e-Poster Presentations

doi:10.1308/rcsann.2022.0159

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

2 Decompressive craniectomy and shunt-amenable post-traumatic hydrocephalus, a single-centre experience

D Jesuyajolu ¹, T Moti ¹, Z Abdullahi ¹, A Alnaser ¹, A Zanaty ¹, T Grundy ¹, J Evans ¹

Abstract

Introduction

Prior studies have shown that decompressive craniectomy may be an independent risk factor for the development of post-traumatic hydrocephalus (PTH). It is against this background that we chose to conduct our single-centre retrospective study to establish the possibility of an association between decompressive craniectomy and PTH.

Methods

A retrospective review involving a database of all patients with traumatic brain injury (TBI) was undertaken. All referrals and admissions with TBI, as defined by the Mayo Classification, from January 2012 to May 2022, were included in the subsequent analysis. Statistical analysis was carried out using IBM SPSS version 28.0.1.

Results

The mean age of the cohort was 44.91 ± 19.16 years with more males (82.3%) than females. Vehicle incident/collision was the most common cause of TBI. Some 84% of the cohort were alive at 30 days, 4% had an intracranial infection, 2.8% underwent shunt insertion procedures and 14.2% received decompressive craniotomies as part of their clinical management. There was a statistically significant association between undergoing decompressive craniectomy, and the development of PTH (odds ratio 4.759 [confidence interval 1.290 to 17.559], p = 0.019). The presence of intracranial infection and insertion of an External Ventricular Drain (EVD) were also independent predictors of developing PTH.

Conclusions

This study adds to the growing body of work regarding the immediate and long-term effects of the procedure. Although life-saving, PTH, needing shunt insertion, is one of the possible complications that surgeons and patients should be aware of.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

3 Disproportionately increased incidence of anaplastic thyroid cancer in the North Yorkshire region: a UK tertiary centre study

A Adedeji ¹, E Omakobia ¹, C Ojo ², A Coatesworth ¹, F Agada ¹

Abstract

Introduction

Anaplastic thyroid cancer (ATC) has an annual incidence of 1.7 per 10,000,000 population in the UK. Globally, the incidence of ATC has shown a stable trend. However, over the past decade, we have noticed a rise in the number of cases in the North Yorkshire region of the UK. The aim of this study is to explore the demographics, incidence and geographical distribution of ATC in North Yorkshire over a 12-year period.

Methods

We searched the electronic database to retrieve the clinical records of all patients with ATC in our facility from 2010 to 2022. The data were analysed to estimate the incidence and geographical distribution.

Results

Twenty patients were diagnosed with ATC within the study period, with a male-to-female ratio of 1:1. The annual incidence rate in the study was 14 per 10,000,000 population. There is clustering of data around the region centre with just a few cases in the periphery.

Conclusions

The incidence of ATC in North Yorkshire is at least eight times higher than the national average. It is difficult to compare our findings with other regions owing to paucity of data. The geographical clustering around the region centre is most likely explained by variation in population density. As observed in the Derbyshire neck survey, in which iodine deficiency was identified as a major cause of goitre endemicity in some UK districts, it would be prudent to investigate the cause of this markedly increased incidence of ATC in North Yorkshire; this is definitely a worthy subject for further studies.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

8 Intrathoracic gastric volvulus in a neonate with Marfan's syndrome: a case report

M Al-Ghazawi ^1,²

Abstract

We report a 14-day-old male who presented with vomiting as a very unfamiliar complication of Marfan’s syndrome, which is sliding hiatal hernia. A chest x-ray demonstrated a gas bubble within the thoracic region, along with a coiled nasogastric tube (NGT) within it. Ultrasound did not visualise any of the stomach in its normally expected anatomical site. Subsequently, complete herniation of the stomach into the thorax was confirmed by contrast study. Exploratory laparotomy was performed and the stomach was reintroduced into the abdomen, this was followed by a hiatal reconstruction. Thal fundoplication and gastrostomy were also performed to ensure its fixation. Although Marfan’s syndrome is characterised by aortic/cardiac abnormalities, it should be considered in any infant with hiatal/para-oesophageal hernia, which should be repaired early to avoid any volvulus-resultant gastric ischaemia.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

24 Ultrasound vs clinical diagnosis: which is better in diagnosing acute appendicitis? A cohort study

CT Kam ¹, J Rait ²

Abstract

Introduction

Acute appendicitis is one of the most common causes of right iliac fossa pain, which often warrants surgical management. In many cases, abdominal ultrasonography is done to confirm the diagnosis; however, negative appendicectomy is common owing to atypical presentation and a different visualisation rate on ultrasound. The unnecessary operative intervention can result in complications. The aim of this study was to compare efficacy between clinical diagnosis and ultrasonography in diagnosing acute appendicitis to avoid negative appendicectomy and prevent further complications.

Methods

A cohort study was conducted in which 1,079 cases of laparoscopic appendicectomies were included and examined for the use of ultrasonography or clinical diagnosis. Sensitivity, specificity, negative and positive predictive values in the ultrasound and data in the clinical evaluation were analysed for their accuracy in the diagnosis of acute appendicitis based on the histology results post appendicectomy.

Results

Clinical diagnosis without preoperative imaging was found to have a significantly lower negative appendicectomy rate of 20.73% compared with 48.21% in those who underwent ultrasound. Some 46.55% of patients who had a subsequent positive histology of appendicitis were misdiagnosed with a normal ultrasound result.

Conclusions

In this study, ultrasound scanning has been shown to be a poor tool in the diagnosis of acute appendicitis which results in high negative appendicectomy rate and misdiagnosis rate. With an increasing burden of health budget and resources, cautious and appropriate use of ultrasonography would avoid the misdiagnosis and prevent further complications. Thorough clinical evaluation and diagnosis remains an important first step and has a role in the diagnosis of acute appendicitis.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

25 Seasonal and cyclical patterns of young pedestrian injuries secondary to motor vehicles

A Akhtar ¹

Abstract

Introduction

Significant morbidity and mortality remain in young pedestrians hit by motor vehicles, even in the era of pedestrian crossings and speed limits. The aim of this study was to compare the incidence and severity of motor vehicle-related pedestrian trauma in a young population according to time of day and season.

Methods

Data were retrieved from the national Trauma Audit and Research Network database for patients aged between 10 and 25 years who had been involved as pedestrians in motor vehicle accidents between 2015 and 2020. The incidence of injuries, their severity (Injury Severity Score [ISS]) and mortality were analysed according to the hours of daylight, darkness and season.

Results

The study identified a seasonal pattern, showing that autumn was the predominant season with 34.9% of injuries, compared with summer with 18.3% of injuries. Importantly, the greatest injury rate (number of injuries/hour) occurred between 3pm and 4.30pm, correlating to school pick-up times. A further significant relationship between ISS and daylight was demonstrated (p = 0.0124) with moderate injuries (ISS = 9–14) commonly occurring during the day (72.7%) and more severe injuries (ISS > 15) during the night (55.8%).

Conclusions

We have identified a relationship between time of day and the frequency and severity of pedestrian trauma in young people. In addition, particular time groupings correspond to the greatest injury rate, suggesting that reduced visibility coupled with school pick-up times may play a significant role. We recommend targeted public health measures that focus on these times and increase the visibility of children.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

30 Pyloroplasty reduces the need for pyloric dilation after oesophagectomy

S Han ¹, C Yu ¹, J Halle-Smith ², M Siddaiah-Subramanya ^3,⁴

Abstract

Introduction

Delayed gastric conduit emptying (DGCE) is a recognised complication of oesophagectomy that can lead to prolonged vomiting, aspiration and reduced oral intake postoperatively. To minimise the risk of DGCE, some advocate the use of pyloroplasty; however, the practice is varied and controversial. The aim of this study is to investigate the effect of pyloroplasty on DGCE in oesophagectomy patients.

Methods

Consecutive patients who underwent an oesophagectomy for oesophageal cancer from September 2011 to December 2020 were identified from a prospectively maintained departmental cancer database at our institution. The primary outcome measured was the need for pyloric intervention following oesophagectomy. Secondary outcomes included cardiac complications, pulmonary complications, anastomotic leaks and chyle leaks. For those who had contrast swallow tests done prior to discharge from the index admission, dilated conduit and delayed gastric emptying were also investigated.

Results

Of 458 patients included in the study, 77 (17%) underwent pyloroplasty. Of the 381 patients who underwent oesophagectomy without pyloroplasty, 44 (12%) later required at least one pyloric dilation. None of the patients who underwent pyloroplasty later required pyloric dilation. On multivariate analysis, younger age, respiratory complications after oesophagectomy and pyloroplasty were significant predictors of the need for pyloric dilation. Pyloroplasty was not significantly related to dilated conduit or delayed emptying on contrast swallow with p-values of 0.979 and 0.147, respectively.

Conclusions

Pyloroplasty reduces the need for pyloric dilation postoperatively. However, further research is required to investigate the nature of this relationship, specifically in terms of contrast swallow.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

35 Comparison of outcomes of mini-sternotomy vs full sternotomy: a 10-year retrospective study

A Faraz ¹, Y Tarar ²

Abstract

Introduction

The purpose of this 10-year retrospective study was to assess the outcomes of patients who underwent Delayed gastric conduit emptying (AVR) via mini-sternotomy.

Methods

Between January 2012 and June 2022, 371 patients underwent isolated AVR at our institution. We reviewed the data retrospectively and assessed outcomes such as wound dehiscence, length of intensive care unit (ICU) stay, mortality and neurological complications.

Results

We found that 371 patients underwent AVR: 238 (64.1%) patients had AVR with full median sternotomy, whereas 138 (37.2%) patients underwent mini-sternotomy. Twelve patients in the mini-sternotomy group underwent redo-sternotomy for bleeding and tamponade. A similar incidence was noted among the full sternotomy group. Sternal wound dehiscence was recoded in a patient with full sternotomy. Stroke and neurological complications were observed among both groups; however, the mini-sternotomy group had a higher incidence than the full sternotomy group (p = 0.02). Length of ICU stay, morbidity and mortality did not differ between the two groups.

Conclusions

There were no significant differences in terms of outcome between patients who underwent full sternotomy vs mini-sternotomy for isolated AVR. However, length of hospital stay and quality of life was better in patients undergoing a mini-sternotomy.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

56 Intussusception in incisional hernia: a rare case and literature review

M Hassan ¹, A Saad ¹, M Jeilan ¹

Abstract

A 79-year-old man presented to the emergency department of our district general hospital experiencing a tender irreducible incisional hernia associated with nausea and vomiting. He was on the waiting list for an elective hernia repair, but COVID-19 cancellations meant this was delayed. He noted the night before that his hernia had increased in size. His background history includes abdominal prostatectomy. On examination, he had abdominal distension and a tender irreducible incisional hernia in the right lower quadrant. His inflammatory markers were mildly raised (white blood cells, 9.79 × 10⁹ per l; C-reactive protein, 47mg/l; haemoglobin, 107g/l). The patient was admitted to hospital and a computed tomography scan of the abdomen and pelvis was arranged which revealed a small bowel obstruction secondary to the incarceration of an incisional hernia He was offered emergency surgery. Laparotomy confirmed a small bowel intussusception. He had a small bowel resection and primary anastomosis. He recovered well on the ward postoperatively. Macroscopic examination of the resected part-reported specimen consisted of a non-orientated small bowel segment with features of intussusception measuring in total ∼ 80mm length × 60mm diameter. No perforation sites were seen. The cut surface at the intussusception point revealed a pale-coloured, ill-defined polypoidal lesion, with areas of haemorrhage, encompassing the prolapsing portion. Microscopic examination sections from the polypoid lesion showed an atypical infiltrate of intermediate to large lymphoid cells with irregular nuclei, coarse chromatin and small nucleoli, with infiltration of tumour cells through the muscularis propria of the small bowel.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

57 The use of flexible nails in the treatment of paediatric long-bone fractures: experience at a Level 1 paediatric trauma centre

A Hunt ¹, N Judkins ¹, A Biggs ¹, P Sedgwick ², C Hing ¹, A Yeo ¹

Abstract

Introduction

Over the past three decades, there has been a trend towards operative management of children’s fractures including utilisation of flexible nails, as popularised by the Nancy group in the 1980s. Some 5%–11% of paediatric forearm fractures are now fixed in this manner with complication rates of 12%–42%. This study shares the experience of a paediatric Level 1 major trauma centre using this technique in managing long-bone fractures in children.

Methods

This retrospective cohort study comprises a sequential series of 109 cases (71 children) of upper and lower limb fractures in children (aged 16 years and below) who underwent fracture fixation using flexible intramedullary nails between 1 April 2015 and 31 March 2019. Radiological and clinical outcomes and complications were assessed.

Results

Ninety-three cases satisfied the inclusion criteria in 57 children with a mean age of 8.6 years. All cases were successfully reduced intraoperatively and 92 (98.9%) achieved union. Considering all complications in the upper and lower limb, the overall complication rate is 30.1% (28 cases) with the vast majority (13 cases, 46.4%) occurring in the upper limb due to the prominence of metalwork prompting early removal.

Conclusions

This study has shown flexible intramedullary nailing to perform well with good stabilisation of a wide variety of paediatric long-bone fractures with restoration of bone alignment, satisfactory outcomes with good union rates and a return to normal function. Although the overall complication rate is not insignificant, major complications are rare.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

60 A rare case of adrenal extramedullary haematopoiesis in a Cypriot woman with β-thalassaemia

A Lisacek-Kiosoglous ^1,², A Georgiou ¹, D Mariannis ³, S Christou ⁴, V Hadjianastassiou ⁵

Abstract

We report a rare case of adrenal extramedullary haematopoiesis (EMH) in a thalassaemia patient in Cyprus. A 40-year-old woman with β-thalassaemia presented with a 2-day history of non-specific right-sided abdominal pain on routine follow-up for her thalassaemia treatment. Her laboratory tests were not dissimilar to her routine results and no palpable mass was detected. Computed tomography findings revealed a 5.8 × 4.2 × 4.6cm solid lesion in the right adrenal gland. Surgical excision was advised for this symptomatic large tumour with the possibility of malignancy in a young patient, and a laparoscopic adrenalectomy was performed. Postoperative follow-up was uneventful. A review of the literature in PubMed and MEDLINE revealed 14 case reports worldwide with adrenal EMH secondary to β-thalassaemia. EMH tumours in patients with thalassaemia have been reported incidentally, which stresses the importance of considering this in the list of differentials of adrenal incidentalomas in this patient population.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

72 Comparison of molecular testing methods for tissue-based detection of EGFR mutations in patients with early-stage or metastatic non-small cell lung cancer

I Karniadakis ¹

Abstract

Introduction

Personalised therapies, driven by the detection of actionable genomic biomarkers, have radically modified the disease course in patients with non-small cell lung cancer (NSCLC), including those carrying epidermal growth factor receptor (EGFR) mutations predictive of the response to EGFR tyrosine kinase inhibitors.

Methods

Although next generation sequencing (NGS) is the method of choice for tumour molecular profiling, implementation of NGS in routine clinical practice is not always feasible, primarily due to the requirements of a complex infrastructure, sophisticated pre-analytics, highly skilled staff and long turnaround times. A viable alternative to NGS for rapid assessment of EGFR mutational status is the Idylla EGFR mutation test. The Idylla EGFR mutation test detects 51 EGFR mutations, in ∼150 minutes, with a low limit of detection. The objectives of the study were to: (a) evaluate the performance of the fully automated Idylla system for the detection of EGFR hotspot mutations on formalin-fixed paraffin-embedded NSCLC samples; and (b) assess the concordance rates and compare the time-to-result between Sanger sequencing and the Idylla system for EGFR mutation testing in NSCLC patients.

Results

In this study, we confirmed the good sensitivity and specificity of the Idylla system and reported that EGFR mutation detection with this assay is associated with significantly reduced turnaround time. In centres with no access to NGS, Idylla assays allow for prompt and accurate EGFR testing in advanced NSCLC.

Conclusions

In conclusion, these study data, in addition to confirming that Sanger sequencing and Idylla are both accurate to detect EGFR-activating mutations, show that the Idylla system is a viable option for rapid and sensitive genotyping of EGFR in NSCLC patients.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

82 Readability and quality of online patient health information on parotidectomy

JY Tan ¹, YC Tan ², D Yap ³

Abstract

Introduction

Parotidectomy is considered the definitive management for benign and malignant parotid gland tumours. Complications of parotidectomy can have a massive impact on patients’ quality of life. The decision making process and consent for parotidectomy need to be supportive, accurate and well-informed. Although there are potential benefits to obtaining health information from the internet, it has its limitations in terms of the quality and accuracy of the information. This research evaluates the readability and quality of online patient health information (PHI) on parotidectomy.

Methods

Top 30 websites from Google, Yahoo and Bing were analysed using readability scores of the Flesch Reading Ease (FRE) test and Gunning Fog Index (GFI). The DISCERN instrument was used to assess quality and reliability. The search terms used were ‘parotidectomy’, ‘parotid surgery’, ‘parotidectomy patient information’ and ‘parotid surgery patient information’. Fifty-three online PHIs were analysed.

Results

The average FRE score was 50.3 ± 9.0, indicating a material that is fairly difficult to read. GFI score showed that the material was suitable for an individual above 12th grade level. DISCERN score indicated that the PHIs had a fair quality. There was a significant difference (p < 0.05) in FRE and DISCERN tool scores according to website category using the Kruskal–Wallis test. In our readability assessment, the average grade level of the 53 websites was above 10th to 12th grade.

Conclusions

Online PHIs on parotidectomy are too difficult for the public to understand and exceed National Institutes of Health-recommended reading levels. Surgeons should guide patients to high-quality websites and discuss the information tailored to their priorities, in order for them to make an informed decision on their treatment.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

85 A case report and review of cases of Aerococcus urinae infective endocarditis

S Haq ¹, T Baston ^2,³, O Usman ³

Abstract

We report the diagnosis and management of a rare but fatal cause of infective endocarditis. Aerococcus urinae is a Gram-positive bacterium primarily known to cause urinary infections, predominantly in elderly male patients with underlying genitourinary pathologies. Rarely, A. urinae can cause infective endocarditis, which can prove fatal if left undiagnosed or untreated. We present the case of a 61-year-old male who presented with fever, dyspnoea and worsening confusion. His past medical history was significant for type two diabetes mellitus, hypertension, heart failure, atrial fibrillation and balanitis xerotica obliterans. His blood results showed raised inflammatory markers. Urine analysis revealed some white and red blood cells, but no esterases or nitrites. He had no clinical manifestations of infective endocarditis. Transthoracic echocardiogram showed a large echogenic mass attached to the right coronary cusp of the aortic valve and impaired left ventricular systolic function. He was started on empirical antibiotics and underwent tissue aortic valve replacement on day 5 of his admission. The valve was excised and sent for polymerase chain reaction analysis and histology, which revealed Aerococcus urinae growth. He was given intravenous benzyl penicillin for 6 weeks postoperatively. He had an uneventful postoperative course. Follow-up echocardiogram at 12 weeks showed a well-seated aortic valve with no leak. Early diagnosis is important to establish the causative organism and tailor antibiotics. Blood cultures are sometimes negative in the case of A. urinae infection; therefore, careful clinical correlation with the laboratory investigations is required. A. urinae endocarditis should be considered when reviewing patients with pre-existing urological pathology, male gender and age >60 years.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

96 The lasting impacts of COVID-19 on head and neck cancer services: a UK tertiary centre study

A Khan ¹, R Taylor ², E Omakobia ³, S Sood ²

Abstract

Introduction

The COVID-19 pandemic led to increased pressure on health services, which combined with variable social restrictions, led to decreased referrals for head and neck cancer. We assess whether there were lasting changes to head and neck cancer referrals during different stages of the pandemic response in 2020 and 2021.

Methods

We conducted a retrospective review of all cases referred for suspected head and neck cancer to the ear, nose and throat fast-track clinic at our institution during the months of January and April 2020 and April and June 2021.

Results

There was a rebound 91% increase in referrals between April 2020 and April 2021 following the 59% decrease in referrals between January 2020 and April 2020. Males made up 47.1% of referrals in January 2020, 40% in April 2020 and 37.82% in April 2021. The referral to treatment target of 62 days was met in 100% of patients in all four time, as was the decision to treat to treatment target of 31 days.

Conclusions

We suggest further research into the reasons why there is a continued decline in male referrals and the effect this has on their outcomes. We speculate that this could be due to changes in healthcare-seeking behaviours after the pandemic or economic issues not leaving sufficient time to seek healthcare. This is of particular concern given the increased incidence of head and neck cancer in the male population compared with the female population and could lead to delayed diagnoses.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

101 Bouveret syndrome: a rare case and review of the literature

S Probert ¹, W Cai ¹, Fa Islam ¹, N Nanjappa ¹, A Salih ¹

Abstract

Bouveret syndrome is a subtype of gallstone ileus, wherein a calculus becomes entrapped in the duodenum via a cholecystocolic fistula, leading to gastric outlet obstruction. Because of the non-specific symptoms that patients present with, a diagnosis is reliant on computed tomography scanning, magnetic resonance imaging or direct endoscopic visualisation. We report a case of Bouveret syndrome and review the current literature, outlining the aetiopathogenesis and management strategies of this condition.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

103 Dual spinal accessory nerve: an anatomical anomaly during neck dissection

F Shah ¹, S Qamar ¹

Abstract

The spinal accessory nerve (SAN) is an important cranial nerve encountered during neck dissection. Preservation of this nerve from iatrogenic damage is crucial to avoid debilitating sequalae, which can be made challenging due to variation in its anatomical course. In this case report we present a patient who underwent supraomohyoid neck dissection and parotidectomy for a parotid tumour, in whom a rare variation of a dual SAN, traversing the internal jugular vein midway, was encountered. This anatomical finding is undoubtedly a valuable addition to existing knowledge of the SAN; ultimately, allowing surgeons to develop further awareness of the variations of the SAN and contributing to favourable postoperative outcomes.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

107 The role of biodegradable temporising matrix in the management of a patient with major burns and anorexia nervosa

R Shah ¹, P Tan ¹, T Hassouna ¹, R Murphy ¹, S McNally ¹

Abstract

Severe malnutrition secondary to anorexia nervosa results in deeper burns and significantly impacts wound healing, which represents a major challenge to burn management. The use of acellular dermal matrices, such as biodegradable temporising matrix (BTM), is a valuable tool to overcome the surgical limitations. We present a 36-year-old female with a background of anorexia nervosa (body mass index of 12.3) presenting with a 30% total body surface area flame burn. All of her burns (26% full thickness and 4% deep dermal) were excised down to fascia due to the absence of subcutaneous fat. Her thin skin and depleted nutritional status significantly impacted reconstructive options. BTM was utilised to create a neodermis and provide adequate time to optimise the nutritional status before autologous skin resurfacing. Through a combined multidisciplinary effort, a detailed nutritional plan was implemented, with consideration towards the high risk of refeeding syndrome in our patient. Subsequently, her weight increased from 36.5kg to 45.9kg, and her blood markers, including iron, calcium, phosphate, magnesium and albumin, wholly normalised. Delamination of the matrix and application of thin autologous skin grafts in stages occurred 3 weeks later and produced robust coverage with minimal donor site morbidity. Despite initial surgical and nutritional challenges, excellent outcomes were achieved in terms of wound healing, scar contractures and mobility.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

119 Disappearing intracanalicular lesion at the cerebellopontine angle

F Shah ¹, A Slim ¹, G Kontorinins ¹

Abstract

Cerebellopontine angle (CPA) lesions are the most common intracranial pathology. The most common being vestibular schwannomas. Imaging characteristics form the basis of diagnosis. It is vital to have a broad differential diagnosis when investigating lesions at the CPA. Here, we report a case of a 44-year-old male presenting with symptoms of unilateral tinnitus and hearing difficulty. Initial imaging showed an intracanalicular lesion at the CPA. Subsequent monitoring revealed a reduction in lesion size and eventually complete resolution in 5-years follow-up, therefore demonstrating a case in which a provisional diagnosis of vestibular schwannoma may be likely. However, on magnetic resonance imaging, a resolution of the lesion was found, thus potentially avoiding surgical intervention and its complications.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

124 Quantitative assessment of dorsal sagittal lateral column instability in unilateral adult-acquired flatfoot deformity

M Elmousili ¹

Abstract

Introduction

The primary aim of the study is to test the hypothesis that patients with pes planovalgus (flat foot) will have a positive heel neutral, lateral push test (i.e. a deficient spring ligament) and an unstable medial column.

Methods

Inclusion criteria were patients with a unilateral stage 2 adult-acquired flatfoot deformity (AAFD) and an unaffected contralateral foot. Exclusion criteria included bilateral AAFD, stage 3 AAFD and a high Beighton’s score. Lateral foot translation was measured as a guide to spring ligament competency. Medial and Lateral column (LC) dorsal sagittal instability was assessed by direct measurement of dorsal first and fourth/fifth metatarsal head motion using a digital Klauemeter, and further quantified using video analysis and motion capture software.

Results

Thirteen patients with unilateral stage 2 AAFD were included. The mean increase in dorsal LC sagittal motion (between affected vs unaffected foot) was 5.5mm (95% confidence interval [CI] 4.534 to 6.455, p < 0.001), as confirmed by direct measurement with a Klauemeter. The mean increase in the lateral translation score was 42.6mm (affected vs unaffected foot; 95% CI 36.434 to 48.850, p < 0.001). The mean increase in medial column dorsal sagittal motion was 7.09mm (95% CI 6.06 to 8.106, p < 0.001). Video analysis also showed a statistically significant increase in LC dorsal sagittal motion between the affected and unaffected sides (p < 0.001).

Conclusions

This is the first study that quantifies a statistically significant increased LC dorsal motion in feet with stage 2 AAFD. Understanding its pathogenesis and its link to talonavicular/spring ligament laxity improves foot assessment and may allow the development of future preventative treatment strategies.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

125 Management of large renal stones with retrograde intrarenal lithotripsy monotherapy compared with percutaneous nephrolithotomy: a prospective descriptive comparative study

M Hassan ¹

Abstract

Introduction

The aim of this study was to evaluate the efficiency of achieving stone clearance status (SCS) of retrograde intrarenal surgery for the management of staghorn renal stones vs percutaneous nephrolithotomy (PCNL). We also describe the morbidities and safety of managing staghorn renal stones with both modalities.

Methods

Twenty-six patients with partial/complete staghorn renal stones were treated randomly by flexible ureteroscopy (fURS) or PCNL in Luton and Dunstable Hospital between February 2020 and the present. Patient age ranged from 18 to 82 years (average = 55 years).

Results

Stone size ranged from 20 to 45mm. fURS stone density was 1,015 Hounsfield units (HU) for fURS and 1,289HU for PCNL, both with a complete to partial staghorn ratio of 3:7. Average operative time was 152.7 minutes for fURS and 171.1 minutes for PCNL. Length of hospital stay was 1 day for fURS and between 1 and 5 days (average 2.3 days) for PCNL. Eight patients undergoing fURS achieved SCS in a single session (partial to complete ratio 7:1); six patients achieved SCS in two sessions (partial to complete ratio 4:2); and only one patient needed three sessions to achieve SCS. For PCNL, eight patients achieved SCS in a single session (partial to complete ratio 7:1). Three patients had a completion fURS session to achieve SCS (partial to complete ratio 2:1). Two patients with >10mm residual after single sessions did not have completion surgery. Two patients had a combined PCNL/fURS first session.

Conclusions

fURS is safe and effective mode of surgical management for staghorn renal calculi and can be offered as an alternative to PCNL with less morbidity.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

130 A feasibility study comparing virtual and face-to-face teaching and objective assessment of basic suturing techniques

EL Finch ¹, M Boal ², D Tandon ³, J Nagi ⁴, B Yassa ⁵, T Gupta ⁶, B Pathmaraj ³, W Ghamrawi ², N Francis ²

Abstract

Introduction

To test the feasibility and efficacy of virtually teaching and assessment of basic suturing techniques, comparing online teaching with face-to-face.

Methods

Group 1 had four evening sessions of virtual teaching and assessment of basic suturing techniques after receiving suturing kits in the post. Their performance was compared with the control group (group 2), who attended a conventional surgical skills training course over a 2-week period. Faculty carried out the training and assessment for both groups. Participants were assessed using a validated Objective Structured Assessment of Technical Skills and Global Rating Scale (OSATS/GRS) tool. An independent samples t-test was used to compare the difference in mean scores over week 1 and week 2.

Results

A total of 41 participants attended the training, groups 1 and 2 consisted of 17 and 24 participants, respectively. Group 1 medical students ranged from years 1 to 4, and group 2 were intercalating students. Baseline OSATS/GRS mean scores were 15.44 and 17.67 for group 1 and 2, respectively, with a significant difference between means of 2.23 (se 0.56, 95% confidence interval [CI] 1.08 to 3.37, t = 3.94, p < 0.01). Final assessment mean scores were 18.88 and 18.44, respectively, with a difference between mean scores of 0.44 (se 0.52, 95% CI −0.62 to 1.50, t = 0.83), which was not significant (p = 0.41).

Conclusions

Virtual suturing skills training is a feasible and valid method of teaching, with comparable outcomes after 4 weeks of virtual teaching.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

132 A lesion in the external auditory canal as the first manifestation of metastatic pancreatic cancer

L Le Blevec ¹, S Shahsavari ², D Walker ¹

Abstract

Metastases to the external auditory canal (EAC) are extremely rare and most often arise from breast, renal or lung carcinoma. To our knowledge, we present the first case of metastatic pancreatic adenocarcinoma to the EAC. This 34-year-old male, smoker, presented with a 15-month history of right otalgia, otorrhoea and hearing loss. Examination revealed a large, fleshy and friable EAC lesion suspicious for neoplastic aetiology. Biopsy and imaging confirmed a diagnosis of metastatic pancreatic adenocarcinoma, for which he was started on palliative chemotherapy. Although metastatic tumours to the EAC are rare, it should be included in the differential diagnosis.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

144 Video analysis of surgical techniques in laparoscopic sleeve gastrectomy: a video-based literature review

L Alghazawi ¹, JY Chen ¹, B Das ¹, MG Fadel ¹, M Fehervari ¹

Abstract

Introduction

Surgical videos have been increasingly used as educational tools, but their utility and quality have rarely been assessed. A recent Bariatric Metabolic Surgery Standardization (BMSS) meeting defined standard anatomic measurements for each bariatric procedure through expert consensus. We aimed to objectively review published videos of laparoscopic sleeve gastrectomy (LSG) procedures and determine the quality of the surgical techniques by checking adherence to BMSS guidelines.

Methods

A PubMed search identified studies that contained published videos using the ‘Video-Audio Media’ filter. An initial search found 515 studies and of those, 26 videos were identified as being of relevance. Final extraction provided ten audible and accessible videos. By using a simple measurement programme (IC Measure, Imaging Source), we were able to estimate the distance from the sleeve resection to both the pylorus and the gastroesophageal junction (GOJ), size of orogastric tube and evaluate patient outcomes postoperatively.

Results

Our analysis revealed that 88.9% of the international LSG techniques were adherent to BMSS guidelines using the distance estimated from sleeve to both pylorus and GOJ and 85.8% used recommended orogastric tube sizes. Most of the published video articles described that all patients had achieved expected outcomes postoperatively and during the follow-up period.

Conclusions

We conclude that adherence to BMSS guidelines can be quantified through video analysis and leads to desirable patient outcomes. Video-based surgical technique analysis has the potential to be incorporated into surgical training and help improve and standardise surgical practice.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

148 A rare case of recurrent ductal carcinoma in situ inside a fibroadenoma in a young female

M Chauhan ^1,², G Singh ², I Karat ²

Abstract

Fibroadenomas are the most common type of lesion found in young women. Patients usually present with a painless, mobile lump in the breast tissue. In the UK, all women presenting with a breast lesion should go through the triple assessment, which includes a clinical examination, imaging and a tissue biopsy.  

Fibroadenomas occur in about one in four women in between the ages of 15 and 35 years. Although they are considered a benign growth with histological findings of stromal cell growth, there is evidence that malignancy may occur in small minority of patients. The occurrence of malignant tumour is between 0.002% and 0.125%. We report a similar case of carcinoma inside a fibroadenoma in a 27-year-old female, who had a known fibroadenoma that started growing in size recently. After the triple assessment she was diagnosed with a fibroadenoma of size 6 × 3cm on ultrasound scan. Histology findings from the initial core biopsy were reported as cores of benign fibrofatty breast tissue showing fibro-adenomatoid pattern, with a mild degree of usual type epithelial hyperplasia. No signs of malignancy were seen in this histology sample. She further underwent surgical excision of the 6 × 3cm lesion. The histopathology report of this sample reported a ductal carcinoma in situ (DCIS) inside the encapsulated fibroadenoma. Eighteen months later she had developed three further fibroadenomas in the same breast, one of which was at the previously operated site. On this occasion, one of the excised samples showed changes consistent with DCIS. This was noted as an unusual case by four different histopathologists. 

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

149 Duodenal intussusception and gastric outflow obstruction secondary to duodenal polyp

M Chauhan ^1,², E Jose ¹, AI Haque ¹

Abstract

Entero-enteric intussusception is a condition in which part of bowel telescopes into a distal part of the bowel. This results in a full-thickness fold of proximal bowel inside the distal part of the bowel. As a result of this, the true lumen of the affected segment becomes narrow; this is of particular importance when the pathology occurs in the small bowel because the lumen is already small. Duodenal intussusception is a rare condition owing to the structure and location of duodenum. he duodenum is a small segment, thick-walled, fixed retroperitoneally and also closely related to the pancreatic head. Because of these factors, it is very difficult for a segment of duodenum to telescope into a distal part. We present a 49-year-old woman who presented with upper abdominal pain, vomiting and reduced appetite. She was initially thought to have symptoms related to pancreatic or biliary pathology. This is an extremely rare case of intussusception with a very difficult diagnosis on initial presentation and management is often challenging. We present this case report with various causes of duodenal intussusception reported in published evidence.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

157 Incidence of distal femoral cortical irregularity in adolescent pivotal knee injuries

A Gaukroger ¹, A Gani ¹, C Hing ¹, V Ejindu ¹, A Rastogi ¹, P Sedgwick ²

Abstract

Introduction

A distal femoral cortical irregularity (DFCI) is a benign lesion in the posterior cortex of the adolescent distal femur. The pathogenesis is not fully understood but is thought to be due to repetitive strain injury.

Methods

A consecutive series of 879 knee magnetic resonance imaging (MRI) scans in adolescents between 2014 and 2019 were reviewed by trained musculoskeletal radiologists to identify and describe DFCI incidence. Electronic patient records were reviewed for demographics and aetiology of injury.

Results

DFCI was present 9.2% of scans and in 12.7% of pivotal knee injuries. The mean size of the DFCI was 3.25mm and DFCI was present at the attachment site of the medial head of gastrocnemius in 96.3% of cases. DFCI was present in a statistically significantly younger group (14.3 vs 15.4 years; p = 0.002), they were more likely to be female (68.3% vs 42.0%; p < 0.001) and less likely to have experienced an anterior cruciate ligament tear (p = 0.023). DFCI was more likely with patellar instability (22.8% vs 16.1%), but less likely with a pivotal knee injury (12.7% vs 29.0%). On multivariate analysis, gender was the only statistically significant difference between MRI scans with DFCI and those without (p < 0.001).

