bluuebunny/crossref_metadata_2025_split huggingface dataset:
126 White-Eyed Blowout Fracture in The Paediatric Patient Thought to Be A Head Injury – A Missed Diagnosis
Authors: Dattani A , Chauhan A , Dave R , Messahel A 
Published: May 2021

Abstract
White eyed blowout fracture or ‘trapdoor fracture’ is an orbital floor injury caused by blunt force trauma directly to the orbit causing ocular muscle entrapment between fractured bones of the floor of the orbit. It is most commonly encountered in the paediatric patient population and presents acutely with little to no periorbital signs of injury. This serious diagnosis is frequently missed at initial presentation due to a lack of obvious soft tissue pathology, termed “White Eyed” blow out fracture. It is frequently misdiagnosed as a head injury due to presenting nausea and vomiting and failure to examine eye movements.
The authors present a case of a 15-year-old male who suffered blunt force trauma to the orbit and a white eyed blowout fracture ensued. This was not identified in the emergency department and the patient consequently suffered permanent motility deficit of the globe. We outline recommendations for emergency department practitioners to help identify such presentations and see their timely surgical management.
131 Concerns of The Unheard: A Qualitative Systematic Review on The Preoperative Concerns of General Surgery Patients
Authors: Cheng J Y J , Chin Y H , Wong B W Z , Ong Z H , Ng C H , Tham H Y , Samarasekera D D , Dev K M , Chon C S 
Published: May 2021

Abstract

Aim

Preoperative care is important for patients and healthcare professionals (HCPs), and greatly influences patients’ postoperative outcomes. This review aims to provide an in-depth understanding of the concerns general surgery patients have in the preoperative period and discover solutions to improve their care.

Method
CINAHL, Medline, PsycINFO, and Web of Science were searched, and articles related to patients’ preoperative concerns were included. Key quotes were extracted, coded, and thematically analyzed according to Thomas and Harden’s methodology.

Results
Three themes were generated from the 27 included articles; lead-up to surgery, the postoperative recovery process, and HCP care provision. Patients were uncertain and concerned about the impact the surgery or disease may have on them while they waited for their surgery to occur. Additionally, perceived inadequate provision of care by patients led to them doubting their HCPs’ ability, heightening their preoperative anxiety. Lastly, postoperative recovery processes were often unclear, leading to increased distress as patients wonder if they could recover from the disease and/or surgery.

Conclusions
Unresolved preoperative concerns increase patients’ anxiety and uncertainty, negatively affecting their postoperative recovery. A combination of individualized preoperative education and complementary therapy can be implemented by HCPs to alleviate these concerns, leading to better postoperative outcomes.
148 Acute Renal Infarcts from Spontaneous Intra-Renal Dissection
Authors: Daga K , Chua B , Taneja M 
Published: May 2021

Abstract
Spontaneous renal artery dissection and acute renal infarcts are rare occurrences and often misdiagnosed in clinical practice. We present four male patients, between 30-50 years of age, who have no underlying cardiac conditions, hypertension, or diabetes mellitus. They presented with abdominal/loin/flank pain due to spontaneous renal artery dissection and were all treated with endovascular stenting. Two patients had renal artery fibromuscular dysplasia, confirmed by CT angiogram, a rare pathology which is reported in literature to mostly affect women. All four patients recovered fully from the operation, with no post-operative complications noted. These patients were post-operatively managed medically with anti-platelet therapy for two years and did not experience any post-procedural complications at their 24-month follow up. Classically visceral artery dissection can be managed by anti-platelet therapy alone, however fibromuscular dysplasia can cause spontaneous dissection with renal infarcts and this requires urgent treatment with endovascular stents. Further research is needed on the post-procedural medical management guidelines.
157 A Rare Case of Cutaneous-Urachovesicoenteric Fistula in a Patient with Crohn’s Disease
Authors: Ghanem Y K M , Clarke J , Jacob T , Ahmad N Z 
Published: May 2021

Abstract

Background
Entero-Uracho Vesicle fistulae are a rare sequelae of aggressive Crohn’s disease with only a small number of case reports being available in the literature. Such cases are most often managed via “SSNAP” principles with many Crohn’s fistulas requiring complex surgical intervention to definitively deal with the offending fistulous tracts. We present a case with an even rarer consequence of uncontrolled Crohn’s disease despite immunomodulatory therapy in a 34-year-old male who presented with a Entero-Uracho Vesicle fistula. We discuss the presenting symptoms and management protocol involved in this case.

