomotic leak, intra-abdominal collection, gangrenous stoma, and para-stomal herniation. ARE resulted in 14.5% mortality.

Conclusion

Abdominal re-exploration is mainly indicated for intestinal obstruction and peritonitis. Inter loop adhesions and anastomotic leak are common surgical findings during re-exploration. The mortality rate is high in patients re-explored for peritonitis, fecal fistula, abdominal collection, and wound dehiscence.
EP.FRI.469 A closed-loop audit regarding the practice of sending Pus Swab for culture and sensitivity in Pilonidal abscess drainage
Authors: Sarodaya Varun , Nasser Mohammad Zeeshan , Hussain Mubashar
Published: October 2021

Aim

The purpose of this study was to determine the role of Microbiological swabs taken during an Incision and drainage for Pilonidal abscess in patient management.

Method

We performed a closed-loop audit to determine the role of pus swabs in the management of pilonidal abscess. Parameters like patient demographics, date of surgery, whether or not pus sent for microbiological examination, the subsequent report, the time required for sample processing, antibiotics prescribed were considered. The data was collated, analysed, and presented at clinical governance. We then implemented in our treatment protocol to stop the practice. This data was again, prospectively collected to complete the audit cycle.

Result

A total of 250 patient were included in this study. Prior to the change of practice, swabs were sent in 77% of the cases. The average reporting time of the swabs was 4.3 days and 92% of the patients were discharged on antibiotics. After conducting multiple teaching sessions for the trainees and educating the theatre staff, the percentage of swabs sent was brought down to 58%.

Conclusion

The pilonidal abscess has high infection and recurrence rate. Hence, the management involves incision, drainage and antibiotics cover in most cases. In our study, the swab results did not alter patients management. Most of them were treated with Co-Amoxiclav and some required additional Metronidazole. Hence, we suggested the routine use of swab for culture in pilonidal abscess cases are unwarranted. This change of practice resulted in huge cost savings at our hospital.
EP.FRI.489 Audit of emergency Operation notes (audit cycle)
Authors: Gulnaz Nadia , Oweis Rami , Abdullah Farooq , Crumley Andrew , Tasleem Sadia
Published: October 2021

The Royal College of surgeons has recommended guidelines for documenting operative surgical notes. An operation note must include ample information about the operation.

In our initial audit, we found some areas for improvement. This re-audit of operative notes was aimed to review compliance with the guidelines by the Royal College of Surgeons and to identify areas of further improvement.

Methods

The notes of all patients who underwent emergency surgery from 1st of January to 15th of March 2020 under the General Surgical department were reviewed. Endoscopic procedures were not included in the study. Electronic records were used to review the operation notes.

Results

Notes of a total of 176 patients were included in the study. Significant improvement was seen in most of the domains. Compliance of 100% was seen in documenting operative findings, type of incision, wound closure technique, procedural details, documenting extra procedures, and post operative instructions.

17.6% notes did not clearly document the indication/diagnosis for surgery. 15.3% notes missed information about DVT prophylaxis. 25.57%notes did not include information about peri-operative antibiotics in the context of prophylaxis or post-op need. A significant number (71.6% ) of the notes were missing information about operative blood loss if there was any or none.

Conclusion

Overall operation notes detail most of the information expected by the Royal College of Surgeons. The key areas for improvement are to include specific details about the following:
EP.FRI.511 Optimising Ambulatory Ultrasound in Emergency Surgery
Authors: Handa Ishita , Pearson Katherine , Day Anne Marie , Kirkby-Bott James , Berry David
Published: October 2021

Aims

Service provision and assessing the impact of future innovations can best be assessed by accurate reproducible data collection. The traditional model for our ambulatory surgical clinic with ultrasound allowed booking directly from the Emergency Department (ED) without discussion with the Surgical Team. We questioned whether this was the correct model and changed to a model of discussion with the Surgical team before booking in an effort to better utilise resource and reduce unnecessary footfall in the hospital.

Methods

We reviewed the outcome data of consecutive ambulatory ultrasound clinic referrals before and after implementation of this change in practice (1 month before and after the change)

Results

Ninety four ambulatory Ultrasound referrals were reviewed. In the first cohort 30 of 50 patients came directly from ED without discussion. A positive USS report was recorded in 8 of the 30 (27% USS positivity rate).  After the change in practice to discuss with the surgical team, 11 of 43 patients originated primarily from ED with a positive finding in 4 patients (36%).