Conclusions

DFCI is more frequent in female adolescents and is not significantly associated with the mechanism of trauma.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

161 Readability, accountability and quality of burns first aid information available online

A Baldwin ¹

Abstract

Introduction

The aim of the study was to assess the readability, accountability and quality of burns first aid information available online.

Methods

The top 50 English language webpages with burns first aid information were compiled and categorised by source and country. Readability was assessed using five validated tools: Flesch Reading Ease Score, Flesch–Kincaid Grade Level, Gunning Fog Index, Coleman–Liau Index and Simple Measure of Gobbledygook Index. Accountability was assessed using Journal of the American Medical Association (JAMA) benchmarks. Quality was assessed using a scale based on previous literature.

Results

Two (4%) webpages were judged to be at the target level using all tools. Calculating median grade scores demonstrated 25 (50%) at the target level. Median grade ranged from 4.6 to 9.6 (M = 6.9, sd = 1.1). One-sample one-tailed t-test determined that median grade was not significantly below the target reading grade of ≤ 6.9 (p = 0.314). Six (12%) webpages satisfied all the JAMA accountability benchmarks. No webpages fulfilled all 15 quality criteria, with a mean score of 9.8 (sd = 2.4). Only 27 (54%) advised 20 minutes of cooling. One-way analysis of variance demonstrated no influence of source or country on readability or quality. Accountability was influenced by source (p = 0.01). Pearson’s correlation coefficient revealed no correlation between accountability or quality and readability. Accountability and quality had a positive correlation (r = 0.32, p = 0.02).

Conclusions

Much of the burns first aid information available online is written above the recommended reading level and fails to meet standards of accountability or quality.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

162 Readability of online patient education materials for congenital hand differences

A Baldwin ¹

Abstract

Introduction

The aim of the study was to assess the readability of online patient information for congenital hand differences.

Methods

The top ten English language webpages with patient information for ten conditions (polydactyly, syndactyly, trigger finger/thumb, clinodactyly, camptodactyly, symbrachydactyly, thumb hypoplasia, radial dysplasia, reduction defect and amniotic band syndrome) were compiled and categorised by source and country. Readability was assessed using five validated tools: Flesch Reading Ease Score (FRES), Flesch–Kincaid Grade Level (FKGL), Gunning Fog Index (GFI), Coleman–Liau Index (CLI) and Simple Measure of Gobbledygook Index (SMOG). To account for the potential effect of each condition’s name on readability, analysis was repeated after replacing the term with a monosyllabic word/s.

Results

Mean readability scores of the 100 assessed webpages were: FRES 56.3 (sd = 10.3), where the target was ≥ 80; FKGL 8.8 (sd = 1.8); GFI 11.5 (sd = 2.1); CLI 10.9 (sd = 1.8) and SMOG 8.6 (sd = 1.4), where the target reading grade was ≤ 6.9. When adjusted for the effect of the condition’s name, all readability scores improved significantly (p < 0.001) with mean improvement ranging from 0.6 to 1.8; however, all scores remained above the target level. Pre-adjustment, three webpages had a median readability score that met the target level, post-adjustment this increased to 13. Two-sample t-test for country and one-way analysis of variance for condition and source demonstrated no influence of these variables on readability, pre- or post-adjustment.

Conclusions

Most of the online patient information for congenital hand differences is written above the recommended reading level, even when adjusted for the effect of medical terminology.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

164 Evaluation of Alvarado score and appendicitis inflammatory response score as diagnostic tools for acute appendicitis

M Hassan ¹, M Jeilani ¹, A Saad ¹

Abstract

Introduction

The aim of this study was to explore the demographic and clinical characteristics of suspected appendicitis cases over a 3-month period and to evaluate the diagnostic accuracy of appendicitis inflammatory response (AIR) and Alvarado scores for acute appendicitis.

Methods

We conducted a prospective and comparative analysis with 73 patients to compare the efficacy of AIR score with the Alvarado score in the diagnosis of acute appendicitis.

Results

Of the 73 patients, 40 (54.8%) were female and the mean age was 31 ± 17 years. Based on histopathology findings, 59 (80.8%) patients had acute appendicitis. In the positive group, 5 (8.5%) patients had a high AIR score, 41 (69.5%) had a moderate score and 13 (22.0%) had a low score in the positive group. In the negative group, AIR scores were low for 12 (85.7%) patients and moderate for 2 (14.3%), with only 2 patients being a false positive. The correlations between the AIR score and histopathology results were highly significant (p-value 0.000). In the positive group, 33 (55.9%) patients had high, 17 (28.8%) had moderate and 9 (15.3%) had low Alvarado scores, whereas in the negative group 6 (42.9%) patients had low scores and 6 (42.9%) scored moderate and 2 (14.3%) patients scored high. In the negative group, eight patients were false positives. The sensitivity of the AIR and Alvarado scores were 77.97% and 67.80% respectively, and the specificity was 85.71% and 78.57% respectively.

Conclusions

The AIR score had higher specificity, sensitivity, positive predictive value and a lower rate of false positives.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

173 Delays in elective surgery due to the COVID-19 pandemic: has it affected genders equally?

H Hodgson ¹, R Golmohamad ², A Gulati ², H Pandit ³, J Palan ³, P Giannoudis ³, A Howard ^3,⁴

Abstract

Introduction

The aim of the study was to examine whether the delay in elective surgery has affected women and men equally.

Methods

Some 151 patients awaiting elective orthopaedic procedures participated in telephone interviews. Questions assessed the impact of the pandemic. Pain was measured by the visual analogue scale (VAS). Anxiety was measured by General Anxiety Disorder Assessment (GAD)-7 score. Gender was identified from patient records. Groups were compared by chi-squared and Mann–Whitney U tests. Significance was set at p < 0.05.

Results

Ninety patients (59.6%) were female and 61 (40.4%) were male. No other genders were recorded. Groups were similar in age (median [interquartile range]: female 67 [23] vs male 62 [32], p = 0.182). Males were more likely to be from minority ethnic groups (female 32.1% vs male 49.1%, p = 0.043). Significantly more female patients reported increased pain since the start of the pandemic (female 70.0% vs male 41.0%, p < 0.001) and reduced mobility (female 38.9% vs male 21.3%, p = 0.023). Current VAS scores were similar between groups (median (interquartile range): female 75 (26) vs male 70 (40), p = 0.15). There was no difference in GAD-7 scores that met criteria for anxiety (female 33.3% vs male 23.0%, p = 0.317), or in self-reported deterioration in mental health (female 11.1% vs male 9.8%, p = 0.803).

Conclusions

Female patients awaiting elective procedures are more likely to have suffered increased pain and reduced mobility since the start of the pandemic. Preoperative pain and mobility are associated with poorer postoperative clinical outcomes and may lead to long-term health inequalities between genders. The disparities experienced by women in particular are concerning and must be considered by service providers and clinicians when planning redesigned elective services, as well as in appropriate pain management in the meantime.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

184 Green light laser prostatectomy in patients presenting with urinary retention: retrospective long-term outcomes from a single high-output centre

A Deytrikh ¹, H Rehman ¹, L Ochieng ¹, M Rabin-Smith ¹, M Laud ¹, N Gogoi ¹, A Browning ¹

Abstract

Introduction

Long-term follow-up data assessing patient outcomes post-green light laser prostatectomy (GLLP) for benign prostatic hyperplasia (BPH) are well documented. However, there have been no long-term follow-up studies on this scale, reviewing the outcomes of GLLP in patients presenting with urinary retention.

Methods

Some 471 consecutive patients with a catheter in situ, who were treated for BPH with GLLP between 2012 and 2018 were reviewed retrospectively using electronic hospital records. Rates of reported complications and retreatment or catheterisation were analysed.

Results

Mean age at date of surgery was 75 (50–94) years. Some 39% of patients were managed as a day case, with a further 34% being discharged on day 1. Mean follow-up duration was 5 years by review of patient hospital records. The rate of complications at 30 days, including any catheter-related issues, was 17.6%; two patients died. Overall re-intervention rate during the follow-up duration was 20%.

Conclusions

This study represents real-world data for all-comers treated with GLLP in urinary retention. To the authors’ knowledge, it is the only study in the literature of this size and length of follow-up in this cohort of patients. The 30-day complication rates and long-term re-intervention rates reported here are echoed elsewhere in the literature, with treatment for urinary tract infection and requirement of long-term catheterisation being the predominant culprits, respectively. The relatively low day-case surgery rate is likely to be a consequence of the evolving nature of GLLP at this centre over the past decade. The durability of GLLP for UR patients is supported by these findings.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

192 Promising results of anterior bridge plating for adult humeral shaft fractures through minimally invasive plate osteosynthesis technique

GAS Sidhu ^1,², H Kaur ^1,², S Pattnaik ¹, HS Selhi ²

Abstract

Introduction

Although, open reduction and internal fixation, with a plate and screws, remains the gold-standard surgical option for humerus fractures, there have increasingly been concerns with the dissection of soft tissues around the fracture site. The anterior bridge plating (minimally invasive plate osteosynthesis [MIPO]) technique for the treatment of these fractures has gained remarkable popularity among orthopaedic surgeons, globally.

Methods

This was a prospective study of 43 adult patients, with a humeral diaphyseal fracture, treated using the anterior bridge plating (MIPO) technique. Patients with closed, displaced diaphyseal fracture of the humerus, aged between 15 and 65 years, were included in this study. Patients with open fractures, associated neurovascular injury and with history of previous infection in the humerus or elbow were excluded from this study Patients were followed clinically and radiographically.

Results

Of 40 patients, union was observed in 38 (95%) fractures. Two fractures did not unite at 6 months follow-up and required bone grafting as a secondary procedure for union. Time taken for radiographic union was found to be <12 weeks in 3 fractures, between 12 and 16 weeks in 33 fractures, and >16 weeks in 2 fractures. On determining the final shoulder functional outcome, 33 patients (82.5%) had excellent result, and 7 patients (17.5%) had good shoulder function, on University of California, Los Angeles (UCLA) score.

Conclusions

Anterior humeral bride plating using the MIPO technique yields high rates of union, minimal biological disruption of the soft-tissue envelope and better cosmesis, along with a fast and good functional recovery in patients with humeral shaft fractures.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

196 The weight of life: the impact of high body mass index on operative time in total hip arthroplasty

M Ahmad ^1,^2,³, H Hughes ^2,³, H Rehman ^2,³, N Awan ^2,³

Abstract

Introduction

Total hip arthroplasty (THA) in obese patients is associated with a greater risk of perioperative complications. The purpose of this study was to investigate the relationship between body mass index (BMI) and operative time for patients undergoing primary THA and to identify whether a BMI threshold exists over which operative time is significantly affected.

Methods

A retrospective review was carried out of all patients who underwent primary THA in one year in a single arthroplasty institution. Data were collected from the Irish National Orthopaedic Registry and included patient age, gender, BMI and operative time. Operative time (from knife-to-skin to closure) was measured in minutes. Patients were classified in to six BMI categories according to the World Health Organization classification of obesity.

Results

In total, 343 patients were included: 190 males and 154 females with a mean age of 68 years (range, 19–89). Most patients (n = 138) were in the 40–65-year age group. The majority of patients were classified as overweight (n = 123) or class I obese (n = 123). The average BMI was 30.2kg/m². The average operative time was 87.93 minutes. Patients with class II or class III obesity had significantly longer operative times than normal weight and overweight patients (p = 0.03).

Conclusions

This study demonstrates a significant increase in operative time for class II and class III obese patients undergoing THA. The deleterious effects of obesity on THA outcomes cannot be ignored. Performing THA on obese patients requires careful risk–benefit analysis and informed consent of potential associated risk.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

201 Anaesthesia in the anaesthetic room vs theatre: what do patients think?

A Dalrymple ¹, A Song ¹, E Heward ¹

Abstract

Introduction

The aim of the study was to establish whether patients have a preference of being anaesthetised in theatre or the anaesthetic room (AR) and the factors impacting their experience, and to establish anaesthetists’ preferred location of anaesthesia and the reasons for a preference.

Methods

This is a qualitative study. We created a questionnaire for patients to complete. The inclusion criteria were age >18 years, elective ear, nose and throat operation, and COVID-19 negative. The questionnaire was completed prior to discharge. Patients were asked to rate surgical equipment in view, noise levels, size of room, professionalism of clinical staff, comfort of the bed, number of staff in the room and the explanation of anaesthetic process. Patients were also asked to rate their overall experience out of 10. A second online questionnaire was sent to anaesthetists to complete regarding their preferences and concerns.

Results

No patients in the AR or theatre group rated any of the factors negatively. The median overall rating for AR and theatre was 10 for both. Positive feedback was received for communication from clinical staff. Most anaesthetists prefer to anaesthetise in theatre. Comments were that it is safer because there are fewer patient transfers and two ventilators per theatre is unnecessary. The reasons cited for anaesthetising in the AR were less patient anxiety, no surgical equipment in view and less distracting chatter from scrub team.

Conclusions

Patients anaesthetised in AR or theatre both had positive experiences. Good communication from clinic staff was cited as the reason for a positive experience. Patients did not share the anaesthetists’ concerns about being anaesthetised in theatre.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

204 Comparative analysis between single-use and reusable flexible ureteroscopes in the management of upper urinary tract calculi

J Vyas ¹, CYB Cheung ¹, S Biyi ¹, A Pai ¹

Abstract

Introduction

The flexible ureteroscope (fURS) now dominates the urologist’s toolbox. Reusable fURS are easily damaged, particularly when treating stones in inaccessible locations, such as lower pole calyces. With each use, reusable scopes undergo degradation, compromising performance and limiting longevity. Maintenance and repair costs are considerable. Single-use fURS are a novel advancement, with purported advantages of consistent performance and no maintenance costs. There is, however, a paucity of evidence on the comparative efficacy and safety of single-use and reusable fURS.

Methods

Clinical outcomes for 30 consecutive patients undergoing ureteroscopy with single-use fURS, were retrospectively compared with 30 consecutive patients undergoing ureteroscopy with reusable fURS, for the treatment of upper urinary tract stones. All cases were conducted by experienced consultant stone surgeons.

Results

There were no significant differences in preoperative characteristics including stone size, stone location or patient factors, such as Charlson comorbidity index. Intraoperative factors, namely, estimated blood loss and operative time were equivalent. Some 43.3% of patients who underwent ureteroscopy using the reusable fURS were booked for repeat flexible ureteroscopy, compared with 3.3% who had a ureteroscopy with a single-use fURS. Stone-free rates were significantly higher in the single-use fURS group. Median length of stay (day case) and postoperative complications (all Clavien–Dindo grade II or less) were equivalent. There were no episodes of scope malfunction in either group.

Conclusions

Single-use fURS is safe and effective, with no repair costs and consistent image quality. The improved stone-free outcomes attributable to consistent performance mean that our institution has definitively moved to single-use fURS.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

206 A retrospective analysis of 105 phyllodes tumour

Y Aung ¹, S Jang ¹, K Weigel ¹, A Bouhelal ¹

Abstract

Introduction

Phyllodes tumours are rare fibro-epithelial breast tumours. Currently, there is a lack of clear guidelines on management. Our objective was to analyse disease presentation and management within our institution.

Methods

A retrospective analysis was conducted, in a single institution, of all histology reports mentioning ‘Phyllodes’ from 2005 to 2021. Data regarding patient demographics, presentation, management and follow-up were extracted manually.

Results

Some 105 patients had diagnosed Phyllodes tumours. Average age at diagnosis was 39.3 ± 16.9 years with 7.6 ± 4.6 years since diagnosis. All patients presented with breast lumps, with 50.5% affecting the left breast. In total, 55.2% had examination scores (average 2.28 ± 0.74), 85.7% had ultrasound scans with scores stated in 93.3% (2.85 ± 0.69), 47.6% had mammograms with scores stated in 82.0% (2.80 ± 0.81), and 91.4% had core biopsies with scores stated in 96.9% (2.67 ± 0.80). Biopsy histology was stated for 96.9%, with 63.8% mentioning possible ‘Phyllodes’. Of the patients, 88.6% underwent wide local excision, with 6.7% undergoing mastectomy and 4.8% lost to follow-up. Final histology comprised 79 benign, 15 borderline and 7 malignant Phyllodes tumours. Of the reports, 36.6% stated the nearest excision margin, which was above 1mm in 16.8%. In 16.8% of cases, the tumour was present at the margins, and 41.0% required re-excision with 2 (2.0%) subsequent mastectomies. There were 13 cases of recurrence, comprising 8 benign, 3 borderline and 2 malignant tumours.

Conclusions

Although rare and variable in disease course, comprehensive guidelines are needed in managing Phyllodes tumours. In our institution, these tumours were largely benign and primarily excised. However, further research is required into desired margins and follow-up for potential recurrence.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

207 Endovascular vs open surgical repair for unruptured infrarenal abdominal aortic aneurysm: a critical summary of randomised controlled trials

H Subbiah Ponniah ¹, M Mandal ¹, A Martindale ¹, HL Chong ¹

Abstract

Introduction

The current surgical interventions available for abdominal aortic aneurysms are open surgical repair and endovascular repair. Endovascular repair has increased in popularity since its introduction owing to its minimally invasive approach and superior perioperative outcomes. Recent evidence suggests that endovascular repair could lead to more deaths in the long term, counteracting its perioperative survival advantage. It is currently unclear whether endovascular repair or open surgical repair offers better outcomes over the long term. This critical summary aims to provide an up-to-date review of evidence from randomised controlled trials comparing endovascular and open repair of unruptured infrarenal abdominal aortic aneurysms, and to critically analyse the evidence relating to their respective surgical and patient-reported outcomes, as well as assess cost-effectiveness of the techniques.

Methods

A literature search of the MEDLINE, Embase and Google Scholar databases was conducted, and 17 papers were identified and analysed.

Results

Evidence from randomised controlled trials suggests that endovascular repair provides a greater health benefit for patients in the short term, but at a significantly higher cost than open repair. Advantages of endovascular repair were reflected by operative outcomes, length of hospital stay, 30-day mortality and early quality-of-life scores. Over the long term, these benefits were diminished by increasing rates of mortality and re-interventions, resulting in no overall survival benefit between interventions.

Conclusions

Endovascular repair could prove useful in patients with shortened life expectancies because risks are weighted away from the perioperative period. Further trials are required to compare the performance of current-generation endovascular devices with open surgical repair.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

217 The epidemiology of paediatric distal forearm fractures

A Terracciano ¹, R Rupra ¹, S Parmar ¹, P Leitch ¹, R Asirvatham ¹, C Hing ¹

Abstract

Introduction

Some 40%–50% of children in the UK experience a fracture in their lifetime, accounting for 9% of annual paediatric emergency department presentations. Few studies have focused on paediatric fracture incidence and temporal trends. This study investigated trends in paediatric forearm fractures over a 7-year period at a level 1 inner city trauma centre to identify at-risk populations.

Methods

Data were collected retrospectively from St George’s Hospital on all children presenting with a suspected distal forearm fracture between 5 September 2012 and 26 June 2019 (n = 4,702). Radiologist reports of x-rays were used to assess for a fracture. Patient demographics and admission data were collected from electronic patient records.

Results

In total, 2,097/4,702 (44.6%) patients were found to have a new fracture; 1,332 (64.4%) were male. Patients were most commonly aged 8–11 years on presentation (759/2,097) and 1,057 (50.4%) were Caucasian. In total, 48.0% of fractures were sustained during sport, most commonly football (450/1,005). The incidence of distal forearm fractures in children more than doubled from 192 to 402 across 2013–2018.

Conclusions

The incidence of paediatric distal forearm fractures is increasing with time resulting in an increased burden on resources. Improved prevention measures could limit injury in higher risk groups such as boys of primary school age that play football.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

223 Butterflies and bladders: exploring the severity of pelvic and urological injuries in motorcycle trauma

O Goulden ¹, D Chou ¹

Abstract

Introduction

A motorcyclist sustains a serious injury every 88 minutes in the UK. Impacts with the fuel tank can be associated with bilateral superior and inferior pubic rami fractures, producing a floating symphysis in a butterfly pattern, and risking urological trauma with the potential for life-altering consequences. We aimed to establish the prevalence of a butterfly pattern in pelvic fractures from motorcycle trauma over a 6-year period at a level 1 major trauma centre and to correlate urological injury with pelvic fracture patterns.

Methods

We examined our local institutional database for pelvic fractures from motorcycle trauma, reviewing notes for urological and other injuries. Available imaging was reviewed for classification and for the presence of a butterfly pattern.

Results

Of 92 patients with pelvic fractures from motorcycle injuries, 13% of had a butterfly-type pattern. This was associated with a higher median Injury Severity Score of 23, compared with 13 for the whole group. Sixteen patients, 17%, had urological injuries. The rate of injuries increased from 7.5% to 50% as the severity of the pelvic fracture increased.

Conclusions

The butterfly fracture pattern is common in motorcycle injuries and is a marker for more severe injury patterns. We show a clear link between severity of pelvic fracture and rate of urological injury. There is a need for a national pelvic fracture database to drive research into the biomechanics of motorcycle injuries. This may help guide safety interventions and motorcycle design to better protect this vulnerable group of road users.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

236 How can we improve colorectal cancer screening to include patients who have a defunctioned ileostomy?

Z Javid ¹, J Thompson ¹, N Henderson ¹

Abstract

Introduction

Defunctioning ileostomy is an option for a small group of patients with slow-transit constipation who remain symptomatic despite conservative measures. In Scotland, colorectal cancer screening begins at age 50, but there is no current pathway for this small patient group. The aim of this study was to evaluate how many of these patients were eligible for colorectal cancer screening.

Methods

A retrospective study was performed using data from a single centre over a 10-year period from 2011 to 2021. Caldicott approval was obtained. Patient demographics, complications, postoperative follow-up and eligibility for colorectal cancer screening were recorded.

Results

Eighteen patients were identified; 17 were female with an average age of 46 years. Thirteen (72%) of the patients had a permanent ileostomy, whereas five (28%) were reversed. The permanent ileostomies have been in situ for between 2.4 and 9.3 years. Five (38%) patients are within the age range for colorectal screening and over the next 5 years, this number will increase to 8 (44%); these individuals are unable to take part in the current national screening programme. One patient in the group developed colorectal cancer, which was picked up with Quantitative Faecal Immunochemical Test (qFTT) following reversal of ileostomy.

Conclusions

A small group of patients are not being screened for colorectal cancer unlike the rest of the population. This is a call for action to advocate for this neglected patient group on a global scale. Further conversations on the screening pathway are essential; including the waste generated by Faecal Immunochemical Test (FTT) unsuitable for use by this patient group.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

237 Anterior resection and defunctioning ileostomy: has the COVID-19 pandemic delayed time to ileostomy reversal?

Z Javid ¹, J Thompson ¹, N Henderson ²

Abstract

Introduction

A temporary ileostomy is created following an anterior resection as a protective measure against anastomotic leaks. The target time to reversal of 2–4 months is seldom met. The aim of this study was to evaluate the impact of COVID-19 on time to reversal and the outcome of delayed stoma reversal on quality of life.

Methods

Retrospective data from August 2011 to August 2021 were collected. Caldicott approval was obtained. Patient demographics and outcome of stoma were recorded. The mean time to reversal pre- and post-COVID-19 was compared using the Student’s t-test.

Results

In total, 149 patients were identified. Before COVID-19, 130 ileostomies were created; 69 (53%) had a delayed closure with a median time of 7 months. Since the pandemic, 19 ileostomies have been created; 12 (63%) of which were delayed with a median closure time of 9.5 months. There was no significant difference (p = 0.78) between time to reversal pre- and post-COVID-19. The delayed time to reversal was mainly due to waiting list pressures. Those with delayed stoma reversal reported the following complications: high-output, leak, skin irritation, parastomal hernias, granuloma and fistula. The number of patients suffering from low anterior resection syndrome was higher in the delayed group (42%) compared with the timely reversal group (32%)

Conclusions

A global pandemic did not increase stoma reversal times because waiting list pressures and low prioritisation were problems already. Delayed reversal is associated with worsening outcomes, which creates a bigger burden on the healthcare system. Future work should consider a change in surgical approach and to consenting patients.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

252 Effect of blood transfusion and anastomotic leak following colorectal cancer resection in the Kingdom of Bahrain

M Srinivasan ^1,², K Bawaliz ^1,³, T Al-Abbasi ⁴

Abstract

Introduction

Colorectal cancer (CRC) persists as the third most frequently diagnosed malignancy. Despite medical advancements, an upward trend predicting over a 60% increase by 2030 persists. In Bahrain, an increasing trend of late-stage diagnosis is prominent with surgical resection and chemoradiotherapy the mainstay of treatment. Because of the nature of malignancy, patients may need pre-, intra- or postoperative blood transfusions. Postoperative complications, notably anastomotic leak (AL), contribute to an increased risk of mortality.

Methods

Following retrospective cross-sectional data extraction from the CRC database from June 2016 to September 2021, statistical analysis of transfusion-related AL incidence was performed. Discrete and continuous variables were analysed with chi-squared, Fisher’s exact test and Student’s t-test accordingly. Cramer’s V, odds ratios were used to determine effect size with a statistically significant p-value < 0.05.

Results

Of 126 patients, 96 underwent surgical procedures necessitating bowel anastomosis, and 9 had significant AL. Of these nine patients, two had intraoperative and 2 had postoperative transfusions; however, there was no statistically significant difference. An increased preponderance of surgical anterior resection towards the development of AL was noted with statistical significance.

Conclusions

The study shows a strong correlation towards the safety of blood transfusions and AL following CRC resections. The results eliminate blood transfusions as a factor in the increased incidence of AL, proving no consequent contribution to the significant escalation in the CRC global burden of disease. We recommend further exploration of the nature of anterior resection and its contribution to AL.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

253 The effectiveness of a 1-day conference in improving knowledge in revision surgery and postoperative infection in trauma and orthopaedics

M Ogunjimi ¹, H Subbiah Ponniah ¹, L Tenang ¹, J Borowicz ¹, L Gabrovic ¹, V Shah ¹

Abstract

Introduction

Orthopaedic Skills Day was a 1-day conference aimed at medical students that included lectures from experienced orthopaedic surgeons, and practical workshops such as lag screws and plastering. Orthopaedics is generally undertaught in undergraduate programmes, despite its prevalence in the emergency department. Two key areas of the specialty that are often overlooked at conferences and in teaching programmes are revision surgery and postoperative infection – the focus of our lectures. The number of revision surgeries increases yearly, with a shift in indication from implant failure to infection. We aimed to compare delegate knowledge and confidence in these two subjects pre- and post-conference.

Methods

Twenty delegates, made up of 21 medical students and 1 junior doctor, were given a pre- and post-conference survey (12 and 22 questions, respectively). The questions, in a five-step Likert-scale format, covered knowledge of revision surgery and postoperative infection in orthopaedics. Knowledge of the training pathway and delegate interest in orthopaedics as a career were also inquired. Significance between the pre- and post-conference results was determined using a Wilcoxon signed rank-test.

Results

The delegates' knowledge and self-determined importance of revision surgery and postoperative infection showed a statistically significant increase post-conference (p < 0.5). The interest of delegates in pursuing a career in orthopaedics also increased, as did their understanding of the training pathway (p < 0.5).

Conclusions

The conference succeeded in improving the knowledge and understanding of revision surgery and postoperative infection, as well as increasing interest in pursuing a career in orthopaedics and an awareness of the training pathway.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

271 Percutaneous drainage vs antibiotics alone in the treatment of diverticular abscesses of differing sizes

B Murphy ¹, S O'Connor ¹, B Creavin ¹, H Earley ¹, P Neary ¹

Abstract

Introduction

Diverticular abscesses account for a significant proportion of acute surgical presentations. Recently, image-guided placement of percutaneous drains (PD) has played an increasing role in the management of these patients. National Institute for Health and Care Excellence guidelines suggest that abscesses >4cm in size should be considered for PD. Our aim was to quantify the use of PD in the management of diverticular abscesses at an Irish university hospital, and to compare short- and long-term outcomes in those treated with PD with those who had antibiotics alone (AA group).

Methods

We conducted a retrospective cohort study of patients in our institution managed with antibiotics alone or PD or over a 10-year period from 2011 to 2020. Data were obtained from our imaging system and electronic patient records. Inclusion criteria were acute diverticulitis proven on computed tomography (CT) scan, with associated measurable abscess – Modified Hinchey Stage 1b or 2. Exclusion criteria were postoperative patients, colorectal malignancy and the presence of fistulae.

Results

In total, 418 CT scans yielded a diagnosis of diverticular abscess or collection: 65 met the inclusion criteria and 7 underwent PD. Mean abscess size in the PD group was 9cm compared with 4.6cm in the AA group. When groups were sized-matched, length of stay was 15 days in the PD group and 25 days in the AA group. Of 27 abscesses measuring 4–6.9cm, none were drained.

Conclusions

At this institution, PD use is limited and reserved for larger abscesses, highlighting potential for increased use of PD in cases of diverticular abscesses. Short- and long-term outcomes appear better in patients treated with PD, for abscesses above 7cm.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

278 Gender relationship with laser retinopexy for retinal breaks: a retrospective analysis

S Hussain ¹

Abstract

Introduction

Our aim was to explore the relationship of gender with laser retinopexy for retinal breaks in a Pakistani population.

Methods

This was a 10-year retrospective study including all consecutive patients who underwent laser retinopexy, between January 2009 and December 2018. Patients were identified through the coding system of the hospital. A structured proforma was used to collect information. All patients who underwent laser retinopexy for retinal tear or high-risk retinal degeneration (such as lattice degeneration) were included. Eyes with a history or treatment of retinal detachment in the index eye were excluded. Data were analysed using SPSS version 23.0. Descriptive statistics was used to the explore relationship between gender and patients undergoing laser retinopexy. A p-value of < 0.05 was considered significant.

Results

We Identified 12,457 patients who underwent various laser procedures. Yttrium aluminium garnet (YAG) laser, laser peripheral iridotomy and laser trabeculoplasty were all excluded. A total of 3,472 patients’ files were reviewed for the study, of which 958 patients met the inclusion criteria. There was a slightly higher preponderance of males (53.87%). Mean age was 43.99 ± 15.377 years. For exploratory analysis, participants were divided into different age groups: <30 (24.16%), 31–40 (16.59%), 41–50 (19.45%), 51–60 (26.40%) and >60 (13.49%). Bilateral laser retinopexy was performed in 48.12% of patients; 24.79% and 27.13% of patients underwent laser retinopexy for the right and left eyes, respectively.

Conclusions

The ratio of males to females was not significantly different from the prevalence of retinal tears and retinal detachment in general population, which has slightly higher male preponderance. In our study, there was no gender bias in patients undergoing laser retinopexy.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

280 Mortality of early vs late coronary artery bypass grafting in patients presenting with acute coronary syndrome: a retrospective study from Pakistan

S Hussain ¹

Abstract

Introduction

Our aim was to compare mortality between early coronary artery bypass grafting (CABG) (within 3 days of symptom onset) and late CABG (within 4 to 7 days of symptoms onset), after index hospitalisation from one of the largest and busiest cardiac centres in Pakistan.

Methods

A 9-year retrospective study was conducted in the department of cardiology, Tabba Heart Institute, Pakistan. Data from 1 January 2011 to 31 December 2018 were collected over a period of 6 months (May to October 2019). We included men and women aged 18–75 years and patients who underwent CABG surgery as the treatment for acute coronary syndrome during the index hospitalisation. Patients were identified from coding for CABG surgery. SPSS version 23.0 was used for data entry and statistical analysis.

Results

Some 888 patients were selected. Mean age was 59.4 ± 8.4 years, and a higher proportion were male (84.6%, n = 751). We recorded mean length of stay, discharge status and status after 30 days, where in-hospital mortality was higher in early CABG (10.2% vs 5.2%; p = 0.008). Thirty-day mortality, although greater in the late CABG group, was statistically non-significant. Moreover, higher odds of mortality were calculated for early CABG (1.83, 95% confidence interval 1.02 to 3.09, p = 0.04). When mortality was analysed separately in both the groups, it was higher in early CABG as well; ie, 8.6% vs 5.0% in early vs late CABG of segment elevation myocardial infraction group (STEMI), and 13.2% vs 6.5% in the non-ST segment elevation myocardial infraction (NSTEMI) group.

Conclusions

Our study with a discussion of high mortality rates of early CABG and our results replicating the same, concluded that CABG should be deferred, when possible, for 3 or more days after AMI.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

287 Methods for objective measurement of skin fibrosis

A Grover ¹, B Turner ², B Langridge ², S Jasionowska ², P Butler ^1,², M Frommer ¹

Abstract

Introduction

Pathological skin fibrosis remains the clinical endpoint in numerous conditions (scleroderma, burns, radiation-induced fibrosis) with serious impacts on quality of life. Treatments are emerging, but a recent systematic review demonstrated a lack of objective measures to determine the severity and extent of skin fibrosis. Instead, physician-reported scores and interpretations are employed, raising issues with inter-physician variability, detection bias, standardisation of outcomes and subjectivity of demonstrated improvements. This review investigated current and future techniques to measure the biomechanical properties of skin and recommend those with the highest utility in detection and assessment of skin fibrosis.

Methods

A search of the relevant literature was undertaken using key terms and the MEDLINE database.

Findings

The stress of a tissue is defined as the external force per unit area within. Strain describes the degree of tissue deformation under a force. The division of stress by strain gives the elastic resistance to the force applied, known as tissue stiffness (elastic modulus). Tissue stiffness can be measured using durometry, fibrometry, cutometry, ultrasound and laser speckle contrast imaging. Histological findings are commonly used to quantify the severity of skin fibrosis. Three-dimensional imaging techniques, such as optical coherence tomography (OCT), show great promise for mapping the extent of skin fibrosis. We recommend implementation of durometers, cutometers and ultrasound imaging in skin fibrosis assessment.

Conclusions

Further validation of newer technologies such as fibrometry and OCT is warranted, to permit assessment of the severity and extent of skin fibrosis in future trials and to demonstrate the benefits of new treatments for patients.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

288 Outcome of TKA when implanted using SIMPLEX HV antibiotic-loaded cement

D Raja ^1,^2,³, K Bhadra ^1,², N Bhamber ², P Hourigan ², A Toms ²

Abstract

Introduction

Patients who undergo cemented total knee arthroplasty (TKA) show low rates of aseptic loosening. This retrospective review investigated the addition of gentamicin to SIMPLEX bone cement on aseptic loosening when used in TKA.

Methods

We undertook a retrospective data review of 100 patients who underwent TKA with SIMPLEX HV Gentamicin performed for end-stage knee osteoarthritis. All had a minimum postoperative follow-up of 2 years. The primary outcome was absence of revision surgery for aseptic loosening. Secondary outcomes included the occurrence of radiolucent lines (RLLs) on postoperative and 2-year follow-up radiographs and the difference between preoperative and postoperative Oxford Knee Score (OKS).

Results

In total 93 of the 100 individuals screened met the study eligibility criteria. Mean patient age was 72 years. Analysis of postoperative radiographs revealed two patients with incomplete radiolucency at the tibial cement–implant interface. Analysis of 2-year follow-up radiographs revealed that 44 patients developed RLLs at the cement–implant interface. Twenty-nine patients had incomplete RLLs in a single zone (n = 13, anteroposterior (A/P) tibia zone 1 or 2; n = 13, lateral tibia zone 1 or 2; n = 3, lateral femur zone 1 or 2). Fifteen patients had RLLs in several zones, two of whom had complete RLLs. No patients required revision surgery owing to aseptic loosening during follow-up. The mean improvement in OKS was (+)20.2, over a mean of 2.4 years.

