bluuebunny/crossref_metadata_2025_split huggingface dataset:
P-BN26 The effect of cholecystectomy on unplanned admissions following endoscopic sphincterotomy and bile duct stone removal
Authors: Toogood Kate , Pike Thomas , Coe Peter , Everett Simon , Huggett Matthew , Paranandi Bharat , Bassi Vinod , Toogood Giles , Smith Andrew 
Published: December 2021

Abstract

Background
Choledocholithiasis is common, with patients usually treated with ERCP and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focussed on recurrent CBD stones, negating the risks of cholecystectomy.

Methods
Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James’s University Hospital January 2015 - December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated.

Results
844 patients received ERCP and CBD clearance with 3.9 years follow up. 209 patients underwent cholecystectomy with 15% requiring complex surgery. 373 patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive.

Conclusions
The majority of patients do not require readmission following ERCP for CBD stones and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but difficult biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.
P-BN27 Novel technique for safe and efficient cannulation of the cystic and common bile duct
Authors: Khan Khurram , McLellan Morag , Mahmud Sajid 
Published: December 2021

Abstract

Background
Concomitant stones in the common bile duct (CBD) at the time of laparoscopic cholecystectomy (LC) are present in up to 15% of patients. In conjunction with intra-operative cholangiogram (IOC), transcystic common bile duct exploration (TCBDE) enables diagnosis and management of ductal stones in a single stage procedure. However, cannulation of the cystic duct (CD) and CBD can be challenging. With repeated attempts at cannulation, there is increased risk of iatrogenic injury by creating a false passage or perforating the duct. We propose a novel technique for the safe cannulation of the CD and CBD.

Methods
Once critical view of safety is achieved, a clip is placed distally in the CD and opened with scissors. A flexible tip 80cm guidewire is then preloaded into 5-French ureteric catheter. The complex is then passed into the introducer through the lateral port. A grasper placed at Hartmann’s pouch is used to retract the gallbladder and straighting the CD. Only the guidewire is advanced out of the catheter, traversing the CD and CBD. Once safely advanced, the catheter can then be slid over the guidewire and the guidewire can be removed. IOC and TCBDE can then be performed if indicated.

Results
This technique was performed on 18 patients who failed CD cannulation during elective and emergency LC for symptomatic gallstone disease in a single center performed by the same surgical team. Median age was 46 years and there was 15 females. A total of 34 cannulations were attempted (in 18 patients) which 100% success rate. There was no added time required for the technique. In majority of cases it decreased the operative time due to quick intubation of CBD. None of the cases required conversion to open surgery.

Conclusions
The novel technique described for cannulation of the cystic duct uses a Seldinger ‘like’ approach. This is a safe an effective strategy for cannulation of the CD, making the skills more accessible and more time efficient. This should encourage more surgeons to perform IOC and TCBDE where indicated.
P-BN33 Should a three-port technique be the gold standard for laparoscopic cholecystectomy?
Authors: Nip Lawrence , Tong Kin Seng , Borg Cynthia-Michelle 
Published: December 2021

Abstract

Background
The four-port technique is currently considered the gold standard technique for laparoscopic cholecystectomy. A three-port technique has been described but there is no consensus over the safety profile and efficacy of this technique compared to the four-port technique.

Methods
A comprehensive systematic review and meta-analysis comparing the three-port technique to the standard four-port technique in laparoscopic cholecystectomy for benign diseases of the gallbladder was performed. Two authors independently conducted an electronic database search of CENTRAL, MEDLINE, EMBASE, CINAHL, WHO ICTRP and ClinicalTrials.gov. For each outcome, we calculated the risk ratio (RR), mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals.

Results
Eighteen trials were included which randomised 2085 participants. Length of hospital stay and postoperative analgesia requirement favoured the three-port group [(MD -0.29, 95% CI -0.43 – -0.16, p &lt; 0.0001) and (SMD -0.68, 95% CI -1.03 – -0.33, p = 0.0001) respectively]. There were no differences in length of procedure and success rate between the two groups [(MD 0.90, 95% CI -3.78 – 5.58, p = 0.71) and (RR 0.99, 95% CI 0.97 – 1.01, p = 0.17) respectively]. There were no differences in the rate of any measured adverse events. There were no mortalities in either group. The GRADE quality of evidence was low.

