bluuebunny/crossref_metadata_2025_split huggingface dataset:
EGS P26 Facilitating the Emergency Surgical Ward Round: The Route to WardNav
Authors: Ireland Philip , Slim Naim , Thornton James , Arvind Nitin 
Published: November 2023

Abstract

Background
The ward round is a corner stone of surgical practice, this is no different when dealing with the acute surgical take. Constant bed pressures result in frequently needing to visit multiple wards, requiring time and effort on staff to ensure patients are reviewed. With frequent rotation of junior doctors, often the responsibility of planning the ward round falls to the ward round leader, who is also making the clinical decisions. We hypothesise a ward round planning tool available to the surgical team would result in more efficient ward rounds, freeing the team to focus on clinical decisions.

Methods
A survey of junior doctors (foundation doctors and core trainees) was distributed assessing their level of engagement with ward round planning while on surgical rotations at Southmead Hospital, Bristol. An initial planning tool was created in Microsoft Excel utilising a node edge graph and an algorithm based on the Hamiltonian cycle. After further survey feedback, the tool was developed into a web-based app using a version of Djikstra’s algorithm.

Results
25 junior doctors responded to the initial survey over two rotations. 100% had to go to multiple wards on a round, 64% actively think about the route required although only 28% would be confident in planning the route. 96% would find a planning tool helpful. Feedback on the Excel based tool from the first cohort revealed appetite for a mobile app-based version. The resultant application was created in R. The final version allows the user to start the round on any ward and creates the optimal route through the building, visually represented on a graph with accompanying text output.

Conclusions
Junior surgical doctors are not confident with planning ward rounds in a large teaching hospital. An app-based ward navigation tool has the potential to remove ward round planning from daily decision making and engage the junior surgical staff.
EGS P27 Twice Recurrent Gallstone Ileus Requiring 3 Laparotomies – A Case Report
Authors: Elnogoomi Ahmed , Loganathan Santhosh 
Published: November 2023

Abstract

Background
Gallstone ileus is a well-known and not an uncommon complication of gall stone disease, with standard management being an enterotomy and extraction of the obstructing gallstone with management of the gallbladder and the billio-enteric fistula being deferred to an interval procedure if indicated. Recurrent gallstone ileus are not unheard of, but are quite rare and are the reason cited by the proponents of a single stage procedure.
While a single stage procedure is possible - involving an enterotomy as well as a challenging cholecystectomy and the management and closure of a duodenal fistula – more commonly than not it is not performed.

Methods
Twice recurrent gallstone ileus is extremely rare and on performing a literature review only 1 published case report has been identified.
Here we present the case of an 87-year-old Caucasian female, presenting with 3 incidences of gall stone ileus in a 30 day period requiring 3 laparotomies. Initial presentation to our institution was in November 2022 with a CT proven localised Gallbladder perforation.
The first presentation with gallstone ileus was on 21/03/2023 with symptoms of bowel obstruction and CT proven obstructing 23mm gallstone 8 cm from the ileocaecal valve as well as pneumobillia and two other stones in the gallbladder.

Results
The index laparotomy was performed and no transition point was found, and bowel run-through from DJ to ICV revealed no intraluminal gall stones and the caecum was full of fluid. The gallstone had passed into the colon spontaneously and no enterotomy was performed.
Two subsequent laparotomies were required due to CT proven incidence of recurrent Gallstone ileus on 30/03/2023 and 20/4/2023, were enterotomies were performed and the obstructing stones extracted each time.
An informed decision not to tackle the gallbladder and the duodenal fistula was taken by a consensus of 3 consultant surgeons due to the frailty of our patient.