Conclusions

This study highlights good clinical outcomes following TKA with SIMPLEX HV Gentamicin. Because 44/93 patients had radiolucency at the cement–implant interface on 2-year follow-up radiographs, additional studies are needed to assess the long-term effect of the cement on aseptic loosening.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

290 Who should perform the laparoscopic cholecystectomy? A single-centre comparative study of the ‘general' surgeon and the upper gastrointestinal surgeon

N Slim ¹, L Huppler ¹, A Shamali ¹, J Williamson ¹

Abstract

Introduction

It is common knowledge within surgery that greater operating volumes yield better surgical outcomes, and this has been demonstrated by the centralisation of services in some subspecialities like hepatobiliary and vascular surgery. The current burden of gallstone disease makes such centralisation impractical. It is commonplace in district general hospitals for gallbladder operations to be performed by general and upper gastrointestinal (UGI) surgeons alike. We set out to explore whether there are differences in operative outcomes and training opportunities as a result.

Methods

A prospective single-centre comparative study was conducted. Data pertaining to operating time, length of stay (LOS), day-case rate, complications and ratio of trainee to trainer operating were collected and analysed according to the specialist interest of the operating surgeon.

Results

Data from 146 laparoscopic cholecystectomies were included for analysis (113 elective, 43 semi-urgent or emergency). The operating time was shorter when performed by an UGI surgeon (mean difference −16 minutes, 95% confidence interval [CI] −27.0 to −6.96, p = 0.001). More elective cases were performed as a day case (odds ratio [OR] 2.43, 95% CI 1.06 to 5.54, p = 0.032); however, there was no significant difference in average LOS (p = 0.414) or complications (p = 1.00). Trainee-led operating was more likely with an UGI surgeon as the responsible surgeon (OR 3.90, 95% CI 1.81 to 8.40).

Conclusions

Our results show that laparoscopic cholecystectomy may be best performed by UGI surgeons because these yields better perioperative outcomes and better training for future surgeons.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

291 The impact of neoadjuvant chemotherapy on immediate free autologous breast reconstruction

N Pantelides ¹, R Jica ¹, V Ramakrishnan ¹, M Morgan ¹

Abstract

Introduction

Neoadjuvant chemotherapy (NAC) is increasingly used in the treatment of breast cancer but its impact on immediate free-flap breast reconstruction is not well established. The published literature is sparse, and many surgeons choose to delay reconstruction owing to concerns regarding safety. We present our experience with immediate free-flap reconstruction following NAC and review the outcomes.

Methods

In total, 406 patients underwent immediate free autologous breast reconstruction from 2017 to 2019, performed by the senior authors. Within this cohort, 105 patients (108 flaps) who received NAC prior to surgery were compared with 105 age-matched controls (114 flaps).

Results

The mean age for both groups was 49 years and there was no significant difference in body mass index, smoking or comorbidities. Patients who underwent NAC had a significantly lower preoperative haemoglobin count (121g/l vs 132g/l, p < 0.0001). There was no difference in total operative times and flap ischaemic times. Comparison of both groups revealed no significant difference in early and late complications, including flap failure (2.9% NAC group vs 1.9% control group, p = 1.000); infection (9.5% NAC group vs 5.7% control group, p = 0.436); thromboembolism (0% NAC group vs 1.0% control group, p = 1.000) and delayed healing (16.2% NAC group vs 20.0% control group, p = 0.591). NAC did not delay the start of adjuvant treatment.

Conclusions

We present the first age-matched comparison of the effect of NAC on immediate free-flap breast reconstruction. NAC should no longer be viewed as a contraindication to autologous reconstruction and patients should be offered the full spectrum of immediate reconstructive options.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

311 Rare presentation of bullous pemphigoid after thumb arthrodesis

ACW Tan ¹, M Young ², B Davies ², J Jones ²

Abstract

Bullous pemphigoid (BP) is an autoimmune subepidermal disorder characterised by formation of tense blisters, urticarial plaques and intense pruritus. Underlying pathophysiology is hallmarked by degradation of the basement membrane secondary to dysregulated T-cell response and synthesis of immunoglobulin (Ig)G and IgE autoantibodies against hemidesmosomal proteins. Twelve-month mortality of BP is estimated as 11% with significant impact on quality of life (eg depression, social isolation and physical limitations). We present a 76-year-old male patient with minimally displaced intra-articular fracture to the base of the left proximal phalanx post-fall. The patient underwent an arthrodesis of the metacarpophalangeal joint of the left thumb, following failed conservative management. Twenty-four days postoperatively, the patient developed ruptured blisters near the surgical wound. The patient was administered a 1-week course of oral antibiotics secondary to misdiagnosis as surgical site infection. Further blisters were evident on the hand, trunk, limbs and foot during week 6 postoperatively. Delayed diagnosis of BP was established by the dermatology team and the patient was commenced on steroid therapy 5-week post symptom onset. The diagnosis was confirmed on indirect serology. The patient was reviewed after 5 weeks of once daily Prednisolone 30mg when complete resolution of the disease was observed. This case demonstrates misdiagnosis and delayed treatment of BP in surgical patients. The case highlights the need for increased awareness of BP as a potential postoperative complication following orthopaedic procedures because prompt recognition, dermatological input and treatment can mitigate debilitating morbidity and mortality.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

313 Patient-reported outcomes after breast lipofilling

Z Bholah ¹, S Absar ¹

Abstract

Introduction

The aim of this study is to identify whether lipofilling improves patient satisfaction.

Methods

This retrospective study included all patients undergoing lipofilling at a single institution between September 2014 and February 2018 (n = 76). Patients received two validated questionnaires (Breast-Q and Sexual Adjustment and Body Image Scale) to measure health-related quality of life and patient satisfaction before and after lipofilling. Data were summarised with simple descriptive statistics. Differences between the scores were tested for statistical significance using the Wilcoxon test for paired samples.

Results

In total, 101 procedures were performed in 76 patients, and 32 completed questionnaires were returned: a response rate of 42%. Lipofilling improves psychosocial wellbeing significantly across multiple areas including patients’ level of confidence (p = 0.0001), and feelings of normality (p = 0.0002) and femininity (p = 0.0002). Reported outcomes concentrating on satisfaction with breasts highlights improved satisfaction when looking in the mirror clothed (p = 0.0001) and unclothed (p = 0.0001). Our patients report that they feel more satisfied in their clothes following lipofilling (p < 0.0001), that they are able to wear more fitted clothes (p = 0.004) and softness of the breast is enhanced (p = 0.0002).

Conclusions

Lipofilling significantly improves a patient’s psychosocial wellbeing and satisfaction with their breasts following surgery. Lipofilling is a useful tool to help improve low self-esteem in breast cancer patients.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

334 The microbial profile, antimicrobial profile and clinical outcomes of diabetic foot infections in a tertiary hospital

HY Ng ¹, I Kubelka ¹, P MacKenney ¹, S Ashwell ¹

Abstract

Introduction

In 2021, the number of people with diabetes in the UK exceeded 4.9 million; 10% of this population will get a diabetic foot ulcer (DFU) at some point in life. DFUs are associated with high morbidity and mortality; 50% of patients die within 5 years of getting a DFU. We aimed to study the microbial profile, antimicrobial profile and outcomes of diabetic foot infections (DFI) in a tertiary hospital.

Methods

A retrospective study was undertaken on 109 cases of inpatient DFI with a positive wound swab or tissue culture carried out between August 2020 and April 2022. Data were collected from medical notes and the laboratory information system.

Results

The majority of DFIs contained Enterobacteriaceae, with the highest numbers contributed by Escherichia coli. Some 47.7% of all cases (n = 52) were resistant to co-amoxiclav. From those, 59.6% (n = 31) were secondary to the presence of AmpC-producing organisms. More than half of the patients were given co-amoxiclav during the infection. However, co-amoxiclav sensitivity and resistance have no significant effect on the proportion of patients who required an amputation (50.0% vs 62.3%, p ≥ 0.05). Four patients (3.7%) in this cohort passed away during their hospital stay.

Conclusions

The involvement of a diabetic foot multidisciplinary team is important to provide best medical and surgical management. Careful selection of empirical antibiotics should be based on the local antibiotic resistance profile and accurate grading of DFI severity. It would be interesting to study the relationship between the duration of DFU and its antimicrobial profile and subsequent patient outcomes.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

339 A rare case of pyoderma gangrenosum involving the face following COVID-19 infection

E Hadjikyriacou ¹, F Bowerman ¹, S Pope-Jones ¹, C Sin-Hidge ¹, K Grounds ¹

Abstract

Pyoderma gangrenosum (PG) is a rare ulcerative condition that can be challenging diagnostically and therapeutically. Usually, it affects the lower extremities in older women, but it can sometimes affect other areas of the body. We present a rare case of PG of the face in a 19-year-old nail technician who was jointly managed by the burns and dermatological teams. The patient was initially treated as ‘acneiform eruption’ following the appearance of small pimples. However, over a 1-month period the lesions developed and extended into painful violaceous ulcers with undetermined serpiginous edges extending into subcutaneous fat in an atypical distribution solely on her face. Incisional biopsy was not conclusive. All investigations revealed no underlying cause or other possible correlation for her symptoms. The possibility of dermatitis artifacta was discussed but dismissed during the course of her treatment when her condition deteriorated following lowering of the steroid dose. Surgery on her eyelid was required for acute eversion of her upper eyelid from the healing contractures. PG can be a very challenging diagnosis and occur with no known aetiology. In our case, the ulcers covered 70% of her face rendering wound management more challenging. Promogran dressings were used and found to promote effective wound healing. Wound care in these cases needs to be conservative as far as possible because of the risk of worsening of the disease following surgery; however, intervention is sometimes required as shown in our case.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

340 Case report of aggressive scalp SCC receiving debulking reconstructive procedure with bipedicle transposition flap allowing early adjuvant radiotherapy and achieving locoregional disease control

E Hadjikyriacou ¹, F Bowerman ¹, R Nanapanini ², R Banner ¹, R Duncan ¹

Abstract

We present a complex case of locally advanced cutaneous frontal scalp squamous cell carcinoma (SCC), spanning the frontal bones, adhering to the superior sagittal sinus. A combined procedure by neurosurgery and plastic surgery achieved maximal surgical debulking, followed by robust flap reconstruction, allowing subsequent delivery of radical dose adjuvant radiotherapy. This combined approach has permitted treatment with curative intent, whereas any single modality treatment would have been palliative. Owing to COVID-19 anxieties, an 80-year-old female delayed her presentation with extensive >8cm diameter fungating SCC to her frontal scalp. Computed tomography scans demonstrated full-thickness erosion of the frontal bones, indenting the dura. Because the tumour was adherent to the superior sagittal sinus radiotherapy was not possible. A 1cm margin including pericranium was taken at the lateral borders. Craniotomy was performed, with piecemeal excision of the deep tumour, which was adherent to dura and superior sagittal sinus. The defect was reconstructed with dura substitute overlaid with a bipedicle transposition flap from temporoparietal scalp, based on superficial temporal vessels bilaterally. Galea was scored, the flap was sutured anteriorly, and bone tunnels burred to anchor retaining sutures posterior. The donor site was repaired with SSG. The patient recovered well postoperatively, being discharged within 48h. Radiotherapy (60Gy delivered in 30 fractions) was completed 3 months later. She remains disease-free 12 months postoperatively, with no adverse side effects. A collaborative multidisciplinary team provides options for combined modality treatments, enhancing outcomes. Bipedicled transposition flaps provide a robust reconstructive option for large scalp defects. Flap reconstruction over exposed dura is essential, allowing early radical dose radiotherapy.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

11 The joint orthoplastic management of an Achilles tendon avulsion: a rare case report

S Shah ¹, A Sehmbi ¹, L Jeyaseelan ²

Abstract

Rupture of the Achilles tendon typically occurs at the mid-substance, and less commonly at the distal insertion or proximal musculotendinous junction. We report the case of a 60-year-old multimorbid patient presenting with an avulsion of the Achilles tendon from the gastrocnemius–soleus complex; a variant of injury previously unrecorded in the literature. Initial orthoplastic management involved debridement and primary fixation of the avulsed tendon to the muscle with a concurrent lateral rotational flap. Flap failure and loss of tendon viability necessitated further debridement and eventual split-skin grafting. A residual dorsiflexion deformity will undoubtedly require further operative intervention. Here, we report the management of this unreported variant of Achilles tendon injury and discuss alternatives to our initial management that could have resulted in fewer procedures and improved long-term functional outcomes.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

65 The trend of hallux valgus diagnosis and treatment: NHS England, population-level data (1999–2019)

A Lisacek-Kiosoglous ^1,², A Georgiou ¹

Abstract

Introduction

Our aim was to determine the trends of hallux valgus diagnosis and minimally invasive treatment in England over the past 20 years.

Methods

ICD code M20.1 and OPCS 4-character procedure codes were systematically searched from publicly available tabulated inpatient Hospital Episode Statistics produced by NHS Digital, from 1999 to 2018/19. Population-level statistics were collected from the Office of National Statistics using the London database. Trends and tabulation data were analysed.

Results

There were 386,008 finished consultant episodes in 1999–2018/19 with a primary diagnosis of hallux valgus. The male-to-female ratio was 1:8. The mean time waited was 143 days and the mean length of stay 1 day. Mean age at diagnosis was 54 years. The average total number of new day cases per year was 10,157. The age bracket with highest incidence per 100,000 population was 55–74 years and the age bracket with highest number of procedures was 60–64 years. The numbers of soft-tissue procedures and osteotomies of the first metatarsophalangeal (not otherwise specified) have increased by ∼600% over the past 20 years, and there has been a rise in the number of arthrodesis for the first metatarsophalangeal by almost 400%.

Conclusions

We were unable to differentiate minimally invasive surgical approaches with publicly available data. Likewise, we were unable to determine the surgical technique used by surgeons to correct hallux valgus deformity. However, we found interesting trends pertaining to diagnosis and treatment, further validating the need for evidenced-based minimally invasive techniques to improve patient outcomes. Our data concurs with previous findings of male-to-female ratio of 1:8 for a diagnosis of hallux valgus.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

187 FAIMS Study: the future of artificial intelligence in medicine and surgery. A study of healthcare professionals' perceptions

EI Bahbah ¹, AE Elgebaly ², Z Shahid ¹, R Richardson ¹, A Nayef Althaher ³, H Abdalla ², R Hassan ², A Narvani ¹, M Imam ^1,^3,^4,^5,⁶

Abstract

Introduction

Artificial intelligence (AI) holds the promise of revolutionising patient healthcare. However, this often not well perceived. We aimed to assess health professionals’ perceptions of AI and its use in daily practice.

Methods

This was a cross-sectional study that distributed a self-administrated online survey targeting healthcare professionals. The survey consisted of 20 five-point Likert-scale questions that assessed different aspects of the perception of AI in healthcare.

Results

A total of 503 responses were received. One-third of respondents were consultants, 27.4% were trainees, 23.3% were team members and 12.7% were team leaders. Most participants were hospital doctors (33.1%). The majority agreed that AI has a role in healthcare and believed that AI would make the healthcare process more efficient. Over half believed that AI would reduce errors in patient care. Healthcare professionals perceived that AI could be effective in diagnosing patients (81.29%), making better decisions (28.07%), healthcare education and training (86.67%), and enhancing the role of the physician (86.67%). About half of the participants had faith in the security of AI-based technologies, 83.10% were comfortable with using the data obtained by AI for public health and research, and 26.51% had confidence in using the data for commercial purposes. Only a few respondents (14.6%) thought that AI would replace doctors in the future, and 49.19% agreed that AI would produce errors in patient care.

Conclusions

The level of healthcare professionals’ perceptions towards AI is acceptable, but not optimal. Unlike research and public health, commercial AI data use is not acceptable to many healthcare professionals.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

64 U-74389G significantly reduced TNF-α in a swine model of acute liver ischaemia–reperfusion injury

A Lisacek-Kiosoglous ^1,², A Georgiou ¹, P Zavridis ³, G Vlachos ⁴, M Tsitskari ³, C Hadjileontis ⁵, A Papalois ⁶, G Zografos ⁷, K Toutouzas ⁷

Abstract

Introduction

Ischaemia–reperfusion injury (IRI) is one of the main causes of increased morbidity in hepatic surgery following portal triad clamping and blood reflow. The aim of this study was to determine whether intraoperative administration of the lazaroid U-74389G can reduce inflammatory activity in Landrace pigs undergoing hepatectomy with Pringle manoeuvre.

Methods

Fourteen Landrace pigs (30 ± 2kg) were randomised into two groups. In group A (n = 7) lazaroid U-74389G was administrated immediately after the Pringle manoeuvre was removed, whereas in group B (control, n = 7) it was not. Blood samples were obtained at four phases: (1) before clamping, (2) 30 minutes after clamp removal, (3) 2 hours after hepatectomy and (4) 24 hours after hepatectomy. Quantitative analyses of the inflammatory markers interleukin (IL)-1β, IL-10, interferon (IFN)-α, IFN-γ, tumour necrosis factor (TNF)-α, IL-4 and IL-8 were performed. To histopathologically evaluate the numbers of neutrophils, lymphocytes, macrophages and apoptotic bodies in liver in the two groups, samples that included at least one big vessel were taken at phases 3 and 4.

Results

Histological analysis revealed the presence of inflammation and apoptosis, of the same density, in both groups. Biochemical analysis revealed a statistically significant decrease (p < 0.01) in TNF-α at phases 2, 3 and 4, and of IFN-α (p = 0.02) at phase 4 in group A compared with the control group.

Conclusions

Pro-apoptotic chemokine TNF-α was significantly reduced for 24 hours after the administration of antioxidant U-74389G in group A. However, the effect of U-74389G did not appear to be obvious in terms of inflammation and apoptosis in histological evaluation.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

67 A case study: the role of Sawbone workshops in undergraduate medical training

A Heidari ^1,², M Borumand ^1,², C Stephen ^1,²

Abstract

Introduction

Workshops using Sawbones provide fantastic opportunities for orthopaedic trainees to undertake a variety of procedures in a safe environment. Sawbones are useful because they are designed to closely reflect the bony architecture and mechanical properties of bones. Although core orthopaedic procedures are covered in medical curricula, students are rarely given an opportunity to gain hands-on experience. Although the evidence surrounding postgraduate training suggests use of Sawbone workshops improve theoretical and practical outcomes, currently there is minimal literature on their use in the undergraduate curriculum. Such workshops may improve students’ understanding, allowing those with specialist interest to explore and gain more experience in the field of orthopaedics. Here we discuss a case study in which medical students led a Sawbone training session on dynamic hip screw (DHS).

Methods

The session was organised by medical students. Twelve Sawbones, two demo kits and two power tools were supplied by DePuy Synthes. Five medical students attended the session. An initial introduction and explanation of relevant anatomy was provided by the registrar. Students were supervised by the registrars and were guided throughout the duration of their trial with the Sawbone models.

Results

Overall, the students found the session to be ‘extremely impactful’ and felt that the session ‘increased appreciation for this specialty’.

Conclusions

The session helped deepen understanding of the indications for DHS. Medical schools could utilise Sawbone workshops for core orthopaedic procedures as part of their curriculum.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

76 A review of the 3D printing applications in ostomy creation and complex intestinal fistula management

M Pandiaraja ¹, CL Soh ¹, M Powar ¹

Abstract

Introduction

This scoping review aims to provide a summary of the use of three-dimensional (3D) printing in colorectal surgery for the management of complex intestinal fistula and ostomy creation.

Methods

A systematic database search was conducted of original articles that explored the use of 3D printing in colorectal surgery in Embase, MEDLINE, Cochrane database and Google Scholar, from inception to March 2022. Original articles and case reports that discussed 3D printing in colorectal surgery relating to complex intestinal fistulae and ostomies were identified and analysed.

Findings

There were eight articles identified that discussed the use of 3D printing in colorectal surgery, of which two discussed ostomy creation, four discussed complex fistulae management and two discussed patient models.

Conclusions

3D printing has a promising role in terms of management of these conditions and can improve outcomes in terms of recovery, fluid loss and function with no increase in complications. The use of 3D printing is still in its early stages of development in colorectal surgery. Further research in the form of randomised control trials to improve methodological robustness will reveal its true potential.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

87 Successful thrombolysis of acute limb ischaemia in an elderly patient with active COVID-19 infection

A Al-Kassar ¹, K Elsayed ¹, C Francis ¹, R Makar ¹

Abstract

We present innovative use of high-dose thrombolysis in the treatment of acute limb ischaemia (ALI) in an active COVID-19 infected patient. An 83-year-old male patient was admitted to hospital with right lower limb ALI for 12 days, and was given a 10mg bolus of tissue plasminogen activator via catheter angiogram. He was then started on 1.5mg/hour (1mg in catheter and 0.5mg in sheath) of Alteplase and 1,000IU/hour heparin during intensive care unit (ICU) admission. On day 1 post-thrombolysis, the patient was clinically improved, and the check angiogram showed that most of the thrombus was resolved.

Over the next day, a small resistant thrombus was seen in the posterior tibial artery. Hence, thrombolysis continued for extra 24 hours. On day 3, the check angiogram showed complete improvement in the blood flow and resolution of the thrombus. Therefore, the patient was commenced on therapeutic Low Molecular Weight Heparin (LMWH) to prevent recurrent ALI. During ICU admission, the activated prothrombin time ratio remained between 1.4 and 1.8, with one reading of 4.6 on the third day. No complication was noticed and the patient stepped down to the wards on day 7 post ICU admission. This is the first case to be reported in the literature for a patient aged >75 years with active COVID-19 infection who had ALI and improved significantly on a high regimen of thrombolysis over 3 days. The use of Alteplase at a high dose showed significant improvement in managing ALI in an elderly patient with active COVID-19 infection.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

95 E-referrals for acute pelvic trauma: a single-centre, major trauma unit experience

T Noton ^1,², G Poole ³, S Ukwenya ³, A Vasireddy ³

Abstract

Introduction

Pelvic trauma is associated with a risk of life-threatening haemorrhage, morbidity and mortality. Patients sustaining such injuries are often referred to tertiary orthopaedic centres that specialise in the management of complex pelvic trauma. E-referral platforms, such as Pathpoint eTrauma and Refer-a-Patient, have recently been adopted by many National Health Service (NHS) trusts.

Methods

A questionnaire, with a selection of closed and open questions, was distributed among orthopaedic registrars, senior clinical fellows and consultants within the orthopaedic department at King’s College Hospital, London. The questionnaire focused on the recent introduction of the Pathpoint eTrauma e-referral system. It was aimed at gauging overall opinion and to help inform on potential improvements.

Results

We received 13 responses from a selection of grades. Some 62% of respondents agree that the eTrauma system improved the quality of referral information; 69% feel that communication has improved since the introduction this system; 77% of clinicians believe that the eTrauma software is intuitive and easy to use, whereas 69% think this process is more efficient when compared with a more traditional method of medical referral. When asked about improvements to the system, a recurring theme was seen, highlighting the lack of training and competence by the refer when using the eTrauma system.

Conclusions

The eTrauma referral system for pelvic trauma has been well received in our department. Although our project has highlighted some minor issues, these can be addressed by working with the developer. Further work should focus on the opinion of the referring clinicians using the eTrauma system.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

108 A remote virtual follow-up strategy for outreach surgery: developing the Malawi model

J Lorimer ¹, A Doorgakant ²

Abstract

Introduction

Visits to low- and middle-income countries delivering orthopaedic aid work are not uncommon. However, following up these patients presents a challenge and often puts the burden on local services. This project aimed to evaluate the feasibility of virtual follow-up for visiting surgeons to Northern Malawi.

Methods

Following visits to Malawi patients were identified for virtual follow-up pilots. Virtual follow-up was carried out using smartphone technology. Patients were seen locally, with the clinical information including photos and pictures of x-rays, sent and reviewed virtually by the link surgeon in the UK. Input was then relayed back to the clinical officers. This was facilitated locally by orthopaedic clinical officers working in Malawi.

Results

Twenty-six patients were identified for virtual follow-up at 6–8 weeks. Of the information requested 54% (14/26) had pictures sent and 36% (8/22) had pictures of x-rays sent. All were of sufficient quality. However, of the patients identified for a second follow-up, at 3–4 months, none of them had information sent. One complication, non-union and prominent metalwork, was identified for a patient who had undergone intramedullary (IM) nailing of a midshaft femur fracture. Revision surgery was organised as a result of this complication being identified.

Conclusions

The rise in telemedicine has shown virtual follow-up can be effective. With increasing accessibility to smartphone technology and the internet, virtual follow-up is feasible for visiting surgeons. However, more work needs to be done to improve the reliability of this strategy if it is to become widely adopted.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

115 Using a kidney dish for intraoperative breast specimen compression: a novel technique

SY Yip ¹, R Tabbakh ¹

Abstract

Breast cancer is the most common cancer among woman worldwide. It currently represents up to 15% of newly diagnosed cancers in the UK. Ductal carcinoma in situ (DCIS) comprises of around 10% of new diagnoses. Mammographically detected microcalcifications are the most common diagnostic feature of this subtype. Treatment for DCIS has historically been extrapolated from invasive breast cancer (IBC) and options include mastectomy and wide local excision (WLE) with definitive radiation therapy. WLE, also known as breast-conserving surgery, is increasingly popular as an effective method of removing breast cancer while preserving the natural aesthetics of the breast. Excision of clear margins is essential for WLE in DCIS to reduce risk of tumour recurrence and reoperation. Studies have reported DCIS having a positive margin rate of around 4%–23% and IBC of about 9%–36%. A study in the UK published a recurrence rate across women having breast-conserving surgery of 12.4%–29.5%, about one in five. Intraoperative specimen radiography is of paramount importance in breast-conserving surgery because it helps the surgeon decide whether further tissue excision is required from the margin in question. In our centre, Faxitron™ is used to enhance the macroscopic examination breast cancer excision margin in the operating theatre. The specimens are subsequently sent for microscopic evaluations as per gold standards. Here, we describe a simple yet and effective method of enhancing the intraoperative radiographic view of the breast specimen.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

121 Integration of a light field hyperspectral imaging system into the neuro-oncology surgical workflow

O MacCormac ^1,², P Noonan ³, M Janatka ³, J Qiu ³, M Elliot ^1,², T Trotouin ³, J Jacobs ³, A Bahl ¹, S Patel ^1,², MS Bergholt ¹, K Ashkan ^1,², S Ourselin ^1,³, M Ebner ³, T Vercauteren ^1,³, J Shapey ^1,^2,³

Abstract

Introduction

This feasibility study aimed to demonstrate that a real-time light field hyperspectral camera can be integrated into the neuro-oncology surgical workflow to acquire 155 spectral bands across the visible and near-infrared spectral range.

Methods

A light field hyperspectral camera (Cubert Ultris X50) was adapted (including grip and custom 3D printed light guide holding to facilitate draping with readily available neurosurgical microscope drapes) so that it could be safely adopted in the open neurosurgical workflow while maintaining sterility. Our software allowed the surgeon to capture in vivo hyperspectral data (155 bands, 450–950nm) at 1.5Hz and was evaluated during brain tumour surgery to remove a posterior fossa meningioma. Feedback from the theatre team was acquired.

Results

Hyperspectral data were acquired for cerebellum and associated meningioma with minimal disruption to the neurosurgical workflow.

Conclusions

This feasibility study demonstrated that a light field hyperspectral imaging system can be integrated for real-time data capture during open neurosurgery. This opens doors for further development and optimisation, given increasing evidence that hyperspectral imaging can provide live, wide-field, label free intraoperative imaging and tissue differentiation.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

133 VR: the future of simulation? A pilot study using virtual reality clinical simulation to assess the feasibility of an innovative technology in medical education

N Sivakumar ¹, G Turner ¹, J Gardner ¹, B Mathew ¹, L Hailston ¹, P Appiah-Odame ¹, E Shahabuddin ¹, M Qureshi ¹

Abstract

Introduction

Simulation is an important tool for medical training, allowing doctors to practise clinical skills in a low-risk environment. Virtual reality (VR) offers a new approach to simulation training, with virtual environments possibly offering a higher level of fidelity. The aim of this pilot study was to assess the feasibility of and attitudes of postgraduate doctors towards a VR simulation session on surgical assessments.

Methods

Oxford Medical Simulation software was used to run a simulation session on assessing acute abdominal pain in VR. Two lunchtime drop-in sessions were advertised via the trust’s intranet to all postgraduate doctors. Participants (n = 8) were asked to complete a questionnaire before and after the session which collected ordinal data on prior knowledge and confidence, including how enjoyable and feasible participants felt it was for simulation sessions to be run using VR. Qualitative data were also collected on how participants felt about the session.

Results

On completion of the sessions, 100% of participants felt that running simulation sessions with VR was feasible, in comparison with 87.5% prior. All participants (100%) found the session very enjoyable, describing it as ‘practical’ and ‘realistic’. After the sessions, 75% of participants felt they would rather partake in VR simulated sessions compared with traditional simulation session utilising mannequins and actors.

Conclusions

We found attitudes towards VR simulation exclusively positive regarding feasibility and satisfaction within this cohort. These results strongly advocate for the expanded use of VR as an innovative and emerging technology in clinical simulation.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

139 Improving accessibility to patient information leaflets: is tech the answer?

H Bright ¹, O Ambler ¹, J Musgrove ¹

Abstract

Introduction

Patient information leaflets (PILs) are used to help inform patients about their medical problems and the possible treatments. However, accessibility to this information is a problem with 7.1 million UK adults having ‘very poor literacy skills’ and PILs often not being available, often because of printing and distributing issues. We evaluated the readability of commonly used PILs with online software and the potential for software to improve the readability; and surveyed patient preferences on PILs accessible using QR codes.

Methods

We evaluated 21 online PILs (the top seven PILs found with a Google search of three common plastic surgery procedures) with an online readability tool using the Flesch–Kincaid score. We then evaluated whether online simplifying tools could improve the readability of these PILs. Finally, we surveyed patients on their preferences of printed vs QR code PILs.

Results

PILs vary greatly in their readability (Flesch–Kincaid score 7.3–14.3). National Health Service (NHS) PILs are often the least readable (average 1.6 Flesch–Kincaid grades less readable than the mean). Online simplifying tools are not helpful in increasing readability of PILs, often making them harder to read and losing accuracy. Some 38% of patients would prefer PILs accessible via QR codes – with a strong preference from younger patients.

Conclusions

NHS PILs are among the least readable patient-focused resources on the internet and an effort must be made to improve this; however, online simplifying technology is not useful in this setting. Although the majority of patients prefer physical leaflets, younger patients prefer QR codes. Therefore, both should be made available.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

142 Assessing retention of anatomical and surgical knowledge using a novel combined near-peer and surgeon-led teaching model: a neurosurgical teaching pilot study

K Pufal ¹, A Mughal ²

Abstract

Introduction

Although an understanding of anatomy is vital in the setting of surgery, surgical teaching is very rarely integrated alongside functional anatomy teaching. We aim to measure the retention of anatomical and surgical knowledge using a novel near-peer and surgeon-led teaching model as part of a neurosurgical pilot study.

Methods

A pilot study was performed on two sessions delivered as part of the Midlands Surgical Anatomy Teaching Series (January 2022). Online question forms consisting of eight very short answer questions (VSAQs) were offered to attendees immediately post session and 4 weeks post session. Electronic responses were independently collated, and question forms were manually marked. Statistical analysis (paired t-test) was performed using SPSS version 27.

Results

Forty-six participants were recorded across two neurosurgical teaching sessions (brain and spinal cord); 76.5% were medical students and the remainder were doctors and other healthcare students. The mean percentage score for the VSAQ form following the neurosurgery brain session was 82.61%. This decreased to 79.35% at 4 weeks post session (mean percentage point difference 3.26%, p = 0.1771). Following the neurosurgery spinal cord session, attendees obtained a mean percentage score of 61.41% which also decreased to 60.87% at 4 weeks post session (mean percentage point difference 0.54%, p = 0.1148).

Conclusions

The combined near-peer and expert surgeon-led teaching model is effective in promoting acquisition of surgical anatomical knowledge. The small decrease in percentage scores 4 weeks after the sessions highlights the long-term retention of surgical anatomical knowledge. Further studies with a larger sample size and wider range of sessions are required to reaffirm the effectiveness of this novel teaching model.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

146 Emergency endovascular stent-grafting for aortic transection from shotgun injury

M Rasquinha ¹, M Acharya ², R O'Neill ², A Szafranek ²

Abstract

Traumatic thoracic aortic transections (TAT) are usually caused by road traffic collision/blunt trauma. Management is usually by open surgery or thoracic endovascular aortic repair (TEVAR), with the latter shown to have more favourable outcomes. However, TAT carries an overall mortality of >90%, with >80% dying at the accident itself. Treatment can be delayed for those who reach hospital as efforts are focused on other injuries. We report a case of TAT secondary to a close-range thoracic shotgun injury that was treated successfully despite other traumatic complications. A 22-year-old man presented following a close-range thoracic shotgun injury. Heart rate was 170bpm with systolic blood pressure of 65mmHg, dependent on adrenaline boluses. Following direct transfer to the operating theatre, a clamshell thoracotomy was performed for evacuation of cardiac tamponade and repair of a left ventricular injury. Two-dimensional and cross-sectional imaging demonstrated multiple shotgun pellets embedded within the left lung with gross pulmonary contusion with intimal disruption and focal thrombus within the proximal descending thoracic aorta consistent with aortic transection. The patient underwent a TEVAR that saw a correction in his haemodynamic status. There is limited literature on the management and challenges of TAT secondary to a shotgun injury. Delay in treatment in this particular case was inevitable because diagnostic and management efforts had to initially be focused on other injuries. Nonetheless, this emergency case demonstrates that life-saving endovascular aortic repair may be achieved in penetrating trauma scenarios where high-risk aortic surgery is not feasible.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

154 Can students teach better than surgeons? Perceptions of medical professionals on a combined near-peer and surgeon-led teaching model for surgical anatomy teaching

A Mughal ¹, K Pufal ²

Abstract

Introduction

An appreciation of surgical anatomy is essential when performing surgical procedures. Despite this, surgical teaching is rarely taught alongside functional anatomy teaching. We aim to investigate and compare the perceptions of attendees of a teaching programme comprised of near-peer and surgeon-led teaching.

Methods

A questionnaire-based study was performed during a continuing professional development accredited teaching programme: Midlands Surgical Anatomy Teaching Series (MSATS). Fourteen virtual webinars were delivered (6 October 2021 to 2 February 2022) covering each anatomical region and surgical speciality. Online questionnaires were offered after each session and responses were independently collated.

Results

In total 1,459 participants were recorded across 14 MSATS sessions. Of these, 76.5% were medical students and the remainder were doctors and other healthcare professionals; 34.1% of participants were from outside the UK. Of the attendees, 68.7% felt the clarity of information from near-peer teaching was ‘very good’ compared with 63.7% following surgeon-led teaching. Similarly, 72.6% and 62.9% of attendees described the slide quality as ‘very good’ for near-peer and surgeon-led teaching, respectively. In addition, a higher proportion of attendees found near-peer teaching more relevant than surgeon-led teaching (69.9% vs 64.3%), whereas 67.9% of attendees felt the combined session improved their ability to make relevant links between anatomy and surgery.

