bluuebunny/crossref_metadata_2025_split huggingface dataset:
P-BN60 Predicting post-operative length of stay following laparoscopic cholecystectomy: derivation and validation of a pre-operative risk score
Authors: Lucocq James , Scollay John , Patil Pradeep 
Published: December 2021

Abstract

Background
To predict the post-operative length of stay following laparoscopic cholecystectomy (LC) will help guide the utilisation of resources, particularly the allocation of day surgery beds. Prolonged post-operative stay (PPS) is associated with morbidity and the acknowledgement of pre-operative factors predisposing to morbidity and PPS will influence surgical decision-making. The aim of the present study was to determine pre-operative factors associated with PPS and both derive and validate a risk score to predict the risk of PPS following LC.

Methods
Patients who underwent emergency and elective LC between January 2015 and December 2019 across three surgical centres were included. Pre-operative, operative and post-operative data were collected retrospectively from multiple databases using a deterministic records-linkage methodology. The cohort was randomly divided into a derivation and validation cohort, by a 3:1 ratio, respectively. The derivation cohort was used to create a risk score for PPS (≥3 days post-operatively) using multivariate logistic regression. The risk score was then applied to the smaller set or ‘validation cohort’ for internal validation purposes and the predictive accuracy was assessed using a ROC curve.

Results
The rate of PPS was 10.6% (294/2768). PPS was associated with intra-operative complication (RR-17.0;p&lt;0.001), bail-out procedures (RR-47.1;p&lt;0.001) post-operative complications (RR-11.9;p&lt;0.001), re-admission (RR-2.4;p&lt;0.001) and post-operative imaging/intervention (RR6.5;p&lt;0.001). Variables associated with PPS included ag ≥ 60 (OR-1.56;p=0.011), male sex (OR-1.47;p=0.022), ASA 2 (OR-1.63;p=0.019, ASA≥3 (OR-3.27;p&lt;0.001), 2 hospital admissions (OR-1.56;p=0.046), ≥3 hospital admissions (OR-2.11;p=0.024), cholecystitis (OR-3.19;p&lt;0.001), pre-operative ERCP (OR-3.49;p&lt;0.001) and cholecystostomy (OR-2.77;p=0.025) and emergency LC (OR-5.20;p&lt;0.001). The AUC (area under curve) for the derivation and validation cohorts were 0.83 and 0.81 respectively. The risks of PPS in low-risk (0-5), medium-risk (5.5-10) and high-risk (&gt;10) groups were 3.3%, 14.9% and 45.1%, respectively.

Conclusions
The rate of PPS following LC is significant and strongly associated with peri- and post-operative morbidity. Our model concludes that multiple pre-operative patient factors can predict the likelihood of prolonged post-operative stay. A patient’s risk score could be used to assess the risk of morbidity. Pragmatic patient selection in accordance with the above model could help surgical centres improve the allocation of beds between tertiary centres and day-surgery units.
P-EGS03 Curious Case of Life Threatening Gastrointestinal Bleed
Authors: SINGH VIBHA 
Published: December 2021

Abstract

Background
Gastrointestinal stromal tumors are mesenchymal in origin, being derived from the interstitial cells of Cajal. These can be found anywhere in the gastrointestinal tract and are commonly found in the stomach followed by the small bowel. Gastrointestinal stromal tumors are usually asymptomatic and are often found incidentally. Chronic bleeding is one of the most common presentation. Gastrointestinal stromal tumors presenting with massive gastro intestinal haemorrhage and mimicking arteriovenous malformation on radiology are rare with only few cases reported.

Methods
Herein we present such a case of a 45-year-old gentleman with massive gastro intestinal bleeding. At presentation, patient was in congestive heart failure due to severe anaemia with a hemoglobin of 2.9g/dL. CECT Angiography localised the bleed to be from a jejunal mass lesion with radiological features consistent with those of arteriovenous malformation. Patient underwent laparoscopy assisted resection and anastomosis.

Results
Histopathology examination revealed a low risk jejunal gastrointestinal stromal tumor with no evidence of arteriovenous malformation. The mass was removed completely and the patient was discharged on 5th post-operative day. Patient was followed up in the out-patient department and was found to be doing well.

