bluuebunny/crossref_metadata_2025_split huggingface dataset:
374 Cognitive Biases and Heuristics in Surgical Settings: A Systematic Review
Authors: Agarwal S , Aylmore H , Marcus H , Pandit A 
Published: August 2023

Abstract

Aim
Cognitive biases and heuristics represent mental shortcuts that can lead to errors in judgement. Both are noted in surgical settings and risk patient safety. Yet, up till now, the extent of biases in surgical settings has not been systematically reviewed.

Method
This PROSPERO registered (CRD42022334828) review was conducted in accordance with PRISMA guidelines. MEDLINE and four other major databases were searched from their inception to 28th August 2022 using “surg*” with “cognitive bia*” and “heuristics” terms. Original primary research studies in English were included, with blinded full text screening. Relevant risk of bias (RoB) tools were employed for each study.

Results
The search identified 26,640 papers. Following de-duplication and screening, 16 final papers were included. 34 biases were identified including three prospective experiments, three retrospective analyses, and 10 questionnaire studies. Confirmation and anchoring biases were the most represented. RoB analysis found broad heterogeneity, with four studies being deemed of high risk. All identified cognitive biases were found to influence relevant surgical outcomes and seven studies cited a negative impact on patient care.

Conclusions
Cognitive biases will continue to contribute to surgical errors and never events unless they are described and recognised with greater precision and de-biasing strategies are implemented. Of note, mindfulness-based training and deliberate reflection tested by two studies demonstrated reduced rates of surgical error. Nevertheless, our review demonstrates a lack of experimental studies which are crucial to understanding why and how biases contribute to negative outcomes and we suggest avenues for further research and systems change.
20 Predictors of Five-Year Recurrence and Five-Year Survival After Pancreatoduodenectomy for Ampullary Adenocarcinoma: An International Multicentre Cohort Study
Authors: Russell T , Labib P ,   RAW Study Collaborators, Aroori S 
Published: August 2023

Abstract

Aim
Pancreatoduodenectomy (PD) is recommended in fit patients with a resectable ampullary adenocarcinoma (AA). We aimed to identify predictors of five-year recurrence and five-year survival using a large multicentre cohort.

Method
Data were extracted from the Recurrence After Whipple’s (RAW) study, a retrospective study of PD outcomes (29 centres from 8 countries). Patients with AA who developed recurrence or died within five-years of PD were compared to those who did not experience these outcomes.

Results
A total of 394 patients had AA and five-year recurrence and five-year survival rates were 44.7% and 53.6%, respectively. The number of resected nodes, histological T stage I-II, lymphatic invasion, perineural invasion (PNI), peripancreatic fat invasion (PPFI) and ≥1 positive resection margin all had a significant association with both studied outcomes. The following correlated with reduced time-to-recurrence: ≥1 positive margin (median difference (MD): 144 days, p = 0.005), PPFI (MD: 214 days, p = 0.004) and PNI (MD; 124 days, p = 0.006). The following were predictors of reduced time-to-death: preoperative biliary stenting (MD: 119 days, p = 0.004), histological T stage &gt;II (MD: 228 days, p&lt;0.0001), histological N stage &gt;0 (MD: 196 days, p = 0.004), PPFI (MD: 287 days, p = 0.007) and PNI (MD: 241 days, p&lt;0.0001).

Conclusions
In our multicentre study of patients who underwent PD for confirmed AA, multiple predictors of five-year recurrence and five-year survival were identified. This information can guide postoperative management as those who are more likley to develop recurrence should arguably undergo earlier and more regular surveilance. In addition, ajuvant treatment is arguably more pertinent in this group.
1136 Modified Nuss Bar Procedure for Pectus Excavatum – Our Experience in Patients Aged 20 and Over
Authors: Bhat S , Pal S , Kolvekar S 
Published: August 2023

Abstract

Background
Pectus excavatum (PE) is a common congenital anterior chest wall deformity characterized by a sunken appearance. The incidence rate is approximately 0.1% with a male to female ratio of 4:1. It is associated with connective tissue disorders, neuromuscular diseases, and linked with some genetic conditions.
In 1987, the Nuss procedure was invented by Dr Nuss and his colleagues as a minimally invasive procedure to correct PE. This is a two-staged procedure and involved lesser hospital stays, smaller incisions, and early mobilisation. Applying this procedure to video-assisted thoracoscopic surgery (VATS), we present our experience on insertion as well as removal of the Nuss bar in patients aged 20 and over with PE.