Conclusions

The combined near-peer and expert surgeon-led teaching model is effective in encouraging application of functional anatomy to surgery. Results have shown teaching delivery and slide quality following near-peer teaching was superior to surgeon-led teaching. This should therefore prompt reforms to surgeon-led teaching to ensure understanding and continued engagement from learners in an attempt to bridge the gap between anatomy and surgery.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

177 A deep learning model for the detection of the ivy sign on MRI scans in moyamoya disease patients

K Kodituwakku ¹, S Biswas ¹, I Kamaly-Asl ²

Abstract

Introduction

The ivy sign is a unique radiological biomarker of moyamoya disease (MMD) and syndrome (MMS). The presence of a preoperative ivy sign on fluid-attenuated inversion recovery (FLAIR) imaging is a significant predictor of postoperative patient outcomes and thus the aim of the project was to develop a deep learning convolutional neural network (CNN) model for the rapid detection and classification of the ivy sign on FLAIR magnetic resonance imaging (MRI) scans of MMD patients.

Methods

Radiological data were retrospectively collected on all MMD/MMS patients at the Royal Manchester Children’s Hospital from 1996 to 2022. Preoperative coronal FLAIR MRI studies were collected in an anonymised Digital Imaging and Communications in Medicine (DICOM) format and converted to the Neuroimaging Informatics Technology Initiative (NIFTI) format for model training. Occlusion sensitivity and performance metric analysis was utilised for the evaluation of the model. All analysis was conducted in Python using the PyTorch framework.

Results

A three-layer 2.5-dimensional fully connected CNN model was developed and tested on 86 patient FLAIR scans. The model was trained on 2,050 coronal FLAIR images and internally tested on an unseen 150 images. Each image was rotated and flipped generating eight projections, with the patients being randomly divided into a stratified training and testing set. The model achieved an accuracy of 70.00% (66.72% to 88.15%) with occlusion sensitivity analysis providing key insights into the radiomic features utilised by the model.

Conclusions

Machine learning algorithms have the potential to be used as clinical decision support tools. Radiological image processing algorithms can help facilitate patient diagnosis and prognosis and enhance the provision of individualised patient care.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

195 Prediction of patient mortality after undergoing surgery for spinal metastasis using machine learning survival models

M Panchal ¹, E Snowdon ², S Biswas ², J MacArthur ², J George ³

Abstract

Introduction

The development of metastasis to the spine may necessitate surgical management, which is not without risk. Therefore, predictors of patient mortality following these surgical procedures can be influential in deciding the most appropriate management route with patients. Although the majority of research focuses on classifying mortality at specific time points after spinal surgery, we aim to train a regression model to predict survival probability over continuous time.

Methods

We collected retrospective data from 163 patients at Salford Royal Hospital who underwent spinal surgery due to metastasis, with a 39% survival rate at 2 years. We evaluated regression performance using fivefold cross validation, Harrell’s concordance index (C-Index) and integrated Brier scores for several machine learning model architectures: Cox proportional hazard regression, random survival forest, gradient boosted trees and a deep learning survival model (DeepSurv).

Results

Recursive feature elimination determined 15 significant clinical features for prediction performance (age, body mass index, haemoglobin, white blood cells, neutrophil count, neutrophil–lymphocyte ratio, creatinine, alkaline phosphatase, albumin, activated partial thromboplastin time, American Society of Anesthesiologists grade, heart failure, stroke, liver disease and haematological malignancy). The gradient boosted trees model outperformed all other model architectures evaluated, with a cross validation C-Index of 0.621 (95% confidence interval 0.581 to 0.661) and a C-Index of 0.681 on a held-out test set of 20 patients.

Conclusions

Our trained model provides good predictions of survival probability after surgery for spinal metastasis, with clinical features identified as significant agreeing with previous literature. We believe that the inclusion of a larger cohort of data from multiple centres will help to improve the performance of our model in the future.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

227 Validating a pilot virtual clinic for patients with suspected base-of-thumb osteoarthritis

J McKay ¹, K Macdonald ¹, A Smith ¹, C Simpson ¹

Abstract

Introduction

This study evaluates the outcomes of a pilot virtual-base-of-thumb clinic (VBOT) for the management of newly referred patients with suspected osteoarthritis of the base of the thumb. We aim to validate the use of this clinic as non-patient-facing pathways become increasingly utilised in response to the COVID-19 pandemic.

Methods

A retrospective review was conducted of the electronic records of 179 patients seen in VBOT between 1 February 2020 and 14 December 2021. VBOT has two definitive outcomes: information pack and patient-initiated-follow-up (PIFU) for 6 months (P&P), or face-to-face review (F2F). Prior to VBOT, all patients had a F2F appointment and physiotherapy-led education session. The primary outcome measure was the proportion of patients able to self-manage their symptoms without clinician input. The outcomes of patients presenting for clinical review were also assessed.

Results

In total, 132 patients (73.7%) received a P&P outcome from VBOT and 91.7% of patients using the pack had no objection to self-management; 24.2% (n = 32) of P&P patients initiated PIFU. Of these, 68.8% (n = 22) sought review for persistent symptoms. All underwent further intervention. Some 106 patients (59.2%) never required a F2F appointment. Of all F2F appointments, only 15.1% (n = 11) resulted in no intervention or onwards referral.

Conclusions

This study validates the use of the VBOT clinic. Three-quarters of the patients receiving the education pack had not initiated clinical review at 6 months, suggesting they are initially able to self-manage their condition. The findings suggest that this virtual pathway is acceptable to patients, is appropriate for their care and maintains access to clinical review and intervention when required.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

228 How to prevent surgery cancellation when being asked to isolate as lead cancer surgeon?

I Eiben ¹, D Bahadori ², P Eiben ², J Geh ¹

Abstract

Introduction

In December 2021 the Omicron COVID-19 variant caused a disturbance in isolation rules and travel. This meant that previously arranged cancer surgeries would have been cancelled as the lead surgeon either had to isolate or had tested positive for the virus. We wondered what can be done if isolating or suffering asymptomatic COVID-19? What if you cannot find a suitable surgeon to replace you from your commitments? We describe a way to avoid cancelling cancer surgeries at short notice. A novel way to ‘save a list’. We applied existing Proximie technology (Proximie Ltd) to allow for remote consultant supervision of a registrar to continue operating fluently with no cancellations. Proximie support systems were used to deliver a multisensory, live operation feed through to the isolating consultant surgeon. A high-definition camera and microphone headset was used to deliver consultants’ live instructions to junior doctors to complete the operation with senior supervision. The process was recorded.

Methods

Patients were consented for a virtual Proximie technique of operating.

Results

Nine cancer cases including a local flap and skin graft reconstructions were successfully completed. As a result, two full days of operating were performed with supervising consultant included in the World Health Organization checklist and debrief.

Conclusions

The Royal College of Surgeons of England reported that COVID-19 continues to cause major disruptions and an estimated 28,000 staff are off work every day due to COVID-19. We describe a contingency plan to avoid cancellations, allow juniors training and the lead surgeon be part of the list.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

238 Novel use of a bronchoscope and bariatric needle holder in total knee arthroplasty: a technical solution for retained intramedullary metalwork

E Oladeji ¹, S Masunda ¹, A Lashin ¹, O Obakponovwe ¹, M Rao ¹

Abstract

Total knee replacements (TKRs) are commonly performed for end-stage knee osteoarthritis. Complications of retained metalwork during TKRs are scarcely reported. Typically, this involves a locking pin, inadvertently misplaced into the medullary canal of the femur. If retained, foreign bodies pose a risk of leading to further complications, can damage the patient-surgeon relationship and significantly increase postoperative paperwork. Our technique utilises a sterile single-use video bronchoscope, the AmbuR aScope™ and a bariatric needle holder. These instruments are readily available in theatres because they are frequently used by anaesthetists and general surgeons. The AmbuR aScope™ connects to a high-definition monitor and gives impeccable views of the medullary canal after insertion, with a variable 180° arc of tip angulation, including flush and suction capabilities. The bariatric needle holder also of narrow calibre, allows easy insertion into the medullary canal, is easy to manoeuvre and is of adequate length to span the femur. Using both instruments the retained pin was retrieved under direct vision in minutes. Various strategies to retrieve retained pins have been described; the gravity method of hanging the leg over the table, the use of a suction device, the use of a bent K-wire under fluoroscopic guidance and a magnetised intramedullary rod. However, from our experience, the above strategies are technically challenging and can push the implant further proximal, compounding the problem. Our technique is easy, reliable, reproducible, fluoroscopy-free and a time efficient way to retrieve retained intramedullary metalwork, minimising both the stress on the patient and surgical team.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

251 Establishing a consensus on the requirements of simulation training using a therapeutic mammoplasty model for breast surgery trainees

SY Choo ¹, N Johnson ¹, S Mavroveli ¹, D Leff ¹

Abstract

Introduction

Oncoplastic breast surgery ensures adequate resection margins and cosmetically satisfying outcomes are achieved. With the European Working Time Directive and increasing consultant-led care, trainees are seeking alternative methods to gain good quality training. One such avenue is through simulation training. This research aims to develop a consensus on the requirements of simulation training using a therapeutic mammoplasty (TM) model.

Methods

To achieve a consensus, an anonymous survey was distributed to consultant breast surgeons using the Delphi method. It contained questions about the consultants’ level of experience, their opinions on breast surgery training using simulation models, important aspects of a TM procedure and how they expect a TM model to behave. The Qualtrix Survey Tool was used to develop the questionnaire, collect and analyse responses.

Results

There were 14 survey responses over a 3-month period. Some 42.9% of consultants had more than 10 years of consultantship experience; 57.1% had less than 10 years. All respondents felt that the frequency of TM has increased as a direct result of breast-conserving surgery. In total, 92.9% consultants were happy to use a TM model to teach trainees and 7.1% were indifferent. There was a consensus that mark-up and choice of pedicle were the most important aspects of learning how to perform a TM. Realism of materials and experience were seen as vital features that a TM training model should have.

Conclusions

This survey indicates that breast surgery consultants are willing to train using a TM model and this consensus can be utilised to aid development of a TM model.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

255 A pilot study using augmented intelligence (AI) to improve thyroid and parathyroid waiting list prioritisation

S Shahnazari ¹, T Soares ¹, N Tolley ¹

Abstract

Introduction

In March 2022, an estimated 4.3 million elective procedures were needed in England. This has been projected to increase to 14.6 million by 2030. At risk are procedures requiring increasingly complex and expensive treatment. Radical innovation is required to identify patients placed at increased harm because of treatment delay. One potential solution may be the application of C2-AI, an augmented intelligence platform. This estimates morbidity and mortality due to treatment delay, assisting waiting list prioritisation. A proof-of-concept pilot study was performed on a cohort of patients waiting for thyroid and parathyroid surgery.

Methods

A sample cohort of thyroid and parathyroid patients from the Imperial College Healthcare NHS Trust waiting list was used. C2-AI’s Patient Tracking List calculated current and delayed morbidity and mortality, helping reprioritise those patients prior based on Federation of Specialty Surgical Associations (FSSA) guidance. The change in priority was compared with existing FSSA methodology.

Results

Twenty patients were identified whose mortality and morbidity were shown to increase based on treatment delay (p < 0.01). C2-AI patient prioritisation was only weakly correlated to FSSA prioritisation (r = 0.2, p = 0.39).

Conclusions

In this very small sample of patients a demonstrable difference in prioritisation risk of patients based on C2-AI compared with FSSA guidance was identified. C2-AI was able to estimate personalised risk resulting from treatment delay. C2-AI has the potential to serve as an additional clinical decision tool when prioritising patients for elective surgery.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

259 Catheter education programme workshop: a success story

P Narayan ¹, S Huf ¹, J Thomas ¹

Abstract

Introduction

A catheter education programme workshop was organised at one of the biggest district general hospitals in the UK by urology-themed core trainee. The programme was in-person and was also telecasted online. It included a lecture session and a wonderful hands-on practice session with personalised feedback.

Methods

Realistic and sophisticated male and female mannequins were used to ensure the simulation was closer to reality. There was a wide variety of catheters ranging from simple to curved tip used for an enlarged prostate. We also had guidewires and open-ended catheters for difficult scenarios. Ingenious use was made of a box model to demonstrate changing a suprapubic catheter (SPC). A disposable cystoscope was demonstrated to illustrate the last resort if all special techniques fail. The workshop also included a session about manage haematuria with a three-way catheter and included techniques to give a proper manual washout.

Results

The workshop was well received and attended by several junior doctors, mostly Foundation Year trainees. Following the workshop and assessment, participants were more confident with catheterisations, including SPC and managing haematuria. This resulted in effective patient care and avoiding any delay while waiting for the urology team. This has improved patient safety at the trust and significantly reduced the number of referrals to the urology team for catheterisation.

Conclusions

Catheter workshops should be delivered in all hospitals by the urology team and will have a remarkable impact on patient care and outcome. The programme should be standardised across National Health Service trusts.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

266 A novel method for quantification of vertebral changes in multiple myeloma bone disease: is there evidence of bone constitution and potential for disease reversibility?

A Heer ¹, S Molloy ², S Verbruggen ³, J Shelton ⁴

Abstract

Introduction

Current literature suggests evidence of new bone development in multiple myeloma bone disease, such as formation of bony spicules. This challenges our understanding of the effects of loading processes on disease progression. Our study explores a novel method to quantify these changes in the vertebrae.

Methods

A retrospective study was performed on 12 patients. Multiple spinal computed tomography images of each patient were selected throughout their disease by an orthopaedic surgeon. A novel method using image acquisition, processing and analyses was performed to create a database of changes in lytic lesions, cortical bone and bony spicules as markers of bone development.

Results

Eleven patients (92%) demonstrated a strong reduction in both volume and area of lytic lesions over time once patient 3 had been discarded. This reduction was significant in the axial plane for patient 6, in whom five repeat independent measurements were made. There was an increase in the area of cortical bone over time, which was most evident in the coronal plane compared with other planes. This increase was also significant in the coronal plane for patient 6. Bony spicules increased in size over time in patient 6 although this was not mirrored in other patients.

Conclusions

Our method was broadly successful in allowing quantification of vertebral bone changes. Results gave insight into disease progression and identified which planes were most critical in defining lytic lesion and cortical area changes. Future studies should focus on machine learning to expand this database for use as a clinical tool.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

273 The fourth annual Oxford Surgical Innovation conference: an effective hybrid platform for supporting innovation in surgery

R Abhari ¹, A Jones ¹

Abstract

Introduction

The fourth annual Oxford Surgical Innovation conference (OxSI) was held on 11 March 2022. The conference aimed to communicate innovation in surgery and educate delegates on how to engage with safe and effective innovation in their fields. Here, we present the feedback from the event.

Methods

OxSI 2022 was held as a hybrid in-person and online event, with the in-person portion at St Catherine’s College, Oxford and the online arm hosted via MedAll. The day consisted of five keynote lectures and four interactive breakout sessions. Feedback was collected from delegates by means of a four-point Likert-style questionnaire.

Results

There were 171 registrations (51 in-person and 120 online registrations from 10 countries). Of these, 122 attendees provided feedback. Overall, the feedback was positive with average scores of 3.37 for engagement of the conference and 3.40 for usefulness of the content. A higher proportion of in-person attendees described the conference as successful and very successful (33% and 65%, respectively) compared with online attendees (50% and 17%, respectively). The most common reason cited for this difference was internet connectivity issues. There was a significant increase in the attendees’ confidence in engaging with safe and effective surgical innovation after the conference (before = 2.08, after = 3.16; p < 0.001).

Conclusions

The hybrid format of OxSI 2022 presented new technological challenges while allowing for increased access and international outreach. We hope the positive feedback received will encourage more engagement with this innovative method of hosting scientific meetings.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

310 The influence of Fusobacterium nucleatum on metabolism, growth and treatment of colorectal cancer cells

R Peysner ¹

Abstract

Introduction

The bacterial species Fusobacterium nucleatum (Fn) is commonly enriched in colorectal cancer (CRC) and has been associated with therapy resistance and worse prognoses. Fn has been shown to influence tumour phenotype; however, its influence in CRC is still largely unknown. This in vitro study investigates the influence of Fn infection on CRC, with an emphasis on cellular metabolism and chemotherapy response.

Methods

The human CRC cell line, Caco-2, was infected with Fn at varying multiplicities of infection (MOI). The influence of Fn infection on cell viability, proliferation and apoptosis was subsequently assessed. The seahorse mitochondrial stress test and crystal violet staining assay were used to investigate Fn-induced changes in cellular metabolism and chemotherapy-induced cytotoxicity, respectively.

Results

Our results revealed that Fn infection at an MOI of 500:1 induced Caco-2 cytotoxicity following 72 hours in co-culture; lower levels of infection did not impact on cell viability. Fn infection significantly increased Caco-2 cell proliferation and reduced apoptosis. Metabolic analysis demonstrated that Fn infection enhanced glycolysis and oxidative phosphorylation in Caco-2 cells. Fn infection also induced oxaliplatin chemoresistance, as indicated by higher EC₅₀ values.

Conclusions

These results demonstrate how Fn promotes a more aggressive tumour cell phenotype evidenced by increased proliferation, protection from apoptosis and resistance to chemotherapy. Taken together, these data highlight the importance of screening CRC patients for colonic Fn infection prior to neoadjuvant chemotherapy and surgical excision. Ultimately, these results emphasise the need for a more personalised approach to treating CRC by incorporating the microbiome as a prognostic tool to guide individual management.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

317 A hybrid approach to plastic surgery skills training

M Wedlich ¹, C Asher ², E Katsarma ³

Abstract

Introduction

Surgical training in the current era requires a multimodality approach to accommodate trainees across regions, with different levels of prior experience, without significant financial barriers. We present our experience running a surgical skills course using a hybrid approach of ex vivo tissue and novel synthetic simulation models to teach trainees essential surgical skills in plastic surgery.

Methods

Twenty participants (foundation doctors, core trainees and junior clinical fellows), attending a live skills course in June 2022 were surveyed before and after participating in the course. They self-assessed their knowledge and confidence across three key domains of the plastic surgery ST3 national selection process: local flaps, tendon repairs and microscope-assisted nerve and vessel repairs. They assessed the utility and characteristics of two novel, low-cost synthetic models for facial local flaps and flexor tendon repairs.

Results

Participants reported an average increase in knowledge of these surgical skills of 122% (1.77/5 to 3.93/5), and increased confidence performing these skills of 149% (1.43/5 to 3.56/5).

Participants rated the prototype synthetic models as useful adjuncts to ex vivo tissue offering improved three-dimensional (3D) spatial awareness and anatomical size with reduced ethical and environmental concern.

Conclusions

Trainees derive educational benefit from the wider implementation of low-cost, synthetic training models. A multimodality approach with the option of synthetic surgical simulators can improve access to training without compromise to increase knowledge, confidence and experience performing skills fundamental to a speciality. Well-designed 3D models facilitate the transition from ex vivo to in vivo, which is particularly useful in the earlier years of surgical training.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

331 A validated simulation-based teaching course: the East of England experience in improving foundation doctors' core ENT skills

L Jegatheeswaran ¹, TKP Naing ¹, B Choi ², R Collins ³, L Luke ³, S Gokani ³, S Kulkarni ¹

Abstract

Introduction

In the UK, a patient presenting with an ear, nose and throat (ENT) condition is usually first assessed and managed by a junior doctor. Although these trainees are expected to act independently before senior support becomes available, many are unfamiliar with the necessary ENT practical skills required. ENT is poorly taught across all levels of medical education. Simulation models exist in ENT; however, most are aimed at senior trainees. For those simulation models documented in literature, there is little validation or demonstrated educational impact assessed. Thus, this study aimed to assess the effectiveness of an ENT simulation course for equipping foundation doctors with core ENT skills in preparation for an ENT Foundation Year (FY) 2 post.

Methods

Forty-one FY doctors in the East of England participated in our two-part simulation course. Pre- and post-course surveys, consisting of Likert scales and a Dundee Ready Educational Environment Measure (DREEM), were sent to assess confidence in core ENT skills and acceptability of course format.

Results

Post-simulation, confidence improved in all core ENT skills taught (p < 0.001), along with confidence and preparedness to work as an ENT FY2 (p < 0.001). Overall course median DREEM score was 48. All participants (100%) would recommend this course to colleagues. A non-significant increase in median scores for likelihood of pursuing ENT as a career was noted post-simulation (p = 0.54).

Conclusions

Simulation improves FY doctors’ confidence in core ENT skills and increases preparedness for working as an ENT FY2. Guidance on core ENT skills requirements should be made available to improve uniformity among ENT simulation courses.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

341 Hyperspectral imaging for wide-field, real-time, quantitative 5-ALA fluorescence: defining new boundaries in glioma surgery

M Elliot ^1,², Y Xie ¹, D Bappaditya ¹, S Patel ^1,², O MacCormac ^1,², T Vercauteren ¹, J Shapey ^1,²

Abstract

Intraoperative 5-aminolevulinic acid/protoporphyrin IX (5-ALA/PpIX) fluorescence for resection of high-grade glioma (HGG) has been shown to increase gross total resection. Its use is limited in low-grade glioma (LGG) by fluorescence levels not visible to the naked eye and subjective interpretation at tumour boundaries. We aim to use novel hyperspectral imaging (HSI) technologies integrated into the operating microscope to capture rich spectral data. Using augmented intelligence (AI) processing this can provide objective, real-time, wide-field quantitative information on fluorescence and tumour boundaries – a step change in glioma surgery. Stage 1 will gather 100 samples from 20 patients with a range of grades of glioma. Analysis using spectrophotometry and spectrofluorimetry will define glioma optical properties (including absorption and scattering) and fluorescence emission spectra. This will be correlated with histology and magnetic resonance imaging (MRI) findings to build a machine learning databank and AI algorithm to process hyperspectral data. Stage 1 will commence in the third quarter of 2022. Stage 2 (third quarter of 2023) will determine the safety, workflow and data acquisition of our HSI system integrated with the operative microscope. We will recruit 40 patients (20 HGG and 20 LGG) to correlate quantitative hyperspectral readings with histology and imaging. Stage 1 will determine optical properties and fluorescence. Stage 2 will demonstrate safety, workflow and feasibility. Existing adjuncts for neuro-oncology surgery are limited by timing (intraoperative MRI), brain shift (neuro-navigation) and resolution (ultrasound). HSI has the potential to provide real-time, objective information to surgeons on tumour location and boundaries. We present a pathway to demonstrate inpatient safety and feasibility, paving the way for future multicentre randomised clinical trials.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

7 Tubularised incised-plate urethroplasty for distal hypospadias in a day-case setting: is it feasible?

R Al-Taher ¹, M Al-Ghazawi ^2,³, H Alshahwan ¹, S Abdelhadi ¹, F Abu Abeeleh ¹, R Al-Armouti ¹, M Rashdan ¹, M Amarin ¹

Abstract

Introduction

The need to study the effect of dealing with tabularised incised-plate urethroplasty (TIPU) patients in a single-day admission as opposed to an admission lasting several days manner has arisen. This is because enhanced recovery concepts are being implemented in the management of paediatric surgery patients, including distal hypospadias repair in patients who are usually hospitalised for several days for pain control and observation of early complications. In this study, we assess feasibility of shifting to a single-day admission style in terms of postoperative complications, postoperative pain control, readmission rate and overall hospital costs.

Methods

The data of patients who underwent hypospadias repair using TIPU techniques from January 2017 to December 2018 were collected. During the first year, patients underwent surgeries in the several days admission manner. In the second year, the paediatric surgical team shifted toward the active implementation of enhanced recovery concepts (single-day admissions).

Results

Data for 60 patients were collected. The first group (several days admission) had 23 patients, and the second group (single-day admission) had 37. Postoperative pain was minor and comparable in both groups. Also, pain control was easily achievable using simple analgesics, with no significant difference. None of the cases developed intraoperative or early postoperative complications. Overall in-hospital costs were not statistically different between the two groups.

Conclusions

Distal hypospadias repair in a day-case setting is safe and feasible, because there was no increase in postoperative complications, emergency department revisits, readmissions or reoperations. Overall hospital costs were not shown to be less in comparison with the old way of dealing with TIPU patients.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

28 Totally laparoscopic abdominoperineal resection followed by early postoperative acute small bowel obstruction: a case report with a review of literature

RU Harvitkar ¹, V Manoharan ², A Joshi ²

Abstract

Abdominoperineal resection (APR) is the long-established therapeutic surgical procedure for cancers of the lower rectum. With the advent of minimal access surgery, APR has come under its ambit. The large pelvic peritoneal defect and raw area left behind after dissection, are unique to APRs. Here we report a case of a 75-year-old male diagnosed with low rectal cancer, who underwent a totally laparoscopic APR and developed an early postoperative adhesive acute small bowel obstruction. Having failed a trial of conservative management, the same was successfully managed by a re-look laparoscopy and coverage of the large pelvic raw area with multiple Intercede^® patches. Adhesions are common postoperative adverse events. The risk of their occurrence decreases significantly with laparoscopy. APR (whether open or laparoscopic) is a unique operation that causes the formation of a large pelvic raw area, which is very prone to attracting small bowel adhesion(s). The advent of various anti-adhesion barriers (liquid and films) has helped in decreasing the incidence of adhesions. However, in spite of the availability of a wide array of options, there is no consensus among surgeons as to the most optimum agent. Ideally, tension-free closure of the pelvic peritoneal defect formed during APR should be attempted. Failing this, covering the wide pelvic raw area with a dual mesh or an anti-adhesion barrier agent (fluid or film) or omentopexy has been reported as an adhesion-preventing measure. Intercede^® promises to be a useful long-term adhesion-preventing barrier option.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

37 Necrotising enterocolitis with a solitary caecal perforation in a preterm neonate: a rare case report

UA Kalu ^1,², T Ibiyeye ¹, J Taiwo ¹, T Odi ¹, S Fadahunsi ¹

Abstract

Necrotising enterocolitis (NEC) is devastating neonatal intestinal necrosis of unknown aetiology, commonly seen in premature infants. Here we reported a case of solitary caecal perforation in a premature baby with a fatal outcome. The patient was a 40-day-old female neonate, who was delivered via caesarean section due to maternal severe pre-eclampsia at gestational age of 35 weeks with a low birth weight of 1,500g. The patient had infant formula feeding until expressed breast milk was commenced on the tenth day of life due to delayed maternal lactation. She developed abdominal distension, which was tender and tensed with peri-umbilical erythema. The abdominal x-ray showed massive pneumoperitoneum and distended bowel loops with pneumatosis intestinalis. Abdominal ultrasonography demonstrated thickened bowel wall with extraluminal fluid collection. Blood investigations revealed anaemia, leucocytosis and normal platelet count. The patient was resuscitated and worked up for surgery. Findings were purulent peritoneal, patchy areas of suspected ischaemia along the terminal ileum, with a solitary caecal perforation. The patient subsequently had a limited right hemicolectomy. The histopathological result of the caecal specimen revealed ulceration of the mucosa, transmural necrosis and haemorrhage, suggestive of NEC. The patient’s postoperative condition remained stable until the 15th day postoperatively when she developed features of overwhelming sepsis with disseminated intravascular coagulopathy leading to her death on the 17th day after surgery. Isolated caecal perforation from NEC in preterm neonates is a rare occurrence and late presentation has a devastating consequence.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

51 Occult hernia: role of laparoscopy in detecting the unseen. A case series with a review of the literature

RU Harvitkar ¹, V Manoharan ², A Joshi ²

Abstract

Introduction

The main objective of this paper is to study the incidence of occult hernias (OH) diagnosed intraoperatively during laparoscopic groin hernia surgery. We also intend to study the incidence of different types of occult hernia characterised on the basis of side, location and type.

Methods

In this retrospective study, we identified 723 patients who underwent laparoscopic repair of groin hernia in our institute by a single surgeon, from 2008 to 2021. OH was found in 120 patients, all during total extraperitoneal repair (TEP) and none during transabdominal preperitoneal (TAPP). The age range of these 120 patients was 22 to 83 years (mean ± sd: 60.7 ± 12.5 years). The patients were also analysed for sex, type of OH, side of OH and postoperative outcomes.

Findings

The incidence of OH in our study was 16.59% (120/723 patients). OH was found in both male and female patients. These comprised unilateral and bilateral OH. Patients with unilateral OH heavily outnumbered those with bilateral OH (n = 117 vs 3). There were three different types of OH in our study: inguinal, femoral and Spigelian. The highest number of cases were inguinal OH (n = 115). Among inguinal OH, patients with direct OH outnumbered those with indirect OH (n = 73 vs 40).

Conclusions

Awareness of OH as an entity is important, because their identification and concurrent repair possibly spare the patient another surgical intervention at a later date.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

74 A tale of two cities: paraduodenal hernia

RU Harvitkar ¹, B Shelke ², A Joshi ²

Abstract

‘It was the best of times, it was the worst of times…’, thus began Charles Dickens in his classic A Tale of Two Cities. We revisit right and left paraduodenal hernia (PDH) here. Our ‘two cities’ are the fossae of Waldeyer and Landzert, respectively. The present is the best of times because cutting-edge diagnostic tools offer us an unambiguous diagnosis of PDH. However, it is also the worst of times because PDH, if undiagnosed, can increase the mortality rate up to 20%. Here we make a side-by-side comparison of right and left PDH vis-a-vis their embryology, diagnosis, laparoscopic ‘first look appearance’, surgical therapy and the end result. Case 1 was a 29-year-old female (full-term normal delivery 4 days previously) presented with complaints of acute intestinal obstruction. X-ray of the abdomen showed multiple air-fluid levels. A contrast-enhanced computed tomography scan of the abdomen (CECT abdomen) was suggestive of left PDH. The patient underwent laparoscopic repair of PDH (marsupialisation) and was asymptomatic at 6-month follow-up. Case 2 was a 33-year-old male who presented with colicky left upper abdominal pain on and off for 15 days, one episode of bilious vomiting, abdominal distension and constipation for 2 days. He had no significant past medical history. X-ray of the abdomen showed distended small bowel loops and a few air-fluid levels in the left upper abdomen. A CECT abdomen diagnosed left PDH. The patient underwent laparoscopic repair (marsupialisation) and was asymptomatic at 11 months of follow-up. CECT abdomen has a high specificity for the diagnosis of PDH, which can be successfully managed by laparoscopy, even in the emergency setting.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

80 Distal end radius osteotomy and fixation of Madelung deformity: a global surgery perspective

PV Bhat ¹, KK Ashwin ²

Abstract

Introduction

Our aim was to assess the functional outcome of radial wedge osteotomy in Madelung's deformity. Madelung's deformity of the wrist arises from premature closure of the medial and volar aspect of the distal radial physis. True Madelung deformities reveal the presence of a ‘Vickers’ ligament, which is a short, volar, radioulnar ligament. Clinically, patients report increasing deformity, pain and poor range of motion. Surgical intervention usually comprises either a ‘Vickers’ ligament release and distal radius physiolysis or a radial osteotomy (with or without ulnar shortening). The patient was a young adolescent female presenting with deformity of the right wrist with progression of range of motion restriction and forearm shortening. Findings included decreased supination and wrist extension.

Methods

Using a modified Henry approach at the distal forearm, a radial wedge osteotomy was performed to correct the volar tilt and ‘Vickers’ ligament was isolated and released. This was followed by external fixation with two K-wires. An above-elbow cast was applied for stabilisation. The radial tilt, ulnar variance and volar angle were measured pre- and postoperatively.

Results

On 3-month follow-up, a 15° increase in supination was observed along with significant improvement in wrist extension, and radial deviation. The cosmetic deformity was also corrected.

Conclusions

Although wedge osteotomy may not be the gold-standard surgical intervention for Madelung’s deformity, given limited resources and the remodelling potential of a young bone, this procedure is an effective method with successful outcomes. Furthermore, in this case ulnar shortening was not required as the ulnar variance was within normal limits.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

84 Endoscopic third ventriculostomy vs ventriculoperitoneal shunt insertion for the management of paediatric hydrocephalus in African centres: a systematic review and meta-analysis

D Jesuyajolu ¹, A Zubair ¹, A Nicholas ¹

Abstract

Introduction

Ventriculoperitoneal shunt (VPS) insertion and endoscopic third ventriculostomy (ETV) are common surgical procedures used to treat paediatric hydrocephalus. There have been numerous studies comparing ETV and VPS, but none from an African perspective. In this study, we sought to compare outcomes from African neurosurgical centres and review the associated complications.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were used in conducting this study. PubMed, Google Scholar and African Journals Online were searched. Data on treatment successes and failures for ETV and VPS were pooled and analysed with a binary meta-analysis. A clinically successful outcome was defined as no significant event or complication occurring after surgery and during follow-up (eg, infection, failure, cerebrospinal fluid leak, malfunction and mortality). Seven studies fully satisfied the eligibility criteria and were used in this review.

Findings

There was no statistically significant difference between the outcomes of ETV and VPS (odds ratio 0.27; 95% confidence interval −0.39 to 0.94, p = 0.42). After reviewing the rates of complications of ETV and VPS from the identified studies, four were recurrent. The infection rates of ETV vs VPS were 0.02% vs 0.1%. The mortality rates were 0.01% vs 0.05%. The reoperation rates were 0.05% vs 0.3%, and the rates of ETV failure and shunt malfunction were 0.2% vs 0.2%.

Conclusions

This study concludes that there is no significant difference between the outcomes of ETV and VP shunt insertion. It serves as a source of evidence for decision making when considering the right method of managing paediatric hydrocephalus in African children.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

163 The prognostic utility of neutrophil–lymphocyte ratio in spinal surgery: systematic review and meta-analysis

O Olukoya ^1,², T Osunronbi ^2,³, D Jesuyajolu ², K Alare ², H Alemenzohu ², R Bello ², T Omoniyo ², O Oyeyemi ², A Yakasai ², H Sharma ⁴

Abstract

Introduction

The neutrophil–lymphocyte ratio (NLR), an inflammatory biomarker, has been reported as an effective prognostic tool across various medical and surgical fields, but its value in spinal surgery is unestablished. We conducted a systematic review and meta-analysis to investigate the relationship between elevated baseline/postoperative NLR and patient outcomes in spinal surgery.

Methods

We performed a systematic search in PubMed, Embase and SCOPUS databases for studies investigating the prognostic value of NLR. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were extracted and analysed by the RevMan version 5.4 software. Where meta-analysis was not possible, we vote-counted the direction of the effect of elevated NLR. The GRADE framework for prognostic factor research was utilised to assess the certainty of the evidence for each outcome measure.

Findings

Five outcome measures (overall survival, mortality, disease-free survival, functional recovery and complications) were assessed across 16 studies involving 5,471 patients. Elevated baseline NLR was associated with reduced overall survival (HR 1.63, 95% CI 1.05 to 2.54; GRADE ++) and worsened functional recovery (OR 0.93, 95% CI 0.87 to 0.98; GRADE ++). There was no association between baseline NLR and disease-free survival (HR 2.42, 95% CI 0.49 to 11.83; GRADE +) or mortality (OR 1.39, 95% CI 0.41 to 4.75; GRADE +). Elevated NLR levels measured on day 3–4 and day 6–7 postoperatively, but not NLR measured at baseline or on day 1–2 postoperatively, are associated with greater risks of complications (GRADE ++).