Conclusions

A key aim of service improvement is to optimise / improve utilisation of resource. This must be achieved without missing pathology. In this study we reduced the number of scans performed by ED whilst increasing the likelihood of a positive scan. This change in practice better utilised resource and reduced unnecessary footfall in the hospital.
EP.FRI.535 A clinical audit of post-operative antibiotics prescription in uncomplicated perianal abscesses
Authors: Zhao Sarah , Najdawi Ahmad , Laliotis Aggelios , Thomas Rhys , Boghdady Michael El
Published: October 2021

Aims

Management of perianal abscesses continues to revolve around prompt surgical drainage. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) guidelines state that all patients should have incision and drainage within 24 hours and antibiotics are not indicated in routine uncomplicated perianal abscesses. We aimed to study the antibiotics prescription after surgical drainage in a London university teaching hospital against the national standard. 

Methods

A single-centred retrospective analysis of all emergency surgical admissions for incision and drainage of perianal abscess was carried out for a 6 month period. Patients’ demographics, Co-morbidities, local and systemic complications and readmissions were studied. 

Results

A total of 36 patients, (mean age 43, 64% males) were included in this study, 21 received incision and drainage without antibiotics prescription, while 15 received empirical post-operative antibiotics. Indications for antibiotic therapy in this group included diabetes, immunocompromise, local complications (necrosis, cellulitis) and recurrence. There was no clear indication for antibiotics in 60% of patients who received them. 86% of patients had surgical drainage within 24 hours of presentation. One patient was readmitted for a second drainage 3 months later. Most common empirical agent used was co-amoxiclav (53%), followed by (33%) combination of co-amoxiclav and metronidazole. 

Conclusion

Although surgical drainage was generally carried out in timely manner according to guidance, there was excessive post-operative antibiotic prescriptions. Increase awareness of guidelines is required to improve antibiotic stewardship in these surgical patients in order to avoid unnecessary drugs’ prescription.
EP.FRI.537 Post-operative antibiotics for cutaneous abscess after incision and drainage: Variations in Clinical Practice or lack of guidelines
Authors: Zhao Sarah , Najdawi Ahmad , Laliotis Aggelios , Thomas Rhys , Boghdady Michael El
Published: October 2021

Aims

Acute cutaneous abscess is a common surgical condition which mostly require incision and drainage. Despite this, there is no standardised national or international guidance on the post-operative antibiotics prescription. Traditionally, antibiotics are not indicated unless complications and/or risk factors such as immunocompromisation, diabetes or cellulitis exist. We aimed to study the local practice of the post-operative antibiotics prescription for cutaneous abscesses in a University teaching hospital in London.

Methods

A retrospective data collection of emergency general surgical admissions for a period of six months from July to December 2020 was carried out. All patients with superficial skin abscess were included in this analysis. Scrotal, breast and limb abscesses were excluded. Patients’ demographics, Co-morbidities, local and systemic complications were studied.

Results

A total of 149 patients presented during this period. Mean age was 40 (54% were male). Most common site of abscess was perianal (24%), followed by pilonidal, axilla, back, gluteal, neck, abdominal wall and groin. At total of 108 (72.5%) were managed surgically with incision and drainage, 70 (65%) got antibiotics and only 23 (33%) had indications for it (i.e. diabetic, immunocompromised, sepsis, cellulitis, MRSA carriage) = (χ2[1] =22.03, p<.0001).

Co-amoxiclav was the most common post-operative empirical antibiotic prescribed in 61% of the patients. 

Conclusions

This study has identified significant variation in clinical practice regarding post-operative antibiotic usage in superficial abscesses. Further research is required in cooperation with microbiologists to develop standardised evidence-based treatment protocol for management of such common surgical condition.
EP.FRI.543 A rare case of acute jejuno-jenual intussusception in a patient with Roux-en-Y bypass secondary to a benign polyp
Authors: Fardanesh Armin , Powell Jamie , Al-Whouhayb Maitham
Published: October 2021

Introduction

Roux-en-Y Gastric bypass (REYGB) amounts for a third of surgical bariatric interventions. Small bowel obstruction (SBO) is a long-term complication in REYGB and can be caused by intussusception of bowel, in approximately 0.5% of procedures.  Intussusception in REYBG is mostly attributed to dysmotility. This report demonstrates a rare case of intussusception in REYGB secondary to a benign polyp. 

