bluuebunny/crossref_metadata_2025_split huggingface dataset:
SP5.2.2 Our Management of Distal Femoral Comminuted Fractures with Femoral Defects
Authors: Zhou Andrew , Jou Eric , Patel Shaan , Lu Victor , Zhang James , Krkovic Matija 
Published: November 2022

Abstract

Aim
Distal femoral fractures account for 3–6% of all femoral fractures. Current management of distal femoral fractures involve reducing bone fragments and placing a locking plate against it. In this study, the surgeon used a ‘selective approach’, whereby only key bone fragments in the comminuted fracture were reduced and fixed whilst the rest were either removed or left unreduced/unfixed.

Method
All patients underwent AxSOS plate/less invasive stabilisation system (LISS) surgery for their comminuted femoral fracture after adopting the “selective approach” during pre-surgical planning. A significant proportion of patients had a degree of bone defect, and most had open fractures. Primary outcomes included post-operative functional ability, quality of life assessed using EQ-5D-5L, Oxford Hip Score (OHS), Oxford Knee Score (OKS), range of movement.

Results
Average OKS and OHS for our cohort (n=10) is 23 and 35, respectively, with a mean knee-flexion of 86° (45°-120°). Average EQ-5D- 5L index value is 0.551; the most common response for mobility, self-care, usual activities, pain/discomfort, and anxiety/depression was moderate. 20% developed pin site infections, 40% reported significant knee stiffness.

Conclusions
Despite a complex cohort whereby many patients had bone defects, and 80% had open fractures, the “selective approach” adopted in the present study achieved comparable outcomes to other studies with less-severe fracture characteristics, with similar operation times and range of knee-flexion. These results suggest that this alternative should be considered as a treatment option, although more studies on a similar cohort of patient to ours is needed to allow better comparison of the surgical approaches.
SP5.2.4 Machine learning development of novel triage tools for major incidents
Authors: Malik Nabeela , Xu Yuanwei , Chernbumroong Saisakul , Bowley Douglas , Belli Antonio , Gkoutos Georgios 
Published: November 2022

Abstract

Aims
Major incidents (MI) are an important cause of death and disability. Triage tools are crucial to identifying patients requiring time-critical, life-saving surgery and/or resuscitation (Priority 1 (P1) patients). We employed machine learning to develop novel primary and secondary triage tools, including external validation.

Methods
Adults from the Trauma Audit and Research Network (TARN) registry (January 2008-December 2017) acted as surrogates for MI victims, divided chronologically (70:30) to yield model training and internal testing datasets, respectively. P1s were identified using predefined criteria. Input variables included physiology, age, mechanism and injury location. Random forest, extreme gradient boosted (XGB) tree, linear regression and decision tree models were trained, including cross-validation, to predict P1 status. Primary and secondary tool candidates were selected; the latter was validated using the UK military's Joint Theatre Trauma Registry (JTTR). Existing tools served as comparators.

Results
Models were internally validated in 57,979 TARN patients. Several outperformed the best existing tool (Battlefield Casualty Drills Triage Sieve: sensitivity 68.2%, AUC 0.688). Inability to breathe spontaneously, presence of chest injury and mental status were most predictive of P1 status. A three-variable decision tree model (sensitivity 73.0%, AUC 0.782) was selected as a candidate primary tool. A four-variable XGB model (sensitivity 77.9%, AUC 0.817) is proposed as a secondary tool, applicable via a portable device; and validated amongst 5,956 JTTR patients (sensitivity 97.6%, AUC 0.778).

Conclusions
Models outperformed existing triage tools in a nationally representative trauma population, these may serve as evidence-based novel tools. The proposed secondary tool demonstrates excellent external validity.
SP5.2.6 The Challenges Experienced by Female Surgeons in Africa- A Review of the Existing Literature
Authors: Jesuyajolu Damilola , Okeke Charles , Obuh Otomi 
Published: November 2022

Abstract

Aims
There has not been any comprehensive analysis of the challenges faced by female surgeons in Africa on a continental scale. These challenges, when brought to the forefront, can be tackled by the necessary stakeholders to increase the participation of women in surgery. This article will review the existing literature, across the African continent, to highlight the challenges experienced by female surgeons.

Methods
We conducted a search using keywords ‘Challenges' ‘Female’ ‘Surgeon’ ‘Africa’ and ‘Bias' on PubMed, Google Scholar, and AJOL from inception till 21st of January 2022. We then searched these keywords on Google in addition to the names of each of the individual countries. 10 papers satisfied the eligibility criteria by discussing the specific challenges that female surgeons faced in practice.