Conclusions
Gastrointestinal stromal tumors though relatively uncommon should be kept as important differentials for acute torrential gastrointestinal bleeding. It is highlighted that a presentation of gastrointestinal stromal tumors similar to that of arteriovenous malformations on cross sectional imaging should be kept in mind. The present case is reported in hope of expanding the knowledge of a rare occurrence, its aetiology, clinical impact and treatment.
P-EGS08 What is the Best Risk Prediction Model for Oesophageal Perforation?
Authors: Alasmar Mohamed , Shehata Zak , Altarawni Mohammad , Casey Patrick , Melhado Rachel , Sultan Javed 
Published: December 2021

Abstract

Background
Oesophageal perforation is a challenging surgical condition associated with high mortality and morbidity. There is a lack of consensus regarding the optimal treatment strategy, when and whom to operate on. Treatment options include primary repair, t-tube repair, emergency oesophagectomy, endoscopic therapy, and palliation.
Whilst many risk prediction models exist, the only specific score to predict mortality in oesophageal perforations is the Pittsburgh Severity Score (PSS). However, there is limited evidence on its validity and even less literature to predict short and long-term morbidity in these patients.

Methods
We compared and validated commonly used risk prediction models, including the PSS, the National Emergency Laparotomy Audit score (NELA score), the Portsmouth Physiological and Operatic Severity Score for the enumeration of Mortality (P-POSSUM), and the Surgical Outcome Risk Tool (SORT) using a dataset of 83 patients ranging from 2009 to 2021. The power to predict mortality and morbidity was assessed using the comprehensive complication index (CCI). The CCI was calculated using complications for both operative and non-operative cohorts.

Results
Of the scores assessed, NELA showed the most robust predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.812, 0.8602, 0.8302, respectively). The PSS also showed significant predictive value for in-hospital mortality, 30-day mortality, and 90 mortality (AUROC 0.792, 0.856, 0.813 respectively). Furthermore, NELA had the strongest correlation between score and CCI (rs 0.644 p &lt; 0.001).

Conclusions
Despite not being validated for oesophageal pathology, NELA appears to be the optimum scoring model to predict mortality and morbidity for this patient population. This is the first study to compare the efficacy of different risk prediction models in oesophageal perforations and could be used to inform shared decision making and peri-operative outcomes. Further large-scale validation of risk prediction tools is required to corroborate these findings.
P-EGS09 The Introduction of an Ambulatory Surgical Pathway
Authors: Wall Joshua , Boag Katie , Kowal Mikolaj , Plotkin Tobias , Maguire Rachel , Peckham-Cooper Adam 
Published: December 2021

Abstract

Background
Since the publication of the Emergency General Surgery Commissioning Guide by ASGBI in 2014, there has been a drive to develop ambulatory pathways for acute surgical patients, saving inpatient stays and reducing the risk of hospital-acquired infections. Many units, like ours, had a large workload increased by seeing next day returns as well as acute presentations. In October 2020 an Institute of Emergency General Surgery was formed who developed an ambulatory pathway to ameliorate some of these issues and provide a point of contact for primary care referrals, for one the busiest emergency general surgical takes in the UK.

Methods
A retrospective analysis was undertaken to identify all acute referrals to general surgery over a 14-day period in February 2019 prior to (Pre-ASC) and 2021 after (Post-ASC) the introduction of an Ambulatory Surgical Clinic (ASC). All patient episodes were reviewed, and descriptive statistics on overall attendance to the surgical assessment unit (SAU), admissions to inpatient wards and referrals to ASC were analysed. Patients presenting to the acute urology take were used as a control to compare the number patients attending the surgical assessment unit both before and during the COVID-19 pandemic.

Results
830 patients presented over the 28-day study period (426 pre-ACS vs 404 post-ACS; 5% reduction), totalling 992 patient encounters including planned returns (525 vs 467; 11% reduction).
After the introduction of the ASC total attendance to SAU was reduced by 42% (525 vs 306); next day return attendances were reduced by 87% (99 vs 13) and attendances from primary care were reduced by 68% (208 vs 67). The proportion of patients admitted was similar (46% vs 50%).
146 patients attended the ASC, and 15 patients received telephone advice alone.
The control group saw attendance increase by 25% (178 vs 223).