Method
This is a single centre, retrospective study carried out in a tertiary cardiothoracic centre. A total of 104 patients, aged 20-57 years, who underwent Nuss bar insertions and removals between 2016 and 2021 (5 years) were included in our study. All the procedures were performed by a single consultant cardiothoracic surgeon using biotech stainless steel bars.

Results
A total of 24 bar insertions, 79 bar removals and 1 bar revision were performed between 2016-2021. The data included 95 male and 9 female patients. The average hospital stay was 2.5 days.
Postoperative complications for the procedure included pleural effusions (3%), pericardial effusion (0.9%), post-operative bleeding requiring re-operation (0.9%), bar dislodgement (0.9%) and wound infection (4%).

Conclusions
We can conclude that VATS-Nuss procedure is a safe procedure for adult patients resulting in shorter hospital stays and reduced post-operative complications.
1267 Application of the Low-Cost Laparoscopic Appendicectomy Simulation (LaApSi) Model for Laparoscopic Training in Low-Middle-Income-Countries (LMIC) and Its Comparison with the Laparoscopic Skills Session in the UK
Authors: Karki B B , Katuwal S , Walshaw J , Rao A , Rao M M , Satyal S 
Published: August 2023

Abstract

Aim
To assess the LaApSi Model’s effectiveness in the surgical simulation within and outside the UK. To assess the delegates' expectations while simulating Laparoscopic Appendicectomy (LA) using LaApSi Model.

Method
LaApSi models were developed using 3D printed mould & Silicon with a production cost under £5 pp. Within 6 months of model development, the quantitative assessment of LaApSi model was done by 18 trainees from LMICs (RCSEd endorsed Laparoscopic Course) and 29 within the UK, 2 Laparoscopic courses (LC) and 1 Intermediate Surgical Skills Course (ISS) evidenced by formal feedback which has further led to the production of the modified version.

Results
For LMICs Lap-courses, 88.9%, n = 16 delegates agreed that the LaApSi model was able to meet their learning objectives whereas it was around 80% for UK courses. Similarly, 90%, n = 16 delegates agreed they were able to understand the General Steps Involved in LA, were more confident with LA and felt the course was relevant whereas it was around 15% less in these domains during UK Lap courses. 80.3% n = 5 delegates responded that the LaApSi model was equally effective in simulating Open Appendicectomy (OA) in a recent ISS course.

Conclusions
There is an unmet need for the development of a Low-Cost simulation model in LMICs and these cost-effective LaApSi models can provide a safe and standardized method for simulation training before operating on real patients. Although the model expectations were found relatively higher among UK delegates, feedback establishes a positive impact of the model among the course delegates.
195 Outcomes of Emergency Groin Hernia Repair: 30-Months Experience of a Tertiary Care Hospital
Authors: Kumar D , Tan B , Guilbert M , Elsllabi M , Soomro F , Muthukumarasamy G 
Published: August 2023

Abstract

Aim
Repair of Emergency groin hernia is variable across different regions and even within same units. Mesh is increasingly used these days. We aim to evaluate peri-operative and long-term outcomes over last 30-months.

Method
Retrospective analysis of all emergency groin hernia repairs from January 2018- July 2020 in a tertiary Centre. Case notes and electronic patient records (clinical portal, PACS system etc.) used for data collection.