Conclusions

NLR is a readily available objective tool with the potential to identify patients who would benefit from surgery and facilitate shared decision making.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

165 Simultaneous occurrence of subarachnoid haemorrhage and cerebral venous sinus thrombosis: a systematic review of cases

O Olukoya ^1,², D Jesuyajolu ³, T Moti ²

Abstract

Introduction

Cerebral venous sinus thrombosis (CVST) can, in rare cases, be associated with subarachnoid haemorrhage (SAH). The purpose of this review is to highlight what is known regarding these cases, how they are managed and to highlight the need for further studies that will serve as a basis for the development of a standard management guideline across board.

Methods

We conducted a systematic search in PubMed and Ovid Embase. A complementary search of Google Scholar and AJOL was done. A grey literature search was also conducted on the Google search engine for any additional relevant papers. We were able to extract data regarding 33 cases from 29 identified studies.

Findings

Headache was by far the most common symptom (27 patients) followed by seizures in 14 patients. Four patients had loss of consciousness, whereas five patients had some form of focal neurologic deficit. Twenty patients had cerebral venous sinus thrombosis in at least two different sinuses. Of the different locations for the CVSTs, the superior sagittal sinus was the most common location (79%), followed by the transverse sinus (57.5%). Twenty-nine cases (89%) were managed with anticoagulation alone and one case had a mechanical thrombectomy prior to anticoagulation.

Conclusions

We have performed a comprehensive review of cases that had the simultaneous occurrence of SAH and CVST, and have identified their peculiarities and the challenges to management. Further research is needed to identify a causal relationship and to serve as a basis for the development of a standard management guideline across the board.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

199 Soft-tissue reaction to drain tract: a rare cause of early failure/loosening of total knee replacement implants

M Ahmad ^1,², DA Satti ³, MA Amir ³, HZ Lone ^2,³

Abstract

Aseptic loosening refers to the failure of joint prostheses without the presence of a mechanical cause or infection. It is caused by osteolysis (bone resorption) and a macrophage-induced inflammatory cellular response due to wear debris occurring 10−20 years after joint replacement surgery. The patient presented with pain and swelling of left knee, 3 years after bilateral total knee replacement (TKR). There was no history of trauma or fever. On examination, there was mild fullness around the knee with no tenderness and full range of active and passive motion. X-rays showed early features of loosening around tibial component, whereas all inflammatory markers were in the normal range. Knee aspiration was negative for infection and crystals and left knee arthroscopy showed significant synovitis and fibrous tissue extending to the femoral notch box. Fluid and tissue cultures were negative, whereas tissue biopsy revealed fragments of collagenised to hyalinised tissue, negative for any granuloma formation or malignancy. Patient symptoms worsened over the subsequent year with severe knee pain and progressive loosening on subsequent x-rays. Revision of the left TKR was planned. During revision surgery, a soft-tissue mass along the tract of postoperative drain was noted. Pathology of the tissue confirmed extensive foreign body giant cell reaction with dense hyalinisation and calcification. The patient was comfortable with pain-free weight-bearing on the knee after revision surgery. A foreign body reaction to the drain tract was an unusual cause of early osteolysis and loosening of the implants in our patient. After a thorough review of the available literature, no such cause is reported.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

202 Using myoplasty in surgical tactics in patients with laryngotracheal injuries of the neck

M Sukhomlyn ¹, V Makarov ^2,³, E Khoroshun ^2,³, V Nehoduyko ^2,³, S Shypilov ^2,³, K Smolyanyk ², M Shannag ⁴

Abstract

Introduction

Surgical methods for treating these injuries are not fully developed and require further study. The purpose of this work is to develop therapeutic and tactical approaches for neck injuries including laryngotracheal ones.

Methods

Twenty-eight patients with neck injuries presented with laryngotracheal lesions. Laryngeal lesions occurred in 14, thyroid cartilage lesions in 4 and tracheal lesions in 10. Stabbing was the cause of the lesion in 23 patients and gunshot injuries in 5. The penetrating nature of the damage was noted. All patients underwent an x-ray and bronchoscopy examinations.

Results

Larynx defects were intubated in six patients, followed by a tracheostomy and then suturing of the larynx. In five patients the first step was tracheostomy followed by suturing of the larynx. In three patients in whom the front surface of the larynx was injured, suturing was performed without a tracheostomy. When thyroid cartilage is injured, an important aspect is preservation of skeletal function and the achievement of aerostasis. For this reason, four patients underwent suturing of cartilage and myopexy was performed using part of the sternocleidomastoid muscle from one side. Another five patients with trachea injuries underwent suturing of the trachea and the same myopexy from both sides.

Conclusions

To improve the results seen in the treatment of neck injuries early restoration of the larynx and trachea is needed to restore the function and achieve hermetism, sanation and drainage of neck spaces located in the area of damage to the respiratory tract.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

205 Evaluating access to key emergency surgery procedures in the UK: a protocol

Abstract

Introduction

The aim of this study is to evaluate access to the bellwether procedures in the UK against the standards set out in the Lancet Commission on Global Surgery’s surgical indicators.

Methods

Through InciSioN UK, data collectors will be recruited in UK hospitals providing bellwether surgical procedures (laparotomy, caesarean section and long-bone open fracture management). Over a 1-month period, performances of and access to these procedures will be reviewed as per the Lancet Commission on Global Surgery surgical indicators. Data will be recorded confidentially on REDCap.

Results

The results of this study will be presented once available.

Conclusions

In 2015, The Lancet Commission on Global Surgery published six global surgery goals for the year 2030, to improve universal access to safe and affordable surgical and anaesthetic care. Although these are aimed at improving healthcare in low- and middle-income countries, given the difficulties faced in the National Health Service with regards to waiting times, our research team thought this study would be of interest to help understand whether access to emergency care in the UK continues to maintain a satisfactory standard. Through our InciSioN branches across the world, we plan to recruit teams to carry out this study internationally, to facilitate an up-to-date understanding of how access to emergency surgery differs in different countries.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

264 The burden of motorcycle road traffic injuries in Nigeria: a single-centre study

C Ezeme ¹, E Oladeji ^1,², S Ogunlade ¹, M Okunola ¹

Abstract

Introduction

Motorcycling is a popular and growing form of intracity transportation in many Nigerian cities. It contributes significantly to road traffic injuries (RTIs), which are a leading cause of death and disability in low- and middle-income countries. This study evaluated the burden of motorcycle RTIs among road crash casualties in a tertiary hospital in Ibadan, Nigeria.

Methods

This is a prospective study. All patients involved in a motorcycle road traffic accident who presented to the emergency department of the University College Hospital, Ibadan between August 2020 and May 2021 were included in the study. Data on patient demographics, history of the crash, injuries sustained, definitive care and the outcome of the care were obtained using a pretested questionnaire.

Results

In total, 156 patients were seen, 74.4% of whom were male; the peak age group for incidences was 18–44 years. More than half of the victims received no prehospital care. The head and the extremities were the most affected anatomical areas, and orthopaedic and neurosurgical procedures were the most required emergency operations. The mortality rate was 17.3%. Patients who presented at 7–24 hours and >24 hours after the accident were 2.99 times and 5.65 times, respectively, more likely to die compared with those who presented within the first 6 hours.

Conclusions

This study identified the growing burden of motorcycle RTIs, deaths and disabilities. It highlights the need for a national strategy to develop an organised urban transport system, and a structured emergency ambulance service and prehospital care system for road crash victims.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

270 The economic burden of motorcycle road traffic injuries in Nigeria: a major public health concern

E Oladeji ^1,², C Ezeme ¹, M Okunola ¹, S Ogunlade ¹

Abstract

Introduction

Motorcycle crashes contribute significantly to road traffic injuries (RTIs) in Nigeria. Assessment of the economic burden is complex because most patients pay out-of-pocket for healthcare services. The study evaluates the economic burden of motorcycle RTIs and compares two methods of assessing medical cost.

Methods

This is a prospective study. All patients involved in a motorcycle road traffic accident who presented to the emergency department of the University College Hospital, Ibadan between August 2020 and May 2021 were included in the study. All medical expenses from time of injury to 30 days after injury were recorded and the medical cost was also assessed by the willingness to pay method.

Results

In total, 112 victims of motorcycle crashes were recruited: 73.2% were aged <45 years and 76.8% were male. Severe injuries occurred in 18.2%, moderate injury in 30.2% and 51.5% presented with mild injuries. The average monthly income for the patients was $121.40 (72.80–180.20) and 75% of them earned less than $180 per month. The average medical cost was $241.72 (142.61–827.98) and $2,427.18 (970.87–7281.55) by the willingness to pay method. The cost of medical care was catastrophic for 45.5% of the patients. The willingness to pay approach of assessing medical cost has a weak correlation with the direct method.

Conclusions

The direct medical cost for motorcycle RTIs is catastrophic for nearly a half of the victims. The willingness to pay approach, although a less tedious way of assessing the economic burden of disease, is not a reliable method.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

321 Burden, management and outcome of osteosarcoma in Africa: a scoping review

E Oladeji ¹, O Olajugba ¹, D Adesola ¹, G Rockson ¹, A Bah ¹, R Abdullateef ¹, D Fadeyi ¹, A Wusu ¹

Abstract

Introduction

Osteosarcoma is a primary bone tumour that is more prevalent in Africans. The threat of its burden, and evidence relating to the management and outcome of osteosarcoma in Africa have not been comprehensively reviewed. We conducted a scoping review to assess the state of research on this subject.

Methods

An electronic database search was performed on African Journals Online, Embase, PubMed, Google Scholar, Web of Science and Cochrane to identify studies related to the topic. An additional search of the reference lists of identified studies and a grey literature search was conducted. Data from relevant articles were extracted and findings summarised.

Results

There is a wide geographical variation in demographics, management and disease outcome across Africa. Osteosarcoma has been reported across a broad age group of 2 to 85 years and accounts for 1.4% to 15% of childhood cancers with an incidence of 1.2 to 4.2 cases per million. Most patients presented late with locally advanced or metastatic tumours. Centres in Southern and Northern Africa are the most resourceful and offer the highest standard of care, which correlates directly with outcome pattern. Overall, there is poor access to oncological services and surgery is the only available therapeutic modality in most parts of Africa, yet it is predominantly limited to limb amputation with limb-salvage procedures less commonly offered.

Conclusions

There is suboptimal care of osteosarcoma across most regions in Africa and outcome is generally poorer than in high-income countries. There is a dire need to develop treatment protocols locally adapted to suit the capacity and resources in the African context.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

342 Challenges facing autologous breast reconstruction in low- and middle-income countries: a systematic review of the literature

V Shah ¹, CL Soh ², K Chhatwal ¹, J Kucharczak ², A Arjomandi Rad ³, G Miller ³, J Malawana ⁴

Abstract

Introduction

Despite the collective drive to strengthen health systems globally, women in low- and middle-income countries (LMICs) continually experience barriers in accessing breast surgery. Although less popularly performed, autologous breast reconstruction exhibits greater patient-reported outcomes in high-income countries; it is unclear whether these trends are mirrored in LMICs. This review aims to synthesise the current practice of autologous breast reconstruction in LMICs, and the challenges facing its provision.

Methods

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Cochrane Collaboration published guidelines. Embase, MEDLINE, Cochrane, PubMed and Google Scholar were searched for original articles that addressed autologous breast reconstruction in countries defined as low or middle income (as per the World Banks’s 2022–2023 classifications) from inception to August 2022. All original articles were included if they reported autologous reconstruction post-breast cancer surgery conducted on patients in LMICs.

Findings

Some 288 articles were identified from the literature search, of which 19 were selected for inclusion within this review post-screening and critical appraisal. Articles reported heterogeneously across reconstructive technique and operative complications. Challenges identified included a lack of information and consensus on the best practices for each country, infrequent and non-standardised outcome reporting and a lack of patient awareness surrounding choosing autologous reconstruction.

Conclusions

Barriers to autologous reconstruction exist across multiple domains in LMICs, remaining difficult to quantify owing to insufficiently robust evidence and standardised reporting outcomes. Future research should address contextual reconstructive demand to gain further perspective on an increasingly growing field.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

4 The role of a tele-haematuria clinic during and after the COVID-19 pandemic

H Maroof ¹, A Ali ¹

Abstract

Introduction

The aim of this study was to improve the efficiency of haematuria services and reduce time from referral to management decision at a district general hospital, during and after the COVID-19 pandemic.

Methods

A closed-loop audit was undertaken on the value of a tele-haematuria clinic in place of flexible cystoscopy in patients referred with haematuria. Prior to the pandemic, all patients referred with haematuria were booked for flexible cystoscopy, irrespective of imaging results. Data from 73 patients were collected and analysed. Ideas for change were discussed, alongside methods for improvement. During the pandemic, patients with imaging appearances concerning bladder malignancy were referred to a tele-haematuria clinic instead of a flexible cystoscopy. A re-audit including 70 patients was conducted. Time from referral to tele-clinic was calculated and compared with time from referral to flexible cystoscopy.

Results

A 7-day reduction in time from referral to tele-clinic vs time from referral to flexible cystoscopy was found, resulting in a faster management decision. There was an increase in flexible cystoscopy capacity and 92% patient satisfaction with new pathway.

Conclusions

Social distancing rules and the influx of critically unwell patients to National Health Service hospitals during the COVID-19 pandemic has significantly impacted patient wait times and in-person clinic access. Telemedicine is vital in facilitating optimal service delivery while minimising face-to-face contact. This study demonstrates the important role of a tele-haematuria clinic in reducing wait times for patients referred with haematuria.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

6 Improving patient safety by optimising operation notes at Royal Bolton Hospital using Royal College of Surgeons of England Good Surgical Practice Guidelines

M Golsharifi ¹, M Malik ¹, C McVickers ¹, O Pope ¹, S Nash ¹, M Whybrow ¹

Abstract

This audit aimed to assess compliance with Royal College of Surgeons of England (RCS England) Good Surgical Practice Guidelines version 1.3 (record your work clearly, accurately, and legibly) for operation notes at Royal Bolton Hospital (RBH) general surgery department. Clinical records (EPR) were analysed retrospectively for consecutive patients who underwent general surgical operations at RBH between 13 and 19 December 2021. A total of 37 patients’ operative notes were audited. Operation notes were checked for each requirement set out in the RCS England guidelines and statistical analysis was performed using a chi-squared test on SPSS. Key areas for improvement were identified. Teaching sessions, as well as posters, were designed and delivered to the surgical team. A repeat audit was perfumed showing marked improvement in the previously highlighted domains. This audit reiterated the importance of maintaining standards by running regular teaching sessions and using standardised proforma to minimise the risk of non-deliberate omission of data from operation notes.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

12 An audit on pharmacological thromboprophylaxis following open radical nephrectomy

K Bugeja ¹, C Mizzi ¹, S Zammit ¹

Abstract

Introduction

Pharmacological thromboprophylaxis after open radical nephrectomy is recommended for all patients by the European Association of Urology (EAU). The aims of this audit are to assess local practice adherence to these guidelines, to analyse demographics of patients undergoing radical nephrectomy and to record bleeding or thromboembolic complications in the first 28 days postoperatively.

Methods

This is a local retrospective audit on 99 patients who underwent open radical nephrectomy for malignancy over a 2-year period. Information regarding prescription of postoperative pharmacological prophylaxis and complications was retrieved through the hospital software system.

Results

Eighty patients (80.8%) received enoxaparin as pharmacological thromboprophylaxis. One patient (1.01%) was discharged on heparin sodium, another (1.01%) on rivaroxaban and two (2.02%) on warfarin. A total of 15 patients (15.15%) received no postoperative pharmacological thromboprophylaxis. The duration of thromboprophylaxis varied, with 74 of 80 patients prescribed the recommended 28 days of enoxaparin. Three patients on various anticoagulants experienced bleeding, and one patient suffered pulmonary embolism on the first postoperative day. None of the patients for whom pharmacological prophylaxis was withheld sustained symptomatic or radiologically identified deep venous thrombosis or pulmonary embolism.

Conclusions

These findings are significant to daily practice because they show a relatively high level of compliance with EAU recommendations. Yet, this audit emphasises the need for stronger adherence to established international guidelines. Based on the fact that none of the patients for whom pharmacological prophylaxis was omitted experienced thromboembolic events, it might be worth considering withholding thromboprophylaxis in those deemed as high risk for haemorrhage.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

13 Making an effective ward round model for University Hospitals of Birmingham NHS Foundation Trust

T Khaleeq ¹, N Lo ¹, J King ¹, A Turner ¹, T Graham ¹, E Howland ¹

Abstract

Introduction

The aim of this study was to improve the quality and standard of ward rounds with a review of care and planning.

Methods

Using the modern-wards report published by the Royal College of Physicians and Royal College of Nursing as a template, six key elements/standards were made for a daily ward rounds model which will be multidisciplinary, clearly documented and handed over to relevant staff. The model consists of a board round, bedside ward round and a debrief, and includes ward round prompts using the REMIND mnemonic: R = Respect form and ceiling of treatment, E = Electronic prescribing up-to-date, M = Mental capacity, dementia, I = Investigations, N = Nutrition and hydration, Nil by Mouth (NBM) status, D = deep vein thrombosis risk assessment and thromboprophylaxis. The departments included in the project were respiratory medicine, trauma and orthopaedics, infectious diseases, acute medicine, gynaecology, general surgery, and others across all the sites of the trust.

Results

After staff and patient template surveys, auditing of the practices against the elements was done. All of the departments showed improvements against the elements, reducing the number of serious incidents in the trust, and also improving discharge processes owing to the increase in multidisciplinary teams. The number of plan–do–study–act cycles undertaken in each department was as follows: trauma and orthopaedics, two cycles; infectious diseases three cycles; respiratory medicine, four cycles; general surgery, one cycle; acute medicine, one cycle; care of the elderly, one cycle; and gynaecology, one cycle.

Conclusions

This proves that ward round standardisation has proven feasible and aided quality of care based on our audit standards. A compulsory Moodle-Teaching module has been introduced for consultant and nurse education in Quality Improvement (QI) methodology to improve sustainability of the project.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

16 The use of virtual reality to improve confidence in assessing patients in third-year medical students

N Jacob ¹, C O'Neil ¹, K Teoh ¹

Abstract

Introduction

The challenges facing medical students and junior doctors during the COVID-19 pandemic has been well documented in the recent literature. The reduction in patient contact in healthcare, particularly surgery, has permeated to medical education, and teaching through face-to-face methods has declined. With anticipated subsequent pandemic waves, alternative novel teaching strategies should be considered to avoid similar occurrences. Virtual reality is one such teaching method known to improve clinical reasoning skills, but is integrated into very few medical school curricula at present. We wanted to evaluate virtual reality simulation (VRS) as a means of increasing confidence in third-year medical students, who enter their first year of clinical placement, to assess patients, with a particular focus on A–E assessments in surgical pathologies.

Methods

VRS was delivered through Oxford Medical Simulation and Oculus headsets to 23 students as part of their undergraduate teaching. Confidence levels were assessed using Likert scales on pre- and post-questionnaires.

Results

VRS was a novel method of teaching for >90% of students, with 100% finding the software easy to use. There were statistically significant improvements in confidence with regards to history taking (p = 0.0003), examinations (p < 0.0001), performing A–E assessments (p = 0.0001), requesting investigations and interpreting results (p < 0.0001) and initiating management in unwell patients (p = 0.0001). All students (100%) agreed that VRS should be used regularly at their medical school.

Conclusions

VRS should be used as an introduction to A–E assessments to prepare students for undergoing high-fidelity simulation as medical students, and for life as Foundation Year doctors.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

23 Fascia iliaca block QIP

A Basha ¹

Abstract

Introduction

The aim of this study was to audit compliance of application of fascia iliaca block (FIB) against Royal College of Emergency Medicine best practice guidelines, improve quality of care for patients who had a neck of femur (NOF) fracture and monitor changes in practice after circulating new FIB kits and relevant posters.

Methods

Data were collected spanning over two cycles for patients who had NOF fractures during 6 months before the first cycle and 6 months after implementing changes and using the new kit. In total data for 321 patients were retrieved and analysed. All NOF patients seen over the period of the study were included, whereas patients presenting with hip pain and no fracture were excluded. The collected data included whether patients received FIB or not, patient National Early Warning Score (NEWS) before and after FIB, the need for painkillers dependent on whether patients received FIB or not, and the types of painkillers used.

Results

The first cycle showed that 68% of the patients with NOF fracture received FIB and 32% did not. The second cycle showed an improvement with 85% of patients with NOF fracture receiving FIB and 15% not. NEWS improved in those who received FIB (60% of patients in the first cycle and 75% in the second cycle after application of kits). The need for painkillers fell dramatically for those who had FIB in the second cycle in comparison with who did not have FIB (25% in the first cycle and 10% in the second cycle of those who had FIB needed painkillers).

Conclusions

FIB improved patients’ pain relief, aided patient care and optimised patients for surgery in order not to breach Best practice tariff (BPT).

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

26 Detection of early surgical site infection using distant photography: a national quality improvement project

M Al-Ghazawi ^1,², R Abuseedou ³, H Salameh ⁴

Abstract

Introduction

Surgical site infection (SSI) remains one of the most common postoperative complications in any surgical patient. This problem can be prevented by early detection and usage of simple antibiotics. In this study, we perform a quality improvement project to prevent SSI by using photographs taken by the patients themselves in a certain pattern and managing any early SSI accordingly.

Methods

Total data for 1,093 patients, across three major hospitals, who had some degree of SSI were collected in 2 phases; phase 1 (11 months) and phase 2 (15 months). After phase 1 patients were asked to send photographs of their wounds at post-discharge days 3, 7, 14 and 21, with some further modification for patients who had an increased risk for developing SSI. Patient sent their photographs via WhatsApp to an assigned phone number.

Results

Around three-quarters of patients developed an SSI (74.12%) during phase one before applying our technique. However, the numbers decreased sharply; 283 of 1,093 patients (25.88%) developed SSI after the start of sending photographs. Moreover, surgical admission rates for SSI during phase two dropped from 35% to only 7%.

Conclusions

Implementing technology in surgery is very useful and promising. Using photographs is an easy and effective way to deal with SSI. Although some patients still suffer from SSI, other measures can be taken to tackle this complication.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

27 Introduction of a common presentations QR poster in a surgical day emergency care unit: increasing access and use of NHS information website

M McKeever ¹, G Kourounis ¹, J Hughes ¹

Abstract

Introduction

It is important to promote high-quality patient information documents, especially in acute settings such as surgical day emergency care (SDEC) units, facilitating patient education and providing reliable safety-netting. We aimed to increase the accessibility and use of National Health Service (NHS) patient information websites with a poster containing QR codes for common presentations in our SDEC unit.

Methods

Convenience sequential sampling of general surgical patients in the SDEC unit was surveyed. Questions included whether patients had sought information prior to attending, and if the NHS website was used. The QR poster was placed in every examination/waiting room and then the process was repeated with the additional question of asking patients whether they had used the poster.

Results

A sample of 30 patients was surveyed in each cycle. The three cycles did not differ significantly in median age and per cent female (p > 0.05). There was a significant increase in patients accessing NHS information via our poster (20.0% vs 63.3% vs 63.3%, p < 0.001). The poster was used by 46.7% and 50% of sampled patients in the second and third cycles.

Conclusions

One in two patients used our QR poster, leading to a threefold increase in patients accessing trusted NHS information websites. This is a simple and easily reproducible quality improvement project that can be used within different units. Patients have verbally recommended additional topics that could be included in future versions of the poster, potentially further increasing its use. The effect of this on patient clinical outcomes remains unclear.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

29 Are we correctly following up patients with non-muscle invasive bladder cancer?

Z Sheng ¹

Abstract

Introduction

The follow-up of patients with non-muscle invasive bladder cancer comprises cystoscopy (interval depends on risk category), and urine cytology (UC) at every cystoscopy and annual computed tomography intravenous (CT/IV) urogram for high-risk cancers as set out in National Institute for Health and Care Excellence/ European Association of Urology guidelines. We assessed our unit’s compliance with these guidelines and set out measures for improvement.

Methods

The initial audit included all patients who had a cystoscopy in January 2020 (n = 55). Collected data included initial histological diagnosis, recurrence histology, interval of cystoscopies and whether imaging and UC were performed adequately.

Results

Thirty-three patients (60%) had high-risk, 16 (29.1%) intermediate-risk and 6 (10.9%) low-risk disease. Altogether, 35 (63.6%) patients had correct cystoscopic follow-up, 7 (21.8%) had UC at every cystoscopy and 5 (15.2%) had annual CT scans. The results were disseminated to all stakeholders in our department. Posters were created and displayed in the cystoscopy suite. Six months later, to assess the intervention’s effectiveness, decision making at cystoscopy appointments during October to November 2021 was re-audited and compared with decision making in January 2020. Post-intervention, 87% cystoscopy timings (previously 78%), 41% CT (previously 25%), and 3% UC (previously 50%; p = 0.001) decisions were correct.

Conclusions

Improvements were seen in the timing of cystoscopies and imaging, but sending UC remained poor. UC is cheap, non-invasive and can help detect malignant cells before tumours become visible on cystoscopy. During the COVID-19 pandemic, this should be utilised even more. Education and awareness of guidelines are imperative. A systematic method of sending UC and local guidance for deciding which/when relevant patients require imaging should be considered.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

31 Renal colic snapshot audit in a district general hospital

MA Hossain ¹

Abstract

Introduction

For patients presenting with renal colic there is an established National Institute for Health and Care Excellence (NICE) guideline for management. Early recognition of sepsis allows antibiotics and analgesia to be given in a timely and effective manner. Proper diagnosis with appropriate imaging, effective management for the patient and good prevention strategies are key to best patient management. Definitive stone treatment with the minimum number of presentations to hospital is the ultimate goal. This audit was undertaken to evaluate whether our centre is acting in line with the standard set by the NICE guideline.

Methods

In our district general hospital, a snapshot audit was taken of the 33 patients who attended the emergency department with renal colic in November 2020. Patients were assessed against the NICE guideline for different domains including safety, diagnostics, efficacy, availability and prevention. The results were compared against national average data derived from the British Association of Urological Surgeons.

Results

On comparison it was found that our results are mostly in keeping with national data. We performed more primary ureteroscopies in our centre; however, because we did not have an on-site lithotripter, no primary electric shock wave lithotripsy (ESWL) was done. Safety diagnostics and prevention domains were in line with national data.

Conclusions

The results were discussed during an in-house urology meeting and the decision was made to maintain the good results and ask for an on-site lithotripter to provide more primary ESWL. After this, will carry out a further audit to confirm that the necessary improvements have been implemented.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

32 Time to CT KUB in acute ureteric colic

M Popoola ¹

Abstract

Introduction

The aim of the study was to investigate local compliance with the national standard of an urgent computed tomography scan of kidneys, ureters and bladder (CT KUB) being performed within 24 hours of presentation in suspected acute ureteric colic. If 100% compliance with the standard was not met, reasons for this were investigated and an intervention implemented.

Methods

All CT KUB requests over a 4-month period (March to June 2021) were examined for information suggesting potential acute ureteric colic. In total, 106 admissions suitable for inclusion. Comparison was made between date/time of admission and scan completion.

Results

We found that 17/106 (16%) patients with suspected acute ureteric colic who were referred for a CT KUB had the scan performed >24 hours after initial presentation. Of the 17 non-compliant presentations, 12 (70%) were patients seen in same day emergency care (SDEC), 4 (24%) were patients seen in the emergency department, and 1 (6%) was a patient admitted to the wards. SDEC was identified as the area of concern with 52% (12/23) of its total admissions non-compliant. This was mainly due to the lack of a SDEC service at weekends, thus delaying a CT KUB until the Monday. SDEC became a 7-day service in January 2022. A re-audit of SDEC over a 3-month period (February to April 2022) showed reduced non-compliance to just 21% (4/19).

Conclusions

A significant proportion (16%) of new admissions with suspected acute ureteric colic did not meet National Institute for Health and Care Excellence standards for timing of CT KUB. There was an improvement in SDEC compliance between the initial audit and re-audit (48% to 79%) with the impact of the SDEC service change evident.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

33 A virtual fracture clinic audit on the use of rivaroxaban for patients with lower limb immobilisation

T Tay ¹, G Talawadekar ¹

Abstract

Introduction

Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality. National Institute for Health and Care Excellence VTE guidelines recommend the need for further studies on the use of direct oral anticoagulant, eg rivaroxaban. Current local trust guidelines recommend use of rivaroxaban as first line of chemoprophylaxis for this indication. We aim to study current practice at our trust in its usage for this indication, among patients referred to the fracture clinic by the emergency department.

Methods

Patients immobilised for lower limb fracture or soft-tissue injuries are referred to the fracture clinic. We reviewed electronic records of all patients referred, between July and early October 2021, to fracture clinics at three sites within our trust.

Results

Among over 300 patients seen in the virtual fracture clinic, 36 had lower limb immobilisation in the form of walking boot (11), back slabs (10), splints (7), casts (6) and bandage/crutches (3). There were 16 (53%) males. The median age was 53.5 years (range 10–80). Among patients with VTE risk assessment, all (100%) had VTE prescribed in the form of rivaroxaban. No VTE episodes were reported in any of the individuals with or without rivaroxaban.

Conclusions

Comparing our results with large-scale retrospective studies, rivaroxaban is an effective and safe intervention for VTE prevention for patients with lower limb immobilisation.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

34 The accuracy of documenting known risks when consenting patients for endoscopic retrograde cholangiopancreatography

J Walshaw ¹, B Karki ¹, E Hope ², G Etim ³, P Sedman ¹

Abstract

Introduction

Correctly informed and documented consent is an ethical and legal responsibility, and there are recognised risks that should be explained when consenting for endoscopic retrograde cholangiopancreatography (ERCP). This study explored the consenting practice for potential risks and additional procedures associated with ERCP and compared the occurrence of these risks with national standards.

Methods

Adult patients who had ERCP for any indication, performed between October 2021 and April 2022, were recruited retrospectively. Individual consent forms were reviewed, and electronic records were used to identify procedure details and any subsequent complications or additional procedures required. The primary outcome was the percentage of consented ERCP risks and additional procedures, with consent inclusion categorised as good (>80%), average (60–79%) and poor (<59%). ERCP complication rates were calculated and compared with the British Society of Gastroenterology (BSG) standards.

Results

The records of 87 patients were analysed, with common bile duct stone being the main indication for ERCP. Consent inclusion was good for bleeding (94.3%), perforation (90.8%) and pancreatitis (89.7%). There was average consent inclusion for sphincterotomy (66.7%) and stent insertion (64.4%). For cholangitis (48.3%), sedation risk (35.6%), aspiration pneumonia (8.0%), blood transfusion (43.7%) and surgery (33.3%), consent inclusion was poor. The overall risk of patients experiencing ERCP complications was 8.0% (BSG standards <6%), and occurrence of bleeding (6.9%) and perforation (4.6%) was higher than anticipated.

Conclusions

There is substantial variation in ERCP consenting practice and the overall ERCP complication rates were higher than expected. We plan to implement a preformed ERCP consent form to standardise the consenting process.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

36 Concordance between biparametric MRI and radical prostatectomy specimen in the detection of clinically significant prostate cancer and staging

R Abdlbagi ¹, E Tezcan ¹, K Tripathi ¹, T Swallow ¹, V Sudhakar ¹, A Pai ¹

Abstract

Introduction

Magnetic resonance imaging (MRI) has an increasing role in the diagnosis and staging of prostate cancer. Multiparametric MRI includes multiple sequences including T2 weighting, diffusion weighting and dynamic contrast enhancement (DCE). Administration of DCE is expensive, time-consuming and requires medical supervision due to the risk of anaphylaxis. Biparametric MRI (bpMRI), without DCE, overcomes many of these issues. This study aims to examine the diagnostic test accuracy of bpMRI in the diagnosis of prostate cancer.

Methods

One hundred and forty patients who underwent bpMRI prior to radical prostatectomy (RP) were retrospectively reviewed from a single institution. Histological grade from prostate biopsy was compared with surgical specimens from RP. Clinically significant prostate cancer (csPCa) was defined as Gleason grade group ≥ 2. bpMRI staging was compared with RP histology.

Results

Overall sensitivity of bpMRI in diagnosing csPCa independent of location and staging was 98.87%. Of the 140 patients, 29 (20.71%) had their prostate biopsy histology upgraded at RP. Sixty-one (43.57%) patients had csPCa noted on RP specimens in areas that were not identified on the bpMRI, and 55 (39.29%) had upstaging after RP from the original staging with bpMRI.

Conclusions

The overall sensitivity of bpMRI in predicting any clinically significant cancer was good. However, there was notably poor concordance in the location of the tumour between bpMRI and RP specimen. Furthermore, a significant number of patients were upstaged at RP from their original staging with bpMRI. Based on these findings, bpMRI results should be interpreted with caution and can underestimate TNM stage, requiring careful consideration of treatment strategy.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

41 Perioperative oxygen prescribing among surgical patients at a tertiary centre: a quality improvement project

I Hugher ¹, J Singh ¹, N Humphry ¹

Abstract

Introduction

National audits have highlighted that oxygen therapy is a problem. Oxygen is frequently given without any prescription in the non-emergency setting. The aim of this project is to assess and improve target oxygen saturations for surgical patients in the perioperative period.

Methods

In April 2022, a prospective data collection across four surgical wards at University Hospital Wales was undertaken to assess the completeness of oxygen prescribing among surgical patients. Alongside this, how correct the oxygen target saturations were was assessed by evaluating patient medical notes. An educational teaching resource alongside visual posters were developed and placed in clinical areas to assess whether this improved prescribing practice among junior doctors.

Results

Of the 81 surgical patients identified from April 2022, only 27% had oxygen target saturations prescribed. Of the 27% prescribed oxygen, 80% had correct parameters that either put them at risk of hypercapnic respiratory failure or had confirmed hypercapnic gas values from previous admission. Following on from the educational intervention, in July 2022 the number of patients with oxygen target saturations increased to 50%. Of these 50% who had parameters prescribed, 97% of these were correct according to their risk factors.

Conclusions

Oxygen prescribing among surgical patients continues to have poor completion and accuracy. Implementing an educational online resource and visual posters on wards remains a low-cost, feasible method of improving completion of this task and also facilitates safer prescribing patterns among these patients.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

42 Improving urethral catheterisation documentation in surgical patients in a district general hospital

S Laulloo ¹, IF Kar ¹, F Laulloo ², K Qayum ¹, G Nawaz ¹

Abstract

Introduction

Urethral catheterisation is a common procedure for patients suffering from conditions including acute urinary retention and acute kidney injury for accurate input/output monitoring. However, complications from catheters such as urinary tract infections and urethral injuries secondary to catheterisation are well documented. Addressing the way catheters are documented and monitored may prevent related infections and complications.

Methods

Fifty patients on the surgical ward at Hereford County Hospital in July 2022 who had a catheter were identified and documents pertaining to catheter insertions were collected and analysed.

