bluuebunny/crossref_metadata_2025_split huggingface dataset:
EP.TH.803VAE for Breast Lesions of Uncertain Potential (B3) -A Quality Improvement Project
Authors: Sandhya Anu , Dent Helen , Oyewole Bankole , Pogson Caroline , Silva Tania De , Waheed Shamaela , Perera Iroshini 
Published: October 2021

Abstract

Aims
Breast lesions of uncertain malignant potential (B3) account for 7% breast lesions biopsied. Management has been controversial and challenging for the MDT. Aim of the study was to compare current NHS BSP guidelines with our trust’s practice and the secondary outcome was a shorter patient pathway and cost effectiveness.

Methods
As per NHS BSP guidelines VAE should be performed for all B3 lesions diagnosed on 14g or vacuum assisted biopsy. We were referring them to other NHS trusts as there were no in-house facilities or doing an excisional biopsy if no resources for VAE available.
From September 2019 VAEs started to be done by in-house consultant breast radiologist after getting the appropriate training and instruments. Data was collected from September 2019 to August 2020 for all patients.

Results
22 VAEs were performed in one year. Out of those 6 (27.2%) were upgraded to malignancy and needed further surgery, 2 (9%) with atypia had 5 years mammographic surveillance and 14 (63%) were discharged including sclerosing lesions, radial scars, fibrosis and chronic inflammation.
The cost of VAE in our hospital is £1330 vs. £2439 for Wire Guided wide local excision. This makes it cost effective.

Conclusion
We were following the VAE protocol as per NHS BSP guidelines. Despite added workload to radiology VAE is minimally invasive, safe and cost effective alternative to surgery providing thorough MDT discussion has taken place.
Greater benefit was provided to patient as all VAEs were performed in radiology department avoiding general Anaesthesia and surgical trauma.
EP.TH.861Compliance with guidelines for inguinal hernia repair in a large teaching hospital
Authors: Nassar Ahmed , Ward Stephen 
Published: October 2021

Abstract

Background
The Royal College of Surgeons of England guidelines recommends laparoscopic repair for bilateral inguinal hernias, recurrent hernia after an initial open approach and Groin hernias in women.

Aim
This study assessed the surgical management of inguinal hernia over 6 years to see how well we adhered to national guidelines and investigated reasons for non-adherence.

Methods
A retrospective study from January 2013 to December 2018 of all patients undergoing inguinal hernia repair. Data collected were patient identifiers, gender, date of birth, date of admission and discharge, type of inguinal hernia, type of repair and the operating consultant. If the type of repair performed was outside of national guidance, patients’ case-notes were reviewed.

Results
2593 patients were included, 93.4% male and median age of 63 (interquartile range 49-74 years). 403 patients underwent laparoscopic repair (15.5%). For unilateral primary inguinal herniae, 221 out of 2222 patients underwent laparoscopic repair (9.9%). 29 of 170 (17%) of female patients underwent laparoscopic repair. 118 out of 160 patients with bilateral hernia underwent laparoscopic repair (73.8%) - no explanation was identified for selecting open repair in 25 out of 42. Regarding recurrent hernia, 64 out of 211 patients underwent laparoscopic repair (30.3%). No explanation for selection of open approach was identified for 61 of the 147.

Conclusion
National guidelines recommending laparoscopic inguinal hernia repair for females, bilateral and recurrent herniae are not well followed. A likely contributing factor is the overall low rate of laparoscopic repair. Changes to practice are underway and repeat audit is planned.
EP.TH.879Does ‘fast -track’ axillary node clearance following positive core biopsy lead to overtreatment of axilla?
Authors: Abdullah Muhammad , Voynov Velin , Stonelake Paul 
Published: October 2021

Abstract

Aims
Axillary node clearance (ANC) can cause lifelong disability and conservative axillary dissection is increasingly preferred. However, direct (fast-track) ANC after preoperative axillary biopsy is still performed, which may be overtreating the patients with low axillary burden. This study aims to identify if direct (fast- track) ANC leads to overtreatment of axilla.

Methods
Retrospective data for all breast cancer patients who underwent surgery between 1 January 2017 and 31 December 2018 were included in this study. The histopathology results of ANC were correlated with axillary ultrasound findings, axillary biopsy or SLNB results and effect of neoadjuvant treatment. These were analysed against the available guidelines to evaluate the current practice.