Conclusions
Our patient made a meaningful recovery after developing an entero-cutaneous fistula that resolved with conservative management and was discharged home on 15/05/2023.
While our patient's frailty and previous gallbladder perforation made the decision not proceed with a cholecystectomy and repair of the duodenal fistula a straightforward one, the incidence of twice recurrent gallstone ileus in the span of a month raises questions as to whether other techniques should be considered in a more fit patient such as a single stage operation or a Cholecystolithotomy.
EGS P33 Audit of Serial Lactate Measurement in Septic Patients Admitted in Acute General Surgery Department
Authors: Hobeita Wesam , Ali Kiren , Khan Khurram Shahzad 
Published: November 2023

Abstract

Background
Timely and effective resuscitation is crucial for the stabilisation of sepsis-induced tissue hypo-perfusion. Elevated serum lactate is associated with increase mortality and longer hospital stays. A reduction in lactate levels towards normal during acute resuscitation is therefore associated with improved clinical outcomes. Surviving sepsis campaign 2021 therefore recommends using lactate as quantitative measure of resuscitation in patient with sepsis and has advised serum lactate levels to be measured within three hours of admission and repeated within 4-6 hours if ≥2mmol. This audit aims to evaluate efficiency of our surgical department in serial lactate measurement in septic patients.

Methods
This was a single centre retrospective audit of patients admitted to general surgical ward between October 2022 to January 2023 with sepsis and Lactate ≥2mmol. Patients were identified electronic handover database. Data was collected for demographics, initial time and value of lactate, NEWS score and time and value of subsequent lactate measurements. All patients with initial Lactate ≥ 2mmol were included in the study, although our laboratory upper limit of normal Lactate is 2.4mmol. This audit was registered with Clinical Quality Project ID: 14730.

Results
Sixty-nine patients were included; median age was 70 years (IQR 58-82) and 35 (50.7%) were female. Median Charlson Comorbidity Index was 4 (IQR 2-6). 56 (81.2%) patients were admitted to acute surgical ward and 13 (18.8%) to the ICU/HDU. 51 (73.9%) patients had first lactate level was between 2-4mmol and 18 (26.1%) had ≥4. 16 (28.6%) patients admitted to surgical ward with high lactate was repeated and 9 (56%) of these were ≥ 8 hours. In HDU/ICU 12 (92%) patients had their lactate repeated in targeted time.

Conclusions
This audit highlights the standards not being achieved. This is likely due to unawareness of the recommendations as well as time pressure. Awareness of the latest guidelines is paramount in improving the adherence to the guidelines.
EGS P37 Colonoscopy Induced Gallbladder Perforation
Authors: Yogarajah Tharsiga , Stevens Jennifer , Majumdar Debabrata 
Published: November 2023

Abstract

Background
Gallbladder perforations are rare and usually affiliated with as an advanced complication of acute cholecystitis. Isolated and unique causes of gallbladder perforations have been reported however the mechanisms of these are often poorly understood. To the best of our knowledge, this is the first report of a colonoscopy related gallbladder perforation in the literature.

Methods
Data was retrospectively collected from the patient’s clinical notes. A literature review of gallbladder perforations and colonoscopy complications was conducted using PubMed and EMBASE.

Results
A 74-year-old gentleman presented with gallbladder perforation post-colonoscopy. The patient had a polyp removal at the proximal ascending colon with cold snare. The following day the patient presented to the Accident and Emergency (A&E) department with abdominal pains. After two repeat presentations to A&E, gallbladder perforation secondary to acute cholecystitis was noted on computed tomography (CT) scan. The patient was treated conservatively with intravenous fluids, antibiotics and a common bile duct stent was inserted to aid with bile flow.

Conclusions
This case highlights a potentially new complication of colonoscopy. Clinicians should be aware of this as rare but potential complication and take caution with the endoscope at the ascending colon. Patients presenting post-colonoscopy with abdominal pain should be investigated for acute cholecystitis and gallbladder perforation and an abdominal symptom screen prior to endoscopy may be of benefit.
EGS P38 Audit of operative notes/ Clinical documentation of emergency laparotomy & laparoscopic bowel resection procedures
Authors: Shalaby Amr Ibrahim , Adenipekun Ayokunle , Zaima Omar , Mohamed Mohamed Saleem Noor , Elhawary Abdelrahman , Bedford Matthew 
Published: November 2023