Conclusions
The three-port technique for laparoscopic cholecystectomy can be chosen by experienced surgeons who perform it regularly. However, the decision to use three ports should not be at the expense of safe dissection.
P-BN34 A single centre study of outcomes for Hiatal Surgery during the Covid-19 pandemic
Authors: Faraz Ahmad , Dobson Gary , Gray Ronan , McCain Scott , Spence Gary 
Published: December 2021

Abstract

Background
Covid-19 has had a significant adverse impact on our ability to maintain provision of surgical interventions for a range of conditions, due to the diversion of resources to care for Covid related emergency admissions. Furthermore, there is clear evidence demonstrating how covid-19 infection in the peri-operative period is associated with dramatically increased rates of morbidity for patients. It has therefore become incumbent on healthcare providers to create peri-operative care pathways which can facilitate delivery of surgical care in a Covid safe environment.

Methods
In response to the Covid-19 pandemic our institution implemented a ‘Covid-lite’ pathway in order to allow the admission for patients for surgical procedures on the basis of urgent need. This included patients requiring surgery benign upper GI conditions. Patients underwent pre-operative PCR Covid testing,and asked to isloate from time of swab until admission for surgery. Post-opertive operative care was provided on the elective surgical ward which is is all single rooms, and was maintianed as a Covid free environment. We conducted a review of outcomes for all patients undergoing hiatal procedures between January 2020 – April 2021. Surgeries included were Para-Oesophageal Hernia Repair (POH), Anti-reflux Surgery (ARS) & surgery for achalasia (LCM). The primary outcome measure was the rate of Covid-19 infection in the peri-operative period. Measurements were also taken of length of stay, and any signifcant morbidity.

Results
Hiatal surgery was performed on 42 patients in this time period (28 female, 14 male). The median age was 73 years. Three patients underwent elective ARS and 39 had repair of POH. All ARS procedures were performed laparoscopically. For those having POH repair, 31 cases were elective admissions. 30/31 cases had laparoscopic procedures, with 50% of emergency cases also treated laparoscopically. All elective maptients were managed via the The median length of stay for elective cases was 2 days vs. 14.5 for emergencies (p = 0.001). Zero patients returned positive Covid-19 tests pre-operatively or during their inpatient stay. Two patients were re-admitted within 30 days, although neither were related to covid-19.

Conclusions
These results indicate that it is possible to safely maintain the provision of hiatal surgery in the Covid-19 era for both elective and emergency cases. The use of a dedicated pathway demonstrates our ability to minimise risk of peri-operative Covid-19 infection and any associated morbidity or mortality. Although there has been a significant attempt prioritise surgery for patients with cancer during the Covid-19 pandemic, these resuts provide a strong case that it possible to provide safe and timely interventions for other necessary surgical interventions with appropriate risk reducing measures.
P-BN44 The impact of the COVID-19 pandemic on waiting lists for laparoscopic cholecystectomy and its effect on patient care and outcomes
Authors: Herbert Geraint , Thomas Charlotte 
Published: December 2021

Abstract

Background
It has been widely reported that the COVID-19 pandemic has had a detrimental impact on waiting lists for elective surgery in the NHS. Delays in laparoscopic cholecystectomy (LC) are likely to prolong suffering for symptomatic patients and risk increasing complications for patients which may then require emergency care and intervention. In this study we aim to quantify the impact of the COVID-19 pandemic on elective waiting lists and to assess what implications this might have on patient care and outcomes.

