bluuebunny/crossref_metadata_2025_split huggingface dataset:
EP-90 Bouveret Syndrome: A challenging case of impacted gallstone within the fourth part of the duodenum
Authors: Smith Emma , Zhao Sarah , El-Boghdady Michael , Sabato-Ceraldi Serena 
Published: November 2022

Abstract

Aims
Bouveret syndrome is a rare condition characterised by gastric outlet obstruction secondary to a gallstone fistulating into the proximal duodenum or pylorus. We present a case of a 68-year-old with recurrent small bowel obstruction secondary to a large gallstone impacted in the fourth part of the duodenum and cholecysto-duodenal fistula. We describe our atypical approach to surgical retrieval.

Methods
The patient presented acutely with abdominal pain and vomiting, on a background of recent admission for gallstone ileus managed conservatively. Initially, due to high anaesthetic risk (P POSSUM score = 14% mortality, 60% morbidity), the patient was managed conservatively with nasogastric drainage and total parenteral nutrition. On day 6 of admission, emergency laparotomy was performed after identifying radiological signs of impending perforation and clinical deterioration. Endoscopic management was not available locally. The stone could not be milked proximally for retrieval via pyloroplasty. Subsequently, high-pressure water flushes delivered via the gastrostomy expelled the stone distally. The stone was then retrieved via a jejunotomy at the DJ flexure.

Results
The patient required a 2-day high dependency unit admission and she was discharged 3 weeks post-operatively at her functional baseline. She was clinically well and asymptomatic when reviewed at the four-month post-operative surgical follow-up appointment.

Conclusions
This is the first report to our knowledge to describe successful surgical management of a gallstone impacted in the fourth part of the duodenum. Enterolithotomy can be considered safe option in patients with large, impacted stone and multiple co-morbidities.
EP-95 Full Cycle Audit on Prescription and Cost Effective Analysis of Metronidazole in Acute Surgical Unit
Authors: Wong Li Siang , Chin Mei Ying , Mcgee Caroline , Mccubbin Kay 
Published: November 2022

Abstract

Aims
Oral Metronidazole has very high bioavailability, similar to that of intravenous(IV) metronidazole. Prescribing oral Metronidazole has many advantages such as saving drug preparation time, reducing risk of line infection and also being more cost effective. We aim to study the incidence of prescription or oral Metronidazole and its cost impact in or acute surgical unit.

Methods
Retrospective analysis on the prescription and cost effectiveness of Metronidazole usage in acute surgical setting. Inclusion criteria for this study was acute surgical patients with viable oral route and who were prescribed oral or IV Metronidazole. Cost assessment was carried out using British National Formulary (BNF). Education and awareness campaigns were held to encourage the prescription of oral Metronidazole. A second cycle audit was done to measure outcome of education.

Results
First audit done in 2020 found only 12.5% of patients were prescribed oral instead of IV Metronidazole. This has improved to 61% during second cycle audit done in 6 months time after the awareness campaigns. Prescribing oral instead of IV Metronidazole would save approximately £64.77 per dose resulting in reducing total cost by £971.55 per standard course of 5 days treatment.

Conclusion
There is clear improvement in the rate of prescribing of oral Metronidazole following equation campaigns. Further improvement can be achieved through continued education of various members of surgical team which will ultimately result in reduced costs, lessen drug preparation time for nursing staff and lower risk of line infection for patients.
EP-124 Local Recurrence after Breast Cancer Surgery – 5 year follow up. Breast Cancer Unit University Hospital North Tees
Authors: Allen Neill , Jain Yogesh , Dordea Matei 
Published: November 2022

Abstract

Introduction
Breast conserving surgery in the form of wide local excision with sentinel node biopsy is a common treatment option for patients with early breast cancer.
The National Institute for Health can Care Excellence recommends that each Breast Unit should audit their local recurrence rates.

Aim
Audit our unit's 5 year local recurrence rate as recommend by national guidelines

National Standard
Early and locally advanced breast cancer: diagnosis and management NICE guideline [NG101] Published: 18 July 2018

Method
Patients who had a breast cancer operation in 2014 were included. Histology records were checked to confirm diagnosis and check for any histological recurrence in the following 5 years.
Data collected were Age at diagnosis, the disease free interval in months and the site of recurrence.

Results
531 patients were included in the study of these 22 patients had local recurrence defined as recurrence in the ipsilateral breast, chest wall or local axillary nodes.
The local recurrence rate was 4.14% for this cohort of patients. This is below the recommended &lt;5%.
The mean age at diagnosis was 62. The mean disease free interval was 39 months.