Abstract

Background
Laparotomies and laparoscopic bowel resections are common emergency procedures carried out in General Surgery emergency theatres. Get It Right First Time (GIRFT), Royal College of Surgeons (RCS) and The Association of Surgeons of Great Britain and Ireland (ASGBI) have made best practice recommendations for documenting operative notes, to ensure effective communication with colleagues and for medicolegal purposes. Ensuing medicolegal issues and patient complaints have cost departments in recent times, due to poor documentation. This audit within a busy General surgery unit, assesses the quality of operative documentations against the standards set by GIRFT, RCS and ASGBI.

Methods
A retrospective audit of operative notes and relevant clinical documentation of 100 emergency laparotomies and laparoscopic bowel resections between August 2022 and March 2023 at a local General surgery unit. Patient Identification Numbers were extracted from the National Emergency Laparotomy Audit (NELA) database. Operative records and clinical documentations were obtained from electronic clinical records. The recommendations from the “GIRFT RCS and ASGBI Best Practice for Laparotomy and Laparoscopic Bowel Resection Surgery Documentation” guidance was used as the Standard. Up to 60 variables were assessed across different stages of the patient journey, from preoperative to intraoperative and postoperative stages.

Results
In the period reviewed, there was varying performance. Good performance in documentations of Indications, Operator names, patient position, incision, and findings, seen in 99, 100, 100, 100 and 100 percent of cases respectively. Anaesthetist name was documented in 48% of cases, whilst WHO checklist was documented in only 20% of cases. 64 of these cases had bowel resections. In this cohort, methods and location of resection was described in 95% of cases. Only 43% had the state of bowel prefusion at transection site documented. VTE prophylaxis, Antibiotics, sutures/clip plan, were documented in 87, 65 and 13 % of cases respectively.

Conclusions
The audit highlights deficits in important areas of documentation, despite the set guideline. Important medicolegal issues can arise when documentations are not clear, and steps considered routine as not written in the operative notes or patient’s records. The findings will be disseminated, and recommendations will be suggested across all grades of surgeons, with the aim to re-audit and improve quality of documentation and ultimately improve delivery of surgical care. A plan to have electronic documentation template or checklist for these procedures has been carried out for trial with the aim of developing standardised documentation process.
EGS P39 The first cycle of an audit assessing the quality of documentation of emergency laparoscopic appendicectomies at Birmingham Heartlands Hospital, a District General Hospital
Authors: Mohamed Yethrib , Mohamed Mohamed Saleem Noor , Rafique Ahmed , Shalaby Amr Ibrahim , Wiggins Tom 
Published: November 2023

Abstract

Background
Laparoscopic appendicectomy is a common general surgical procedure. Poor documentation can a) result in misunderstandings between healthcare workers looking after patients and b) limit fair investigation of incidents. The Get It Right First Time (GIRFT) guidance was produced to advise on the information that should be available in patient records to reduce risk of both of the above.

Aims and objectives
To assess how well laparoscopic appendicectomies are documented in accordance with the GIRFT criteria. To then develop interventions to improve documentation and ultimately improve communication with other healthcare workers and allow defence of good medical practice.

Methods
Three people collected data on 100 laparoscopic appendicectomies that took place in 2022-2023 at Heartlands Hospital. Data was collected based on the 34 GIRFT recommendations and the sources were: electronic patient notes (adults); scanned patient notes (children); electronic operation notes (all); and theatre logbooks. It was then analysed and grouped into factors that were documented well (&gt;75% of the cases), moderately well (&gt;50% but £75%), poorly (&gt;25% but £50%) or very poorly (£25%).

Results
Factors that that were documented well (23%) included use of a sterile bag for appendix removal (83%), details of closure (96%), and instructions for post-operative antibiotics (88%) and recovery (97%).
Those documented moderately well (19%) included port location and size (70%) and achievement of haemostasis (62%).
Those documented poorly (23%) included whether ports were inserted under direct vision (38%) and whether any residual appendix was left behind (39%).
Those documented very poorly (36%) included sending a sample to histology and grade of doctors. Several of these were documented primarily in paper records that are not scanned - hence not readily accessible).