Case:
A 34-year-old male with known Crohn’s disease presented with an entero-uracho vesicle fistula, which further developed into a cutenaous-urachovesicoenteric fistula while awaiting surgery during his index admission. The fistula tract was confirmed via Computed Tomography with evidence of significant inflammation. Bowel rest, antibiotics, and nutritional support with Total Parenteral Nutrition preceded total excision of the fistulous tract with ileo-caecal resection of the diseased bowel with primary anastomosis, and resection of the urachus and closure of the cutaneous fistula site with desirable outcome. Patient completed a full-recovery with return of normal bowel function and nutritional status, with no delayed complications at 6-month follow-up.
175 Open vs MIS Lumbar Surgery: A Systematic Review of Cost Effectiveness
Authors: Oduoza U , Eseonu K , Monem M , Tahir M 
Published: May 2021

Abstract

Introduction
Minimally invasive surgery has benefits over open surgery for lumbar decompression and/or fusion but there is no established consensus regarding its cost effectiveness.

Method
A systematic electronic search of databases (MEDLINE, EMBASE and Cochrane Library) and manual search from the Cost Effectiveness Analysis (CEA) database and NHS Economic Evaluation Database (NHS EED). Two authors reviewed abstracts against exclusion criteria. Studies including adult populations undergoing surgery for degenerative changes (lumbar stenosis, lumbar radiculopathy, spondylolisthesis) of the lumbar spine, reporting outcomes of costing analysis, CEA or Incremental cost effectiveness ratio (ICER) were included.

Results
Two of the 5 studies comparing open vs single level MIS fusion surgery (TLIF) reported a statistically significant reduction in direct cost for MIS compared to open surgery. The mean non-inflation adjusted cost was $31,626, and $34757 for the MIS and open TLIF groups respectively.
One paper comparing open versus MIS two level TLIF reported a statistically significant difference in costing but not in QALYs.

Conclusions
Generally, studies reported a reduced cost associated with MIS versus open surgery. One study reported a statistically significant change in QALY. The majority had a high risk of bias. This review was unable to recommend MIS over open surgery from a cost effectiveness perspective.
196 A Rare Case of Chemical Burn: Dithranol With Salicylic Acid
Authors: Raj D R S , Adjei B , Kamil M L , Al Nahhas O 
Published: May 2021

Abstract
A 16-year-old female with psoriasis was admitted to our Plastic Surgery department with a significant chemical burn to the neck, upper torso, and left cheek (TBSA 6%). She applied a concoction of cream prescribed by her dermatologist in her native country, Poland when she returned to the United Kingdom. A few hours after application she developed a burn with pH of 5.
A review of the cream revealed a mixture of 19% Dithranol and 5% Salicylic acid. This combination is recognized for managing psoriasis, however the strength of dithranol in the combination given is of a high concentration (normally &lt;3%). This alone can cause a burn to the skin if left for a prolonged period of time.
Salicylic acid is an enhancer which augments the stability of dithranol and increases its penetration and efficacy. The concentration of 5% is also on the higher end.
Our patient was admitted for pain relief and further irrigation till normalization of the pH which was achieved after 3 days.
A worrying aspect in our patients’ case is that she was given the cream to commence at home. High concentration preparation is normally commenced in a controlled setting under medical supervision.
205 Internal Herniation of The Caecum and Ascending Colon Through the Foramen of Winslow: A Case Report
Authors: Lasheen O , Amin A 
Published: May 2021

Abstract

Introduction
An internal hernia occurs when part of the bowel protrudes through a mesenteric or a peritoneal orifice which could be either normally present or acquired. These hernias usually represent a challenge to diagnose. Of the natural anatomical orifices is the Foramen of Winslow through which the caecum and the ascending colon could herniate.

Case

Report

An 85-year-old gentleman presented with a one-day history of abdominal pain. His pain had a sudden onset, an intermittent course and was limited to the epigastric region. He was nauseated but not vomiting. He had opened his bowels a day before presenting to the hospital. CT scan of the revealed herniation of the caecal pole through the foramen of Winslow and into the lesser sac. The decision was made to perform a laparotomy where it was revealed that the caecum and part of the ascending colon had herniated through the foramen of Winslow. Content of the hernia, which was viable, was carefully reduced and right hemicolectomy was performed.