Recommendation
Our unit are meeting the national local recurrence rate for early and locally advanced breast cancer.

Plan for re-audit
Re-audit annually to ensure maintaining quality clinical care. To review method of admission (breast screening vs symptomatic clinic) and the method of detection for the recurrence.
EP-138 Pseudomyxoma peritoni induced by appendiceal mucinous adenocarcinoma- a case report
Authors: Rauf Fatima , Sial Fakhar Munir , Hanif Muhammad , Malik Muhammad Naveed , Khan Huma Sabir , Butt Adam Umair Ashraf 
Published: November 2022

Abstract

Introduction
Appendiceal tumours are rare and mucinous tumours account for 58% of the malignant tumours of appendix according to SEER data base, with remaining being carcinoid tumors. Mucinous tumours of appendix have a potential of peritoneal spread in the form of gelatinous material, resulting in pseudomyxoma peritoni (PMP). We report a case of mucinous adenocarcinoma of appendix inducing pseudomyxoma peritoni in a 37 year old male.

Case summary
A 37 year old male presented with generalised abdominal pain for 2 months and gradually increasing abdominal distension over a period of one month. On examination, abdomen was tense, distended and mildly tender. Rest of systemic examination was unremarkable. Biochemical investigations revealed normal blood complete picture. AST was mildly raised. ALP was 330 (normal upto 130 U/L. Bilirubin, total proteins and renal function tests were within normal limits. CECT abdomen and pelvis showed omental caking and moderate ascites with no overt bowel mass lesion. Diagnostic laparoscopy was done which showed extensive mucinous deposits over peritoneum. Biopsy was taken which revealed metastatic mucinous adenocarcinoma with appendix as primary organ of origin on immunohistochemistry (CK 7 -/CK 20 +, CDX 2 positive). CEA levels were done which were 220 ng/ml (normal upto 10 ng/ml). Patient was referred to oncology centre for further management.

Discussion
PMP occurs in 7th decade of life and more common in females with a M: F ratio of 1:4 and is almost always of appendiceal in origin.

Conclusion
PMP is rare tumour with negligible incidence in younger population.
EP-145 Prescription of antimicrobials…according to the guidelines?!
Authors: Rai Anil , Mahmood Ahsan , Singh Rhea , Kudchadkar Shantata , Mehana Omar , Sagar Jayesh 
Published: November 2022

Abstract

Aim
The trust guidelines do not recommend prescription of Co-amoxiclav and Metronidazole concurrently in the mentioned group of patients. This study aims to discern and improve the adherence to trust guidelines of antibiotics prescription in general surgery and urology patients.

Methods
A retrospective review over a period of three months was analyzed, wherein record sampling was done on two occasions with 584 and 490 patients respectively, with majority (280 and 254) admitted electively. The study comprised patients admitted to general surgery and urology departments. Data was assembled on patient demographics and use of antibiotics.

Results
51 patients (8.73% of 584) were prescribed both Co-Amoxiclav and Metronidazole during the first cycle. This number fell to 34 (6.9% of 490) during the second cycle. Prescription of antibiotics was observed to be maximum in emergency patients admitted in A&E. Furthermore, one patient in the first cycle was prescribed Metronidazole despite being allergic to it. Patients reported to be penicillin allergic were 48 and 26 in the two cycles respectively. It was found out that majority of the patients were discharged on the same day of admission.

Conclusion
Although, a minimal improvement (1.8%) in antibiotic (Co-Amoxiclav & Metronidazole) prescription was observed over the duration of the study, the trust guidelines on antimicrobials usage was not adhered to satisfactorily. Therefore, there is a need to create awareness among clinicians regarding the guidelines of appropriate antibiotic prescription.
EP-186 Recurrent Boerhaave's Syndrome
Authors: Loganathan Santhosh , Gul Rahman , Whittaker Laura 
Published: November 2022