Conclusions
While there are several aspects of documentation which we are currently doing well, there is still much scope to improve documentation as a whole. The current format of the operation note itself limits the information which can be communicated. This in combination with the documentation of some important information on paper – which is largely inaccessible outside of theatre or once a patient has been discharged – produces unnecessary ambiguity. Discussion is ongoing with electronic records teams to alter the operation note format to improve documentation quality. These findings will be discussed at a departmental audit meeting to specify changes before re-auditing.
BS P01 Case Report: Emergency Laparotomy for Retrograde Intussusception after Roux-en-Y Gastric Bypass
Authors: De Pablo Ana Springall , Hutton Michael , Clarke Michael 
Published: November 2023

Abstract

Background
Roux-en-Y gastric bypass (RYGB) is a common operation performed to treat obesity and associated co-morbidities. When done with weight management programs, it is associated with 60% excess weight loss. A rare complication is retrograde intussusception (RI), which can require emergency surgery due to risk of bowel ischaemia and necrosis.
We report a case of a 66-year-old female who developed intermittent then acute RI, requiring urgent laparotomy for reduction of the intussusception and small bowel resection of the perforated invaginated segment. Her case is compared to the literature available, and a pathophysiological mechanism aiming to explain post-RYGB RI is proposed.

Methods
We compare the case of a patient with RI post-RYGB, to the available literature. The literature search was done on PubMed: “retrograde intussusception AND Roux-en-Y”. Results were limited to English language and human species. Paediatric and Maternity journals were excluded.
The patient is a 66-year-old female who had a laparoscopic RYGB for obesity in 2018; and lost 106% excess weight. In 2022, she presented with laparoscopic evidence of a resolved intussusception. In 2023, she was re-admitted with CT and laparotomy-confirmed RI and small bowel obstruction at the jejuno-jejunal anastomosis. She was managed with small bowel resection and anastomosis.

Results
The non-specific clinical presentation of RI makes prompt diagnosis challenging. Usually, patients have abdominal pain and lack peritonism. Severe cases may present with bowel ischaemia, as the intussuscepted segment can have compromised vascularity. Hence, prompt diagnosis and timely management is essential to reduce morbidity and mortality.
CT-AP is the diagnostic imaging test of choice, but delay in diagnosis of &gt;48h may increase mortality to 50% due to delayed intervention. The surgical management is emergency surgery with gentle reduction of the intussusception. Resection of the invaginated small bowel segment with anastomosis may be indicated if there is bowel ischaemia.

Conclusions
We report the case of a patient with RI post-RYGB, with evidence of gut dysmotility prior to intussusception. The literature suggests that dysmotility disorders could underpin RI, as 80% of cases are anti-peristaltic. Obesity has a strong association with slow gastric and intestinal motility, likely due to impaired gut-brain biochemical messaging and altered gut microbiota. RYGB will disrupt these pathways, and we hypothesize that this may lead to further motility dysregulation. However, further research is necessary to provide supporting evidence. Nevertheless, this report provides a helpful reminder to prompt urgent investigation in patients who present with non-specific abdominal pain post-RYGB.
BS P02 Equitable access to bariatric surgery: an exploration of trends in health inequalities and patient profiles over the last 15-years
Authors: Aizan Luqman Naim Bin , Ahmed Babur , Syed Akheel , Alkhaffaf Bilal 
Published: November 2023

Abstract

Background
Bariatric surgery is a safe and effective treatment for obesity and associated co-morbidities. Equality of access to bariatric surgery in the NHS has long posed a serious challenge with significant variation in eligibility criteria between different regions. Obesity disproportionately affects more deprived groups and some ethnic minorities, who have also been shown to experience a worse quality of healthcare and poorer health outcomes. This study aimed to understand the profile of patients accessing bariatric surgery and explore changes in trends over a 15-year period to identify important areas of development for obesity-related healthcare services in our region.