Results
There was a paucity of data from most of the individual African countries, highlighting the need for more research in this aspect. Out of the 10 published papers that were eligible, problems with work-life balance was the most common challenge with underrepresentation being second. Harassment, insufficient support, disrespect from colleagues, exclusion from activities, and stereotypes were also part of the challenges identified.

Conclusion
Despite the increasing participation, female surgeons continue to face different challenges ranging from the unfavorable work environment to the pressures put on them by society. This narrative review serves as a stimulant for major health stakeholders in Global surgery to promote gender inclusivity in the African surgical workforce; a feat that will ultimately benefit the people who need access to quality surgical care.
SP5.2.7 Direct line: Implementation of a novel clinician triage service to safely prevent unnecessary surgical admissions
Authors: Shahid Mishal , Gurowich Louise , Dru Rebecca , Barton Jessica , Lock Kate , Hollyman Marianne 
Published: November 2022

Abstract

Introduction
With the NHS under increasing pressure, the number of patients being referred to secondary care is increasing. Ambulatory clinics are being set up to reduce admission in some patient groups.
In our unit, GP referrals to General Surgery were previously being accepted to the admissions ward, without triage. A new system which allowed referrers to contact senior on-call team members was trialled to identify whether patients could be safely diverted to an ambulatory clinic, avoiding inpatient admission.

Methods
A cascade triage system of referrals was trialled between September 2021 and January 2022, over a total of 30 days. Data were collected on who triaged the call, outcome of the call, and admission rate of patients.

Results
Some 195 calls were analysed. Consultants were able to divert 62%(66/106) of patients to an ambulatory clinic compared to 30%(14/46) for junior doctors and 35%(15/43) for specialist nurses(p&lt;0.001). The overall admission rate was 50%, with half of patients being successfully managed ambulatorily.
Improvement was shown over time in triage by junior doctors, with 1/10 in first 10 patients versus 4/10 in the final 10 patients triaged to the ambulatory clinic.
Average weekday admissions to the ward dropped from 12.1, to 7.5 on trial days.

Conclusion
The trial has demonstrated senior decision makers are the most effective at directing patients to an ambulatory pathway, while junior doctors have scope to improve their skills with experience.
Clinician triage is successful at reducing the number of surgical admissions when there is access to an ambulatory clinic.
SP5.2.8 Management of Small Bowel Obstruction: Are we improving?
Authors: Cox Kofi , Kenington Cleo 
Published: November 2022

Abstract

Aims
Recently 2 national audits evaluating the management of small bowel obstruction (SBO) have been published, recommending areas for improvement (NASBO and NCEPOD: delay in transit). We conducted a retrospective audit to evaluate if the management of SBO at a University Hospital reflects these recommendations.

Methods
The audit questionnaire and standards were designed using recommendations from the national audits. Patients were identified using hospital coding data over a 6-month period: February-July 2021. Patient data was extracted using electronic patient records.

Results
81 patients were identified. Adhesions (59%) and hernias (26%) were the predominant aetiologies. 53% were managed conservatively, 36% with early surgery and 11% with delayed surgery. 93% of cases received a CT; time to CT diagnosis was slower in patients also investigated with abdominal radiographs. Mean time from triage to CT diagnosis was 7.5 hours (2.2 days in NASBO). 84% of surgical cases arrived in theatre less than 72 hours after triage and 65% of conservatively managed cases received Gastrografin (28% in NASBO). Dietician review occurred in 68% of patients at moderate-severe risk of malnutrition (39% in NASBO). 48% of patients had urine output recorded within 24 hours of admission and AKI incidence was 14% (8% in NCEPOD: delay in transit). No surgical cases were successfully managed laparoscopically and 20% of frail patients had geriatrician input.

Conclusion
Whilst improvements have been made since the NASBO and NCEPOD: delay in transit, fluid balance consideration, care of frail patients, laparoscopic surgery and use of abdominal radiographs remain key areas for improvement.
SP6.1.1 The Safety of Laparoscopic Feeding Jejunostomy Insertion in Patients with Oesophago-gastric Pathology
Authors: Ahmed Babur , Dasa Michael , Mitra Roshni , Alasmar Mohamed , Alkhaffaf Bilal , Farooq Naheed 
Published: November 2022

Abstract

Aims
Feeding jejunostomy (FJ) to support enteral nutrition has traditionally been placed using an open approach (OA). As minimally invasive surgery (MIS) for oesophageal and gastric surgery gains popularity, it is imperative to develop a standardised technique and examine its safety. We describe our MIS approach to FJ insertion and compare outcomes to OA.