Methods
Electronic health records were retrospectively interrogated for patients undergoing LC in both March 2019 (prior to the COVID-19 pandemic) and March 2021. The following data was captured: age, gender, elective vs emergency operation, laparoscopic vs open, total vs subtotal cholecystectomy, use of drains, length of stay/daycase rates, the number of emergency presentations prior to operation and the number of days between being listed for surgery and their operation. The results were analysed using SPSS Statistics (IBM, New York).

Results
111 patients were included in the study (25 male and 86 female). Of these, 60 had their LC in 2019, and 51 in 2021. The age and gender distribution of the patients in both time periods were similar. The median number of days on the waiting list was significantly higher (P &lt; 0.001) for patients in 2021 at 379.5 days, compared with 153 days in 2019. There was a significant increase in the number of emergency presentations prior to LC in 2021 (P = 0.025) with an average of 0.7 presentations per patient compared with 0.45 in 2019. Additionally, there was a significant increase in the number of emergency LC performed in 2021 (P = 0.002), with 15 performed compared with 4 in 2019, representing 29.4% and 6.7% of all LC respectively. There was no significant change in rates of conversion to open, drains or subtotal cholecystectomy. There was no significant difference in daycase rates for elective patients in either period (55% vs 58%).

Conclusions
Whilst there has been no change in the operative outcomes for patients undergoing LC, there has been a stark increase in the length of time patients are on a waiting list prior to undergoing elective LC. This has resulted in a significant increase in the number of emergency presentations and the number of emergency LC performed. This study demonstrates the wider impact of increasing waiting list times beyond the prolonged suffering of symptomatic patients. A significant reduction in waiting list times would be beneficial to both patients and healthcare providers, with the aim of reducing the number of emergency presentations. A reduction in these would have a positive impact on acute services and on the associated cost implications.
P-BN45 The Impact of Covid-19 on Benign Upper GI Operations in England During 2020
Authors: Sandland-Taylor Laura , Jenkins Barbara , Beckingham Ian 
Published: December 2021

Abstract

Background
Since the cancellation of elective surgery in early 2020 due to the threat of Covid-19, surgical provisions in England have continued to be affected by the Covid-19 pandemic. Elective surgery makes up the majority of surgical procedures performed in England and therefore cancelled operation lists and increased demand for ITU beds has had a significant impact upon the surgical services delivered to patients through out 2020. The following research looks at the impact of Covid-19 on benign upper GI surgery in England and reviews the relationship between Covid-19 deaths and operations performed throughout England and analyses the data at a regional level.

Methods
Data relating to operation numbers was taken from The Surgical Workload Outcomes Audit (SWORD) database. The SWORD database was interrogated for the years 2017 – 2020. A mean number of operations was calculated using the 2017-2019 data and compared to data from 2020. Operations performed and other demographic data was analysed regionally and compared to Covid-19 deaths throughout England. Covid-19 data was obtained from the national government dashboards.

Results
The results show that there is a correlation with increasing Covid deaths and lower rates of elective surgery. Furthermore, elective surgery was worse hit than emergency surgery with a slower recovery overall. Cholecystectomies were reduced by a total of 20817 (31.4%) for the year 2020 with a greater reduction seen in elective operations (35.6%). However, similar reductions were seen in both laparoscopic (31.4%) and open (37.5%) Similarly, bile duct explorations and elective splenectomy were reduced by 34.4% and 23.4% respectively. Comparatively, both paraumbilical and inguinal hernias also saw reductions of greater than 40% in 2020 when compared to the mean of the previous 3 years. Regional variances were seen between operation numbers performed and Covid-19 rates, however the overall trend remained the same for national level data.