Conclusions
With the scarcity of similar cases, we currently have no consensus of management. Dealing with the hernia at laparotomy would be usually the choice of the surgeon depending on tissue viability and other operative findings.
231 Breast Lymphedema After Breast Conservative Surgery; An Up-To-Date Systematic Review
Authors: Abouelazayem M , Elkorety M , Monib S 
Published: May 2021

Abstract

Background
While arm lymphedema following breast cancer treatment is a common complication; breast lymphedema following treatment is not uncommon. Several risk factors were found to contribute to breast lymphedema,

Aim:
We aimed to provide a systematic review to help avoiding or management of breast lymphoedema

Method
The search term 'breast lymphedema' was combined with 'breast conservative surgery' and was used to conduct literature research in PubMed and Medline. The term lymphedema was combined with breast, conservative and surgery to search Embase database. All papers published in English were included with no exclusion date limits

Results
A total of 2155 female patients were included in this review; age ranged from 26 to 90. Mean BMI was 28.4, most of the studies included patients who underwent conservative breast surgery. Incidence of breast lymphedema ranged from 24.8% to 90.4%. Several risk factors were linked to breast lymphedema after conservative breast surgery, such as body mass index (BMI), breast size, tumour size, tumour site, type of surgery and adjuvant therapy. Treatment options focused on decongestive lymphatic therapy, including Manual lymphatic drainage (MLD), self-massaging, compression bras or Kinesio taping.

Conclusions
Breast lymphedema is a relatively common complication, yet there is no clear consensus on the definition or treatment options.
232 To Report A Rare Case of Fungal Necrotising Otitis Externa (NOE) Centred on The Left Temporomandibular Joint (TMJ)
Authors: Khan A , Omakobia E , Smith I , Hasnie S , Barton R , Oktseloglou V , Gopalan P 
Published: May 2021

Abstract

Introduction
NOE is a rare life-threatening complication of otitis externa, affecting the skull base, mastoid and temporal bones. Pseudomonas aeruginosa account for 95% of cases, making fungal NOE unusual. Complications secondary to NOE include cranial neuropathies, meningitis and dural sinus thrombophlebitis.

Case-study
A 67-year-old man with stage-5 chronic kidney disease presented with left otalgia and otorrhea. He was treated with antipseudomonal topical antibiotics and microsuction for months as an outpatient. Aspergillus flavus was grown on an initial swab, but subsequent cultures were negative. Computerised Tomography scans revealed inflammatory changes in the left masticator space with mastoid bone involvement suggestive of left NOE. He received three months of intravenous anti-pseudomonal antibiotics, microsuction and topical aminoglycosides. Despite interventions symptoms persisted and magnetic resonance imaging scanning revealed disease progression into the left TMJ, prompting maxillofacial surgical opinion. Following washout of the TMJ, a tissue biopsy was positive for DNA on pan-fungal PCR, and the sequence identified as Aspergillus flavus group. The patient was successfully treated with oral posoconazole and topical amphotericin and discharged home.

Conclusions
Fungal NOE remains poorly treated as there is limited guidance on antifungal choice and duration of treatment. It should always be considered, particularly in immunocompromised patients with intractable cases of NOE
241 Have We Learnt Any Lessons from the 2018 NASBO Report?
Authors: Osuji J , Majeed T , Sommereux L A , Aiynattu S 
Published: May 2021

Abstract

Introduction
Small Bowel Obstruction (SBO) is a common presentation requiring a multidisciplinary approach to its management. However, patient outcomes remain poor. Until the NASBO 2018 report1, there were no standard protocols. This study is an evaluation of our local service, assessing our compatibility to NASBO guidelines and identifying areas to improve patient outcomes.

Method
A retrospective cohort study was carried out on patients with SBO during 2018-19. In a busy emergency surgery unit in North West England, with the highest number of emergency laparotomies (NELA 2019)2. Clinical assessment, management, outcomes, and complications were compared to the national data reported in NASBO 2018.

Results
Of 200 patients (median age 73), 60% were treated conservatively and 40% surgically, of which &lt;50% were initially treated conservatively. 59.5% had a nutritional assessment on admission, of which 33.5% were at nutritional risk and started on TPN. Complications during stay were within the target range (&lt;5%). 16% were admitted in HDU. The 30-day mortality was 8%, with 3% requiring palliative care for malignancy and severe comorbidities.