Methods
This was a retrospective analysis of patients undergoing FJ insertion via MIS and OA in a high volume tertiary oesophago-gastric centre, from 2018 to 2020. Identifying and placing FJ in first jejunal loop at low pneumoperitoneum pressure, constructing Witzel tunnel and placing antitorque sutures are our institution's standardised steps. Outcomes assessed included catheter-related adverse events.

Results
Of 226 patients, 130 (57.5%) had MIS, while 96 (42.5%) had OA. Median age (63.0 vs. 66.0 years, p=0.04), BMI (26.1 vs. 26.2 kg/m2, p=0.30), Charleston comorbidity index (4.0 vs. 4.0, p=0.73) and gender (75.4% vs. 76.0% males, p=1.00) were comparable. Median days FJ remained in situ was 162, 85.0% were placed in patients undergoing cancer resection, while MIC tube was used in 80.5%. A higher peri-catheter infection was seen with MIS (p=0.01); however, no differences (p≥0.42) were observed between MIS vs. OA, in tube dislodgement (9.0vs.6.0), fracture (2.0vs.2.0), blockage (2.0vs.0.0), peri-catheter leakage (6.0vs4.0), bowel obstruction (5.0vs.2.0) and perforation (0.0vs1.0). No feed inspissation or enterocolitis was observed. Misplacing FJ beyond first jejunal loop caused volvulus, necessitating reintervention.

Conclusion
FJ insertion via MIS is safe, provided standardised steps are followed meticulously. Evaluating confounding factors for better understanding of MIS-associated peri-catheter infection is recommended.
SP6.1.3 A Decision-Analysis Study of Endoscopic, Surgical and Pharmacological Treatment Options for Chronic Gastro Oesophageal Reflux Disease
Authors: Bradley Alison , Wong Li Siang , Mcmillan Paul , Buter Anton 
Published: November 2022

Abstract

Aims
To compare emerging endo-luminal interventions for the treatment of chronic gastro-esophageal reflux disease (GORD) to pharmacological and surgical interventions.

Methods
An advanced decision-tree model was constructed and populated with data from 19 randomised controlled trials to compare competing treatment pathways that included: Laparoscopic Fundoplication, Stretta, Transoesophageal Incisionless Fundoplication (TIF) and medical management with proton pump inhibitor (PPI). Model transition probabilities were calculated using weighted pooled estimates of proportions calculated using Freeman-Tukey arcsine square root transformation under random effects model to account for heterogeneity.
Model uncertainties for all included components were tested with one-way deterministic sensitivity analysis. Monte Carlo Probabilistic Sensitivity Analysis (PSA) was set to 10000 iterations with model probabilities sampled from the entirety of the data distribution of each variable.

Results
Base-case analysis at 12months follow-up showed that Laparoscopic Fundoplication had the highest probability of treatment success followed by TIF, Stretta and PPI respectively.

Conclusion
Endo-luminal interventions, although not shown to be superior to surgery, may have an emerging role in the management of GORD, but data on long-term follow-up and cost-effectiveness is lacking.
SP6.1.4 Novel methods to enhance anti-tumour immunity in oesophageal adenocarcinoma; hypofractionated radiotherapy may be superior to CROSS regimen chemo-radiation
Authors: Donlon Noel , Davern Maria , Sheppard Andrew , Donohoe Claire , Reynolds John , Lysaght Joanne 
Published: November 2022

Abstract

Background
CROSS regimen (41.4Gy;carboplatin&paclitaxel) is a standard trim-modality treatment for locally advanced oesophageal adenocarcinoma (OAC). The addition of adjuvant immunotherapy targeting PD-L1 may improve outcomes, hence the impact of radiation therapy on the tumour microenvironment is of considerable interest. The dosing has not been studied in this context, especially hypofractionation, and this study explored immunogenic cell death, specifically Damage Associated Molecular Pattern (DAMPs) release,and the impact of immune checkpoint blockade(ICB).