Abstract
Boerhaave's syndrome is a rare clinical entity. It is caused by severe straining, vomiting or prolonged severe coughing, affecting the distal intrathoracic part of oesophagus. The clinical presentation is varied and associated with high mortality if there is a delayed diagnosis. Therefore, the mainstay of treatment is early diagnosis, drainage of intrathoracic collection if indicated and restoration of the oesophagal integrity. The recurrent Boerhaave's syndrome is rare, and only a few cases have been reported in the literature.
We present a 27-year-old female diagnosed to have Boerhaave's a year back which was managed conservatively, presented to hospital with sudden onset of epigastric pain radiating to left shoulder and chest associated with multiple episodes of vomiting. Abdominal examination revealed a tender epigastric region with elevated white cells and C-reactive protein. CTTAP showed a recurrent para-oesophageal collection of fluid and gas adjacent to the distal oesophagus at the same site, with no pneumoperitoneum. She was managed conservatively for a week with peripheral nutrition. The CTTAP was repeated with oral contrast, which showed partially improved left para-oesophageal collection, and surrounding inflammatory changes had also partly improved with no leak of contrast. She was hemodynamically stable, clinically well, and tolerated oral feeds, so she was discharged from the hospital.
As the recurrent presentation is rare, the treatment should be customised for individuals as per their clinical condition. We emphasis on recognising this condition in both acute and chronic condition, which could be vital in preventing the mortality from this condition.
EP-190 Comparative Study of Single Clip Laparoscopic Cholecystectomy (SCLC), Two Clips Laparoscopic Cholecystectomy (TCLC) and Clipless Laparoscopic Cholecystectomy (CLLC) Vs Conventional Laparoscopic Cholecystectomy (CLC)
Authors: Devkaran Bhavesh , Attri Anshu , Chandel Upender Kumar 
Published: November 2022

Abstract

Introduction
Laparoscopic cholecystectomy has been accepted as the “gold standard” for the treatment of symptomatic gallstone disease. Conventionally 6 titanium clips are used for laparoscopic cholecystectomy (LC). Cost of 6 titanium clips are high and have been associated with complications in form of migration.

Material and Methods
200 patients of proven gallstones were randomly divided into four groups of 50 patients each, undergoing dissection of gall bladder by harmonic scalpel with application of one titanium clip, two titanium clips and absorbable Vikyl suture on cystic duct in Group 1 (SCLC), 2(TCLC) and 3(CLLC) respectively before division of duct and artery with harmonic ace. Group 4(CLC) patients underwent conventional LC with electrocautery and application of 6 clips.

Results
Mean operative time was statistically significant when CLC was compared with SCLC, TCLC and CLLC (CLC 43.10 ± 9.68 min vs 26.80 ± 8.44 in SCLC, 28.76 ± 8.23 IN TCLC, 37.30 ± 8.22min in CLLC group). Approximate blood loss in the CLC group was 28.90 ± 11.71ml as compared to 7.8 ± 3.06 in SCLC, 8.10 ± 3.18 ml in TCLC and 8.40 ± 3.70 ml in the CLLC group. Pain score was significantly better in the SCLC, TCLC and CLLC group. Conversion to open cholecystectomy was comparable in all the groups. Post operative hematoma formation and overall cost was significantly high in the CLC group.

Conclusion
SCLC, TCLC and CLLC are comparable to standard 6 clip laparoscopic cholecystectomy in all aspects. SCLC and TCLC have a clear advantage of decreased operative time, blood loss and low cost.
EP-241 Surgical virtual clinic (VC) practice: an audit of practice in the University Hospitals Sussex NHS Trust
Authors: Saleem Mohamed , Tahir Irtesam , Mohamed Mazin , Swaminathan Christie , Uheba Mokthar , Sajid Muhammad 
Published: November 2022

Abstract

Aims
The aim of the study was to assess the appropriateness of surgical virtual clinic practice (VC) in the University of Sussex hospitals.

Methods
A retrospective assessment of Six consecutive clinics of three consultants, a total of 216 patients, was audited according to guidelines of the Royal College of Surgeons (1). Additionally, feedback forms were obtained from ten Consultants and matched against RCS guidelines. Ethical approval was obtained from the quality improvement department.

Results
The study cohort mean age was 67 (20–94) years with 1: 1.2 female to male ratio. VC site was 68% from home. The VC attendance rate was 97.5% (2.5% DNA rate) and 93% patients were suitable for VC appointment because 2.8% needed physical examination and remaining percentage was not suitable due to hearing impairment and language barrier. Telephone was the mode of virtual consultation in addition to 100% documentation and 100 conclusion documentations. Four blocks of RCS guidelines compliance based upon the opinion of the consultant surgeon was reported from 65% to 97.5%.