Results

Some 10% of the patients had a documented consent. The indication for a catheter, name and grade of the healthcare professional inserting the catheter or whether a chaperone was present was documented in 34%, 38% and 36% of patients, respectively. During catheter insertion, clear documentations on ease of insertion, volume of sterile water used for balloon inflation, description of urine drained, and a plan post-catheterisation was documented in only 22%–26% of the 50 patients.

Conclusions

Although a certain quality of catheter insertion and documentation was maintained, a clear guideline must be implemented to mitigate catheter-related complications such as urethral injuries. We propose information leaflets on wards and in the emergency department as a reminder of appropriate documentation during catheter insertion. Moreover, educating new starters, with regular refreshers for current staff would be of great benefit. We aim to repeat this audit in 2 months following interventions proposed to assess improvements in documentation of catheter insertion.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

43 Utilisation of a urology emergency bag at a tertiary referral centre: a quality improvement project

I Hughes ¹, J Singh ¹, J Featherstone ¹

Abstract

Introduction

Use of a urology emergency bag at University Hospital Wales (UHW) means that clinicians can intervene in a timely manner while minimising time searching for equipment. The aim of this quality improvement project is to prospectively identify and collect data on the readiness of this urology emergency bag and to assess compliance of refilling the bag.

Methods

A 3-week prospective data collection of refilling the urology emergency bag at UHW was undertaken between 28 June and 12 July 2022 to ascertain initial data. A formal teaching session and checklist sheet was developed and placed on the wall in urology room. A plan–do–study–act (PDSA) cycle was completed in July 2022 to identify if improvements were seen in completion of urology grab bag.

Results

Baseline results for three consecutive weeks revealed that average completion of urology grab bag was 47%. Following implementation of the daily checklist, the average percentage for the completion of the bag improved to 96% following the intervention across 3 weeks.

Conclusions

This quality improvement project demonstrates that there was a substantial improvement in the filling of the urology emergency grab bag following implementation of a simple daily checklist for junior doctors to complete. This intervention is feasible, takes minimal time to complete and minimises time spent searching for urology equipment while on call, thus intervening in a timely and prompt manner and providing best medical care possible.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

44 Improving urine dipstick result documentation in surgical patients presenting with abdominal pain

S Laulloo ¹, IF Kar ¹, F Laulloo ², G Nawaz ¹, K Qayum ¹

Abstract

Introduction

According to National Institute for Health and Care Excellence (NICE) guidelines, patients presenting with abdominal pain require urine dipstick tests on admission. The various compounds present on the dipstick allow for a quick, easy and non-invasive way to exclude differentials as well as point towards a definite diagnosis. The test, despite providing such crucial information, does not have a well-defined area in the patients charts for records, hence requiring healthcare professionals to search for that information, rendering patient care inefficient.

Methods

Fifty surgical/urological patients presented with abdominal pain in the emergency department at Hereford County Hospital in July 2022. In this study, the patients’ clerking sheets were reviewed and checked for a documented urine dipstick test result.

Results

It was found that 13 of 50 patients (26%) had their urine dipstick test result documented on their clerking sheet on admission.

Conclusions

During the audit, we found out that a urine dipstick result was not always documented on admission. The lack of a pre-set space on clerking sheets to document urine dipstick results made it a struggle, especially in busy ward rounds, to know whether a test had been performed on admission. To improve urine dipstick result documentation, we propose an updated clerking sheet for patients in the emergency department with a new table for easily accessible test results. We aim to repeat this audit 2 months after implementation of the updated clerking sheets to assess for improvements in test results documents.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

45 Urology diagnostic and treatment centre: improving access to healthcare

S Laulloo ¹, A Wong ¹

Abstract

Urology is a constantly evolving speciality pioneering novel technologies from developing safety valves for urinary catheters (TUC valve) to robotic surgery. There is a significant increase in patients presenting with urological conditions in the elective and emergency setting, putting even more pressure to the department and trust. The urology team at Hereford County Hospital (HCH) have worked tirelessly to provide excellent care for patients and increase our capacity despite the pandemic. The Urology Diagnostic and Treatment Centre was established to improve access to care for patients in Herefordshire.

Results

In the last 12 months, the urology team has achieved significant successes and results. We were the first trust in Europe to use disposable flexible cystoscopes, reducing waiting times for cystoscopic surveillance by 18 months. Lithotripsy services were also introduced in both elective and emergency settings. The introduction of local anaesthetic template prostate biopsies allowed patients to avoid undergoing general anaesthetic for a diagnostic procedure. Independent nurse-led urodynamics and benign prostatic hyperplasia clinics were set up. Furthermore, the team reached out and offered mutual aid to neighbouring trust, providing 482 diagnostics tests over 3 months for Worcester Royal Hospital.

Conclusions

With innovation and forward thinking, the urology team at HCH have managed to reduce waiting times for a first outpatient appointment from 38 to 13 weeks, while reducing those waiting >52 weeks by 62%. As a result, the team was awarded the Clinical Excellence Award for the second year in a row.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

46 The PACU reimagined: Whipps Cross Hospital's COVID-19 recovery initiative

H Murdeshwar ¹, J Matthews ¹, S Kwok ¹, G Kandasamy ¹

Abstract

Introduction

Offering major elective surgeries during the COVID-19 recovery phase presents operational challenges. Restriction of care to green (COVID-19-free) zones of the hospital and limited access to level 2 or 3 beds demand innovative modifications of existing perioperative pathways. The reimagined post anaesthesia care unit (PACU) is a collaborative effort to reduce unplanned intensive care unit (ICU) admissions and enhance patient experiences by offering up to level 1.5 care (inotropic support and enhanced monitoring) in a two-bedded facility. This study aims to assess its utility in empowering the unit to formalise this setup in future.

Methods

We retrospectively analysed various perioperative parameters of all scheduled PACU admissions following major elective surgeries between April 2021 and April 2022. The cohort included 54 patients aged 42 to 92 years.

Results

Fifty-one patients needed further detailed assessment at preoperative planning clinics, 46% received preoperative optimisation. Early postoperative one-to-one nursing care, reviews by anaesthetists, surgeons and enhanced recovery practitioners ensured timely oral intake, seamless discharge to a ring-fenced ward bed and prompt escalation to ICU. The average PACU stay was 18 hours, and the hospital stay was 8 days. Some 38% of patients developed complications of whom four were admitted to ICU. PACU could effectively manage all other non-surgical complications.

Conclusions

Our PACU model promises improved patient safety, minimises unplanned ICU admissions and errors during the transition of care with potential economic benefits. The efficient integration of perioperative care across all surgical specialities reduces the number of cancelled major surgeries through the use of enhanced care as recommended by the Getting It Right First Time report (September 2021).

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

48 Administration of oral nutritional supplements post elective colorectal surgery

K Nadi ¹, R Abdou ¹, C Houlden ¹

Abstract

Introduction

The aim of this study was to look at the provision of oral nutritional supplements (ONS) in postoperative colorectal resection/surgery. For a medication to be administered by the patient, it must be prescribed first by doctors and then dispensed and given to the patient by a nurse.

Methods

Consecutive unselected series of patients in the general surgical department undergoing colorectal resections were been followed up during their hospital stay. The period of study was 20 weeks (14 September to 20 November 2020 and 14 September 2021 to 20 November 2021). Data collected were patient age, gender, date of admission, operation undertaken, whether or not ONS was prescribed, whether ONS was given by a nurse or not, and what was the reason for this.

Results

The most common reasons for not dispensing ONS are patient refusal or unknown cause. There were 19 elective colorectal operations in first study (COVID-19 prioritisation, several cancellations). The prescription rate was 5/19 (26.3%). In these five patients, the prescription was one bottle QDS. In three of the five patients the level of dispensing the ONS was <25% of the prescribed amount, and in two patients the level of dispensing the ONS was between 50% and 75% of the prescribed amount. In the re-audit there were 43 elective colorectal operations (COVID-19 prioritisation, several cancellations). The prescription rate was 15/43 (34.8%). In these 15 patients, 60% of the prescriptions were one bottle QDS. In 3 of the 15 patients the level of dispensing OSN was 50%–75%. In 2 of the 15 patients the level of dispensing the OSN was <25%.

Conclusions

There is a need to consider prescribing ONS for every Colorectal cancer (CRC) resection. The nursing role and encouraging ONS documentation is key. Basic services like reviewing drug charts and nurses' notes is crucial.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

50 Improving surgical teaching for FY1 doctors in a university hospital: a quality improvement project

J Tempany ¹, J Hutchings ¹, M Harris ¹

Abstract

Introduction

The aim of the study was to deliver specific surgical teaching for Foundation Year (FY) 1 doctors to improve confidence and knowledge through a formal teaching programme in a university hospital using plan–do–study–act (PDSA) cycles.

Methods

FY1s completed a survey assessing confidence in dealing with unwell surgical patients and knowledge on surgical specialties. From the results, a weekly teaching programme was constructed over a 4-month period beginning in 2020. Sessions were delivered by FY2 to surgical registrar level doctors. Feedback was sought after each session and a post-course survey was collected to assess confidence and knowledge in the surgical topics taught. Improvements were made after each cycle when post-course feedback was assessed. A total of three teaching cycles were run, with different junior doctors contributing to different teaching sessions.

Results

On average, six FY1s attended each teaching session. Pre- and post-course feedback was sought across all three teaching cycles, using a 5-point scale (1, strongly disagree; 5, strongly agree). The pre-course survey for each cycle showed that confidence in the day job was initially 2.8, 3.0 and 2.8. The post-course survey revealed confidence had improved to 4, 4.5 and 4.2. The post-course mean score for quality of the teaching sessions for the three cycles was 3.6, 3.9 and 4.2. The level of engagement for each cycle was 3.5, 5 and 2.5.

Conclusions

FY1 confidence in surgical topics improved after each teaching cycle. Engagement varied as a result of multiple factors including ward pressures and location of the teaching. More frequent PDSA cycles are required to implement smaller more sustainable changes in keeping with weekly feedback.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

53 Appropriate safety-netting advice to ENT patients

A Adedeji ¹

Abstract

Introduction

Patients are often puzzled about who to reach out to when they require advice after discharge. An inquest of a recent surgical complication in our facility alluded to this. This project investigated the various safety-netting advice received by ear, nose and throat (ENT) patients in our trust and recommended that patients should contact ENT doctors directly if they have urgent concerns post-discharge.

Methods

Thirty discharge letters were assessed to see where patients were safety-netted to after discharge. We then introduced our recommendation. After a month, compliance with this was assessed by examining another set of 30 discharge letters.

Results

During the first stage 30% did not receive safety-netting advice. Another 30% were asked to ring the consultant secretaries. About 20% were not given a specified body to contact, whereas only a few were asked to consult with their general practitioners (GP). None of the patients was told to contact the ENT doctors directly. During the second stage 73% of the patients were asked to contact the ENT doctors directly. The rest were either referred to the emergency department, consultant secretaries or an unspecified location.

Conclusions

Safety-netting patients appropriately helps to reduce the risk of red-flag symptoms degenerating to full-blown complications. If patients ring the consultant secretaries, they might not receive prompt care during weekends and on-call hours, and if they are referred to the GP, there might be delay in securing appointments. We therefore recommended that patients ringing the doctors directly is the safest and most reliable option as there is always an ENT doctor on call every time.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

54 Prolonged waiting times and elective joint arthroplasty in the post COVID-19 era: a single-centre cross-sectional study

V Kutuzov ¹, H Shah ¹, E Hayter ¹, R Anakwe ¹

Abstract

Introduction

The COVID-19 pandemic has increased surgical waiting list times for elective operations, with patients reporting a quality of life ‘worse than death’ as a result. We undertook a study to assess the effect of length of wait on patient health status and further assess the impact of patient age, social deprivation and allocated surgical priority.

Methods

A single-centre, cross-sectional study of priority three and four patients awaiting elective joint replacement post COVID-19. Seventy patients underwent a structured telephone interview to complete the Euroqol, EQ-5D-3L questionnaire and their self-reported health status (time-trade off) was calculated.

Results

Patients who had been waiting longer for their surgery reported a poorer health status (p = 0.0382). There was a statistically significant negative correlation between increasing time on the waiting list and decreasing time-trade off for the under 65 cohort (p = 0.0303) and the category four priority cohort (p = 0.0160). Our data suggest patients waiting for treatment for extended periods do suffer harm. We expect that patients who wait for treatment for longer than 29.5 weeks will report a health status ‘worse than death’, time-trade off <0 (p = 0.0282).

Conclusions

Patients’ self-reported health status declines with an increase in time waited for an elective joint replacement. This is significant in patients under 65 years of age. For those waiting more than 29.5 weeks, a health status ‘worse than death’ may be reached. In the setting of extended surgical waiting lists, this may represent a marker of clinical harm.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

55 Management of preoperative anti-hypertensive medication

J McVeigh ¹, M Williams ²

Abstract

Introduction

There is clear national guidance on holding diuretics and renin–angiotensin aldosterone system (RAAS) blocking agents preoperatively owing to a risk of adverse outcomes. However, there is a lack of any specific guidance on holding these medications for surgical patients at the Nuffield Orthopaedic Centre, Oxford. This four-cycle audit has set out to improve the management of anti-hypertensive medication preoperatively.

Methods

Data were collected over a 2-week period to find the proportion of angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs) and diuretics appropriately held preoperatively. This was repeated a month later post intervention following an update to the clerking proforma and teaching sessions for junior doctors. Data on the proportion of ACEi/ARBs and diuretics appropriately held preoperatively was collected 1 and 2 years later to identify whether there was a sustained impact.

Results

In the initial audit, we identified 29 eligible patients, 8 were on ACEi/ARBs (with 88% held appropriately) and 6 were on diuretics (with 17% held appropriately). In the re-audit post intervention, there were 36 patients, 5 were on ACEi/ARBs (with 100% held appropriately) and 4 were on diuretics (with 100% held appropriately). Our audits 1 and 2 years later have continued to show 100% of ACEi/ARBs and diuretics held appropriately on data of 28 and 32 patients, respectively.

Conclusions

Following our interventions, we have shown an improvement in the proportion of anti-hypertensives being appropriately held preoperatively in concordance with national guidance. We have also shown a sustained improvement after both 1 and 2 years for patients undergoing orthopaedic procedures at the Nuffield Orthopaedic Centre.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

58 Getting TURBTs right first time: single cycle audit

Z Sheng ¹

Abstract

Introduction

Transurethral resection of bladder tumour (TURBT) is commonly performed for the diagnosis and treatment of bladder cancer. The presence of detrusor muscle (DM) is an important surrogate for resection quality as it can help predict residual disease, early recurrence and need for radical treatment. We audited our department’s TURBTs to identify areas for improvement.

Methods

All patients whose TURBT histology was discussed by a urology multidisciplinary team (MDT) between January and June 2021 were included (n = 109). Collected data included tumour grade, level of surgeon, presence of DM, MDT outcome, re-resection grade and their eventual treatment outcome.

Results

Sixty-three (57.8%) specimens contained DM. Among specimens where DM was absent, 17 (47%) where high-grade tumours so clinical decision making would have likely benefitted from the presence of DM. Thirty-five (32%) required re-resection, and the histology was upstaged in six. One proceeded to have a radical cystectomy and one curative chemotherapy owing to the re-resection grade. There was no statistical significance between the attainment of DM in TURBT by a trainee vs consultant.

Conclusions

Obtaining DM is vital in TURBT. In patients with high-risk bladder cancer, it is often the decisive factor between conservative and radical treatment. Half of our DM-absent histology revealed high-grade bladder cancer so would then likely require re-TURBT. Although our data is in concordance with national TURBT DM attainment rate, improvements are essential to avoid extra operations and ensure patients receive appropriate treatment as soon as possible. Our data suggest the presence or absence of DM in TURBT is not related to surgical experience.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

61 Does ‘on-call’ simulation training have a place in medical education programmes? A pilot study

A Lisacek-Kiosoglous ^1,², R Rees ¹

Abstract

Introduction

Newly qualified doctors feel underprepared for working ‘on-call’ shifts. The aim of this study is to determine how final-year medical students from medical schools in Cardiff and Swansea University, UK benefit from a short 1–2 hour simulation-based teaching programme.

Methods

Forty-four final-year medical students completed a 1–2 hour on-call simulation session at Bronglais General Hospital, Aberystwyth during their final-year clinical placement. Students were treated and expected to perform as day 1 Foundation Year doctors in the UK. All students completed a questionnaire after the workshop with the purpose of measuring subjectively what was gained and whether they felt more confident attending their first set of on-call shifts. Twenty-three students were asked an additional question before the workshop to determine how confident they felt attending an on-call shift based on their current training.

Results

Forty-four students provided outstanding feedback from the simulation training stating they felt more confident with working on call. This was substantiated with 23 students’ average measure of confidence and safety pre-workshop being 3/10, which increased to 7/10 post-workshop. All students reported they had not had formal independent training in being on call. The most common learning points for practice included better prioritisation and being clear with patient information and handover to seniors.

Conclusions

This study gives testament to the growing body of literature that there may be a place for on-call simulation training for undergraduate medical students that mimics the stressors of being on call.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

69 The effects sociodemographic factors have on obtaining a place in core surgical training

M Sarsam ¹, M Spazzapan ², H Magill ³, L Songra ⁴, G Pandey ⁵, Z Salahuddin ², B Chew ⁶

Abstract

Introduction

Competition for core surgical training is rising, placing a strong emphasis on interview performance. Several interview courses offer to help candidates secure their chosen surgical job but at premium fees. A group of London-based core surgical trainees (CSTs) started a free course that offers high-quality mock interview experience to over 90 applicants in 2022, with the aim of providing an accessible opportunity for financially disadvantaged candidates.

Methods

Course candidates completed three sets of questionnaires, pre- and post-mock interview and a final one on job allocation. Candidates’ educational background and schooling history was obtained as well as their self-assessment score, eventual rank after interview and the rank of the job they had accepted.

Results

The three sets of questionnaires were completed by 87, 73 and 45 candidates, respectively. There was a statistically significant difference in their confidence scores after the course (p < 0.001). There was no statistically significant difference in the self-assessment score of the 44.2% of candidates who had attended private education in the UK compared with publicly educated candidates (p = 0.0525), nor was there a difference in their rank after interviews (p = 0.236). Candidates who spent £50 or more had higher self-assessment scores (p = 0.042) but did not rank higher in overall scores (p = 0.591).

Conclusions

Interview preparation courses are helpful in increasing candidates’ confidence; however, spending more money does not translate into a better overall interview performance. Our study shows that candidates from private education backgrounds do not have an advantage in the CST application process.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

73 Indications for CT in the severely injured patient. Audit to assess the adequacy of clinical information on major trauma CT requests in the emergency department

K Mallalieu ¹

Abstract

Introduction

Increasingly radiological imaging is used in polytrauma following the primary survey to provide a quick and thorough assessment of intracranial, cervical, thoracic, and abdominal pelvic and limb traumatic injuries. Radiologists form a key part of the trauma team, interpreting imaging and formulate a report based on clinical communication. Evidence suggests that correlation between inadequate clinical information and inaccurate radiology reporting.

Methods

A retrospective audit was undertaken examining all trauma calls that generated computed tomography (CT) scanning of the head, neck, thorax, abdomen and pelvis in September 2021 in a major trauma centre in the northwest of England. CT requests were then examined to see whether they complied with the Royal College of Radiologists (RCR) guidelines on adequate clinical information on trauma CT request.

Results

All (100%) CT requests met the criteria for polytrauma CT. However, only 69% (43) of CT requests contained details of the mechanism of injury; 58% of the requests included details of the visible and suspected injuries. In total, only 60% (37) included adequate clinical information on the CT request as per the RCR guidelines. The target is 100%. Findings were presented to the trauma team, emergency department and general surgery teams. Re-audit following these interventions showed an 18% improvement.

Conclusions

The accuracy of radiology reporting in major trauma is dependent on adequate clinical information. In this case, awareness campaigns and education on the RCR guidelines led to a departmental increase in the inclusion of mechanism of injury and visible and suspected injury on CT requests for polytrauma patients.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

77 Can electronic operation notes enhance patient care and communication between medical staff?

R Abdlbagi ¹, M Gado ¹, A Pai ¹

Abstract

Introduction

Operation notes represent a comprehensive account of what took place during surgery. Accurate and detailed documentation of surgical operation notes is crucial, both for postoperative management of patients and for medicolegal clarity. The aims of this study were to compare operation documentation against the Royal College of Surgeons of England (RCS England) guidelines and to compare the before-and-after effect of introducing an electronic operation note system.

Methods

Initially the handwritten operation notes of 30 patients undergoing urological surgery were reviewed. All operation notes were assessed for compliance with the RCS England guidelines. Electronic operation note proformas were subsequently introduced for all urological operations and a re-audit carried out after its implementation for 30 patients.

Results

The results after implementation of electronic operation notes demonstrated a marked improvement. Three of 20 handwritten operation notes complied with all of the RCS England guidelines compared with 29 of 30 electronic operation notes. Nursing staff also reported preference of reading electronic postoperative notes.

Conclusions

This study has demonstrated that implementation of an electronic operation note system markedly improves the quality of documentation, both in terms of information details and readability. We would recommend this template system as a standard for operation note documentation.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

78 Impact of COVID-19 on outpatient management of epistaxis: an audit study

K Ari ¹, R Collins ¹

Abstract

Introduction

Epistaxis is a common presentation to hospitals across the UK. In March 2020, new guidelines allowed patients to be discharged home with nasal packs in situ to reduce the risk of inpatient COVID-19 transmission rates. The objective of this audit is to review how successful these new guidelines were and whether they could be safely maintained in future practice.

Methods

This was a retrospective data analysis at a local tertiary ear, nose and throat referral hospital. A ‘pack and home’ criteria was implemented on patients admitted with epistaxis during September 2019 to September 2020. A closed-loop audit cycle was carried out. Primary outcome measure was compliance with the criteria and length of inpatient admission.

Results

A total of 131 patients made up the final audit, with 72 patients (55%) in loop 1 and 59 patients (45%) in loop 2, all of whom required nasal packing. In the first loop, all 72 patients (100%) were admitted for inpatient care, whereas in the second loop, 21 patients (36%) were discharged home with nasal pack in situ and 59 patients (64%) were admitted. Of those discharged, two patients represented at 48 hours with re-bleeding. The average total length of inpatient stay in loop 1 was significantly higher at 45.7 hours compared with 29.6 hours in loop 2 (p < 0.05). All discharged patients attended their outpatient appointment in under 3 days.

Conclusions

The ‘pack and home’ criteria successfully identify patients who are suited for an outpatient management pathway. This could reduce inpatient load, free up surgical elective beds and impact the way we manage epistaxis.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

86 A junior doctor-led virtual teaching and mentoring project on quality improvement and audits

T Tay ^1,², Z Abidsohail ¹, A Sohail ¹, E Thomas ¹, N Kamaruzaman ¹, P Patel ¹

Abstract

Introduction

Quality improvement and audits (QIA) are vital components of the formal curriculum. Yet only a small proportion of students are aware that QIA are mandatory competencies in postgraduate training. A literature review conducted in December 2022 revealed that no reports have been published to evaluate the mentoring provided by junior doctors to medical students about QIA. Initial pilot study reflected strong interest from students to gain more experience in research and audits through a formalised teaching pathway. We aim to evaluate the effectiveness of a mentoring project to provide undergraduate medical students with the skills and experience of conducting a closed-loop audit alongside formal virtual teaching sessions about QIA.

Methods

A monthly series of academia-related teaching was developed and delivered across 6 months (January to June 2022). Students were recruited to participate in an international surgical audit project to apply the knowledge gained from the teaching series. Qualitative feedback was collected and analysed through Google forms.

Results

In total, 25 students joined the teaching series, 18 participated in the audit and 9 students completed feedback forms. None participated in an audit as part of their undergraduate curriculum. On a 5-point Likert scale (1, not confident at all, 5, very confident), 7/9 students rated an increase in their confidence levels of QIA from ‘1–2’ (pre-teaching) to ‘4–5’ (post-teaching). Using Kirkpatrick’s evaluation model, students reported increased interest in academia, QIA and future career prospects.

Conclusions

We demonstrated that our teaching series, mentoring and involvement of students in an international audit improved students’ knowledge and preparation of conducting QIA.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

88 Management of acute diverticulitis. Are we doing it right?

A Dosu ¹, G Akritidis ¹, M Adesida ¹, E Akritidis ¹

Abstract

Introduction

This audit reviews the management of patients admitted to hospital with a diagnosis of acute diverticulitis proven on computed tomography (CT) scan and compares our practice with the national guidelines and current recommendations.

Methods

This is a retrospective review undertaken for patients admitted as a surgical emergency through the surgical ambulatory unit over a 6-month period (January to June 2021). Electronic patient records were used to collect the data that included demographics, imaging results, hospital length of stay (LOS), antibiotic therapy and surgical intervention. We compared the compliance of management according with the national guidelines.

Results

A total of 60 patients were assessed for management of acute diverticulitis. Median age was 60 years (range 53–74) and there was a gender ratio of 2:1 (male/female). On admission, 98% and 100% of patients had CT scan and routine bloods (including white blood cells and C-reactive protein), respectively. LOS was 7.5 days. The readmission rate of 21%. Uncomplicated presentations were found in 61% and complicated presentations in 38%. Conservative management was undertaken in 78% and 22% required surgical intervention. Antibiotics regimen according to national/trust guidelines were 81% correct. Follow-up endoscopic assessment was performed with colonoscopy or flexible sigmoidoscopy in 57% and 3%, respectively.

Conclusions

There was good compliance with CT imaging and blood inflammatory markers on admission. However, the antibiotics regimen according to national/ trust guidelines and follow-up endoscopic assessment requires improvement. The audit was presented to all junior doctors and consultant surgeons. We aim to re-audit and assess the improvement in the above areas.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

92 Weight charting in postoperative cardiac surgery patients

S Haq ¹

Abstract

Introduction

The aim of this study was to check adherence to weight charting in postoperative cardiac surgical patients

Methods

We carried out a plan–do–study–act cycle, in line with best quality improvement practice. Daily weight charting is important in patients following cardiac surgery because it is one of the significant parameters because titrating the diuretic therapy and fluctuations in weight can be an indirect indicator of cardiac status. There were 20 patients in cycle 1 and 21 in cycle 2. Inclusion criteria were postoperative patients after cardiac valve replacement or coronary artery bypass grafting (CABG) who were on diuretics.

Results

In cycle 1, preoperative weight charting was undertaken in 100% of case, and daily postoperative weight charting in 65%. Interventions were as follows. Weight charting was discussed with nurses on the wards and the importance of regular weight charting was emphasised. Posters were put on counters as a reminder to ensure that weight charting is being done for all the patients. A weight chart section was included alongside the bloods in the nursing booklet for the morning rounds, and hurdles to regular daily postoperative weight charting were identified. In cycle 2, there was 100% preoperative weight charting and 90% daily postoperative weight charting.

Conclusions

The improvement in regular daily postoperative weight charting led to ease in titration of diuretics therapy in the morning rounds and the anticipation, prevention and early management of fluid overload and electrolyte imbalance. Unnecessary extra days of diuretic therapy were prevented on the basis of weight if the patient otherwise clinically well. We recommend a re-audit in 3 months’ time, that new ward staff/ bench staff are made aware of the importance of weight charting, and that the idea is forwarded to ward clerk for consideration of putting scales in all the bays.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

97 Thyroxine replacement rates following lobectomy

A Khan ¹, P Bijoor ¹

Abstract

Introduction

Hemithyroidectomy is a common procedure performed for both benign and malignant pathology. The incidence of hypothyroidism after thyroid lobectomy remains unclear and varies nationally. The purpose of this study was to determine the incidence of postoperative hypothyroidism in patients undergoing thyroid lobectomy, as well as the time taken to initiate thyroxine replacement in a single centre.

Methods

We retrospectively reviewed patients who underwent a thyroid lobectomy over a 12-month period from January 2021 to January 2022 in a single centre. Our exclusion criteria included patients on thyroxine preoperatively.

Results

In this study, 69 patients were included and overall; 13% developed postoperative hypothyroidism and required thyroid hormone supplementation. Two-thirds of these patients were initiated on thyroxine 3–7 weeks postoperatively; the longest time it took to initiate therapy for a patient was 50 weeks. This study is in concordance with a previous study, which found that 14.3% of patients developed postoperative hypothyroidism after undergoing lobectomy for benign disease. Other papers however, found a much greater number of patients requiring thyroxine replacement estimated between 5% and 49%. Further research into other factors influencing postoperative hypothyroidism following lobectomy such as preoperative thyroid-stimulating hormone, microsomal antibodies and presence of thyroiditis would also be useful.

Conclusions

This study has limitations because it only looked at patients over a 12-month period from a single centre; however, its findings correlate with existing literature. This will ensure patient-centred appropriate preoperative counselling and allow patients to make informed decisions.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

98 Improving the quality of orthopaedic trauma meeting documentation: a closed-loop audit at a major trauma centre

H Hodgson ¹, T Samuel ¹, R Anakwe ¹

Abstract

Introduction

The aim of the study was to assess the quality of trauma meeting documentation.

Methods

All orthopaedic referrals over 2 weeks were included. In the absence of national guidance on documentation content, Royal College of Surgeons of England Good Surgical Practice Guidelines was used to guide the standard required. Documentation was considered acceptable when the following were included: (1) name(s) of clinician(s); (2) injury and/or reason for referral; and (3) a clear plan. Data were extracted from patient records according to a pre-trialled proforma. The intervention involved designing a documentation proforma and disseminating this within the department. The audit was repeated to complete the audit cycle. Groups were compared using chi-squared test.

Results

Some 274 referrals were included (pre-intervention, 139; post-intervention, 135). The number of satisfactorily documented referrals was significantly greater in the post-intervention group (68% vs 41%, p < 0.001). Improvements were demonstrated in the name(s) domain (96% vs 72%,p< 0.001), and plan domain (98% vs 90%, p < 0.01). There was no difference in the injury domain (71% vs 63%, p = 0.16).

Conclusions

A high-quality record of the trauma meeting is essential for communicating with other specialities within the trauma network, as well as from a medicolegal perspective. A simple proforma significantly improves the quality of documentation. Trauma meetings occur in all orthopaedic departments, yet there is an absence of standardised guidance from a national body on the advised content. A lack of clarity over what is expected may have been driving substandard documentation within our trust. Specific guidance from a national body, similar to that available for operation note content, may facilitate higher quality documentation on a larger scale.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

99 A quality improvement project assessing handover with the trauma and orthopaedic department. Ditching old practice for a new clinical application: Careflow

E Menyah ¹, SB Taiwo ¹, S Garcia ¹

Abstract

Introduction

Effective clinical handover is integral to protecting patient safety. We assessed handover practice within the trauma and orthopaedic department and identified ways to improve quality and reduce variability using an application called Careflow.

Methods

Patients who underwent surgery on Friday and Saturday trauma lists were identified and reviewed retrospectively over 3 months. Patient records were reviewed to check whether there was a documented postoperative doctor’s review, and if bloods tests and x-rays were requested. A survey was distributed to clinical team members to understand current practice.

Results

There were 21 survey respondents, all of whom agreed a weekend handover would be beneficial in improving continuity of care. However, 45% did not routinely receive any handover (written or verbal) and believed that handovers received were poor quality; 81% were aware of the hospital trust’s handover application, Careflow; 57% claimed to use the app and 65% were unsure how to. Seventy-six patients should have had a documented day 1 postoperative review, of whom only 23 (27%) did. The average time to first postoperative review by a doctor was 2.18 days. Five patients did not have a documented postoperative review prior to discharge. Day cases were excluded. Average time to check radiograph request was 2.71 (range: 0–10 days).

Conclusions

Existing handover practices were inadequate and highly variable, risking patient safety and care. New handover guidelines have been implemented, using the Careflow application and the quality of handover will be reassessed.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

100 Consenting practice for chronic pain as a complication in open inguinal hernia repair

S Probert ¹, W Cai ¹, M Iqbal ¹, O Lesi ¹, S Haque ¹, B Lovett ¹, SJ Walton ¹

Abstract

Introduction

The aim of this study was to determine whether there has been any improvement in consenting practice, for surgical procedures, by comparing consent forms from 2015 (the year of the Montgomery ruling) and 2019. Looking in specific regard to the risk of chronic groin pain following an open inguinal hernia repair with mesh.

Methods

This was a retrospective review of patients who underwent open inguinal hernia repair using a prosthetic mesh in 2015 and 2019. Medical records were retrieved on the trust’s electronic medical record system using the patient’s hospital number. The following parameters were obtained: patient demographics, preoperative clinic letters, operation notes and consent forms. The clinic letters and consent forms were systematically reviewed for any mention of chronic groin pain.

Findings

In 2015 and 2019, 163 and 56 open inguinal hernia repairs with mesh were performed, respectively. The median age of patients was 63 years (28–88) and 64.5 years (19–88) in those respective years. Throughout both years there was a predominance in male patients, and the majority of cases were performed on an elective basis. Consent for chronic pain was present in 60.7% and 62.5% of cases in 2015 and 2019, respectively (p = 0.055).

Conclusions

Despite the importance of adequate consenting practice, we found no significant improvement in consenting practice for chronic pain following open inguinal hernia repair in the 4 years following the Montgomery ruling.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

104 Is ‘hot laparoscopic cholecystectomy’ performed effectively after diagnosis of pancreatitis secondary to gallstones? A clinical audit in a district general hospital

G Karagiannidis ¹, F Youssef ¹

Abstract

Introduction

Early laparoscopic cholecystectomy in mild gallstone pancreatitis within 2 weeks after discharge, has been shown to be effective with no significant increase in morbidity as per the British Society of Gastroenterology. We aimed to audit this in a district general hospital and review the difficulties limiting its implementation.

Methods

Electronic notes were retrospectively reviewed for all patients with first presentation of gallstone pancreatitis over a 6-month period in 2021. The main parameters were to see if and when the surgical pathway for laparoscopic cholecystectomy was initiated, if they were operated on a ‘hot laparoscopic cholecystectomy’ list, reason to delay surgery and plan regarding cholecystectomy timing.

Results

Forty-one eligible patients were identified: none (0%) underwent cholecystectomy within 7 days. The surgical pathway was initiated in an inpatient setting and operation happened within 30 days for seven (17%) patients. The surgical pathway initiated in the outpatient setting for 18 (44%) patients, but the operation did not happen within 30 days. Finally,16 (39%) patients never received a follow-up in clinic and the surgical pathway never initiated.

Conclusions

Results were disappointing with non-early cholecystectomies performed. The hot laparoscopic surgical pathway needs to be emphasised to all staff, and early upper gastrointestinal review of all patients with acute biliary pathology to facilitate early cholecystectomy when possible is required. Regular re-audit and efficient utilisation of hot laparoscopic cholecystectomy lists is needed for the improvement required.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

105 Safe postoperative patient handover from theatre to ward setting

F Shah ¹, M Jaffer ¹

Abstract

Introduction

Safe handover is a crucial part of patient safety and continuity of care. The Royal College of Surgeons of England (RCS England) has produced a document of recommendations that sets out the requirements for a safe postoperative handover. Following a standardised protocol across departments could ensure safe patient care as well as clear instructions for postoperative management. In our quality improvement project, we examined postoperative follow-up instructions of 40 patients being admitted to the ear, nose and throat (ENT) department. The follow-up instructions/format was compared with the recommendations set out by the RCS England. A protocol was then formulated in line with the recommendations and distributed across the department. Following this, data on a further set of patients was collated. The results were then compared with provide evidence that implementation of a standardised protocol allows adherence to a safe postoperative handover.