Case description

A 45 year old female, three years post REYGB, presented to A&E with acute, extreme upper abdominal pain, with three days absolute constipation. She was tender on examination with normal blood tests. CT scan demonstrated small bowel intussusception. Initial concerns were of intussusception of the jejuno-jejunostomy anastomosis causing SBO.  She had an exploratory laparotomy, which confirmed intussusception, however this was 20cm distal to the jejuno-jejunostomy. Bowel was gently reduced, and deemed viable. On thorough run-through, a small segment at the transition point, was considered abnormal on palpation. This region was resected and a 1x1cm intraluminal polyp was identified as the causative lead point. The patient did well postoperatively. 

Discussion

Small bowel intussusception in adults is typically attributed to pathological lead point, such as benign or malignant lesions. Intussusception in REYBG is a rare but well-documented cause of intestinal obstruction, usually attributed to dysmotility, secondary to ectopic pacemaker cells particularly around anastomoses. In this case, the intussusception was caused by an unusual pathology separate from the jejuno-jejunal anastomosis. We recommend thorough examination of all adjacent bowel to exclude lesions, in this case a polyp, which could result in recurrence.
EP.FRI.650 Are we calculating and documenting the NELA Score pre-operatively?
Authors: Rajain Sakshi , Kotecha Sita , Narula Harjeet Singh
Published: October 2021

Aim

Emergency laparotomy is a common procedure associated with high risk of mortality and morbidity. NELA risk score calculation for patients undergoing emergency laparotomy improves the quality of patient care and compares the organisation of patient care provided to the outcomes following surgery. The aim of this study was to determine if NELA score was calculated and documented pre-laparotomy.

Methods

A retrospective analysis was conducted for patients who had emergency laparotomy at a primary care hospital in England. This study included reviewing the case notes and consent forms to assess if NELA risk score was calculated. Following further education of the surgical team, the audit loop was closed.The primary outcome was to identify not only calculation but also that the score was documented.

Results

Measures taken to enhance NELA risk calculation included theatre co-ordinator asking for NELA risk score while booking for laparotomy and documentation on the booking form and posters on surgical ward. Consequently, 40% notes included Scoring which improved to 70% after making the above changes. 

Conclusion

The NELA risk score should be calculated for all patients undergoing emergency laparotomy as it estimates an individual’s risk of death within 30 days of surgery. It also standardises the risk calculation among all laparotomy patients and aids in clinical decision making, therefore is vital to be calculated in pre-operative phase. To ensure it is correctly calculated at all times, regular teaching and updates of NELA score is recommended.
EP.FRI.663 Surgeons’ Views on Documentations on Resuscitation and Escalation Status in Emergency Surgical Admissions
Authors: Chan Deona Mei Lam , Yalamarthi Satheesh
Published: October 2021

Aim

Resuscitation and escalation of care are not always in the best interests of all patients. We surveyed the consultants’ and surgical registrars’ views on the completion of resuscitation and escalation documentations on admission.  

Methods

A questionnaire was sent to the clinicians of the surgical department via Google Questionnaire. Data from the responses were collated. 

Results

:5 consultants and 5 surgical registrars completed this part of the survey. 80% stated they fill out the section for resuscitation and escalation status; 60% stated they routinely fill this in and 20% would get their trainees to fill in this part of the booklet if they didn’t do it themselves. 40% fills in this section because it enables clear decision-making and 30% felt the lay out of the form is easy to fill in. Overall 50% of the participants feel there are time constraints. Some surgeons indicated sometimes the decision could not be made at presentation and they needed investigations and establish rapport with patients before decisions are made. 40% indicated they would go back and amend the section once a decision is made.