Conclusions
When compared to the national average, our department had a similar performance in management. Use of laparoscopic approach, ERAS, nutritional assessment and elective HDU/ITU admissions were identified as areas for improvement.
243 Thromboprophylaxis In Elective Arthroplasty Patients: Assessing DVT Rates
Authors: Maki S , Baskaradas A , Smith J 
Published: May 2021

Abstract

Introduction
Deep vein thrombosis (DVT) in elective hip and knee arthroplasty range from 1-25%. The NICE Guidelines for Venous Thromboembolism (VTE) advise offering chemical prophylaxis with anti-embolism stockings (AES) as VTE prophylaxis. The aim of this study was to assess the role of anti-embolism stockings, by analysing the rates of DVT in patients who had chemical VTE prophylaxis in combination with anti-embolism stockings compared to patients who had chemical prophylaxis alone.

Method
Retrospective data analysis of patients who underwent elective primary hip or knee replacements from April 2018 to April 2019. Patient records were reviewed for each patient to identify any subsequent DVT diagnosis.

Results
759 patients were identified. 595 patients had combined chemical VTE prophylaxis and AES. 164 patients did not have AES. 12 patients who received the combined therapy presented to A+E with suspected DVT, which was confirmed in two patients. Of the patients who did not receive AES, there were no cases of DVT.

Conclusions
There was no increase in DVT rates in patients who were not offered anti-embolic stockings. Taking into account the risks associated with AES and the costs incurred, the routine prescription of stockings must be carefully reviewed by orthopaedic departments.
270 Spontaneous Trans-anal Evisceration of Small bowel: A Case Report
Authors: Lasheen O 
Published: May 2021

Abstract

Introduction
Trans-anal evisceration of small bowel is a very rare surgical presentation. The first case ever reported was in 1827. The exact mechanism of how this develops remains poorly understood. Majority of the cases recorded there was a perforation in the anterior wall of the rectum.

Case Report:
A 70-year-old female patient with a history of multiple strokes, presented with multiple small bowel loops eviscerated through the anus. The bowel was covered with warm saline soaked packs and the patient was transferred to theater. Abdominal exploration through was done. The bowel was carefully reduced. There was a longitudinal defect on the anterior wall of the rectum at the recto-sigmoid junction. There was also a large mesenteric defect and thrombosed mesenteric vessels compromising blood supply to part of the bowel, so resection of 50 cm of ileum, jejunostomy and a mucous fistula were performed.

Conclusions
Several pre-existing pathologies, like diverticular disease or rectal prolapse can result in thinning out of the wall of the rectum. That combined with increased intra-abdominal pressure can explain trans-anal evisceration of the bowel. This condition is typically managed by surgical intervention. The operation will depend on the extent of viability, contamination, and patient’s general condition.
271 Factors Affecting the Decision to Perform Same Admission Cholecystectomy Following Biliary Pancreatitis: A Comparative Study
Authors: Dick L , Young J 
Published: May 2021

Abstract

Introduction
Same admission cholecystectomy is recommended following biliary pancreatitis to prevent recurrent attacks. However, delaying surgery may be appropriate in certain cases. We aimed to compare patient and admission factors between those undergoing same admission and delayed cholecystectomy.

Method
Admissions with confirmed biliary pancreatitis over a 5-year period were included. Demographics, co-morbidities, need for intensive treatment unit (ITU) admission and endoscopic retrograde cholangiopancreatography (ERCP) were analysed to determine differences between those undergoing same admission and delayed cholecystectomy.

Results
55 and 46 patients underwent same admission and delayed cholecystectomy respectively. There was no difference in age (59 vs 59.2 years, p = 0.947), history of cardiovascular disease (38.2 vs 34.8%, p = 0.724), diabetes (7.3 vs 8.7%, p = 0.792) anticoagulation (7.3 vs 6.5%, p = 0.882) or previous abdominal surgery (0 vs 6.25%, p = 0.05) between groups. Only need for ITU admission (5.5 vs 21.7%, p = 0.01) and ERCP (9.1 vs 28.3%, p = 0.01) were found to be statistically different between groups.