Conclusion
The attendance of VC clinics was 97.7% with suitability for VC up to 93%. There was a good compliance with RCS guidelines reaching up to 97.5%. However, few areas which needs improvement are obtaining consent (documentation if consent was taken), confirmation of alternative contact details, length and details of VC and reassurance that VC is equivalent to face to face clinic in terms of service provision.
EP-270 A meta-analysis of the randomized controlled trials exploring the effectiveness of oral versus topical use of metronidazole following excisional haemorrhoidectomy
Authors: Imsirovic Anja , Baig Mirza K , Sains Parv , Sajid Muhammad S 
Published: November 2022

Abstract

Objective
Metronidazole has been proven an effective proctological analgesic and antimicrobial agent in patients undergoing excisional haemorrhoidectomy. The aim of this article is to evaluate the efficacy of topical versus oral administration of metronidazole to in controlling the post-operative pain following excisional haemorrhoidectomy.

Method
A comprehensive systematic search was undertaken with the help of local librarian and relevant published randomized controlled trials (RCT) were shortlisted according to the inclusion criteria. Summated outcomes of the poste-operative pain on day one and day seven were analyzed using the principles of meta-analysis on RevMan 5 statistical software.

Result
Two RCTs on 286 patients undergoing excisional haemorrhoidectomy were included in this review. There were 143 patients in topical metronidazole group and same number of patients were in oral metronidazole group. the antibiotics group (AG) and 877 patients in the no-antibiotics group (NAG). In the random effects model analysis, day 1 [standardized mean difference -0.06, 95% CI (-0.30–0.17), z = 0.55, p = 0.59] and day 7 [standardized mean difference 0.09, 95% CI (-1.29–1.47), z = 0.12, p = 0.90] post-operative pain score was statistically similar in both groups. There was significant heterogeneity [Tau2 = 0.96, chi2 = 32.49, df = 1; p = 0.00001, I2= 97%] between included trials.

Conclusion
Both topical and oral administration of metronidazole as post-haemorrhoidectomy proctological analgesic is an effective modality. However, this evidence is based upon the findings of two RCTs on 286 patients and should be taken cautiously. A major, high quality RCT is mandatory to validate these findings.
EP-276 Tall Cell Carcinoma with Reverse Polarity (TCCRP) of the breast; a rare form of breast cancer
Authors: Shulman Zachary , O’Neill Anne , Kouneli Sofia , Shaaban Abeer , Jenkins Stephanie 
Published: November 2022

Abstract

Aim
A case report on the diagnosis and treatment of this rare low grade triple negative breast cancer.

Case Report
A 41 year old female presented with a palpable left breast lump. Family history includes a sister with a rare myeloproliferative disorder. On examination, a left breast lower outer quadrant 2–3 cm hard irregular lump was palpable. Mammography and ultrasound revealed a 25 mm suspicious lesion (which was biopsied), with normal appearing lymph nodes.

Results
Biopsy revealed a grade 2 invasive apocrine carcinoma. Oestrogen and Herceptin receptors negative. Breast conserving surgery with sentinel lymph node biopsy was performed. Histology revealed a 22 mm well circumscribed tumour with nests of epithelial cells in micropapillary pattern with apocrine like appearance. The most striking feature was that the nuclei were at the apical rather than the basal poles of the epithelial cells (reverse polarity). No lymphovascular invasion present. Lymph nodes were negative (0/3). Diagnosis was then confirmed by molecular testing.

Conclusion
Tall cell carcinoma with reverse polarity (TCCRP)1, a rare cancer resembling tall cell variant of papillary thyroid carcinoma, was first reported by Eusebi et al in 20032. Although morphologically similar to metastatic papillary thyroid cancer, neither the immunohistochemical markers nor genetic profiles have established any connection3. Accurate diagnosis of TCCRP is important as it carries an excellent prognosis. Treatment is local regional radiotherapy. There is no indication for systemic therapy in this case, due to its indolent low metastatic potential.
EP-289 Acute gallstone pancreatitis – if a picture is worth a thousand words, how many images do we need?
Authors: Chen Si , Karki Smriti , Iqbal Qamar , Mallappa Sreelakshmi 
Published: November 2022

Abstract

Aims
Accurate diagnosis and prompt definitive management of choledocholithiasis is vital in acute gallstone pancreatitis (GSP). Sensitivity of detection of choledocholithiasis varies across imaging modalities. Magnetic resonance cholangiopancreatography (MRCP) is most sensitive, but may not be necessary, and may result in delayed implementation of definitive management.
We aimed to evaluate the range of radiological investigations patients with acute GSP underwent at our Trust, and the clinical appropriateness of MRCP if performed.