Methods

A questionnaire was created based on the safe handover guidelines set out by RCS England and completed for 40 postoperative patients by junior doctors. A safe handover protocol was the created in accordance with RCS England. Following implementation of this protocol, data were collected on further 40 postoperative patients and the results evaluated.

Results

The overall percentage of handovers increased from 40% to 94% and instructions for removal of stitches (ROS) increased from 40% to 93%.

Conclusions

Postoperative handover was demonstrably improved through the use of a handover protocol. This ensured safe postoperative care for patients.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

114 A quality improvement project to assess and improve nurses’ recognition of compartment syndrome at a major trauma centre in northwest London

I Redman ¹, M Gill ¹, H Hodgson ¹, E Matthews ¹

Abstract

Introduction

The aim of this study was to improve the recognition and initial management of compartment syndrome by nurses at a major trauma centre by utilising an education-based quality improved programme reflecting current British Orthopaedic Association (BOA) and Royal College of Nursing (RCN) standards of practice.

Methods

In plan–do–study–act (PDSA) cycle 1 a seven-point questionnaire assessing the clinical features of compartment syndrome was distributed to the nursing staff across seven surgical wards. The responses were used to design posters reflecting current BOA and RCN guidelines. The posters were displayed at nurses’ stations and educational boards across the wards. Miniature versions of the posters were made into 85mm × 55mm cards that facilitated attachment to lanyards. PDSA cycle 2 was a re-audit of the above; a second questionnaire was distributed to assess any improvements in knowledge following the above interventions. The results were compiled, analysed and fed-back to the matrons on each ward as potential areas for future development and improvement.

Results

Thirty pre- and post-intervention questionnaires were completed. Some 63% of nurses identified tibial fractures as high risk for compartment syndrome, this improved to 90% post-intervention. Pre-intervention, 40% of nurses recognised pain out of proportion to the injury as the single most important clinical finding, this improved to 87% post-intervention. Pre-intervention, 43% of nurses incorrectly identified ‘absent pules’ as the most important clinical finding, this improved to less than 25% post-intervention.

Conclusions

The improvements observed throughout this project highlights the need for and benefit of teaching and training using simple and cost-effective implements: lecture-based interventions and ward-based protocols.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

117 Readmission rates within the first 90 days after robotic-assisted radical prostatectomy

S Dranova ¹, H Harrison ¹, W Abou Chedid ¹

Abstract

Introduction

The most recent National Prostate Cancer Audit (NPCA) results showed an 11% hospital readmission rate following surgical treatment for prostate cancer. We have examined the hospital readmission rate within the 90-day period after robotic prostatectomy to establish both surgeries related and not related readmission rate at our trust.

Methods

The audit was conducted retrospectively at Royal Surrey County Hospital, Guildford, UK. The department is a national leader in urological robotic surgery as of early 2022. A total of 226 patients post radical robotic prostatectomy between April 2019 and March 2020 were included and followed up telephonically. Hospital readmission was considered any emergency or planned hospital stay for one night or more.

Results

During telephone follow-up only 19 patients (8.4%) reported any kind of hospital readmission. The NPCA in 2021 showed a readmission rate of 11%. Furthermore, of these 19 readmissions, 6 (32%) were non-surgery related, and 13 (68%) were directly related to the prostate surgery. This means that, if we exclude the six patients who had an emergency admission that was unrelated to the surgery, the actual readmission rate due to postoperative complications was only 5.8%.

Conclusions

Overall, the trust has demonstrated excellent results and showed significantly lower surgical complication and readmission rates when compared with the NPCA results. The results show the importance of identifying the reason for readmission. In addition, the study shows that trusts using robotic-assisted radical prostatectomy as a gold standard of treatment realise significantly better results when it comes to postoperative complications.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

122 A survey investigating the competency in confirmation of nasogastric tube placement among Foundation Year doctors in the UK

W Cai ¹, S Probert ¹, SY Pendyala ¹, C Lipsos ¹, MR Iqbal ¹

Abstract

Introduction

Nasogastric (NG) tubes have two primary indications: administration of medications and decompression of the stomach. Despite NG tube insertion being a common medical procedure, malposition happens frequently. Administration of medications or feeds through a malpositioned NG tube is considered a ‘never event’ because the consequences are potentially fatal. This study aims to assess Foundation Year (FY) doctors’ competency in ascertaining NG tube placement.

Methods

A three-part survey was devised. Part 1 assesses participants’ knowledge on current NG tube placement guidelines. Part 2 provides education, in leaflet form, and part 3 reassesses participants’ knowledge on NG tube confirmation following this education. This survey was distributed among FY doctors across the UK. All responses to date have been collated and analysed in Microsoft Excel.

Results

One hundred and seventy-three Foundation Programme doctors participated in the survey between January 2022 and July 2022. Participants work mainly in hospital trusts in England, with only three from Wales and three from Scotland. Some 74% of participants correctly identified the first-line method of confirming NG tube placement and 83% correctly identified the second-line method. This improved to 96.5% (p < 0.05) and 98.8% (p < 0.05), respectively, in the reassessment. Furthermore, 75.1% would like to receive further NG tube training.

Conclusions

Our results show that current knowledge on NG tube positioning is lacking among FY doctors but can be improved significantly with simple educational leaflets. To improve NG tube safety, more education should be provided to FY doctors.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

123 A quality improvement project to reduce the non-attendance rate from the 20% most deprived backgrounds in an orthopaedic foot and ankle clinic

A Dhiran ¹, C Hing ¹, D Woodruff ¹

Abstract

Introduction

The aim of this study was to reduce the did-not-attend percentage (DNA%) rate from the most deprived 20% of the national population by May 2022.

Methods

The National Health Service (NHS) Core20Plus5 approach defined a target population cohort of the most deprived 20% of the national population (as identified by the national Index of Multiple Deprivation [IMD]). The foot and ankle clinic was selected because it had a higher-than-average number of IMD1 and IMD2 patients. Between 5 July 2021 and 7 February 2022, IMD1 and IMD2 patients with appointments in the foot and ankle clinic were identified, the DNA rate between these dates was calculated, and methods to improve this rate were discussed. The change to be implemented was a modification to the text message sent to patients to make it easier for them to rearrange appointments, assuming that this would make them more likely to attend. Between 28 March 2022 and 20 May 2022, the process was repeated to assimilate DNA results for the two periods to compare and discuss the outcomes.

Results

Data collected from the two audits showed a 30.8% decrease in DNA% after implementing a change in the text message sent to patients. Furthermore, a time-series graph showed DNA% before the text message change as a volatile metric, due to two data points lying outside the upper process limit. Comparatively, there were no spikes shown post the change in text message.

Conclusions

This initial quality improvement project shows the possibility of improvement in the DNA rate due to the implemented change. A longer assessment period and larger sample size of more clinics is required to evaluate the effectiveness of the implemented change.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

126 Renal colic fast-track pathway quality improvement project carried out at Wythenshawe Hospital, Manchester University NHS Foundation Trust

M Elmousili ¹, S Iqbal ¹

Abstract

Introduction

Renal colic is a common presentation in the emergency department. National Institute for Health and Care Excellence (NICE) guidelines highlight the management of suspected renal colic from the time of presentation to referral to the urology team. This project aims to have a certain performa placed in the emergency department, urgent treatment centres and triage rooms to decrease the breach time of patients presenting with suspected renal colic in the emergency department and improve the overall patient experience and pain management.

Methods

A printed performa designed specifically for the renal colic fast-track pathway (RCFT) was provided to the emergency department team. The form includes strict exclusion criteria of patients who are aged under 18, haemodynamically unstable, have evidence of a urinary tract infection or positive pregnancy on urine analysis, worsening kidney function, patient known to have abdominal aortic aneurysm (AAA), suspected history of urinary tract trauma or solitary functioning kidney, or finally if the pain cannot be controlled. Urine analysis and patient details are written on the back of the form to facilitate referral to the urologist. Patients who are suitable for the pathway are offered analgesia (Dicolofenac PR) as to take out (TTO), booked for computed tomography scan of kidneys, ureters and bladder on the following day, offered RCFT leaflets and booked for surgical ambulatory care receiving unit.

Results

The pathway helped to improve the emergency department waiting time for suspected renal colic patients and provided earlier discharge for patient with early arrangements of investigatory tools. In addition, improving quality of care and reducing waiting time to treatment for other conditions such as chest pain or proximal femoral shaft fractures, that can be more urgent to be seen by emergency department clinicians.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

127 Safe surgical handover in ENT: a prospective closed-loop audit

M Ahmed ¹, U Ahmed ²

Abstract

Introduction

Accurate information transfer between clinical teams during handover is essential for patient safety and continuity. Royal College of Surgeons of England Good Surgical Practice Guidelines outline information sharing for safe and effective handover. Our acute team cares for ear, nose and throat (ENT) inpatients as well as outpatients requiring urgent review with twice-daily handover. We present our results after introduction of a new safe surgical handover template.

Methods

We conducted a prospective closed-loop audit before and after introduction of a novel handover sheet. Handover data for ENT inpatients and acute referrals was reviewed for a 15-day period in October 2021 and November 2022, aiming for >95% compliance in standards studied. Handover sheets were examined for correct patient details, investigations, responsible consultant and management plans.

Results

Our audit found that accurate information transfer improved in almost all categories examined after introduction of the handover sheet. Over 95% compliance was improved for 9/16 standards compared with 2/16 in the first cycle. The accuracy of ENT inpatient data improved to >95% in most categories although 60% of significant investigations were recorded (no improvement). Recording of clinician name and referral date showed the greatest improvement increasing from <10% to >89% in both categories. Acuity of referral is still not being recorded. Detailed history and management plan were found in >98% of second-cycle data.

Conclusions

Our simple but comprehensive ENT handover sheet has markedly improved safe surgical handover although significant investigations including bloodwork are still inadequately recorded. This will be improved further through a handover checklist for night Foundation Year 2 doctors and subsequently re-audited.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

128 A rare case of traction-related injury during hip fracture fixation

L AlSaket ¹

Abstract

We present a case of an elderly and comorbid patient who was scheduled to undergo a hip fracture fixation using an intramedullary nail. Unfortunately, this was delayed by 3 weeks because the patient was unfit to undergo this procedure. She was placed on to the traction table and intraoperatively sustained a superior and inferior pubic rami fracture while attempting reduction on the traction table. This case report and review highlights a rare but significant complication of usage of the traction table. Although traction tables are invaluable in the management of most extracapsular hip fractures, their use is not without risk and this needs to be considered as part of the preoperative work-up of a patient; especially one with several risk factors as highlighted above. We have presented several practical strategies to mitigate some of these risks, which should inform surgeons of ways to prevent such occurrences. We recommend: perioperative planning, use of foam pads and gel at sites of pressure, adequate use of muscle relaxants, periodic release of traction if needed for longer duration, thicker perineal posts and rationalising the force of education with the bone.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

129 Abdominal x-rays in the acute abdomen: two-cycle audit to assess compliance with iRefer guidelines

T Zaimis ¹, I Daugirdaite ¹, M Mohammed ¹, CJ Magee ¹, J Wilson ¹

Abstract

Introduction

The aim of this assessment is to measure compliance with the indications of abdominal radiography in the acute abdomen, as per the iRefer guidelines, before and after raising awareness in our trust.

Methods

The analysis was based on retrospective data gathered from surgical admissions to the emergency department that required abdominal x-rays during their initial assessment. The first cycle of data were dated between January and April 2022, and the second cycle was dated between June and August 2022.

Results

A total of 84 cases were randomly selected from a pool of 1,050. During the first cycle, compliance to iRefer guidelines was 53% improving to 68% after intervention. Surgeons achieved slightly higher compliance with guidelines of 64% compared with emergency department doctors who achieved 60% compliance. Some 63% of cases required computed tomography imaging, and 72% of them were obtained within 12 hours because 77% of the x-rays did not show any specific finding. Analysing the scans that had a specific finding, it is shown that they were indicated in 95% of cases. The most common reason for the examination was to assess for obstruction, and the most common non-indicated reason behind the examination was to assess for perforation.

Conclusions

After raising awareness within the trust, compliance with iRefer guidelines improved; however, further efforts are necessary to achieve a higher level of compliance. When indicated, an abdominal x-ray may offer more specific findings, thereby assisting with diagnosis and treatment.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

134 The design and instigation of a flexor tendon repair workshop

E Faulkner ¹, S O’Rourke ¹, P Rust ¹

Abstract

Introduction

The aim of the study was to devise a series of low-cost workshops for Foundation Year doctors and core surgical trainees to teach a core competency in plastic surgery – a flexor tendon repair.

Methods

A programme of small-group workshops running weekly over 5 weeks, taught a two-strand modified Kessler tendon repair. Each session lasted 1 hour and was led by either a consultant hand surgeon or plastic surgery registrar. Low-cost desktop models, using surgical mask straps fixed to a stationary platform, were used to allow trainees to practise the skill. Trainees were encouraged to attend multiple sessions. Assessment using validated questionnaires tracked trainees’ improvement in the skill and subjective confidence over time.

Results

Trainee subjective confidence at performing the skill improved during the first session, from a mean of 2/10 at the start to 6/10 at the end (measured on a 10-point Likert scale.) Trainee confidence also improved incrementally if they attended multiple sessions, from a mean of 6/10 at the start of their second session to 8/10 after it. Objective trainer assessment of trainees also reflected an improvement in the skill of 47% (measured using objective assessment of skill steps) between sessions one and two. All trainees (100%) who attended at least one session either strongly agreed or agreed with the statement ‘I feel I can take my learning from the sessions and apply it in clinical practice’.

Conclusions

It is possible to integrate low-cost skill workshops into busy clinical departments, aiding trainees’ acquisition of new surgical skills.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

135 The surgical admissions proforma: sustainable or superseded?

K Bhanot ¹, A Symons ², JY Chen ^1,², J Watfah ²

Abstract

Introduction

Accurate and coherent surgical clerking is essential for patient safety and quality of care. The Royal College of Surgeons of England (RCS England) have outlined specific criteria that must be documented when a patient is assessed in the surgical admissions unit (SAU). The introduction of electronic record keeping has been a major development in note keeping over the past decade and this audit examines whether surgical clerking proformas continue to have a role in the SAU at Northwick Park Hospital.

Methods

Three plan–do–study–act cycles (PDSA) were completed in the SAU at Northwick Park Hospital from 2017 to 2022. Each cycle was conducted over a 5-day period and assessed patient notes on 17 criteria set out in the Guidelines for Clinicians on Medical Records and Notes by RCS England. Notes were assessed pre-proforma (n = 28), post-proforma (n = 23) and once again post-proforma combined with digital capture (n = 47).

Results

Five of 17 criteria showed significant differences post proforma implementation. The third PDSA cycle showed no paper proforma utilisation; however, four additional areas showed statistically significant rates of improved documentation using Fisher’s exact test (p < 0.05). The areas of improved documentation were next of kin, family situation, height and weight.

Conclusions

This long-term audit demonstrates how paper surgical admission proformas are not sustainable in improving patient documentation. In a growing digital age, it is clear that electronic platforms are more effective at capturing essential patient data. Future efforts should therefore be directed towards ergonomic electronic platforms that can produce consistent clerking in busy surgical departments.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

136 ‘Ouch it hurts’: an audit on the adherence to BOAST (British Orthopaedic Association of Standards of Trauma) guidelines of intraoperative tourniquets at a major trauma unit

S Sambhwani ¹, S Sridhar ¹, D Peck ¹, A Pathan ¹, N Picardo ¹, A Ullah ¹, L Cutler ¹

Abstract

Introduction

Tourniquet use is common in limb surgery; however, it carries risk of tissue damage perioperatively with improper use. With patient safety and potential medicolegal consequences the British Orthopaedic Association have issued guidance pertaining to the optimal tourniquet use and documentation. We aimed to assess compliance against British Orthopaedic Association of Standards of Trauma (BOAST) guidelines within a major trauma unit.

Methods

Retrospective data from trauma and elective procedures were independently collected over a 1-month period. Data from 107 patients (split equally across both cohorts) were collected pertaining to the safe use and documentation of tourniquets; focusing especially on tourniquet skin condition pre- and postoperatively, isolation method, padding usage, tourniquet time, pressure and site. Selection bias was eliminated with strict inclusion criteria and excluding author affiliated operations.

Results

Overall tourniquet site (96%), safe tourniquet pressure (100%), tourniquet start (93.4%) and end time (87.9%) were well documented across both cohorts. There was poor documentation of preoperative skin condition (1.9%), postoperative skin condition (0.9%), isolation method (0%) and appropriate padding documentation (0%). There were four potential exsanguination contraindications and one case of tourniquet use that were not documented clearly.

Conclusions

Overall, we found poor adherence to BOAST guidance on the use of intraoperative tourniquets in a major trauma unit with critical safety concerns. Results have been disseminated with staff, education and development of a tourniquet decision making tool have occurred as part of a quality improvement initiative, which incorporates good documentation and highlights key safety parameters. Current use has been effective and formal results will be collected prospectively over a 2-month period.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

138 Implementation of laparoscopy for impalpable testis and audit of orchidopexy outcomes for undescended testes

R Sadera ¹, J Thomas ¹

Abstract

Introduction

Undescended testes (UDT) affects 1% of male infants at 1 year. This is corrected by inguinal orchidopexy for palpable testes. For impalpable testis, laparoscopy is the gold standard. In 2004–2005, only 50% of orchidopexies were managed in a district general hospital, with later research showing that 75% of orchidopexies were managed by paediatric surgery units. British Association of Urological Surgeons guidelines recommend surgery between 6 and 18 months. We audited our outcomes compared with the national standard.

Methods

A retrospective analysis of 62 patients was done over 20 months between 4 January 2020 and 17 August 2021 for open orchidopexy and 36 months for laparoscopic cases.

Results

Some 45% of cases were seen in outpatient clinic and diagnosed with UDT before 12 months, with 13% being diagnosed before 6 months. In total, 47% of cases were operated on between 6 and 18 months. Fifty-eight cases (58/62, 94%) had a successful primary operation. No patient with a palpable testis required orchidectomy but four cases required a re-do procedure. Twenty-four patients were identified as having impalpable UDT. At surgery, 17 required laparoscopy and 7 had open orchidopexy as the testis was identified in the groin at the time of surgery. No complications were recorded in the laparoscopy group. All surgery was performed as a day case.

Conclusions

This audit demonstrates the successful implementation of laparoscopy at a large district general hospital. Earlier referral from general practitioners is needed to increase percentage of cases being done within 6–18 months. Re-do surgery is higher than the national standard and this will need to be re-audited. No complications of orchidectomy or testicular loss occurred.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

140 Are we consenting to COVID-19 risk?

A Rahman ¹, M Badawi ¹, M Swamad ¹, M Koundo ¹, M Rddah ¹, H Willmott ¹

Abstract

Introduction

The UK is one of the countries most affected by the COVID-19 pandemic, with almost 22 million positive cases diagnosed and over 163,000 reported deaths in England alone to date. Nosocomial transmission of COVID-19 has been a concern owing to the astonishingly high associated risk of mortality and morbidity. The Royal College of Surgeons of England in their Recovery of Surgical Service Guideline emphasises the importance of discussing COVID-19 risk when consenting to operative procedures.

Methods

A retrospective analysis of all elective and emergency cases admitted to the general surgery department between 24 and 30 January 2022 at East Sussex Healthcare NHS Trust was undertaken. The analysis was presented at the local governance meeting on 25 May 2022. A similar retrospective analysis was performed between 27 June and 3 July 2022 and the results were compared.

Results

Among the 29 cases in the first cycle, compliance in documenting COVID-19 risk in the consent form was 41.38%, which dipped to 35.19% in 54 cases during the second cycle. Although among emergency cases the percentage remained the same (75%) in both cycles, we noticed an increased compliance rate from 17.65% to 28.26% among elective cases. Core trainees maintained a 100% compliance rate in both cycles, whereas there remains scope for improvement among registrars and consultants.

Conclusions

There was a lack of compliance with discussing COVID-19 risk during our study period. A holistic approach should be taken to create awareness regarding open discussion of such risk with every patient undergoing a surgical procedure.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

143 Numb and numb-er: a service evaluation study into the use of an informative cartoon video in paediatric plastic surgery

R Mistry ¹, N Wilson-Jones ¹

Abstract

Introduction

The Welsh Centre of Burns and Plastic Surgery partnered with ForMed films to create an informative cartoon for children undergoing surgery under local anaesthetic. We decided to assess how effective the video has been for paediatric patients undergoing plastic surgery under local anaesthetic in the form of questionnaire feedback.

Methods

Paediatric plastic surgery patients undergoing local anaesthetic procedures between 20 January and 21 May 2021 were followed up to gather feedback on the video. The parents/legal guardian of the patients were contacted to see whether the patient and parent/legal guardian had watched the video; if they had, with consent, a link to a questionnaire on SurveyMonkey was sent via text message and email. The questionnaire was a modified version of the Patient Picker Experience Question-15.

Results

Responses were received from seven eligible participants, all of whom reported they found the video completely helpful, easy and would recommend the video to friends/family with children undergoing surgery. Six of the seven participants reported that the video completely answered their questions and four of the seven participants reported it completely helped to make surgery less stressful. The majority of participants reported adequate support from doctors and nursing staff.

Conclusions

The video ‘Numb and Numb-er’ has been of value in paediatric plastic surgery practice helping to provide patients and their parent/legal guardian with information on what to expect. Similar videos may be of value in other specialities and future practice in a healthcare service that is becoming more digital.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

145 A multicycle audit of outcomes of patients with acute biliary pathology from a busy university hospital

I Fabre ¹, D Thompson ¹, S Caplin ¹

Abstract

Introduction

Acute biliary pathology is a common surgical admission and evidence suggests the benefits of early definitive management. The Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (2020) states that ‘symptomatic gallstone disease should be treated with laparoscopic cholecystectomy within 6 weeks’. The British Society of Gastroenterologists (2020) states ‘gallstone pancreatitis should be operated on during the index admission within 2 weeks’. Many changes were implemented within a multicycle audit to assess outcomes and adherence to guidelines.

Methods

Surgical take lists were collated for months of May 2018, October 2019, November 2020 and February 2021. Patients with biliary diagnosis were identified and retrospective data were collected from documentation. Major changes were implemented in line with recommendations from the Cholecystectomy Quality Improvement Collaborative including increased access to theatres, hot gallbladder lists and a new consultant was employed with the focus of acute cholecystectomy.

Results

Biliary pathology accounted for 14.7% of the take during the months audited. The percentage of patients undergoing a laparoscopic cholecystectomy within 6 weeks improved: May 2018, 0%; October 2019, 16%; November 2020, 14%; and February 2021, 32%. Average wait times for those who had operations reduced from >6 weeks (May 2018) to 15 days (February 2021). However, the number of patients who underwent definitive treatment for gallstone pancreatitis within 2 weeks decreased: May 2018, 75%; October 2019, 86%; November 2020, 75%; and February 2021, 50%.

Conclusions

This project led to an increase from 0% (May 2018) to 32% (February 2021) of patients receiving definitive management, demonstrating improved patient outcomes including quality of life and reduction in readmissions with biliary pathology. However, further changes and a re-audit are required to meet guidelines.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

150 Positive impact of an ERAS programme on living and deceased donor renal transplant recipients’ recovery during COVID-19 pandemic

O Pestrin ¹, R Thomas ², A Sutherland ², H Usher ², H Meredith ², L Winn ², E Simpson-Dent ³, A Balfour ², M Webb ³, L Marson ^2,³, S Wakelin ², GC Oniscu ^2,³

Abstract

Introduction

Enhanced recovery after surgery (ERAS) programmes have been introduced in many surgical specialties, reducing the length of stay (LOS) while maintaining safe care. We implemented an ERAS programme to minimise the risk of nosocomial COVID-19 transmission by shortening LOS.

Methods

After a literature review and multidisciplinary team discussion, an ERAS protocol was distributed to wards with informative posters. Patients on the renal transplant waiting list were provided with detailed programme information. The primary outcome was hospital LOS with secondary outcomes including opiate use, mobilisation, bowel function and patient-reported outcomes. Compliance was recorded prospectively. ERAS patients (n = 28) were compared with a historical control group (n = 25). Data were analysed in GraphPad Prism and groups compared with Student’s t-test and chi-squared test.

Results

Twenty-eight recipients completed the ERAS protocol. The pre-ERAS and ERAS groups had comparable baseline characteristics. ERAS significantly reduced median LOS from 8 to 5 days (p = 0.01) and 54% of ERAS patients were discharged within the targeted 5 days compared with 8% of pre-ERAS patients (chi-squared 12.59, p < 0.001). Of patients with extended stays, 33% had graft issues (eg, need for biopsy) as well as potentially preventable reasons (eg, medication education). ERAS was associated with reduced opiate use and shortened time to first bowel movement. In total, 79.2% of recipients mobilised on day 1 postoperatively. One ERAS recipient was readmitted and one required re-catheterisation.

Conclusions

The ERAS programme successfully reduced the median LOS by 2.5 days, had a positive impact on patient care and minimised adverse events. We hypothesise that appointing a specialist ERAS nurse would improve compliance and effectiveness.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

153 Reducing the rate of perioperative catheter-associated urinary tract infections in the orthopaedic patients: retrospective analysis in an orthopaedic department of a district general hospital

M Gad ^1,²

Abstract

Introduction

Urinary tract infections (UTI) and catheter-associated urinary tract infections (CA-UTI) are reported as one of the leading causes of Escherichia coli and Gram-negative bloodstream infections in the UK. Indwelling catheterisations, in most cases, are inappropriately inserted without any clear indication, hence resulting in avoidable complications from UTI, patient distress/pain, nursing distress, increased costs and duration of hospitalisation. This study aims to identify the CA-UTI rates for a period of 3–5 months to showcase the incidence rate of CA-UTI and present a toolkit/bundle with evidence-based infection-prevention practices that can be hopefully recommended and implemented at the trust.

Methods

A retrospective analysis was done to establish a baseline CA-UTI prevalence for the Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust.

Results

All (100%) hip and knee replacement patients had an indwelling catheter inserted. Most of the catheters were inserted in the emergency department (75%) with the rest being inserted mostly in theatre and on the ward. Fewer than one-third of the sample who had an indwelling catheter inserted had residual volume documented in the notes. The main reasons for indwelling catheter insertion were fluid monitoring (70%), retention (20%) and fluid monitoring (10%). Analysis of the monthly incidence of CA-UTI revealed that around 25% of UTIs in the orthopaedic patient cohort were associated with indwelling urinary catheter use.

Conclusions

Given that the overuse of indwelling catheters contributes to the incidence of CA-UTI, with a rate of 25% within the orthopaedic department, our aim was to identify the rate of infection and to reduce the rate of postsurgical UTI by 50% within 4 months by implementing a multifaceted multidisciplinary bundle to standardise the protocol.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

155 Re-audit of consultant emergency admission ward round and time to first review acute surgical admissions within a district general hospital

M Gad ^1,²

Abstract

Introduction

The aim of this study was to audit the adherence of our acute surgical admissions to National Institute for Health and Care Excellence (NICE) guidelines and National Health Service (NHS) England Seven Day Services Clinical Standards. All emergency admissions are to be reviewed by an appropriate consultant within 14 hours from admission, and there should be 7-day access to consultant-led and directed diagnostics.

Methods

The study was a prospective audit over a 2-week period.

Results

Females made up around 54.8% of admissions. Clerking of the admissions was done directly by specialist registrar/registrar in 66.7% of cases, Foundation Year (FY) 1/FY2 in 31% of cases and a consultant in 2.4% of cases. In total, 69% of patients were seen by a consultant within the recommended 14 hours of admission (target, 90%). Thursdays had the lowest compliance rate. Although diagnostics were available on all days, investigations were more readily done within 12 hours on Monday, Tuesday and weekend days (Friday and Saturday). Lack of documentation of date and time made it difficult to work out important parameters in some of the patients. There is a need for documentation to be stressed at junior doctors’ August induction, reminder sheets/banners to be displaced in the surgical admissions unit office and doctors’ office, flexibility in evening ward round timing, especially if it clashes with emergency theatre sessions, and the presence of the charge nurse during every bedside review.

Conclusions

The 90% target of acute surgical admissions receiving consultant review within 14 hours of admission was not met.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

156 Systematic review of outcomes in traumatic zone 1–3 flexor pollicis longus tendon injuries

P Graber-Gleed ¹, G Yim ², E Jenkins ³, H Pringle ⁴, H John ², A Watts ¹

Abstract

Introduction

Surgical technique, postoperative care and outcome measurement advances have progressively altered flexor pollicis longus (FPL) repairs, warranting evaluation.

Methods

Comprehensive review of FPL repairs between 2016 and 2020 was performed by retrospectively reviewing patient notes, examining patient and injury demographics, surgical methods and postoperative outcomes using the Buck-Gramcko and White outcome assessment systems.

Findings

Traumatic zone 1–3 FPL injuries were repaired in 29 patients with between 2016 and 2020. Annual incidence ranged from two to nine cases per year and mean patient age was 35 years (range 5–76). Left thumbs comprised 18/29 (62%) of injuries, with the majority 16/29 (55%) being to the non-dominant hand. Most common injury mechanisms were circular saw and glass lacerations, each accounting for 7/29 (24%) injuries. Some 79% of injuries were to zone 1 or 2, with 18/29 patients having concurrent neurovascular injury. Modified Kessler (12/29) and cruciate (10/29) core suture techniques with two or four core strand methods (9/29 vs 14/29) were most common, with the majority being epitendinous (23/29). One repair ruptured 3 weeks postoperatively and one repair had slow attenuation at 7 weeks with subsequent tendon graft. One-third of patients had no reported outcome measure (Buck-Gramcko or White). In total, 8/19 vs 5/19 patients had good or excellent outcome assessments by Buck-Gramcko and White systems, respectively.

Conclusions

A low proportion of patients had good or excellent postoperative outcomes. Outcome documentation and follow-up was poor: range of movement was not documented postoperatively in a third. This queries whether increasingly better ranges correlate with better thumb function. Overall, this review necessitates a further detailed case review, literature appraisal and quality improvement.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

159 A closed-loop audit of temporal artery biopsies done at a single vascular unit

S Pherwani ¹, E Charles ², S Parsapour ³

Abstract

Introduction

We performed a closed-loop audit, assessing the investigation and management of patients with suspected giant cell arteritis (GCA), pre- and post-implementation of the trust’s new rapid-access ultrasound service.

Methods

We retrospectively reviewed the electronic medical records for all patients referred for temporal artery biopsy (TAB) at our vascular unit. The first cycle was from January 2020 to February 2021. The second cycle was from January 2022 to July 2022. Fisher’s exact test was used to analyse the data.

Results

There were 34 patients in the first cycle and 13 in the second cycle. Mean age was 70.4 years (range 40–91) and 37 patients were female. From the first cycle, only three patients (8.82%) were referred for TAB by rheumatology. The biopsy positive rate was 20.6% (7/34). There was no significant difference in the management of these patients compared with those with negative biopsies and a high clinical suspicion of GCA (n = 8, p = 1.000). In the second cycle, all patients (100%) were reviewed by rheumatology and underwent ultrasonography prior to TAB. No patient had a positive TAB, however nine patients (69.2%) had positive ultrasound scans. Of these, six remained on prolonged steroid courses. All patients with both a negative ultrasound scan and TAB were deemed unlikely to have GCA and had their steroids weaned quickly.

Conclusions

Post implementation of a rapid-access ultrasound service, patients are reviewed by rheumatology and undergo ultrasound scanning prior to TAB. A negative ultrasound scan is further evidence to stop steroids in cases in which the diagnosis is unlikely.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

160 Requesting of blood tests: reviewing necessity and cost (a closed-loop audit)

E Galbraith ¹, M Gopalaswamy ², J Fewtrell ², S Stockdale ², R Calvert ², R White ², J Dunning ², B Waterhouse ²

Abstract

Introduction

Blood tests are a vital component of inpatient care, yet resources within the National Health Service are finite, and this has never been more apparent. We aimed to find whether some requested tests and venepuncture episodes were unnecessary.

Methods

A baseline service evaluation was performed cross-referencing medical notes, pathology requests and results to assess appropriateness of each test in cardiothoracic surgery inpatients. Estimated costs for each test were taken from NHS reference costs. Following educational interventions, including posters, small-group teaching and circulating policy by email, a prospective second audit cycle was performed, completing the loop.

Results

Common unnecessary investigations requested included liver function tests, C-reactive protein, lipid profile and amylase. The number of sets taken per patient was unchanged (3.05 vs 3.73, p = 0.146). Cost per set of bloods taken decreased significantly (£21.43 vs £13.30, p < 0.0001), mirroring the reduction in unnecessary investigations per set (4.02 vs 2.34, p < 0.0001). Per patient, the cost was £66.47 in round 1 and £50.63 in round 2 (p = 0.094) corresponding to 12.38 vs 8.92 investigations (p = 0.045).

Conclusions

A significant reduction was achieved in the number of unnecessary investigations requested with a set of blood specimens. Significant savings can be achieved by a change in local policy and staff education. Per-patient reductions may not have been seen because the original cohort included thoracic patients whereas round 2 included cardiac and thoracic patients (for thoracic only, costs reduced to £29.38, p = 0.021); this will be explored further in the next audit cycle. Expanded educational investigations will be implemented shortly, aiming for further reductions in cost.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

166 Acute testicular presentation and its management: a re-audit

O Mehana ¹, A Rai ¹, Y Rai ¹, L Muzavazi ¹, S Kudchadkar ¹, A Alam ¹

Abstract

Introduction

Testicular torsion is a devastating condition yet is salvageable with immediate intervention within the golden time frame of up to 6 hours. The salvageability rate for testes is 90% within the golden time and in many cases imaging has limited value.

Methods

The data for 30 patients between June 2021 and February 2022 were derived electronically and retrospectively from our system and reviewed and analysed. About two-thirds of our patients were aged between 10 and 20 years. Data analysis included method of admission, emergency department triage time to surgical clerking time, emergency department triage time to induction of anaesthesia and undergone surgeries.

Results

Some 90% of patients were admitted through emergency department. The time between emergency department triage and surgical clerking was <30 minutes for seven patients; nine patients did not have an appropriate documentation of time. The time between emergency department triage and induction of anaesthesia was <6 hours (golden time) in 25 patients; only 4 patients passed that time frame. Of 30 testicular explorations, 26 patients were taken to theatre within 6 hours and 4 patients after 6 hours. Eighteen testicular torsion (on-table diagnosis) cases were saved from orchidectomy.

Conclusions

Early presentation, diagnosis and intervention of testicular torsion are essential to improve the salvageability rate of testes. Three ultrasound scans were booked, and two patients underwent orchidectomy. One patient crossed the golden hour. Our re-audit shows promising results and improvement in the trust’s adherence to National Institute for Health and Care Excellence guidelines, as manifested in a reduction in unnecessary imaging that delays appropriate intervention and management for testicular torsion.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

167 Preoperative blood tests in emergency scrotal explorations, saving the NHS a nut at a time: a quality improvement project

S Fatima ¹, M Rddah ¹, A Rahman ¹, MK Quraishi ¹, G Watson ¹

Abstract

Introduction

Emergency scrotal exploration constitutes a significant operative burden for urology. The majority of scrotal explorations are performed to exclude testicular torsion. There remains a paucity of guidelines dictating the role of preoperative blood tests in such circumstances, which may delay the operative pathway.