Results
Of 89 emergency groin hernia repairs 62(69.7%) males, 32/89 (35.9%) indirect inguinal hernia and 29 (32.5%) femoral hernia. Median age 72 years (range 20-95), 74(83.1%) primary hernia and 15(16.9%) recurrent hernias. Femoral hernia was most common in females 25/27 (92.5%) in contrast 58/62 males (93.5%) had inguinal hernia. All patients, except 1(1.1%) laparoscopic, had open repair, 11/89 cases (12.3%) required bowel resection, of those 10 (90.9%) had suture repair. Additionally, 6/89 cases (6.7%) needed laparotomy. Of 68/89 (76.4%) cases who had mesh repair, 52(76.4%) were inguinal and 23.5% (16/68) femoral hernia. Only 55% femoral hernias repaired with mesh. Median LOS was 3 days (range 0-54), 6/89 cases (6.74%) had wound complications (3 wound infections, 2 haematoma and 1 fluid collection). With median 19 months (range 6-36 months) follow-up, 1(1.1%) recurrence each in both mesh and suture repair groups, no mesh infection and 2/89 (2.2%) 30-day mortality recorded.

Conclusions
Mesh repair is increasingly used in emergency groin hernia repair without increased risk of mesh infection, although suture repair is still preferred in groin hernias requiring bowel resection.
219 Post-Skin Cancer Scalp Defect Reconstruction with Integra® as Single Stage Surgery: A Case Series
Authors: Locurcio L , Breen M , Haq J 
Published: August 2023

Abstract

Aim
Large post-surgical scalp defects represent a common challenge in skin cancer surgery reconstruction. Despite the multiple options available the patients, often elderly, may prefer to have the least amount of surgery done and/or have comorbidities that may impair adequate wound healing. In order to reduce the number of hospital appointments and the risks of COVID19 exposure for the frail patients we used Integra®, a very versatile Dermal Regeneration Template for the treatment of skin defects. Originally, Integra® was designed to be followed by a second-stage surgery with a full thickness skin graft (FTSG). We retrospectively collected, in our busy OMFS Unit, a 40-case series of post-skin cancer scalp defects reconstructed using Integra® as single-stage approach without any further surgery.

Method
We have carried out a literature review of its use on the scalp and examined a series of parameters from our experience including:defect sizedressing appointments and total healing timeanticoagulation, peri-operative antibiotics prescribingcomplications

Results
The total healing time for the scalp wounds treated with Integra® averages 3.8 months, requiring 7.8 hospital appointments for dressings and checkups. Two infections, 3 significant bleeds and 4 failures were reported.

Conclusions
The Integra® is a valid and optimal substitute for local flaps and FTSG in patients that may prefer a single-staged approach wishing to avoid a second surgical site and minimising hospital attendance. The drawbacks are the longer time to heal compared to flaps/FTSG, the costs and the risk of delaying radiotherapy if complete epithelialisation is not achieved.
284 Eye Protection Compliance in the Operating Theatres of a Regional Major Trauma Centre
Authors: McMahon D 
Published: August 2023

Abstract

Aim
Surgical procedures inherently involve risk of blood splatter. Various studies have consistently demonstrated significant (&gt;40%) contamination of face masks worn by surgeons, though this may be macroscopically visible in fewer than half of cases; laparoscopic surgery is similarly not devoid of risk, with a comparable contamination profile. Nevertheless, routine use of eye protection by scrubbed surgical staff is inconsistent. This study audited the use of eye-protection by scrubbed surgical staff in a Major Trauma Centre.

Method
Local Trust guidelines mandated scrubbed surgical staff to wear eye-protection (namely disposable visor-masks or plastic glasses, not including spectacles). Operations over an initial 6-week cycle were audited to determine the rate of eye-protection use by surgical staff. Following a presentation to theatre staff, a further audit cycle was completed to assess for improvement in guideline compliance.

Results
98 operations were recorded in the first cycle, 39 of which were open procedures. Compliance rates were measured for different staff grades. Across all operations, 301 staff were scrubbed (183 surgeons). 52.2% of scrubbed staff (35% of surgeons) wore the requisite eye protection. Re-audit involved 88 operations, including 31 open procedures, with a total of 243 scrubbed staff (146 surgeons). A demonstrable increase in compliance occurred across all staff grades with a total compliance rate of 67.5% (49% of surgeons).

Conclusions
Conjunctival contamination presents significant risk to surgeons without adequate protection. The results of this study demonstrate the inadequacy of current protective practice; increasing awareness of the necessity for adequate eye protection is thus a clinical priority.
562 Retrospective Study on Pain Management Pathway for Patients with Suspected Renal/ Ureteric Colic in a UK Accidents and Emergency Department
Authors: Ojo C , Osunde U , Thapa S , Lim M L , Kelly M 
Published: August 2023

Abstract

Aim
To understand local compliance with the NICE guideline for pain management in suspected renal/ ureteric stones which includes use of NSAIDS, Intravenous Paracetamol and Opioids as first, second and third-line analgesics respectively and not offering antispasmodics.