Methods
An observational study of patients diagnosed with acute GSP between 01/05/2019 and 26/02/2021 was performed. Data were collected from electronic patient records.

Results
50 patients were diagnosed with acute GSP (median age 56years). 41 had transabdominal ultrasound (USS), 22 had computed tomography (CT) and 16 patients had MRCP. Median waiting time was 1, 0 and 4 days for respectively. All patients who had MRCP had prior USS and/or CT (Table 1).
As definitive management, 14% underwent endoscopic retrograde cholangiopancreatography (ERCP), 28% underwent laparoscopic cholecystectomy and 30% had initial ERCP followed by laparoscopic cholecystectomy. 14% patients were readmitted with pancreatitis prior to definitive management.

Conclusions
Detailed description of the CBD in initial radiology reports in acute GSP may mitigate the need for unnecessary subsequent imaging, reducing cost and facilitating early definitive management. We recommend establishment of a guideline to streamline imaging in the assessment of acute gallstone pancreatitis.
EP-325 Congenital peritoneal encapsulation rare pathology for Acute intestinal Obstruction
Authors: Chowdhury Ashim , Shamsuzzama Md , Paisios Evangelos , Shah Ankur 
Published: November 2022

Abstract

Background
Congenital peritoneal encapsulation (CPE) is a rare, congenital entity in which the small bowel is surrounded by an accessory peritoneal membrane. This condition is usually asymptomatic and rarely causes intestinal obstruction. This report highlights this rare congenital anomaly as a cause of intestinal obstruction.

Case
A 28-year-old fit man presented to A&E with classical features of intestinal obstruction. Abdominal CT scan showed features of mechanical small bowel with 360-degree rotated mesentery, and a suspicion of closed loop obstruction. An emergency laparotomy was performed. A large congenial peritoneal sac, wrapped the small bowel from D-J flexure to proximal part of ileum, and this sac was rotated 360 degrees with multiple adhesions and a single band to the left lateral wall. Early ischemic changes were noted, along with congested mesentery. The sac was opened, dissected and adhesiolysis was performed. The thick solitary band was released. There was immediate restoration of the blood supply and the bowel was viable. Patient recovered and discharged home on day 3

Discussion and conclusion
Worldwide, only 50 cases on CPE have been published till date, with the maximum reported from the UK. The other common conditions that mimic CPE are internal paradodenal hernia, abdominal cocoon and sclerosing encapsulating peritonitis. Young patients with abdominal pain and feature of closed loop high small bowel obstruction on CT scan will need a high index of suspicion, before confirming the diagnosis. At this point, it will remain a rare occurrence and an incidental finding at laparotomy.
EP-345 How do we get these lines out?
Authors: Teo Tessa , Alim Adam , Vasanthan Biruntha , Durojaiye Abiola , De Figueiredo Fatima , Gambhir Raghvinder 
Published: November 2022

Abstract

Aims
The aim of our study was to identify the factors influencing patient decision-making in conversion from tunnelled lines to arterio-venous fistulas/ grafts (AVF/G).

Methods
We consented and interviewed 40 patients who were currently dialysing through lines at a main dialysis unit in a tertiary hospital to understand factors influencing their decision. We designed and implemented a patient intervention education programme.

Results
Age range 24 to 86 years, (median 59), Females to Males ratio-1:1.4. Twenty-three patients (57.5%) started dialysis on a line and have remained on a line, 8 (20%) have a maturing graft and 9 (22.5%) have a fistula that is not maturing well or one that has failed.
None on lines had had any previous face-to-face education regarding the benefits of fistulas over lines. After one session, 14/18 patients (78%) agreed to attend the access clinic. The remaining 5 patients did not participate in the intervention.

Conclusion
We were able to convert 78% of patients in just one single face-to-face education session. In the Patient Reported Experience of Kidney Care in the UK 2020 (PREM) report “Patient experience of Sharing Decisions About Your Care” received the lowest scores (5.49/7) among the 13 theme scores. Just providing a leaflet to the patient is not enough. Hence, an educational intervention like ours should be made part of the routine practice at all dialysis units.

Reference
The Renal Association and Kidney Care UK (2020) ‘Patient Reported Experience of Kidney Care in the UK 2020’, p. 14. Available at: https://renal.org/sites/renal.org/files/KQuIP/PREM report 2021.pdf