Conclusion

This survey identified surgeons do make efforts to complete documents on resuscitation and escalation status during emergency take. Common factors to stop them doing so are time-constraints and inability to make decision at the time of presentation. We recommend the surgeons to fill in the documentation retrospectively as soon as decisions on resuscitation and escalation are made.
EP.FRI.680 “Avulsion of the Corona Mortis following low energy pubic rami fracture: a rare but life-threatening injury.”
Authors: Sinha Anurag , Kemp Mark , Rohra Satish
Published: October 2021

We describe the case of an 81 year old gentleman who presented after a trivial fall with haemodynamic instability and worsening abdominal pain and swelling. An initial trauma CT identified superior and inferior pubic rami fractures associated with a large intra-pelvic collection. A subsequent CT angiogram confirmed a large pelvic haematoma with an active arterial bleeding from a ruptured vessel adjacent to the superior pubic rami fracture. This was managed by resuscitating him with fluids and blood transfusions followed by fluoroscopic guided Internal Iliac artery embolisation. The “Corona Mortis” is an aberrant arterial connection between the inferior epigastric artery and obturator artery and is prevalent in the hemipelvis of more than 49.3% of the population. Very rarely it can be damaged during low energy pubic rami fractures leading to haemodynamic compromise and potential death. For this reason and the fact there is a high chance that it could be missed, we wish to highlight this case, and management and emphasise the need to consider this life-threatening complication even in cases when the mechanism of injury may seem trivial.
EP.FRI.704 Emergency colorectal surgery outcomes within a non-specialist split site service – a retrospective cohort study
Authors: Swan Rebecca , Ventham Nicholas , Damaskos Dimitrios
Published: October 2021

Aims

Within this region, Upper GI and Colorectal subspecialties are located at separate hospitals. This study aims to determine outcomes of critically unwell patients undergoing emergency colorectal surgery off-site at the non-colorectal specialist centre.

Methods

An observational retrospective study of emergency colorectal laparotomies at a major acute teaching hospital (non-colorectal specialist centre) between January 2016 and August 2020 was performed. The primary outcome was 30-day mortality. Secondary outcomes included rate of primary anastomosis, complications and overall mortality. The NELA predicted mortality risk was obtained from notes or retrospectively calculated. Subgroup analysis of colorectal surgeon involvement was performed. 

Results

One hundred and eighteen patients were included (median age 64 years, 55% female).  The median NELA mortality score was 5.8% (IQR 1.9 – 14.7%). The 30-day mortality rate was 22% (26/118). The rate of primary anastomosis was 31%. Patients having an anastomosis had a lower median NELA score compared those patients who did not (1.6% vs. 7.85%). Forty five (38%) patients had Clavien-Dindo grade IV-V complication. Colorectal Surgeon involvement in the operation (23/118), was associated with a lower 30-day mortality (17.4% colorectal surgeon vs. 23.2% emergency general surgeon alone) albeit in patients with a lower median NELA score (4.5% vs. 6.7%) and a similar rate of primary anastomosis was achieved (31.6% vs. 30.9%).

Conclusions

The high mortality rate highlights a specific group of acutely unwell patients unfit for transfer to the subspecialist unit. Good outcomes were seen where a colorectal surgeon was involved, however a similar rate of primary anastomosis was demonstrated.
EP.FRI.719 Gastric Perforation Leading to The Diagnosis of Classic Ehlers Danlos syndrome: A Case Report of an Unusual Presentation
Authors: Alotaibi Ahad , AlAamer Ohood , Bawazeer Mohammed , Alzahrani Ali
Published: October 2021

Background

Ehlers-Danlos syndromes (EDS) are clinically and genetically heterogeneous group of heritable connective tissue disorders caused by defective collagen synthesis or structure. Vascular subtype (EDS IV) is reported to be associated with a higher incidence of gastrointestinal ruptures. The Most reported site of perforation was the colon particularly the sigmoid colon followed by small bowel. It is very rare to have stomach perforation. There were no reported cases among classic type I and II. In addition, this patient presented with Marfanoid habitus which may develop acute gastric volvulus in combined with pre-existing EDS, perforation can occur.

Case description

A 14-year-old girl attended our Emergency Department (ED) with abdominal pain and vomiting. Initially diagnosed with gastroenteritis and discharged once her condition improved. 24 hours later, she developed severe abdominal pain with recurrent vomiting with peritonitis evident on clinical examination. Initial KUB failed to show any free air, however, enhanced Computed Tomography (CT) revealed free air and proximal gut contrast extravasation. During exploratory laparotomy, an ischemia anterior and posterior gastric wall with gastric perforation was encountered. A free-hand partial gastrectomy was done. Her post-operative period was complicated with wound infection that managed successfully with Vacuum-assisted closure (VAC) dressing. She recovered well without gastrointestinal sequelae in 4 years follow up.  