Methods
This was a retrospective study of all patients undergoing primary and revisional bariatric surgery (gastric band, sleeve gastrectomy, RNY and single anastomosis bypass) for weight loss at our regional bariatric surgical centre since its inception in 2008 until the end of 2022.
Data was extracted from a combination of electronic records and a surgical database. Variables included gender demographic and procedure related data, baseline characteristics including height, weight, deprivation scores, co-morbidities, bloods, and micronutrient levels. Changes in patient profiles were mapped over the 15-year period and compared to population-level data derived from the national census and other publicly available sources.

Results
2062 (mean age 47) patients were included. 11 (0.5%) patients were aged over 70 and 155 (7.5%) were less than 30 years of age. 75% patients were women; 42% of patients in 2013 were men which steadily decreased to 17% in 2022 (p &lt; 0.05). The mean BMI of patients undergoing surgery was 54 in 2010 and gradually decreased to 48 in 2022 (p&lt;0.05). White British patients represented 93% of all patients. This decreased from 96.5% in 2009 to 86% in 2022. White British ethnicity was estimated to make up 81% of patients with obesity in the NW of England.

Conclusions
Several major groups who are likely to significantly benefit from bariatric surgery are disproportionately under-represented by patients accessing treatments for obesity. This includes those at the extremes of ages, men, lower BMI patients and ethnic minority groups. Trends over the last 15 years have either worsened or have insufficiently improved to bridge the gap in health inequalities. The findings from our study underscore the urgent need for wider-scale targeted approaches which aim to address obesity and increase more equitable access to these life-changing treatments.
BS P04 The Legacy of the Adjustable Gastric Band; 5-year study of the presentation and management of gastric band-related complications
Authors: Abunimeh Bara , Alwani Omneya , Alabdellat Osama , Alkhaffaf Bilal 
Published: November 2023

Abstract

Background
Laparoscopic adjustable gastric banding (LAGB), once one of the most popular surgical treatments for obesity, now represents less than 10% of procedures undertaken nationally. No accurate figures exist regarding how many UK patients have undergone LAGB; approximately 5000 procedures were submitted to NBSR between 2013-2015. Alongside procedures undertaken abroad and privately, the total number is likely to be several multiples of this figure over the last 20 years. Currently there is a perception that LAGB-related complications account for a disproportionate volume of non-elective episodes compared to other procedures. This study describes the presentation and management of gastric band dysfunction.

Methods
This was a retrospective review of all referrals, attendances and admissions to a regional bariatric service with a dedicated bariatric on-call, serving the North West of England between. The study period was January 2018 and April 2023. All elective outpatient (OPC) and non-elective (NE) LAGB-related episodes were included. Patient demographics, band-related data, presentation, investigations, interventions, and related complications were collected and described.

Results
375 episodes (212 OPC; 163 NE) accounted for 58% of all OPC and 44% of NE activity. Most patients had LAGB in the independent sector (OPC presentation 73% UK, 18% abroad; NE presentation 80% UK, 20% abroad). Median time from index surgery was 8 years (IQR 5-11, range 0-30 years). Erosions and infections accounted for 4% (14/375) and 5% (20/375) of cases, respectively. LAGB removal was required in 59% of OPC and 60% of NE presentations. LOS for NE presentations was 3 days (IQR 2-6, range 0-41 days). 5 patients required ITU admission (median LOS 2 days).

Conclusions
Whilst representing only a small proportion of current elective practice, LAGB-related complications represent the majority urgent and non-elective activity in the outpatient and emergency settings. Given that LAGB related complications often present many years after the index procedure, it is likely that this phenomenon will continue to be a challenge for UK surgeons and services for years to come. This has training implications for the future generation of bariatric surgeons and general surgical trainees, many of whom will likely never have seen a gastric band placed, and yet will have to manage complications, a significant proportion of which are complex.