Methods
The ability of CROSS-regimen (3×1.8Gy) and hypo-fractionation (3×4Gy) to induce immunogenic cell death was assessed by flow cytometry of DAMPs calreticulin&HMGB-1.Expression of DAMPs were evaluated on OAC tumour and whole blood samples (n=10) pre and post conventional therapies versus hypofractionation. The immunostimulatory effect of CROSS and hypofractionation using post-treatment tumour cell secretomes with/without ICB on the cytolytic ability of OAC-donor lymphocytes was interrogated by CCK8-assay.

Results
The expression of Calreticulin&HMGB1 was significantly higher on tumour tissue compared to whole blood post chemo(radio)therapy(p&lt;0.01). Hypofractionation increased TNF-α&IFN-γ production by T-cells greater than CROSS fractions ex vivo(p&lt;0.01). The post-CROSS and hyporfractionated tumour cell secretome enhanced lymphocyte mediated killing of tumour cells(p&lt;0.01), further enhanced with dual immune checkpoint blockade (nivolumab&ipilimumab)(p&lt;0.01). High expressors of DAMPs pre-operatively had a significantly (P&lt;0.01) better Tumour Regression Grade (TRG1–2) compared to low expressors.

Conclusions
The current CROSS regimen radiation for OAC is immunogenic,however,hypo-fractionated doses boosted the immune response to OAC, and was synergistic with ICB. This may warrant further exploration in a clinical and translational trial.
SP6.1.5 The effect og major Oesophageal oncological surgery in promoting a pro-tumour, pro-metastatic phenotype that is partly inhibited by immunotherapy
Authors: Donlon Noel , Davern Maria , Sheppard Andrew , O'Connell Fiona , Reynolds John , Reynolds Joanne 
Published: November 2022

Abstract

Background
Adjuvant immunotherapy for oesophageal cancer is set to become a standard of care following the Checkmate-577 trial proving the efficacy of adjuvant nivolumab. Scientifically, the key mechanisms are unclear. This study profiled systemic anti-/pro-tumour immunity and circulating pro-metastatic factors perioperatively in patients, and the impact of immune checkpoint blockade on key pathways.

Methods
Systemic immunity in oesophageal cancer patients (n=14) was immunophenotyped prior to surgery (postoperative day(POD)-0) and POD-1,3,7 and week-6, using flow cytometry. Longitudinal serological profiling was conducted by multiplex ELISA characterising systemic immunity and pro-metastatic signalling. The cytolytic ability of circulating lymphocytes against oesophageal cancer cell lines was assessed with and without immunotherapies; nivolumab/ipililmumab.

Results
PD-1+ and CTLA-4+ T-cells peaked on POD-1, significantly decreasing by week 6(p&lt;0.01). Circulating soluble checkpoints significantly (p &lt;0.001) increased from POD-3, with decreases in Th1 cytokines (IFN-Y,IL-12p40,IL-1RA,CD28,CD40L) and increases in Th-2-cytokines(IL-4, IL-10) observed(p&lt;0.001). Circulating pro-inflammatory cytokines (TNF-α,MCP-1) and pro-metastatic factors(VEGF-α,FLT-1,Tie-2,PIGF) significantly (p&lt;0.001) increased in the immediate post-operatively. In an ex-vivo model, the cytolytic ability of circulating lympohcytes peri-operatively (p&lt;0.01) was propagated with the use of nivolumab/ipilimumab. Surgery decreased the frequency of circulating Th-1 like cells, an effect inhibited by nivolumab/ipilimumab.

Conclusions
Major oesophageal cancer surgery promotes a switch from Th1 to Th2 cellular immunity, dampening the cytolytic ability of T-lymphocytes. In an ex-vivo model, PD-1/CTLA-4 inhibition induced a shift to a Th1-like cytotoxic phenotype, highlighting a potential pathway through which such therapies can effect minimal residual disease, and a need to study optimal timing of adjuvant therapy.
SP6.1.6 Symptoms and Satisfaction after Nissen Fundoplication – A 10 Year Follow Up
Authors: Innes Ailsa , Hughes Georgina , Menon George , Virupaksha Suvi 
Published: November 2022

Abstract

Introduction
Laparoscopic Nissen fundoplication remains a key option for surgical treatment of refractory gastro-oesophageal reflux disease. However, limited long term data are available on postoperative symptoms and satisfaction. We aimed to evaluate these in our patients 10 years following their operation.

Methods
144 patients were contacted by telephone. Participants were asked about heartburn and obstructive symptoms. If heartburn or dysphagia was present they scored this on a scale of 1–5. Satisfaction was scored from 0–5 and using a four point outcome scale. Respondents were also asked whether they would recommend the operation or have a reoperation if needed.