Conclusions

A high level of suspicion must be maintained for heritable systemic connective tissue diseases in any young patient with unusual spontaneous perforation. As these patients can develop life-threatening conditions, immediate intervention is required in addition to prepare for anticipated complications.
EP.FRI.743 Mortality Risk prediction in Emergency Laparotomy (ORIEL) Study Outcomes at Wythenshawe Hospital
Authors: Pittam Bradley , Carey Charles , Mobarak Shahd , Varley Rebecca , Kingston Jennifer , Agwunobi Anselm
Published: October 2021

Aim

Emergency laparotomy is a high-risk procedure with significant morbidity and mortality. ORIEL is a multi-centre national study aiming to compare the 30-day mortality predictions generated by NELA, P-POSSUM, ACS-NSQIP and SORT risk calculators with observed 30-day mortality rates in patients undergoing emergency laparotomies. We present the data collected from Wythenshawe hospital.

Method

Data were collected retrospectively on adult patients undergoing an emergency laparotomy between 01/12/2017 to 30/11/2019 at Wythenshawe hospital from the online NELA database. The median pre-operative mortality risks were calculated using the four risk calculators for all patients. Mortality and morbidity were compared with data reported in the Sixth NELA report.

Results

The median predicted pre-operative mortality (IQR) for all patients studied using NELA, P-POSSUM, ACS-NSQIP and SORT were: 4.3 (13.0), 5.2 (14.2), 3.4 (8.2) and 2.9 (9.3) respectively. Among patients who were alive 30 days post-operatively, the median predicted mortalities (IQR) were: 3.8 (8.5), 4.8 (11.0), 2.6 (6.9) and 2.8 (7.1) respectively, and among those who died were: 30.8 (18.9), 30.3 (63.4), 16.9 (13.9) and 20.3 (16.2). Compared to the national average, mortality rates at Wythenshawe were lower (9% v 9.3%), the median length of stay in hospital was lower (12 days v 15.4 days) and the percentage of high-risk patients admitted to critical care was higher (93% v 85%).

Conclusions

Similar values were generated with all the scoring systems among all patients. Wythenshawe hospital reports lower mortality rates and shorter stays in hospital despite operating on higher risk patients (ASA grades 3-5).
EP.FRI.745 Information Sustainability: SCR+: A bespoke module to optimise information flows around the Somerset Cancer Register to enhance the multidisciplinary cancer team process
Authors: Rahman Fatima , Hales Alan , Beegan Ryan , Cable David , Rew David
Published: October 2021

Background

Many surgeons work within multidisciplinary cancer teams. The Somerset Cancer Register (SCR) is a national reporting system for service performance which is in use in more than 100 NHS Trusts. However, the core system has not yet been optimised for MDT users or for the surfacing of clinical data for research and other uses.

Methods

SCR replaced our legacy cancer reporting system in 2014. Working with the SCR developers, we integrated our cellular pathology and imaging records with the SCR MDT outputs. We subsequently developed SCR+ to optimise workflows for MDT coordinators and information presentation to clinical users.   

Results

Our HTML-enabled SCR+ software application displays all cancer patients by pathological type and year of presentation on dynamic histograms, for ease of visualisation and interaction. Every selected case is displayed in list order for each and every MDT meeting, with a fast hyperlink to our integral Lifelines EPR interface, to electronic pathology records back to 1990, and to our Breast Cancer Data System for relevant patients.

Conclusions

The SCR+ module transforms the access and visualisation of cancer workload across our Trust for all authorised MDT users, with appropriate data security. The agile programming methodology allowed us to build a sustainable cancer data system with further development potential. The product substantially enhances user experience, data recall and productivity over legacy systems. Close cooperation between clinically proficient  IT teams and clinicians as the end consumers of digital health data systems yields significant operational benefits at pace and with very modest costs.
EP.FRI.753 Investigating the use of a novel pre-hospital triage tool for acute abdominal surgical emergencies – a two-phase single centre cohort study
Authors: Misbert Emily , Hughes Michael , Burke Joshua , Schofield Claire , Young Alistair
Published: October 2021

Aims

Despite recent improvements, delay to theatre in emergency laparotomy(EL) continues to be associated with increased mortality in the UK. This study aimed to assess if patients requiring urgent surgical intervention for acute abdominal surgical pathology could be identified in the pre-hospital setting.