Method
This was a retrospective single centre study wherein records of patients suspected to have renal/ ureteric colic between 18th July, 2022 and 30th September, 2022 were retrieved. Patients were identified by their presenting complaints of “loin-to-groin” pain at triage and “working diagnosis” from comprehensive history-taking and examination. We checked the first, second and third-line analgesics administered and, if Buscopan was given. Data was entered into Microsoft Excel and our pain management pathway matched against NICE guideline.

Results
78 patients were suspected to have renal/ ureteric colic. M:F = 1.2:1. CT-KUB confirmed 90% to have stones and 3% to have no stones. 6% did not have CT-KUB done because they were young patients and urinalysis showed no microscopic hematuria. One patient self-discharged before CT-KUB was done. Overall, compliance with the NICE pain management guideline for suspected renal/ ureteric stones was full in 22% of cases but poor in 78% of cases.

Conclusions
Clinicians ability to correctly diagnose renal/ ureteric stones is remarkable. However, the low compliance rate is concerning. This may be due to poor awareness of the NICE guideline or doctors having affinity for certain analgesics as compared to others. This information will be used to explore further with the clinical team, reasons for non-compliance, develop a teaching strategy and perform a re-audit thereafter.
640 Ambulatory Ultrasound - Could We Be More Efficient? Re-Audit -a District General Hospital Experience
Authors: Idama D , Shafi A , Lasheen O , O'Connor A 
Published: August 2023

Abstract

Aim
Right iliac fossa (RIF) pain is a common presentation to General Surgery departments and appendicitis is a possible cause. There are diagnostic challenges in these patients. Over a fifth undergoing appendicectomy have a histologically normal appendix (1). National guidelines recommend performing Ultrasound Scans (USS) in select patients (2). Aim is to review if there is better use of a limited service.

Method
A retrospective review of all ambulatory USS from June - December 2020 comparing to data from June 2019 - December 2019 for RIF/lower abdominal pain. We collected demographics, working diagnoses, imaging request details and outcomes.

Results
109 patients were included. 106 were female and 3 males. Of these, 35 had a working diagnosis of ovarian/ gynaecology pathology, whilst 25 had one of ‘appendicitis vs gynaecological pathology’. The USS was reported as no abnormality detected in 73 patients. 94(86%) had matching working diagnosis to USS request (41% in 1st audit). 22 (20%) had a working diagnosis matched with USS results (13%). In total 101 patients were discharged – there were 5 admissions (3 CT scans + 2 laparoscopic appendicectomies) and 3 referrals onwards to gynaecology.

Conclusions
We recommend using USS pelvis in women of childbearing age to identify gynaecological causes of RIF pain, more focused requests in order reduce requests of abdominal USS in lower abdominal pain, males should only receive hot clinic scans for biliary concerns, and increased use of CT for females &gt;40 years old.
678 The Safe Use of Intraoperative Tourniquets in Orthopaedic Procedures
Authors: Chien D C S , Adewale Ad , Li X , Ramsingh V 
Published: August 2023

Abstract

Aim
The use of intra-operative tourniquets in orthopaedic procedures is required to provide bloodless fields, enabling surgical procedures to be performed with improved quality, accuracy, and safety. Documentation of tourniquet use is necessary for optimising patient safety, as this provides an essential medico-legal role, as well as ensures the continuity of care for patients.

Method
All patients who had orthopaedic procedures in the local hospital in November 2022 were reviewed. There were a total of 123 procedures. 40 procedures required intra-operative tourniquet use were included in our study. The primary outcome is the documentation of tourniquet use, which includes the site of the tourniquet applied, the pressure, and the duration of tourniquet use. The secondary outcome is compliance with tourniquet use according to the national guidelines set by BOA Standards for Trauma and Orthopaedics (BOAST). This states the maximum authorized pressure, depending on the age (below/above 16), and the type of procedures (upper/lower limb).