Results
82 patients out of 520 had ANC (15.7%). Four groups were identified. 35.5% of patients diagnosed with nodal infiltration on preoperative biopsy (Group A) had only 1- 2 positive nodes following ANC. Complete pathological response was observed in 37.5% patients with nodal infiltration who had ANC following neoadjuvant chemotherapy (NACT) (Group B). No further nodes were subsequently found in 63.6% of patients who underwent ANC following positive SLNB (Group C). Group D included 2 patients with axillary recurrence.

Conclusions
15.7% of breast cancer patients required ANC. The practice of direct (fast-track) ANC after axillary biopsy leads to overtreatment of the axilla, which needs re-evaluation. Targeted axillary dissection could avoid unnecessary axillary dissection in patients with abnormal nodes. This is now recommended in patients who have received NACT but has not been evaluated yet in patients with up front surgery.
EP.TH.916Managing Gallstone Pancreatitis: Are We Doing Enough?
Authors: Malik Salim , Evans Thomas , Zaman Shafquat , Budhoo Misra 
Published: October 2021

Abstract

Background
Acute pancreatitis carries significant morbidity and has an estimated annual incidence of 30-50/100,000 in the U.K. 50% of these cases are related to gallstone disease. NICE/BSG guidelines recommend definitive management of gallstone pancreatitis during the index admission or within 14 days of hospital discharge. We audited our compliance against these national guidelines.

Methods
Retrospective data was collected for patients admitted with acute gallstone pancreatitis over a 12-month period. Patient demographics, admission details, length of stay, previous/future admissions, timing of cholecystectomy and ERCP were recorded.

Results
47 patients were included (mean age: 50.7 years) with a mean length of stay of 6.2 days. Only 6% had a cholecystectomy during the index admission or within 14 days of hospital discharge. 12 (26%) patients had an ERCP performed with a mean time of 45 days. The mean time to surgery after initial discharge was 97 days.

Conclusion
There is poor compliance with national guidelines in the management of gallstone related pancreatitis in our cohort of patients. Definitive management reduces readmissions, resulting in financial savings and improved patient care. This audit demonstrates the need to develop a robust ‘hot gallbladder’ pathway to improve the management of patients with acute pancreatitis secondary to gallstones.
EP.TH.917An Audit of Compliance with NICE guidelines for Acute Cholecystitis
Authors: Malik Salim , Evans Thomas , Zaman Shafquat , Budhoo Misra 
Published: October 2021

Abstract

Background
Gallstone disease is common and affects approximately 10-15% of adults. Laparoscopic Cholecystectomy (LC) is the definitive management of cholecystitis. NICE and RCS guidance recommend that in patients diagnosed with acute cholecystitis a LC should be performed during the same admission or within 7 days. We audited our compliance against these national guidelines.

Methods
Retrospective audit of all patients admitted with uncomplicated acute cholecystitis over a 4 month period. Patient demographics, admission details, timing of cholecystectomy, complications, follow-up, and re-admission data were collected.

Results
50 patients (60% female, 40% male; mean age: 60.7 years) with acute cholecystitis were included. Mean length of stay was 4.8 days. Only 10% had a cholecystectomy within 1 week of diagnosis. Of those discharged without a LC on the index admission, 14% were readmitted with further gallstone related complications (cholangitis, pancreatitis) within 48.6 days from initial discharge. The mean time to surgery after initial discharge was 125.8 days.

Conclusion
There is poor compliance with NICE guidelines to perform an early LC in our cohort of patients, primarily because of the lack of Trust based guidelines. This audit demonstrates the need to develop a robust ‘hot gallbladder’ pathway within our hospital to improve current practice.
EP.TH.930Contemporary trends in the management of micrometastatic axillary disease in the setting of mastectomy – a 5 year single institution experience
Authors: Earley Helen , Denis Evoy , Geraghty James , McDermott Enda , Prichard Ruth , McCartan Damian 
Published: October 2021

Abstract

Background
Since the ACOSOG Z0011 trial, rates of axillary node clearance (ANC) for micrometastatic axillary disease have declined among women undergoing breast conservation surgery (BCS). However, for women undergoing mastectomy, it remains unclear whether omission of ANC is a safe and feasible option.

Aims
Identify current practice relating to management of the axilla in women with early stage, clinically node negative breast cancer, found to have micrometastatic disease on SNB, who undergo mastectomy

Methods
From 2013 to 2017 patients with clinical T1-T2Nmi breast cancer undergoing upfront surgery were identified from a prospective institutional database. Receipt of adjuvant radiotherapy or subsequent ANC were assessed. Patients who received neoadjuvant chemotherapy or BCS were excluded.