Methods

A two-phase, single-centre, cohort study was performed. Phase 1 retrospectively investigated patients who underwent emergency laparotomy between 01/01/2019-31/12/2019 at Leeds Teaching Hospital Trust (LTHT) through the NELA database. Phase 2 prospectively assessed NEWS2 for all patients presenting to LTHT Surgical Admissions Unit with abdominal pain between 01/01/2020-31/01/2020. 

Results

Phase 1: 45 patients were coded through NELA and confirmed through operation note as undergoing EL for gastrointestinal perforation. 66%(n = 30) were assessed by the ambulance service and 80%(n = 24) had a NEWS2 of 3 or greater. Phase 2: 319 patients were assessed in SAU/ED resus of which 69 were initially treated by the ambulance service. 30%(n = 21) of these patients had an initial NEWS2 of 3 or above. The sensitivity of a NEWS2 score of >/3 in predicting the need for immediate surgical intervention including EL was 95%(95%CI, 74-99) and specificity was 95%(95%CI, 83-99) with a PPV of 86%(95%CI 67-95) and NPV of 98%(95%CI, 87-99). 

Conclusion

A NEWS2 score of >/3 predicts the need for emergency surgical intervention including laparotomy for gastroinestinal perforation with reasonable sensitivity in this cohort. A pre-hospital triage tool for patients presenting with abdominal pain could utilise NEWS2 as an adjunct to decision-making in an acute abdominal pathway.
EP.FRI.821 Operative Treatment of Abscesses – Optimising A Timely Route to Theatre
Authors: Ikram Hamza , Taylor Roland , Dosis Alexios , Robinson Jonathan
Published: October 2021

Aim

1st audit cycle to assess whether patients presenting to the acute surgical service had their abscesses incised and drained in a prompt and timely manner. To develop a pathway for improving efficiency

Methods

All general surgical patients admitted to the surgical admissions unit between 1st September and 31st October 2020 by reviewing clinical and operative notes. Only those patients that had abscesses drained under general anaesthesia. Other specialties abscesses were excluded. Guidelines from the American Society of Colon and Rectal surgeons for draining abscesses acutely were used. Data was collected on various parameters. 

Results

A total of 62 patients had abscesses drained. The mean age of patients was 32 years. The average waiting time between decision to operate and surgery was 14 hours and 54 minutes. 19% of the patients were sent home after decision was made to operate and brought back in the morning.

Conclusion

This 1st audit cycle concludes long waiting times and unnecessary overnight stay. A re-audit will be carried out using the same parameters in March 2021. Implementing a dedicated general surgical abscess pathway for patients without significant co-morbidities will improve efficiency and patient satisfaction.

References 

1. Kumar C, Page R, Smith I, Stocker M, Tickner C, Williams S, et al. Day case and short stay surgery: 2. Anaesthesia. 2011;66(5):417–34. 

2. Balakumar R, Samuel N, Jackson A, Butterworth J, Shiwani MH. Day-surgery approach for incision and drainage of an abscess. Surg Pract. 2016;20(4):157–60.
EP.FRI.828 Accidental Placement of Nasogastric Tube into the brain
Authors: Harvitkar Rafique , Ansari Khursheed , Peri Harish
Published: October 2021

The nasogastric tube (NGT) plays a very vital role in the early resuscitation of head injury patients for various reasons. Though considered a simple procedure, it can be associated with multiple dreadful complications. Our patient was a 44-year-old male, referred from a peripheral health center for further management of severe head and faciomaxillary injuries following a motor vehicular accident. On arrival at the hospital, the endotracheal tube and NGT were in situ. A computed tomography scan of the brain revealed the NGT piercing through the cribriform plate of ethmoid and coiling into the cranial cavity with pneumocephalus. The NGT was retrieved under C-arm guidance and his injuries were managed respectively. The patient was discharged after prolong hospitalization with an acceptable outcome. With this case report, we want to remind emergency health care providers to avoid this catastrophic complication of NGT insertion in a faciomaxillary trauma patient by doing it transorally. We report a novel method of safely removing NGT which has not been reported in the past.
EP.FRI.857 Audit and quality improvement project; data entry into the NELA database from Royal Stoke university hospital
Authors: Nair Nandu , Kalatzis Vasileios , Gudipati Madhavi , Gaunt Anne , Machineni Vishnu
Published: October 2021

Aims

During the period December-2018 to November-2019 a total of 84 cases were entered on the NELA website, corresponding to HES data suggesting 392 laparotomies. This suggests a possible case acquisition of 21% prompting us to look at our data acquisition in detail.