Results
We gained 49 participants with operation dates from 2009–2011. 5 participants had since had a redo operation so were excluded from the symptom analysis. There was a high prevalence of obstructive symptoms in the respondents, and a significant minority still experience a degree of heartburn.

Conclusion
Satisfaction with Nissen fundoplication remains high for most patients 10 years post-operation. However, there remains a significant obstructive symptom burden. This is important to consider as alternative procedures such as Toupet fundoplication become more prevalent.
SP6.1.8 The Impact of Drain and Reinforcement on the Outcomes of Bariatric Surgery: A Prospective Study
Authors: Noureldin Khaled , Salman Mohamed , Tourky Mohamed , Issa Mohamed 
Published: November 2022

Abstract

Purpose
Aimed to investigate the impact of reinforcement and abdominal drains on the outcome of laparoscopic sleeve gastrectomy (LSG).

Methods
A prospective study included obese patients scheduled for LSG. Patients were assigned to receive drain, reinforcement, or both according to surgeon's preference and followed up for one month after surgery. Primary outcome was identification of the association between intraoperative drain/reinforcement and incidence of postoperative complications.

Results
125 (20.3%) patients received intraoperative drains. The proportion of postoperative morbidity was comparable between the drain and non-drain groups (3.2% versus 1.6%; p = 0.25). Drain group had similar incidence of blood transfusion (2.4% versus 1.7% in non-drain group; p = 0.43) and postoperative leakage (0.8% versus 0.2% in non-drain group; p = 0.36). Incidences of blood transfusion (p = 0.56) and reoperation (p = 0.98) were comparable between the drain and non-drain groups. There were no statistically significant differences between the drain and non-drain groups regarding postoperative mortality and wound infection (p &gt; 0.05). In contrast, 440 (71.3%) patients received reinforcement. The proportion of postoperative morbidity was comparable between reinforcement and non-reinforcement groups (1.6% versus 2.8%, p = 0.07). Patients in reinforcement group were less likely to develop postoperative bleeding (0.7% versus 4% in the non-reinforcement group; p = 0.004), while no significant difference was detected in terms of postoperative leakage (p = 0.33) and in-hospital mortality.

Conclusion
Abdominal drainage did not reduce the complications of LSG patients. Reinforcement has role in controlling the bleeding but not leaks. Both techniques did not significantly impact the mortality rate.
SP6.1.10 Prevention of internal hernia by closure versus non-closure of the mesenteric defect in patients undergoing Roux-en-Y gastric bypass- a meta-analysis of published randomized controlled trials
Authors: Ojofeitimi Oluwamayowa , Ahsan Amiya , Sajid Muhammad , Khan Mansoor , Singh Krishna 
Published: November 2022

Abstract

Objective
The objective of this article is to evaluate the prevention of internal hernia by mesenteric defect closure (MDC) versus non-closure of the mesenteric defect (MDNC) in patients undergoing Roux-en-Y gastric bypass.

Method
Standard medical electronic databases were searched, and relevant published randomized controlled trials (RCT) were shortlisted according to the inclusion criteria. Summated outcome of post-operative surgical variables including the incidence of internal hernia were analyzed using principles of meta-analysis on RevMan 5 statistical software.

Result
Five RCTs on 3285 patients undergoing Roux-en-Y gastric bypass operation for any indication or approach were found suitable for meta-analysis. There were 1635 patients in the MDC group and 1650 patients in the MDNC group. The duration of the operation was statistically longer in MDC [random effects model, standardized mean difference (SMD) 0.73, 95% CI (0.22–1.25), z=2.78, p=0.005]. There was no statistical difference related to length of hospital stay [random effects model, standardized mean difference (SMD) 0.15, 95% CI (-0.41, 0.44), z= 1.01; P= 0.31] between the two groups. The incidence of internal hernia was significantly reduced in MDC group. This difference was statistically significant [random effects model, odds ratio 0.36, 95% CI (0.19–0.66), z=3.27, p=0.001]. However, there was significant statistical heterogeneity (Chi2= 31.99, df = 4 (P &lt; 0.00001) among included RCTs.

Conclusion
The routine closure of mesenteric defect in patients undergoing Roux-en-y bypass may be an effective approach to reduce the risk of internal hernia. However, more RCTs of robust quality recruiting higher number of patients are required to validate these findings.