Conclusions
The results clearly show that the introduction of the ASC has decreased attendance to SAU, freeing clinicians to dedicate more time to those acutely unwell. The similar proportion of admissions after the introduction of the ASC suggests that the ambulatory pathway correctly identifies those who are well enough to be managed as outpatients. The increased attendance in the control group suggests that the data were not the results of a decrease in referrals due to COVID-19. The results shared here should encourage other large units to consider developing ambulatory pathways.
P-EGS10 Clinicopathology of Critically Ill Patient With Coffee Ground Vomitus Undergo Oesophagogastroduodenoscopy
Authors: Salleh Muhammad Hafizuddin , Samad Abdul Rahim , Yunus Mohammad Alif , Sagap Ismail 
Published: December 2021

Abstract

Background
The incidence of acute gastrointestinal bleed in Malaysia is approximately 72 per 100000, as the incidence in patients who had mechanical ventilation is 2.6%. Coffee ground vomitus is one of the presentations of upper gastrointestinal bleed, and the decision for upper gastrointestinal endoscopy in a critically ill patient with such presentation would be a dilemma as endoscopy might lead to several complications such as endotracheal tube dislodgement, transient bacteremia, cardiopulmonary event, and perforation. We studied the clinicopathology of patients who were referred to our unit with coffee ground vomitus in a critically ill condition, as it would help us further in determining the severity and outcome of the patients.

Methods
This was a retrospective cross-sectional study from 59 patients in the critical unit in Hospital Melaka who were referred to the surgical department for coffee ground vomitus and underwent esophagogastroduodenoscopy. The study was conducted from November 2020 till July 2021.

Results
The median age of the patient was 73 years old and the mean body mass index was 25.6.. The primary diagnosis of patients in the critical care was Acute Coronary Syndrome 18%, Sepsis 17%, and cerebrovascular accidents 10%. The mean systolic blood pressure was 126 and the mean pulse rate was 94. The mean hemoglobin level upon admission was 10.7 and 9.07 upon referral. Other laboratory parameters that were analyzed were urea, INR, platelet, and lactate. 51% had history of taking antiplatelet or anticoagulants. 92% of patients underwent urgent OGDS (within 24 hours of referral), and 30% of them had findings of high-risk ulcers (Forrest 1b, 2a, and 2b) which need urgent intervention.

Conclusions
The data from the study would be beneficial in providing evidence for further clinical research in our center on identifying the factors that will predict the outcome of OGDS towards the patient either for endoscopic intervention or diagnostic endoscopy only.
P-EGS14 From Gallstone Disease to Cholecystectomy: An audit looking at the waiting times for cholecystectomy in a small District General Hospital
Authors: Mewse Jacob , Ledda Virginia , Connor Ellie , Mason Peter Frank 
Published: December 2021

Abstract

Background
Gallstone-related disease accounts for a third of emergency general surgery admissions and referrals. The average waiting time for acute gallstone presentations to laparoscopic cholecystectomy is about 7 days in England. This audit aims to identify emergency admissions and compare local management to the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) guidelines standards with a focus on waiting times for laparoscopic cholecystectomy (LC). Where AUGIS standards were not met, number of re-admissions and complications were identified. A cost analysis was also completed looking at the overall costs of delayed treatment.

Methods
We identified all patients admitted as an emergency between September 2019 and September 2020 with gallstone-related pathology. Patients not referred to the surgical team, with negative Ultrasound Scans (USS) or known HPB malignancy were excluded. The patients were divided into a pre- COVID -19 and during COVID-19 category (respectively before and after March 2020), to identify whether the cancellation to non- urgent elective surgery (due to COVID-19) had caused further delays or complications. Each patient’s management was compared to AUGIS guidelines depending on their diagnosis at presentation (biliary colic, cholecystitis, cholangitis, gallstone-related pancreatitis), focusing on the timing between presentation and LC.

Results
A total of 99 patients were identified. Of the patients presenting with biliary colic (n = 9 pre-COVID, n = 5 during COVID), none underwent LC within 72 hours from presentation as recommended by AUGIS. Of the patients presenting with cholecystitis (n = 20 pre-COVID and n = 16 during COVID), none had LC within the recommended 72 hours. 5 patients in each COVID group had LC, with a significantly longer waiting time compared to the pre-COVID group. Re-admissions and complications were similar for the cholecystitis patients in both COVID groups. In the gallstone-related pancreatitis group, only 1 patient underwent LC within the recommended 2 weeks.