Methods

Interrogation of the NELA data from January–March 2020 was done from NELA website and hospital records.

Results

Analysis revealed that during this period 45 patients had laparotomy recorded whereas hospital database recorded 68 laparotomies. Of the 45 cases entered on the NELA database, only 1 patient had a complete data set entered.  22 cases had 87% data entry and 22 cases had <50% of the data fields completed. Firstly, we were not capturing all patients who underwent an emergency laparotomy and secondly our data entry for the patients we did report was incomplete.  This led us to engage in a quality improvement project with following measures -

Conclusions

We re-assessed the case ascertainment and completeness of data collection in the period April 2020 – June 2020 and case ascertainment rate increased to 54% and all the entries were complete and locked.
EP.FRI.949 “When it works, it works brilliantly…. on the days that it doesn’t work, it tends to just all kind of crumble” – a qualitative study of patient and staff experience of ambulatory care on the surgical assessment unit
Authors: Massey Lisa , Day Jo , Bethune Rob , Lang Iain
Published: October 2021

Aims

To explore patients’ experiences of being managed in an ambulatory manner and to explore medical staff’s experiences and attitudes of emergency ambulatory care.

Methods

Twenty patients and 12 members of staff (nurses, HCAs, junior doctors and consultants) underwent in-depth telephone (patients) and face-to-face (staff) interviews about their experience of emergency ambulatory care. The transcribed interviews underwent thematic analysis.

Results

Patients’ opinion on ambulatory care is influenced by factors including whether they felt that they were “ill enough” to need to stay in, a fear of staying overnight in hospital and how much they valued their individual home environment. Many thought that this sort of care had been introduced to “save the bed”.

Staff were passionate about the service as a good option for many patients who would otherwise have hospital admissions. However, some thought it had been brought in to manage patients who could be managed in primary care. Some factors thought by doctors to influence their decision-making include their perception of the risk involved, previous negative experiences and external pressures such as theatre availability and bed status. There are varied views on whether the service should be more or less protocol-led. Many believe that it is “easier” for them to admit people than manage them in an ambulatory manner.

Conclusions

There is definitely scope to expand ambulatory care but patients may not engage with this if they feel ill enough to stay in. Decision-making in staff is influenced by a number of factors on an individual level.
EP.FRI.1023 Clinical Portal: a clinician-led IT solution to the ‘surgical list’
Authors: Bleakley Cait , Wright Chloe , Salem Rola , Bowling Kirk
Published: October 2021

Aim

Burnout amongst junior doctors is an emotive topic, with time pressures during busy on-call shifts negatively impacting efficiency and morale. Historically, within busy surgical firms the most junior team members commonly worked beyond scheduled hours. It has been highlighted within our trust that our IT systems significantly contributed to this. Thus leading to the creation of a clinician-led IT solution, enabling direct access to accurate information at a single point.  This study aims to measure the impact of the systems introduction on efficiency and shift experience of our junior doctors. 

Methods

'Clinical Portal’ was introduced in August 2019. This IT system enables all patient information to be collated in one place, with the added benefit of simplifying the creation of patient lists. Number and duration of Exception Reports (ER) by on-call surgical juniors were measured for two months pre and post intervention. A qualitative survey was also distributed to this cohort to measure satisfaction and experience during on-call shifts within this period. 

Results

Following introduction of 'Clinical Portal', the total length of time included in ERs reduced. Surgical juniors expressed an improvement in their on-call experience, most notably dedicating less time to collating patient information and ward list formation. The overall experience improved despite time required to become proficient at using the new system. 

Conclusions

Streamlining of IT systems used during on-call shifts demonstrates improved efficiency amongst juniors reflected in a reduction of ERs. A direct consequence of these implemented changes is significant improvement in morale amongst our juniors.