Conclusions
Overall, the Covid-19 pandemic has had a significant impact on operations, particularly on those deemed as benign and ‘less urgent’. Whilst a global impact across all benign operations was seen, greater reductions were seen in elective operations compared to emergency operations. Hernia operations and bile duct exploration saw greater overall reductions compared to cholecystectomies and splenectomies, which suggests that whilst operation numbers were reduced, efforts were made to prioritise operations with greater clinical need throughout the pandemic. On analysis of the data in relation to Covid-19 rates and deaths, variation was seen across the regions in the UK, however overall the trend remained the same. Centres and regions worse hit by Covid-19 performed less operations during 2020. However, further qualitative research to investigate why certain centres maintained higher levels of performance during the pandemic would be beneficial for planning for future waves and future pandemics.
P-BN46 Risk Factors for Anastomotic Stricture after Hepaticojejunostomy for Bile Duct Injury – A Systematic Review and Meta-Analysis
Authors: Halle-Smith James , Hall Lewis , Mirza Darius , Roberts Keith 
Published: December 2021

Abstract

Background
After major bile duct injury (BDI), hepaticojejunostomy (HJ) is usually required. This can lead to good long-term patency but anastomotic stricture unfortunately remains common cause of long-term morbidity after major BDI. Although risk factors for adverse outcomes of BDI repair are reasonably well understood, there is a need to assimilate high level evidence to establish risk factors specifically for development of anastomotic stricture after HJ for BDI.

Methods
This was a systematic review of studies reporting rate of anastomotic stricture after HJ for BDI was performed according to PRISMA guidelines. Where possible, meta-analyses were then performed to establish risk factors for anastomotic stricture after HJ for BDI.

Results
The meta-analyses performed included five factors with a total of 2,155 patients from 17 studies. An increased rate of anastomotic stricture after HJ for BDI was shown amongst patients with concomitant vascular injury (OR 4.96; 95%CI 1.92-12.86; p = 0.001), post-repair bile leak (OR: 8.03; 95%CI 2.04-31.71; p = 0.003) and repair by non-specialist surgeon (OR 11.29; 95%CI 5.21-24.47; p &lt; 0.0001). Level of injury according to Strasberg Grade did not significantly affect the rate of anastomotic stricture (OR: 0.97; 95%CI 0.45-2.10; p = 0.93). Due to heterogeneity of reporting it was not possible to perform meta-analysis for impact of timing of repair on anastomotic stricture rate.

Conclusions
Repair by a non-specialist surgeon was the only modifiable risk factor revealed by this meta-analysis and systematic review, which demonstrates the importance of broad awareness of these data. That said, knowledge of these risk factors permits evidence-based risk stratification of follow-up as well as better informed consent and understanding of prognosis for patients who have experienced major BDI and require HJ.
P-BN56 Anti-Reflux Surgery in the end-stage of the pandemic: Early results of the ARROW audit
Authors:   The ARROW collaboration
Published: December 2021

Abstract

Background
Gastro-oesophageal reflux disease (GORD) affects 10-20% of the population. Lifestyle modifications and medications such as proton pump inhibitors are generally well tolerated, however a variety of surgical and endoscopic interventions may be more suitable for well selected patients. Despite national guidelines and evidence from trials there is lack of consensus regarding the best approach to antireflux surgery (ARS).
We designed a national audit (ARROW) to describe variation in UK clinical practice of ARS and adherence to clinical guidelines. Our audit was designed in two phases. First, a survey of national practice; Second, a prospective audit of compliance with available guidelines.

Methods
International guidelines and consensus statements were collated and reviewed by the ARROW steering committee. Sources included NICE, ICARUS and BSG guidelines and AUGIS commissioning guidelines. Definitions were adopted from the Montreal consensus statements and the Chicago Classification of Esophageal Motility Disorders. Audit fields were then iteratively developed by the steering committee and an online tool was developed to prospectively collect pseudo-anonymised patient data.
Participants were enlisted through AUGIS, social media, personal contacts and the ROUX group of upper GI trainees. The online tool was piloted in three centres. The protocol was published in Diseases of The Esophagus in January 2021.

Results
Of 240 registered patients on 25th August 2021, 171 had complete data. Median age was 57(range 19-83), 60.2% were females. 156 (91.2%) had OGD performed prior to surgery. 105 (61.4%) had manometry and 97 (56.7%) had 24-hour pH studies performed. 91 DeMeester scores were recorded, median score 38 (IQR 24-70). Median days from referral to surgery was 471, (range 1 to 1374). 167 patients (93.3%) underwent some variant of fundoplication. The most common wrap was a posterior 360° (44%) followed by a posterior 270°(27%) and anterior 180°(23%). 2 patients returned to theatre, 1 for recurrent hernia and 1 for ischaemia.