Results
47 patients undergoing mastectomy for ESBC had micrometastasis identified on SNB. The majority of tumours had invasive ductal histology. 16/27 women underwent completion ANC (34%). Six patients had further nodal disease identified in the ANC specimen. 2 had &gt;5 nodes positive. During the study period 31 patients (65%) received adjuvant radiotherapy. Of the patients who did not undergo ANC, 21 (67.7%) received adjuvant radiotherapy.

Conclusion
At this institution the majority of patients requiring mastectomy with micrometastatic disease on SNB do not undergo subsequent ANC (&gt;60%). Although this is a small patient cohort, these data indicate the rate of residual axillary disease is low, and are in keeping with trends in the literature, and may help inform management decisions in this patient group.
EP.TH.939Is routine CTU necessary in the investigation of haematuria?
Authors: Miller Alexandra , Rake Grace , Bright Elizabeth 
Published: October 2021

Abstract

Aims
Upper tract urothelial cancer’s (UTUC) are rare of which 17% have concurrent BT’s. Whilst CTU is the gold standard imaging for UTUC, its routine use is questionable due to low diagnostic yield.1
There is no consensus in our department regarding the use of CTU in screening haematuria patients, regardless of whether a BT is identified. We therefore sought to investigate the diagnostic yield of CTU.

Method
Retrospective case-note review of haematuria patients (May-October 2018), screening tests utilised and their diagnostic yield.

Results
764 patients (mean age=68) presented with VH (n = 448) or NVH (n = 316). All underwent flexible cystoscopy (FC) and upper tract imaging, (346 = USS; 126=CTU; 257= USS and CTU).
BT and UTUC were diagnosed in 69 (9%) and 5 patients (0.7%), respectively. Of the 5 patients with UTUC (VH = 4, NVH=1) 2 had synchronous bladder tumours, both were low grade. All 5 underwent CTU but only 3 had a prior USS, of which USS detected UTUC in 2 of these 3.
CTU was performed in 384 patients (VH n = 323, NVH n = 61) yielding only one UTUC diagnosis when other investigations were negative. This patient presented with VH. CTU provided no additional cancer detection in all patients with BT.

Conclusions
Due to the small sample of synchronous tumours, location or grade of BT is not a predictor of UTUC2. In all patients screened with FC and USS, CTU only detected one additional UTUC. On the basis of these results, CTU screening is not indicated for patients presenting with NVH.
EP.TH.959Meta-analysis of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer surgery: An ongoing dilemma
Authors: Hajibandeh Shahin , Hajibandeh Shahab , Bhattacharya Pratik , Zakaria Reza , Thompson Christopher , Peravali Rajeev 
Published: October 2021

Abstract

Aims
To evaluate comparative outcomes of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer resection.

Methods
We systematic searched MEDLINE; EMBASE; CINAHL; CENTRAL; the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists. Overall perioperative complications, anastomotic leak, surgical site infection, ileus and length of hospital stay were the evaluated outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models.

Results
We identified 4 studies reporting a total of 436 patients comparing outcomes of temporary loop ileostomy closure during (n = 185) or after (n = 251) adjuvant chemotherapy following colorectal cancer resection. There was no significant difference in overall perioperative complications (OR 1.39; 95% CI 0.82-2.36, p = 0.22), anastomotic leak (OR 2.80; 95% CI 0.47-16.56, p = 0.26), surgical site infection (OR 1.97; 95% CI 0.80-4.90, p = 0.14), ileus (OR 1.22; 95% CI 0.50-2.96, p = 0.66) or length of hospital stay (MD 0.02; 95% CI -0.85-0.89, p = 0.97) between two groups. Between-study heterogeneity was low in all analyses.

Conclusions
The meta-analysis of best, albeit limited, available evidence suggests that temporary loop ileostomy closure during adjuvant chemotherapy following rectal cancer resection may be associated with comparable outcomes to closure of ileostomy after adjuvant chemotherapy. We encourage future research to concentrate on completeness of chemotherapy and quality of life which can determine appropriateness of either approach.
EP.TH.965Use of Oral Antibiotics as Adjunct to Systemic Antibiotics and Mechanical Bowel Preparation for Left Sided Colorectal Surgery. It is the time to trust the best available evidence and change the practice
Authors: Hajibandeh Shahin , Hajibandeh Shahab , Thompson Christopher , Thumbe Vijay , Torrance Andrew , Peravali Rajeev 
Published: October 2021

Abstract

Aims
To prospectively evaluate the clinical efficacy of oral antibiotics as an adjunct to intravenous antibiotics and mechanical bowel preparation (MBP) in patients undergoing left sided colorectal surgery.