Conclusions
This audit showed that locally we are failing to meet AUGIS guidelines for LC within 72 hrs, 2 weeks or 6 weeks both pre and during COVID. This has caused re-admissions of patients with cholecystitis, pancreatitis and perforated gallbladders. Factors that cause delay are limited access to USS, limited staff and theatre availability. To improve outcomes, it is necessary to implement a hot gallbladder service with dedicated theatre slots. A change in the overall perception of LC is also needed: this is should be considered an emergency operation as its delay has a significant negative impact on patients’ outcomes.
P-EGS17 Evaluation of Different Surgical Risk Prediction Models in Predicting Morbidity and Mortality in Emergency Giant Hiatus and Diaphragmatic Hernia Repairs
Authors: Alasmar Mohamed , Moore Eleanor , McKechnie Iona , Chaparala Ram 
Published: December 2021

Abstract

Background
Emergency presentation of giant hiatus and diaphragmatic hernias are associated with significant morbidity and mortality, and predicting perioperative risks can be difficult. There are several preoperative risk evaluation models used commonly in emergency general surgery. Not only can they help clinicians stratify risk, but they can also be valuable tools to outline surgical risks to patients and families. This study aimed to evaluate the suitability of different risk prediction models when predicting morbidity and mortality in emergency giant hiatus and diaphragmatic hernia repairs.

Methods
This was a retrospective cohort study of all emergency hiatus and diaphragmatic hernia repairs at a tertiary upper gastrointestinal centre from 2010 to 2021. The outcomes were compared to the predicted mortality and morbidity of different risk prediction models. The mortality models SORT (Surgical Outcome Risk Tool), NELA (National Emergency Laparotomy Audit) and ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Programme) were compared using the area under the curve (AUC). Morbidity was evaluated by calculating the comprehensive complication index (CCI). CCI was compared to P-POSSUM (Portsmouth – Physiological and Operative Severity Score) and ACS-NSQIP predicted morbidity using Spearman correlation.

Results
108 patients were included in the analysis. 49.1% were female, and 50.9% were male. The median age was 69 (IQR 59-78). The 30-day mortality rate was 6.93%. ACS-NSQIP had the highest predictive power for mortality (AUC = 0.845), in comparison to NELA (AUC=0.809) and SORT (AUC = 0.740). Both ACS-NSQIP and P-POSSUM showed moderate correlation to CCI (rho = 0.489, p &lt; 0.001 and 0.446, p &lt; 0.001 respectively).

Conclusions
ACS-NSQIP is a better predictor of both mortality and morbidity in emergency giant hiatus and diaphragmatic hernia repairs when compared to NELA, P-POSSUM and SORT. ACS-NSQIP may have a role in pre-assessment and consenting of emergency giant hiatus and diaphragmatic hernia repairs. Multi-centre prospective studies could be used to validate these findings.
P-EGS19 Complete oesophageal transection during thyroidectomy; Successful management of anastomotic leak using endoluminal vacuum therapy (EVT) following failed primary repair
Authors: Afzal Zeeshan , Gourgiotis Stavros , Hardwick Richard , Safranek Peter , Sujendran Vijayendran , Bennett John , O'Neill Robert , Noorani Ayesha , Hindmarsh Andrew 
Published: December 2021

Abstract

Background
Perforation of the cervical oesophagus is an extremely rare but recognised complication of thyroidectomy. As with all oesophageal perforations management depends on timing of diagnosis in relation to the timing of injury, the size of the oesophageal wall defect, extent of extraluminal contamination, and how unwell the patient is with respect to sepsis. We report a case of complete transection of the cervical oesophagus during total thyroidectomy and its subsequent management.

Methods
A previously well 32-year-old female had a complete cervical oesophageal transection during total thyroidectomy and neck dissection for papillary carcinoma of thyroid. This was recognised by her ENT surgeon who repaired the oesophagus primarily. Subsequently, she developed sepsis with cellulitis of her anterior chest wall. Cross-sectional imaging demonstrated a leak at the site of the cervical oesophageal repair. Gastroscopy confirmed a 50% dehiscence of the oesophageal anastomosis. Control and management of her oesophageal leak was achieved with EVT delivered using an ad-hoc endoluminal vacuum device (EVD) constructed from open cell foam sutured around the distal end of a nasogastric tube.