Conclusions
In keeping with all non-cancer elective work in the UK, ARS is recovering from the effects of the COVID pandemic, and this is reflected in long delays between referral and surgery. Compliance with established guidelines and consensus opinions has similarly been affected as access to diagnostic services has been impeded. Variation persists in the interventions offered to individuals and long-term outcomes monitoring to compare interventions is beyond the scope of this audit. Complication rates are very small with only 2 returns to theatre, 9 patients experiencing any short-term complication and only 24 delayed discharges.
P-EGS01 Cholecystectomy after gall stone pancreatitis
Authors: Ammar Ahmed , Elsayed Ahmed , Mohsin Mohammad , Shaaban Hossam 
Published: December 2021

Abstract

Background
According to the UK guidelines for the management of acute pancreatitis commissioned by the British Society of Gastroenterology,
All patients presenting with gallstone pancreatitis should be considered for cholecystectomy when they are well enough to undergo surgery. In cases of mild biliary pancreatitis, cholecystectomy should ideally be performed during the index admission or within 2 weeks of discharge as interval cholecystectomy is associated with a significant risk of readmission for recurrent biliary events.
In cases of severe gallstone pancreatitis, cholecystectomy may need to be delayed until collections have improved, unless the patient is well enough for surgery and the gallbladder is some distance from the collection

Methods

Methods
Inclusion Criteria
Exclusion Criteria

Results
80 patients were collected during the study period, 96 % of them were classified as mild pancreatitis
Cholecystectomy rate
Total percentage of cholecystectomies performed for mild gall stone pancreatitis during index admission or within 2 weeks from discharge : 37%
Percentage of early cholecystectomies for eligible patients (i.e.after ruling out unfit patients, patients declining treatment, previous cholecystectomy..etc) : 54%
Re-admission rate
Re-admission rate for early cholecystectomy patients : 7.4%
Re-admission rate for delayed cholecystectomy patients : 20.7%

Conclusions
P-EGS04 Assessment of Malnutrition in emergency laparotomy patients. A QIP highlighting simple measures can improve early recognition and optimisation of high-risk patients
Authors: Raslan Charef , Lasheen Omar , Tomalieh Feras , Siddique Khurram 
Published: December 2021

Abstract

Background
Early recognition of high-risk malnourished patients is important for optimisation of nutritional status leading to better outcomes. The accurate recording of malnutrition universal screening tool (MUST) results is vital in this regard. This quality improvement project (QIP) aimed to review the quality of nutritional assessment of emergency laparotomy patients against the National Institute for Health and Care Excellence (NICE) guidelines and outline area of improvement.

Methods
The QIP was conducted at Royal Oldham Hospital in 2019-2020 over a seven-month period. Fifty random patients were included in the first audit cycle over a 4-month period, followed by implementation of recommended changes and a re-audit of 30 patients over a 2-month period. The initial MUST scores which were calculated and documented by nursing staff were identified as the nursing staff MUST score (NSMS). To assess the accuracy of NSMS, we developed a MUST rescoring method which was performed by a senior member of the medical team and was identified as the medical team MUST rescore (MTMR).

Results
The initial audit showed a significant difference between NSMS and MTMR scores. According to MTMR, 23 patients (46%) had an inaccurate MUST score assessment by the nursing staff. A multidisciplinary approach using a standard online calculator were recommended. The second phase of the QIP showed an obvious improvement in the accuracy of MUST assessment. Our interventions improved the accuracy rate of MUST scores significantly (27, 54% vs 29, 96.6%, P = 0.00005).

Conclusions
A multidisciplinary team approach and online calculator are useful in improving the accuracy of MUST assessment in emergency laparotomy patients. This helped early involvement of the dietitian leading to improvement in morbidity and mortality.