Methods
All participants aged 18 years or older and of any gender undergoing an elective open or laparoscopic left sided colorectal resection for benign or malignant colorectal pathologies were considered. The intervention of interest was oral neomycin 1g every 4 hours combined with oral metronidazole 400mg every 8 hours from 24 hours before the proposed surgery. Surgical site infections (SSIs), anastomotic leak, paralytic ileus, need for intervention, and mortality were the evaluated outcome parameters.

Results
Forty-two consecutive patients received oral antibiotics as an adjunct to intravenous antibiotics and MBP before left sided colorectal surgery. The mean age was 58.8 ± 11.5. There were 23 males (54.8%) and 19 females (45.2%). Use of oral antibiotics was associated with SSI infection rate of 2.4% (1 patient). The rates of clinically significant and non-significant anastomotic leak were 0% and 2.9%, respectively. Moreover, postoperative ileus happened in 11.9% of patients. Furthermore, there was no mortality or need for re-intervention.

Conclusions
Use of oral antibiotics as an adjunct to intravenous antibiotics and MBP in patients undergoing left-sided colorectal surgery was associated with a surprisingly low rate of SSIs and no significant anastomotic leak. It is time to trust the best available evidence and incorporate the use of oral antibiotics as an adjunct to intravenous antibiotics and MBP in colorectal surgery protocols in the UK hospitals.
EP.TH.1025The necessity of pre-operative investigations for elective surgical patients
Authors: Barman S , McGeehan M , Joseph E , Perakath B 
Published: October 2021

Abstract

Introduction
Patients admitted for elective surgeries tend to get quite a few investigations at pre assessment. Are these strictly necessary? Are there significant cost implications? National Institute for health and Care Excellence first issued guidance on routine preoperative tests for elective surgery in 2003.

Aims
To carry out an audit of pre-operative investigations of elective surgical patients at pre-admission. To determine level of unnecessary tests.

Results
Regarding correlation between ASA grades and over testing, grade 4 is the highest and grade 2 is the lowest in meeting standard guideline per ASA grade. Only 20% intermediate surgical cases meet the guideline whereas 30% of minor and 85% of major cases meet guideline per surgery grade respectively. Majority of unnecessary tests are carried out in minor and intermediate cases. Very few cases of missing tests. Only four tests that should have been taken as per the guideline weren’t done in the whole cohort. For all cases,57.4% of FBC,38.2% of U&Es, 48.5% ECG and 5.9% lung function tests carried out unnecessarily.

Conclusion
Generally we are over-testing patients at pre-assessment. This seems to be an issue with minor and intermediate cases, with majors generally doing better in fulfilling the guidelines. This may not be deliberate but coincidence as major surgeries call for more tests. Over-testing is more of an issue in lower (1-2) ASA grades in minor and intermediate surgeries. Under-testing is very rare. Using NICE’s estimated costs for each test, approximately £965.78 was spent in 1.5 months for tests which were not needed.
NELA.03Laparoscopy in Emergency Surgery is Associated with Lower Risk-Adjusted Mortality
Authors: Darbyshire Alexander , Kostakis Ina , Pucher Phil , Prytherch David , Toh Simon , Mercer Stuart 
Published: October 2021

Abstract

Aims
To compare risk-adjusted outcomes after emergency intestinal surgery by operative approach.

Methods
Data from December 2013-November 2018 was retrieved from the NELA national database. Complete data on 102,154 patients with P-POSSUM was available, and 47,667 had NELA score. AUROC curves were calculated to assess model discrimination (c-statistic), and calibration plots to visualise agreement between predicted and observed mortality. Standardised Mortality Ratio's (SMR) were calculated for the total cohort and by operative approach. Operative approach was divided into: laparotomy, completed laparoscopically, converted to open and lap assisted.