Results
All procedures (N = 40) recorded the site of the tourniquet attached. 68% (27/40) of procedures recorded the length of the tourniquet use and 63%(25/40) recorded the maximum pressure applied. From the recorded procedures, the length of tourniquet use (N = 27) and maximum pressure applied (N = 25) is compliant with the national BOAST guideline regardless of the age group and type of procedures.

Conclusions
Overall this study highlighted the importance of documentation of tourniquet use for medico-legal purposes while demonstrating high compliance with the BOAST guidelines. This could ultimately overcome the challenges associated with intra-operative complications, thus optimising patient safety.
733 ERAS Audit: Junior Doctor Compliance with the Elective Colorectal Enhanced Recovery After Surgery (ERAS) Pathway at Bristol Royal Infirmary
Authors: Memory K , Brennan L , Smith A , Simpson A , Kobetic M , Griggs R 
Published: August 2023

Abstract

Introduction
The Enhanced Recovery After Surgery (ERAS) pathway is an evidence-based protocol aiming to reduce morbidity and improve post-operative outcomes. Two important recommendations included are early prescribing of post-operative nutritional drinks and avoidance of post-operative opioids. Junior doctors are integral to ensuring the compliance of these guidelines. Therefore, this audit aimed to review junior doctor adherence to ERAS recommendations with regards to nutritional drink prescribing and opioid avoidance within the colorectal department at the Bristol Royal Infirmary.

Method
Inpatient data was collected retrospectively from all patients undergoing elective colorectal surgery on the ERAS pathway from January to June 2022. Patients’ notes were analysed on two parameters: post-operative opioid prescribing and prescribing of post-operative nutritional drinks (fortisips/fortijuice). Educational interventions were implemented; face-to-face education to new colorectal junior doctors, and posters displayed in the doctor's office.

Results
104 patients were identified, 16 excluded for insufficient data. Of those 88 included, early post-operative nutrition and/or solid food intake was achieved by 60 patients (68.2%) and nutritional drinks were prescribed for 39 patients (44.3%). The average time to prescribe nutritional drinks was 3 days. Avoidance of systemic opioids was achieved by 7 patients (7.9%).

Conclusions
This audit highlights that improvements are required to ensure better adherence to the ERAS protocol within our department. Junior doctors can facilitate this by ensuring nutritional support is promptly prescribed post-operatively, and by prompting discussions regarding opioid prescribing. A second cycle post intervention will allow review of our chosen outcomes to ensure we are optimising post-operative outcomes for elective colorectal patients.
906 A Prospective Clinical Audit of Pre-Operative Fasting Practices at a Tertiary Care Hospital in India
Authors: Mendonca J , Upadya M , Arora M 
Published: August 2023

Abstract

Aim
Even in the face of evidence-based recommendations, the ‘nil by mouth from midnight’ regimen has persisted because it is easy to administer and allows for theatre flexibility. We aimed to audit preoperative fasting practices at Kasturba Medical College Hospital Attavar, India against the Indian Society of Anaesthesiologists (ISA) national guidelines.

Method
Prospective clinical audit involving ASA 1 and 2 patients undergoing elective, non-obstetric surgery under general/regional anaesthesia or sedation. Data were collected from patient notes and from an interview on the morning of surgery (at least one hour prior to induction of anaesthesia).

Results
Baseline Data (N = 100) Median fasting durations of 10 hours and 12.5 hours from clear fluids and solids, respectively.
99% of patients gave an incorrect reason or did not know at all the reason for preoperative fasting.
Interventions:Patient information leaflets (in English and the local language) were made and distributed to every ward; to be shown to elective surgery patients on the day before surgery.Surgical trainees, anaesthesiology trainees and nurses were made aware of the audit findings.
Re-Audit (N = 40)
Median fasting duration of 3 hours and 11 hours respectively clear fluids and solids.
Thirty-five percent of patients knew the correct reason for preoperative fasting. 50% gave an incorrect reason, while 15% did not know the reason.

Conclusions
Prolonged fasting was observed initially despite guidelines. Significant reduction in clear fluid fasting duration was achieved (10 hours to 3 hours) by creating awareness.