Conclusions
Severity of pancreatitis, rather than patient factors, alone seems to influence the decision to perform same admission cholecystectomy in those with biliary pancreatitis. Further work is needed to understand surgeon factors in the decision-making process.
310 Management of Anterior Penetrating Abdominal Injuries and the Role of Computerised Tomography
Authors: Sanchez-Thompson N , Frith D 
Published: May 2021

Abstract

Introduction
Optimal management of anterior penetrating abdominal injuries (A-PAI) is an area of ongoing debate. Randomised controlled trials are missing and guidelines are based on expert opinion. The accuracy of computerised tomography (CT) is challenged, and hence diagnostic laparoscopies are still widely used.

Method
We retrospectively reviewed the TARN database identifying patients presenting with A-PAI to a London Major Trauma Centre between 01/19/2015-31/03/2018 and reviewed their clinical notes.

Results
143 patients were identified (79% male, mean age = 30). Non-operative management (NOM) took place without complication in 15% (n = 12) of cases, despite 38% (n = 8) showing a potential peritoneal breach on CT, and 19% (n = 4) a definitive intra-abdominal injury. Of the 37% (n = 53) of patients undergoing laparoscopy, half revealed no intra-abdominal injury. When comparing CT consultant reports to intra-operative findings, the accuracy of CT in identifying peritoneal breach was calculated to be 93% and sensitivity at 95%. Negative predictive value was 62%.

Conclusions
We concluded that a significant number of patients have unnecessary laparoscopies, which are not without risk. CT is an excellent resource, but negative predictive value is poor. NOM with serial abdominal examination remains a valid clinical option in the stable non-peritonitic patient and in the absence of definitive viscous perforation on CT.
324 Outcomes of the Exeter V40 Cemented Femoral Stem at a Minimum of 10 Years in a Non-designer Centre
Authors: Mahon J , McCarthy C , Sheridan G , Cashman J , O'Byrne J , Kenny P 
Published: May 2021

Abstract

Introduction
The Exeter V40 cemented femoral stem was first introduced in 2000. The largest single-centre analysis of this implant to date was published in 2018, with excellent results at a minimum of 10-years for the first 540 cases performed at the designer centre in the Exeter NHS Trust. The aim of this current study is to report long term outcomes and survivorship for the Exeter V40 stem in a non-designer centre.

Method
All patients undergoing primary total hip arthroplasty using the Exeter V40 femoral stem between January 1st 2005 and January 31st 2010 were eligible for inclusion. Outcome measures included data on all components in situ beyond 10 years, death occurring within 10 years with components in situ and all-cause revision surgery.

Results
A total of 829 stems were included in the data set. Of these, 808 (97.5%) had no further surgery within the follow-up period; 648 stems (78.1%) were in situ beyond 10 years, and 165 (19.9%) were in situ at death before 10 years. The mean preoperative WOMAC score was 61±15.9 with a mean postoperative score of 20.4±19.3.

Conclusions
The Exeter V40 cemented femoral stem demonstrates excellent functional outcomes and survival when used in a high-volume non-designer centre.
327 Rare Synchronous Volvulus of Sigmoid Colon and Caecum, Management of Two Cases
Authors: Butt M A , Lee A , Smith J 
Published: May 2021

Abstract
Colonic volvulus accounts for approximately 5% of cases of large bowel obstruction. Sigmoid volvulus is commonest (75%), followed caecal volvulus (15%). Synchronous volvulus of the caecum and sigmoid is rare, with five reported cases in the literature. We report two cases in a London teaching hospital managed within 6 months. Both male patients (aged 72 and 79 years) had presented to the emergency department on multiple occasions (2-5 times in the preceding 1-8 months), with obstructive symptoms including tender abdominal distension and constipation. On all occasions, sigmoid volvulus was diagnosed based on plain abdominal films and flatus tubes were inserted, with initial clinical resolution. On their final presentation, both patients were admitted for definitive surgery. CT scans of the abdomen and pelvis were consistently reported as showing only sigmoid volvulus. Only intra-operatively was the diagnosis of synchronous caecal and sigmoid volvulus appreciated. Complete symptom resolution was achieved with subtotal colectomy and ileostomy formation. The key learning points from these cases are: 1) synchronous large bowel volvulus is a rare and easily missed diagnosis, 2) conservative management is unlikely to be successful, 3) radiological appearances may only suggest one type of large bowel volvulus and 4) definitive diagnosis is made intra-operatively.