Results
Both P-POSSUM and NELA score displayed good discrimination for total cohort and by operative approach (P-POSSUM c-statistic=0.801-0.815; NELA score c-statistic=0.851-0.880). Calibration plots demonstrated that P-POSSUM was highly accurate up to 20% mortality, after which it substantially over-predicted mortality. NELA score was highly accurate up to 25% mortality after which it slightly under-predicted.
Overall SMR of observed vs expected deaths was 0.77 using P-POSSUM, 0.8 for laparotomy and 0.46 for laparoscopy. Restricting cases to &lt; 10% predicted mortality (n = 65,000), overall SMR improved (0.9) and was considerably lower for cases completed laparoscopically (0.41) compared to open (0.97). Using NELA scores of &lt; 10% predicted mortality (n = 27,000) had similar overall SMR (0.96), with cases completed laparoscopically displaying much lower SMR (0.61) compared to laparotomy (1.0).

Conclusions
SMR's calculated using P-POSSUM and NELA score have demonstrated that laparoscopy has significantly lower observed vs expected mortality rate compared to laparotomy. This raises the question of why laparoscopy is associated with reduced mortality and should operative approach be included in risk models?
SPOD.01A double-blind, placebo-controlled, randomised trial of extracorporeal shockwave therapy as a novel treatment for intermittent claudication
Authors: Cai Paris , Pymer Sean , Raza Ali , Ibeggazene Said , Chetter Ian , Smith George 
Published: October 2021

Abstract

Aims
Intermittent claudication (IC) is a prevalent manifestation of peripheral arterial disease. Pilot data has shown Extracorporeal ShockWave Therapy (ESWT) as a novel, non-invasive treatment for IC. We aim to compare the effects of ESWT on quality of life (QoL) and walking distances of patients with lower limb IC through a randomised trial.

Methods
A double-blind, placebo-controlled, randomised trial, where patients with lower limb IC were randomised at a 1:1 ratio to ESWT or placebo. Primary outcome was the physical functioning domain of the SF-36 QoL questionnaire at 12-week follow up. Secondary outcomes included claudication and maximum walking distances, and Ankle Brachial Pressure Index (ABPI).

Results
Full study power achieved with 138 patients randomised. The ESWT group had a significantly higher physical function score at 12 weeks (Mdn 41 vs 34, z=-2.1, p = 0.033). At 12 weeks the ESWT group had significantly longer claudication and maximum walking distances (Claudication Mdn 125 vs 88, z=-2.9, p = 0.004) (Maximum Mdn 179 vs 129, z=-2.4, p = 0.013). The increase in claudication and maximum walking distance at 12 weeks from baseline was also significantly higher in the ESWT group (Mdn 51 vs 24, z=-2.8, p &lt; 0.01) (Mdn 63 vs 17, z=-4 p &lt; 0.01).

Conclusion
This study demonstrates ESWT is clinically effective in improving QoL and walking distances in patients with lower limb IC.
EP.TU.142Impact of PC-CRC on curative intent and survival of patients
Authors: Elsayeh Karim , Brown Alexander , Chintapatla Srinivas , Lim Michael 
Published: October 2021

Abstract

Introduction
PC-CRC is an important benchmark of endoscopy performance and results in a delayed diagnosis of cancer for patients. Little is known of the impact of PC-CRC on survival; we chose to study this in a cohort of patient at our institution.

Methods
A retrospective analysis was performed on all PC-CRC from 2015 to 2020. Electronic endoscopic records and case-note review were performed to identify cases. Suitable patients underwent surgery in the absence of widespread metastatic disease after MDT discussion. Survival data were recorded, Kaplan-Meier curves were constructed; the log rank test was used to compare groups, a p-value of &lt; 0.05 was deemed significant.

Results
There were 32 (24 male) patients with a PC-CRC out of 1207 patients during this interval. The 5-year PC-CRC rate was 2.6%. Median age was 72 (IQR 63-79) years. 10 patients had metastatic disease, 9 with large volume disease that was not resectable. All 9 were palliated with a median survival of 3 (IQR 2-23) months. Twenty-three had potentially curative disease and all underwent surgery. On follow-up a further seven patients died with recurrent disease at a median of 19 (IQR 13-35) months. Sixteen are alive with a median survival of 38 (IQR 27-52) months. The survival curves for the 3 groups are significantly divergent, p-value &lt;0.001.

Conclusion
The impact of PC-CRC on individual patients is significant as a quarter die within 3 months of diagnosis. A further quarter die within 24 months despite a potentially curative operation due to metastatic disease.