Results
The patient was managed in the intensive care unit (ICU) with appropriate organ support and antimicrobial cover. A surgical jejunostomy was placed to facilitate enteral feeding. EVT was delivered using the ad-hoc EVD which was placed endoscopically and situated intraluminally across the anastomotic leak site. Continuous negative pressure (125 mmHg) was applied. Six EVD changes were required to heal the leak. Her total length of stay was 41 days, of which 38 days were in ICU. There were no periprocedural complications related to using the EVD or EVT, although the patient subsequently developed an oesophageal stricture which required endoscopic dilatation.

Conclusions
Accidental complete transection of the cervical oesophagus is extremely rare. This case highlights the importance of a multidisciplinary team approach for managing such cases. EVT is an emerging treatment option for upper gastrointestinal (UGI) leaks and is reported to be safe and effective for leaks from a wide range of causes throughout the UGI tract. Successful resolution of the oesophageal leak in this unusual case demonstrates the utility of EVT in difficult clinical situations which may otherwise pose a formidable management challenge using traditional treatment strategies.
P-EGS30 Audit of the management of patients presenting with gallstone pancreatitis during the COVID-19 pandemic
Authors: Thomas Christophe , Hutchinson Katie , Brown James 
Published: December 2021

Abstract

Background
In the UK around 50% of cases of pancreatitis are caused by gallstones. BSG guidelines recommend ERCP is undertaken within 72h of onset of pain and patients should undergo definitive treatment with cholecystectomy if fit enough during the index admission or within two weeks of discharge to avoid the risk of potentially fatal recurrent pancreatitis. A national audit in 2015 showed that 34.2% of patients receive definitive treatment. During the first COVID-19 wave our surgical service was forced to modify practice including more conservative/non operative management potentially increasing the possibility of recurrent pancreatitis and thus complications.

Methods
We performed a retrospective audit of patients presenting to our unit with gallstone pancreatitis during the first wave of the COVID-19 pandemic from March to August 2020 (COVID) and compared this to the same period in 2019 (pre-COVID). Patients were filtered from a larger dataset of all admissions with an ICD-10 coding of any biliary disease. Patient demographics, admission details, investigations, surgical management and post-operative complications were recorded. This was then audited against the standards in the BSG guidelines for the management of pancreatitis.

Results

Conclusions
There were significant differences in the management of the groups. Most significantly in the number of hot procedures and number of patients receiving definitive treatment, a consequence of the conservative approach during COVID. Our pre-COVID results are similar to our previous audit in 2016; 76% received definitive treatment. Those that didn’t have definitive treatment were generally due to frailty/co-morbidities. Majority of ERCP delays were due to weekend effect. Of the 40 patients who didn’t receive definitive treatment 16 have represented with biliary flares/pancreatitis in the year following the study period highlighting the importance of definitive treatment.
P-EUS01 Pancreatic metastases from Renal Cell Cancer; endosonographic features and outcomes of a rare clinical entity
Authors: Ahmed Wafaa , Farman Muhammad , Joshi Deepak , Harrison Phillip , Devlin John , Reffitt David 
Published: December 2021

Abstract

Background
The pancreas is a rare site for metastatic deposits in the absence of disseminated metastatic disease. They can be difficult to differentiate from primary pancreatic malignancy based on the clinical history and radiological features alone. Renal cell cancer (RCC) is the most common source. We describe their endosonographic characteristics and clinical outcomes.

Methods
Patients undergoing EUS- FNB with a positive diagnosis of pancreatic metastatic disease from RCC from 2017 to 2019 were retrospectively identified. Recorded variables included patient demographics, endosonographic features and patient outcomes.

Results
Five patients were identified. Mean age was 63 (range 53-72 years old). Mean time from diagnosis of the primary RCC to diagnosis of pancreatic metastasis was 12.75 years (range 6-18 years). All had resection of the primary lesion.
Mean diameter on EUS was 37.80mm (range 15mm to 100mm). The lesions were homogenous, well-circumscribed, hypoechoic and hypervascular. Tissue acquisition was performed using a 22G FNB needle.
Two underwent surgical resection of the metastasis, one of which had recurrence at the surgical bed after 26 months. One had disseminated malignancy at the time of diagnosis. One passed away prior to surgical resection.

Conclusions
Pancreatic metastasis from renal cell cancer have characteristic endosonographic features and can present many years after initial diagnosis and resection. EUS-FNB has a central role in confirming this diagnosis.