Methods

We performed a retrospective review of clinical records of patients under the age of 31, undergoing emergency scrotal explorations at a district general hospital during a 12-month period.

Results

Of the 51 patients meeting our inclusion criteria, 35% (n = 18) had preoperative blood tests. A comprehensive analysis deduced that only 4% (n = 2) of the study population had a clear indication for preoperative blood tests based on the clinical presentation or comorbidities, prior to the scrotal exploration. Of the patients who underwent a preoperative blood test, 89% of the tests were deemed unnecessary. The total cost saving that could have been achieved, by avoiding unnecessary tests was £500. We estimated that at least 4,267g of CO₂ emissions could have been avoided. We intend to create a standard pathway for preoperative investigations for emergency scrotal surgeries, to minimise unnecessary blood tests and delays to the theatre.

Conclusions

We have disseminated these findings and our proposed pathway at our regional governance meeting and to our colleagues in the emergency department, to establish an evidenced-based streamlined testicular pain pathway for preoperative blood tests, which currently does not exist. We aim to optimise time to theatre and economic burden, and make progress towards reducing the carbon footprint towards achieving the goals of a net zero National Health Service.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

168 Noise in orthopaedic theatres, is it safe?

M Ayoola ¹, C Kellett ², S Radcliffe ³, C Hing ¹

Abstract

Introduction

Daily personal noise exposure greater than 85 decibels risks the development of noise-induced hearing loss (NIHL). The aim of this study is to determine whether noise levels in trauma and orthopaedic theatres exceed the limit.

Methods

We measured the average noise levels in trauma and orthopaedic theatres using a Decibel X sound level meter app to determine the daily exposure to noise at work level (LEPd) and compared these with the recommended values set by the Control of Noise at Work regulations 2005. We convenience sampled a selection of elective and trauma procedures to determine average noise levels. The surgeons and theatre teams were blinded to the study to prevent a Hawthorne effect. The data were analysed using descriptive statistics, R-squared and the Mann–Whitney U test.

Results

The greatest contributors to noise levels were the surgical instruments. More than two acetabular fixations, two tibial plateau fixations, two acetabular fixations or two total hip replacements per day in isolation were found to exceed the safe LEPd levels. The number of people in the room and whether music played was not found to contribute significantly to the overall noise level.

Conclusions

The average noise levels in trauma and orthopaedic theatres were within the hazardous range. Reduction in noise levels, careful list planning and mandatory hearing protection are potential options for preventing NIHL in theatre staff. There is a need for further studies in this area to determine the cumulative effect of an operating list with different surgical procedures and the effect on patients as well as staff.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

169 Are patients satisfied after their day-case surgery: a study at a district general hospital

R Moussa ¹, A Aziz ¹, A Prabhudesai ¹

Abstract

Introduction

Day cases account for a large proportion of elective surgery in the UK. They are efficient and cost-effective procedures with high satisfaction rates. Most studies assessing day cases attribute success rates to length of hospital stay or complication rates. There is no consensus on the information provided to patients in the postoperative period.

Methods

A retrospective study was carried out at Hillingdon Hospital (THH). A total of 50 patients (25 male and 25 female) aged 19–83 years (mean 49.26) were recruited consecutively from day-case surgical logbooks. Patients were telephoned to answer a survey of nine questions: eight closed and one open. Data were analysed using an Excel spreadsheet.

Results

The most common procedure was laparoscopic cholecystectomy (22%) followed by haemorrhoid surgery (12%). Forty-seven (94%) patients were satisfied with the care and the information provided. Three (6%) patients reported being somewhat satisfied. These patients were all below 50 years old, employed, with no disabilities or previous operations at THH. These patients did not receive leaflets and 66% reported that surgeon did not update them or their next of kin postoperatively. Over half (54%) of patients who provided feedback wanted more information regarding aftercare; 71.4% of these patients were female. Prolonged wait time on the day of the procedure did not seem to affect satisfaction; however, patients wanted to be informed of delay.

Conclusions

Leaflets regarding aftercare should be provided to all patients. The surgical team should update all patients and their next of kin to prevent anxiety in the postoperative period and decrease attendances to general practitioners or the emergency department.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

170 Healing the patient while harming the planet: a drive towards sustainable surgery

YK Lee ¹, A Hariri ¹, D Kim ¹

Abstract

Introduction

The operating theatre alone contributes ∼ 70% of all hospital waste, with healthcare making up over 1% of all domestic waste in the UK. We reviewed waste production and the recyclability of surgical instrument packaging used in a common ear, nose and throat procedure (hemithyroidectomy) and suggest strategies to improve surgical waste and make surgery more sustainable.

Methods

We prospectively collected waste packaging from six hemithyroidectomies performed at the Royal Marsden Hospital, UK between July and August 2022. This was weighed, categorised and analysed after the operation. Recycling labels were recorded if present.

Results

On average, for each thyroidectomy 218g (39%) of plain paper/cardboard, 178g (32%) of soft plastic film, 141g (25%) of laminated paper, 9g (2%) of hard plastic and 9g (2%) of foil packaging were used. Of all items collected, only one had a recycling label. When extrapolated to the 8,454 thyroidectomies performed each year in the National Health Service, the total packaging waste weight was 4.7 tonnes, of which only 34kg is indicated as being recyclable.

Conclusions

By weight, although 42% of the packaging was potentially easily recyclable, less than 0.7% contains a recycling label. Product manufacturers should place clear recycling labels, switch to recyclable materials where possible and remove unnecessary information booklets that can be easily accessed digitally. Simple steps must be taken to ensure that we make surgery of the future more sustainable and reduce the environmental impact.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

171 Improving operative note adherence to the Royal College of Surgeons of England standards in a teaching hospital paediatric surgery department

J Walshaw ¹, M Eltom ¹, M Fleet ¹

Abstract

Introduction

Well-written accurate operation notes are essential for postoperative management, continuity of care and medicolegal records. The aim of this study was to compare operation note completion in line with the 2014 Royal College of Surgeons of England (RCS England) Good Surgical Practice Guidelines, and to improve adherence to these guidelines through surgeon education and implementation of an operation note template.

Methods

We retrospectively identified 32 paediatric patients who underwent any acute or elective surgical procedure in January 2022. We audited the completion of the operation notes against the RCS England standards. Following this, education on the standards was provided at the local trust audit meeting and an operation note template was implemented. The completion of operation notes for 20 patients was re-audited in August 2022. The primary outcome was the percentage of completion of the operation note fields, this was compared pre- and post-implementation of the template.

Results

The first cycle revealed poor documentation in ‘elective/emergency procedure’ (0%), ‘operative diagnosis’ (33.0%), ‘operative findings’ (77.8%), ‘incision’ (71.4%) and ‘closure technique’ (42.9%). After education and implementing the operation note template, these results increased to 90.0%, 95.0%, 95.0%, 100% and 100%, respectively. The re-audit demonstrated a marked improvement in completing the operation note fields. We plan to design an electronic template to evaluate for potential further improvement in operation note completion.

Conclusions

Operation notes have an essential role in postoperative patient care. Surgeon education and implementation of a standardised operation note template based on the RCS England guidelines resulted in a notable improvement in the completion of surgical operative notes.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

174 Electronic consent improves the quality of consent documentation for breast cancer surgery: a closed-loop audit

A Lee ¹

Abstract

Introduction

At baseline, variable consenting practices were noted at the authors’ breast unit. Electronic consent (e-consent) has been shown to reduce consent form errors, medicolegal risk and improve documentation. Our main aim was to compare the quality of consent documentation before and after the introduction of e-consent, with respect to the trust’s consent standards and the Royal College of Surgeons of England’s Good Surgical Practice Guidelines.

Methods

Audit standards included: (1) documentation of patient and responsible clinician details on consent forms; (2) provision of written consent before the day of surgery; and (3) inclusion of legible, non-abbreviated procedure names, benefits and complications on consent forms. All patients undergoing breast-conserving surgery, mastectomy, axillary node clearance or sentinel lymph node biopsy were included. Data were collected at baseline (March 2022) and post-intervention (May 2022).

Results

Fifty-seven patients were included (34 at baseline; 23 for cycle 1). Post-intervention, 57% of consent forms were electronic. E-consent was associated with improvements in documentation of responsible clinician (32% vs 65%; p = 0.01), legibility of risks (71% vs 100%; p = 0.02) and consenting for important complications such as venous thromboembolism (59% vs 87%; p = 0.04), COVID-19 (53% vs 91%; p = 0.00), pain (56% vs 91%; p = 0.00), numbness (32% vs 78%; p = 0.00), blue dye skin staining (61% vs 93%; p = 0.03) and inability to localise sentinel node (5% vs 57%; p = 0.00). The proportion of patients consented before the day of surgery did not improve.

Conclusions

E-consent improved the quality of consent documentation. Future cycles should aim to improve the uptake of e-consent and the proportion of patients consented in advance.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

178 Re-audit of infrainguinal bypass graft surveillance: 2017–2018 and 2020–2021

L Nadjarpour ¹, A Mohamed ², A Ibrahim ², TH Lo ², F Siracusa ², A Mekako ²

Abstract

Introduction

Following an infrainguinal bypass, surveillance scanning in patients is required at 3-, 6- and 12-month intervals. An initial audit performed in 2017 found a high rate of scans not requested, and check-up attendance rates were suboptimal. Interventions such as electronic operation notes and vascular lab online requests were implemented. In this re-audit, we assessed whether these interventions have improved scan request rates, if patients are attending follow-up scans, and if surveillance scans are identifying at-risk grafts.

Methods

A random sample of patients from each year’s cohort were selected, these were patients from Hull, and the greater northeast Yorkshire area who had an infrainguinal bypass performed in Hull Royal Infirmary. Seventy-six patients from 2017–2018, and 91 patients from 2020–2021 were included in this re-audit. Demographic and clinical data were collected and analysed statistically, with close attention paid to follow-up adherence.

Results

The COVID-19 pandemic and its impact on presenting age, and disease severity in patients requires consideration. Overall, the patients presenting during the pandemic were significantly older than their 2017 counterparts. Significantly more femoro-distal bypasses were performed in 2020 compared with 2017, with reduced usage of the great saphenous vein as the primary source of the graft. Surveillance scan request rates improved significantly during this time.

Conclusions

There was a significant improvement in surveillance scan requesting following the introduction of online vascular lab requests; however, this did not correlate with improved check-up attendance. There is a clear need to improve adherence to follow-up through improvement of patient education/informative leaflets.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

179 Improving weekend handover in general surgery

J Musai ¹, S Streather ¹, B Benoiton ¹

Abstract

Introduction

Handover is a major preventable cause of patient harm. Effective handover between shifts is vital to protect patient safety. Our primary aim was to design and implement a weekend handover list and checklist to unify the multiple individualised handovers between staff, reducing the number of missed patients to zero so as to deliver a more efficient and safer system.

Methods

A total of four plan–do–study–act cycles were completed which resulted in a unified electronic weekend list and a weekend checklist. The list is populated by each team on Friday afternoons with patients having a weekend plan entry (an existing weekend plan proforma). A weekend checklist poster was put in the doctors’ office detailing pre-weekend jobs.

Results

Prior to the introduction of the unified list, the average time to create a list and prepare notes for a typical ward round of 25 to 35 patients was 47 minutes. The average number of missed patients was four. There was a reduction to zero after introduction of the weekend list. The post-intervention survey showed that 90% of the respondents were satisfied with the new handover system, 90% said they would now use the trust weekend proforma and 80% were satisfied with the weekend checklist saying that it made their work quicker and more efficient.

Conclusions

The results endorse the permanent practice of the unified weekend list. The introduction of a weekend checklist comprising pre-weekend jobs improved the transfer of patient information in a clear and standardised fashion.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

180 Prescription practice of antibiotics for diverticulitis in a district general hospital

QAA Atif ¹, E Essiet ¹, K Ahmed ¹, S Bedi ¹, N Thapa ¹, S Kalaskar ¹

Abstract

Introduction

To examine the level of adherence of local antibiotic prescription practice for uncomplicated diverticulitis to National Institute for Health and Care Excellence (NICE) guidelines.

Methods

A prospective review of patients admitted to the emergency department between August 2021 and October 2021 with a suspicion of diverticulitis. Patients with complicated diverticulitis and other diagnoses were excluded. Data were analysed by the local audit department using SPSS version 27 for descriptive analyses and associations.

Results

Of 635 surgical patients, 50 were identified with diverticulitis; 48 (96%) patients received antibiotics and 32 (64%) of the 48 patients had an antibiotic need based on NICE guidelines, whereas 16 (32%) did not.

Conclusions

According to NICE recommendations, antibiotics should be prescribed in the presence of systemic signs, immunosuppression, significant comorbidities or suspected diverticular complications. Our local antibiotics prescription practice for diverticular disease is not based on NICE guidelines, adherence rate being only 64%. No local guidelines are available to guide prescription practice.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

181 MRSA decolonisation prescribing in acute surgical patients

P Kaushal ¹

Abstract

Introduction

Staphylococcus aureus lives as a commensal, but can also cause infections. Methicillin-resistant Staphylococcus aureus (MRSA) is resistant to some antibiotics, causing additional challenges in treatment. MRSA is a leading cause of healthcare-associated infections. Use of decolonisation can reduce this. Trust guidelines state that decolonisation must be prescribed to all patients aged over 65. This audit evaluated the prescribing of MRSA decolonisation in acute surgical patients aged over 65 at a single site.

Methods

Patients admitted under general surgery or urology via the surgical assessment unit (SAU) across a random week and aged over 65 were identified. Their electronic medication chart was accessed to evaluate whether MRSA decolonisation was prescribed on admission. The first intervention involved sending an email to all junior doctors involved in admitting acute surgical patients to inform them of the guidelines. The second intervention was a poster in the doctors’ office in SAU. Following each intervention, a week was chosen to re-evaluate.

Results

Baseline data showed 0% of patients aged over 65 were prescribed MRSA decolonisation on admission, 3% (n = 1) were prescribed MRSA decolonisation after the first intervention and 26% (n = 10) after the second intervention.

Conclusions

Although the interventions demonstrated improvement in MRSA decolonisation prescribing on admission, there is much room for improvement. Further education is required for doctors as well as the wider clinical team. A paper checklist for the nursing team exists however it is uncertain whether this is regularly completed, and outcome communicated to the medical team. Education within the pharmacy team should also be considered.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

182 The management of nasal bone fractures to the otolaryngology rapid-access clinic: streamlining services and outcomes

A Ahmed ¹, M Crossdale ¹, S Akbar ¹, S Khwaja ¹

Abstract

Introduction

It is common practice for nasal bone fractures to be referred to the otolaryngology rapid-access clinic within a 21-day period for manipulation under local anaesthesia for deformity. This service has reduced the number of patients requiring a general anaesthetic for a relatively quick and uncomplicated procedure. Nevertheless, the frequency of patients presenting to the otolaryngology rapid-access clinic for this procedure for whom no intervention is undertaken is abundant. Reasons for this include unlikely underlying fracture, no perceived deformity and no desire for manipulation despite deformity. Efforts to reduce pressures on the National Health Service (NHS) by preventing unnecessary referrals are explored.

Methods

Hospital electronic records were scrutinised for all patients presenting to the otolaryngology rapid-access clinic with nasal bone fractures over a 6-month period. The frequency of patients who underwent intervention was recorded. A ‘fracture of nasal bones pathway’ was created that included advice for referrers regarding counselling for patients/relatives prior to referral for manipulation under local anaesthetic procedures, including contact details for the otolaryngology clinic should patients wish to book/cancel appointments.

Results

The majority of patients presenting to the otolaryngology rapid-access clinic did not undergo intervention. Following introduction of the ‘fracture of nasal bones pathway’ it was found that there was a reliable reduction in unnecessary referrals to the clinic by 50%.

Conclusions

A ‘fracture of nasal bones pathway’ was found to significantly reduce unnecessary referrals to the otolaryngology rapid-access clinic, in turn, reducing pressures on an overwhelmed NHS following the COVID-19 pandemic.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

183 Time to presentation of acute scrotal pain according to ethnicity in patients with suspected testicular torsion

A Ahmed ¹, Z Panayi ¹, N Kiruparan ¹

Abstract

Introduction

A recent publication suggested that ethnic minorities with suspected torsion presented significantly later compared with Caucasian patients, putting them at an increased risk of testicular loss. Our audit aimed to investigate whether ethnic minorities do indeed present later, resulting in higher rates of orchidectomy, and the factors that influence this.

Methods

We carried out a retrospective review of case notes from 2019 at East Lancashire Hospitals NHS Trust. Inclusion criteria were: patients of any age presenting with acute scrotal pain and undergoing emergency scrotal exploration; and patients with delayed presentation who underwent urgent orchidectomy and/or orchidopexy. Exclusion criteria were: patients undergoing elective orchidopexy for intermittent torsion and patients undergoing radical orchidectomy. Data collected included age at presentation, ethnicity, time to presentation and more.

Results

In total, 76% of patients were Caucasian, 22% were Asian and 2% were categorised as ‘other’. The average time to presentation was 1,504 minutes for Caucasian patients and 2,739 minutes for Asian patients (p = 0.33). Eleven per cent of Caucasian patients had salvageable testis compared with 30% of Asian patients (p = 0.07). Eleven per cent of Caucasian patients had torsion resulting in testicular death, compared with 10% of Asian patients (p = 0.46).

Conclusions

Asian males presented later to secondary care; however, the testicular death rates for Caucasian and Asian populations were similar. There is scope for education directed at young males in schools and primary care on the signs and symptoms of testicular torsion. Our intervention is to email primary care centres within the trust, followed by re-auditing data in 6 months.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

188 Should we scan all suspected scaphoid fractures? A pragmatic observation study during COVID-19 time

GAS Sidhu ^1,², S Pattnaik ¹, H Khan ², M Thiami ², C Kitsis ², N Ashwood ²

Abstract

Introduction

National Institute for Health and Care Excellence (NICE) guidelines advise that magnetic resonance imaging (MRI) directly from the emergency department should be considered for suspected scaphoid fractures; however, only a minority of the evaluated centres offer this. This study reports on the real-life value of further imaging in cases of suspected scaphoid fractures, particularly with negative initial radiography, as observed in routine practice at a district general hospital.

Methods

This study involved 222 patients with suspected scaphoid fractures who were assigned to a ‘scaphoid pathway’ after initial radiography. They were seen in 2 weeks and assessed for anatomical snuffbox and/or tubercle tenderness; if these signs were present, they were sent for repeat x-rays. If these second x-rays were negative, a computed tomography (CT) or MRI scan was requested, the choice of which was made by the reviewing clinician.

Results

Of 222 patients suspected of scaphoid fractures, 40 (18%) had positive initial radiography. Of the remaining 182 with negative initial x-rays, 4 (2%) had a positive second x-ray. Of the remaining 178 with two negative x-rays, 2 (1%) had positive scan results, 1 of which was CT and the other MRI.

Conclusions

The overwhelming majority of scaphoid fractures were diagnosed on initial radiography (87%) with repeat radiography accounting for a much smaller proportion of diagnoses (9%). The remainder of diagnoses were made by CT or MRI and represented only a tiny fraction of the total number (4%). In the context of lengthy outpatient follow-up and the cost of the further imaging, attention must be paid to the latter’s value in diagnosing scaphoid fractures that have not been detected on initial radiography.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

189 Importance of consenting in a timely manner: a trauma centre experience

M Eldoadoa ¹, A Abouelnaga ¹, A Mustafa ¹, T Abdelrahman ¹

Abstract

Introduction

According to the Royal College of Surgeons of England, patients must have sufficient time to make an informed decision. There are few published articles with regards to the adequacy of informed consent in trauma patients. Consenting in a timely manner is important for reflection on the consent. The aim of this audit was to identify the timing of consenting trauma patients in a major trauma centre (MTC).

Methods

Following audit approval, data were collected over 1-month. Data collection included patient demographics, surgery type, time of consenting and timing of surgery. All trauma admissions were included except patients requiring emergency surgery and patients with cognitive impairment. There are no gold standards in the literature with regards to the ideal consenting time, so we defined this as within 24 hours from admission.

Results

Forty-nine patients were included, with an average age of 45.3 years (range 19–81 years). There were 33 males and 16 females. Injuries included foot and ankle (30%), upper limb (28%), pelvis, hip and femur (2%), tendon injuries, laceration (16%) and abscesses (6%). Twenty-two (44.9%) patients consented in <24 hours and the remaining 27 (55.1%) consented >24 hours post-admission. Of the 27, 10 (20.5%) consented from 72 hours onwards. Twelve (24.5%) consented on the day of the surgery or within 24 hours before surgery.

Conclusions

Consenting in a timely manner is challenging in an MTC. National standards need to be defined regarding adequate timing for consenting. Patient leaflets and audio-visual aids must be provided in line with National Health Service patient information. Research is required to investigate trauma patients’ satisfaction with regard to the consenting process.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

190 Impact of leadership behaviours on surgical trainees’ perceptions of their learning environment in the operating theatre: a questionnaire study

P Leow Zi May ^1,², B Patel ¹

Abstract

Introduction

Surgical training is the time at which surgical trainees gain the necessary skill sets to become competent surgeons. However, their ability to learn and obtain these skill sets are dependent on their learning environment (LE). Recent studies have shown that a trainee’s perception of their LE is strongly determined by the leadership behaviour(s) portrayed by their surgical trainers. The aim of this study was to understand the relationship between effective leadership behaviours and the experiences of surgical trainees in the operating theatre.

Methods

The Leadership Behaviour Frequency (LBF) Questionnaire was produced to measure the frequency of effective leadership behaviours as experienced by surgical trainees in the UK. The 27-item questionnaire based on seven domains of effective leadership behaviours was distributed via social media to surgical trainees, trust grade doctors, Foundation Year (FY) 1 and FY2 doctors or medical students who have had at least one surgical rotation.

Results

A total of 120 responses were received. Most trainees rated their learning environment in the operating theatre as positive. There is a strong correlation between the LBF scores and the trainees’ perception of their LE. Trainees who scored their trainers highly on the LBF were more likely to rate their LE as positive.

Conclusions

The LBF questionnaire has the potential to be used as a feedback and quality assessment instrument for trainers by trainees. This allows for areas of need to be highlighted within the surgical learning environment and for targeted change to be implemented to help improve surgical trainees’ overall LE.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

193 Reducing inappropriate referrals in the ENT Foundation Year 2 emergency clinic: the introduction of standardised clinic referral proformas

L Jegatheeswaran ¹, B Choi ², K Willis ¹, TKP Naing ¹, O Burgan ¹

Abstract

Introduction

Anecdotally, ear, nose and throat (ENT) Foundation Year (FY) 2 doctors have reported that referrals seen in the ENT FY2 emergency clinics have been of varying quality and appropriateness. Referrals for this clinic are accepted by the ENT FY2 on call, who will receive calls from the emergency department, general practitioners, in-house specialties and surrounding hospitals in Norfolk. The ENT FY2 role consists of doctors of various backgrounds, from FY2 to Core Surgical Training Year 2 (CT2), and overnight, cross cover from the plastics on-call FY2.

Methods

A retrospective audit of ENT referrals to the ENT FY2 emergency clinic at a tertiary centre, between March and June 2021, was performed. Based on these findings, a new referral proforma was created and implemented in July 2021. A teaching session was provided during the August changeover induction. The new proforma was audited between August and September 2021.

Results

Fifty-two referrals were identified and included for analysis (26 pre-intervention and 26 post-intervention). The most common referrals included: suspected nasal fracture, Bell’s palsy and acute otitis externa. During the pre-intervention stage, 15.4% of referrals (n = 4) were deemed inappropriate for the emergency clinic, with one notable case of a 2-week wait referral being accepted. Post-intervention, a reduction was noticed with 3.8% of referrals (n = 1) being deemed inappropriate (p = 0.24).

Conclusions

A standardised referral proforma can be key to regulating the quality and appropriateness of referrals being made to the ENT FY2 emergency clinic. This can also help streamline the patient’s care pathway and experience. A simple clear proforma can also help standardise referral quality especially during FY2 changeover periods.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

200 As we move towards local anaesthetic transperineal (LATP) biopsies for the diagnosis of prostate cancer, are mpMRIs as helpful as they used to be?

J Nowers ¹, D MacDonald ¹, K Jefferson ¹

Abstract

Introduction

The aim of this study was to evaluate the diagnostic accuracy of the multiparametric magnetic resonance imaging (mpMRI) scan in comparison with local anaesthetic transperineal (LATP) biopsy in detecting clinically significant prostate cancer.

Methods

Retrospective data were collected from consecutive patients undergoing LATP biopsy between 1 April and 1 December 2020. We included all patients who underwent mpMRI followed by LATP biopsy. Patients with >3 months between mpMRI scan and biopsy, and those on active surveillance were excluded.

Results

Over this 9-month period, 211 patients underwent LATP biopsy, of whom 146 met the inclusion criteria. Significant prostate cancer (grade group 2 and above) was detected in 87 men.

When compared with LATP, we found the sensitivity of mpMRI in detecting significant prostate cancer to be 71% and the specificity to be 69%, giving a negative predictive value (NPV) of 62%. Of those patients with Prostate Imaging Reporting and Data System (PI-RADS) of 1 or 2 on mpMRI, 37.9% were found to have significant cancer.

Conclusions

The sensitivity of the mpMRI in detecting significant prostate cancer is said to be high, with a high NPV (88% and 76% respectively; PROMIS trial), but with the change in biopsy modality from transrectal ultrasound to LATP biopsy, we suggest that the accuracy of mpMRI has changed. Although there are some limitations to this study, it raises concern around discharging patients with a clinical concern for prostate cancer after a negative mpMRI only, as is currently suggested. We recommend local data analysis should be carried out to assess individual centres diagnostic accuracy, which would allow for adequate patient counselling.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

203 Transurethral laser ablation of non-muscle invasive bladder cancer: a new service

M Sardar ¹, L Corrigan ¹, A Pai ¹

Abstract

Introduction

Some 70%–75% of newly diagnosed cases of bladder cancer are non-muscle invasive bladder cancer (NMIBC). The highest incidence in the UK is in the 85–89 years age group. The risk of progression is <1% for low-risk disease; however, risk of recurrence is much higher. This subjects an elderly, comorbid population to multiple invasive, risk-associated treatments, requiring general anaesthetic (GA) and hospital admission. Transurethral laser ablation (TULA) is an outpatient, local anaesthetic (LA) procedure for recurrent NMIBC.

Methods

Following clinical governance approval, training and laser safety certification were undertaken. A 1,470nm diode laser was utilised. Over a 15-month period there were 32 attendances for TULA. Patient-reported outcome measures were collected prospectively, including a visual analogue pain scale.

Results

Mean age was 82 years. One patient, unfit for GA had high-risk disease (g3pt1). All other patients had recurrent, low- or intermediate-risk disease. Thirty-four per cent of patients had a concurrent LA biopsy, with all showing low-grade, superficial disease. Fifty-four per cent of patients had unifocal recurrence and 46% had multifocal areas. Median tumour size was 1cm (range 0.5 to 4cm).

All (100%) patients reported that they would recommend the procedure. There were no postoperative complications. Seventy-four per cent of patients preferred it to GA and transurethral resection of a bladder tumour. The maximum pain score was 2/5; 56% patients experienced no pain and 44% patients experienced a little pain. No patients had progressive disease.

Conclusions

TULA is an efficient, cost-effective and safe alternative to theatre-based treatment of NMIBC. This well-tolerated outpatient procedure reduces the requirement for repeated GA in an elderly population.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

208 How does adoption of the NICE guidelines for surveillance of non-muscle invasive bladder cancer impact patients and departments?

RM Abdlbagi ¹, CYB Cheung ¹, M Sardar ¹, S Tikkiwal ¹, A Pai ¹

Abstract

Introduction

Non-muscle invasive bladder cancer (NMIBC) represents a significant proportion of bladder cancer diagnoses. The probability of recurrence for high-risk disease is high with up to 75% recurring and 20% of cases progressing to muscle-invasive disease. Therefore, NMIBC patients undergo a rigorous surveillance flexible cystoscopy schedule to facilitate early diagnosis and treatment before progression. However, flexible cystoscopy is an invasive procedure with associated physical and psychological morbidities, such as pain, infection and anxiety. The National Institute for Health and Care Excellence (NICE) has updated surveillance guidelines for NMIBC. These guidelines risk-stratify surveillance regimes, with patients at low risk for progression and recurrence being discharged earlier. The impact of these new guidelines on the workload of departments has not been quantified.

Methods

We retrospectively reviewed the electronic notes of 50 consecutive patients. Half the patients were under the previous surveillance regime and the remaining patients followed the newly introduced NICE guidance.

Results

In the cohort under the previous surveillance regime, 11 of 25 patients (44%) would have been discharged with the new surveillance regime. Within the new cohort, 6 of 25 patients (24%) were discharged because of the new surveillance regime.

Conclusions

Adoption of updated NICE guidelines for surveillance of NMIBC prevents a significant proportion of unnecessary invasive procedures, particularly in the low-risk group. As a department, we perform 5,000 flexible cystoscopies per annum, and it is estimated that the adoption of the new guidelines will save 50 days of procedure room time per annum.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

209 Ureteral stents with extraction strings: patient-reported outcomes

R Abdlbagi ¹, R Odeh ¹, S Biyi ¹, U Bhatt ¹, A pai ¹

Abstract

Introduction

Short-term ureteric stents are commonly placed after ureteroscopy procedures. Their removal usually involves having a flexible cystoscopy, which entails a further invasive procedure. There are often delays in removing the stent as departments have limited cystoscopy availability. However, if a stent with extraction strings is used, the patient or a clinician can remove it. The aim of the study is to assess the safety and effectiveness of the use of a stent with a string.

Methods

A retrospective, single institution study was conducted over a 3-month period. Twenty consecutive patients had a ureteric stent with string insertion. Ten of the patients had a stent removal procedure previously with flexible cystoscopy. A validated questionnaire was used to assess outcomes. Primary outcomes included: dysuria, haematuria, urinary frequency and disturbance of the patient’s daily activities. Secondary outcomes included pain experience during the stent removal.

Results

Fifteen patients (75%) experienced haematuria and frequency. Two patients experienced pain and discomfort during stent removal (10%). Two patients had experienced a disturbance in their daily activity (10%). All patients who had stent removal before using flexible cystoscopy preferred removal of the stent using a string. None of the patients had stent displacement. The median stent dwell time was 5 days.

Conclusions

Patient-reported outcome measures for the indwelling period of a stent with extraction string are equivalent to the published data on stents. Extraction strings mean that the stent dwell time can be reduced. The removal of stents on extraction strings is more tolerable than that of a conventional stent.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

210 Evaluation of surgical ward round documentation on paper-based records in a district general hospital

Y Aung ¹, S Jang ¹, A Karunakaran ¹, K Khan ¹, Y Patel ¹, M Sharif ¹, A Bouhelal ¹, S Samlalsingh ¹

Abstract

Introduction

Whether paper-based or electronic, adequate ward round (WR) documentation is crucial in maintaining patient safety and medicolegal accountability. This study aimed to audit our surgical WR documentation against national standards.

Methods

WR documentation of 150 random patients, comprising 30 each from 5 surgical teams, was audited against Royal College of Physicians’ ‘Generic Medical Record Keeping Standards’ from February to April 2022. Patients admitted for under 48 hours were excluded.

Results

Folders were found in their slots in 87.3% of cases. Where not found, records took 9.33 ± 7.51 seconds to locate. WR documentation was identified in 99.3% of cases (n = 149), with patient name and medical record number documented in 98.6% and 93.3%. In 16.0% of cases, records were not chronological over 5 days, mostly they were found in the wrong order (70.8%) or missing pages (25.0%). Entries were titled ‘WR’ in 91.3% of cases, and surgical documentation was referenced in 44.3%. The most senior physician present was documented in 92.6% of cases. Of 72 patients who had undergone an operation, 66.7% had the operation date or postoperative length stated; 89.9% documented examination findings. Sixteen per cent of patients had drains and stomas placed separately, with output recorded in 66.7% and 20.8%, respectively. Plans were documented in 99.3%. Entries contained a date in 100% of cases, time in 73.8%, signature in 96.6%, physician name in 63.8% and registration number in 30.9%.

Conclusions

Paper records present unique challenges to documentation. However, it is imperative that our WR documentation improves in terms of physician accountability, particularly so for surgical patients, in documenting postoperative length, examination findings and outputs.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

211 Improving surgical ward design

F Morriss ¹, D Green ¹, N Marshall ¹, L Hutchinson ¹, A Weatherhead ¹, A Mahatantila ¹, D Amendra ¹

Abstract

Introduction

The aim of this study was to improve the efficiency of gathering equipment on surgical wards.

Methods

In collaboration with stakeholders, we developed a scenario-based quality improvement project to reduce the time taken to gather equipment. We designed the task around cannulation, as a common procedure frequently performed by ward staff and with a well-defined set of components. We undertook an initial survey of nurses and junior doctors throughout our trust to understand attitudes towards current cannulation practices. We then performed an initial trial scenario to obtain a baseline for comparison. Participants throughout our cycles included nursing staff, healthcare assistants and junior doctors. Our group completed four iterative plan–do–study–act cycles. First, by informing participants where the necessary equipment was located. Second, by inclusion of an additional labelling system. Third, by the centralisation of equipment. Fourth, by alteration of the room layout. In addition to the overall time taken, our measured values included the percentage of required components successfully collected, the number of rooms entered and surfaces touched.

Results

Our interventions reduced the average time taken for scenario completion by 133 seconds. For our cohort of 26 Foundation Year 1 doctors, this represents an annual saving of 251 hours of work and £3,406 in costs.

Conclusions

Simple design changes can meaningfully improve efficiency on surgical wards.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

212 Closed-loop audit of indications for abdominal plain radiograph

M Van ^1,², S Masoodi ^2,³, E Cribb ², N Pawa ²

Abstract

Introduction

Abdominal plain radiographs (AXRs) are the most common first-line investigation for abdominal pathology. AXR has a lower radiation exposure (0.7mSv) compared with computed tomography scanning (CT; 10–20mSv) and the average cost per AXR is £25 compared with £106 per CT. However, given that CT imaging yields more diagnostic information, AXRs are ineffectual in comparison as an aid to decision making and are perhaps unnecessary. The Royal College of Radiology (RCR) published the iRefer guideline on AXRs indication. Adherence to the guidelines can reduce non-indicated AXRs. We aimed to improve the appropriate use of AXRs to minimise unnecessary radiation exposure to the patient and reduce health costs.

Methods

A closed-loop audit was performed looking at indications for AXR requested in the emergency department and inpatients in comparison with RCR guidelines. Both audits included AXRs performed over 1-month period. The first audit was from 9 August to 10 September 2021. Following an oral presentation to the surgical department as well as application of an AXR indication poster in the emergency department, the second audit (10 June to 11 July 2022) was conducted.

Results

There were approximately 500 AXRs in the first and second audits, and a total of 1,000 AXRs were included in the cycle. There was an increase in appropriate requests from 67% to 75%. In the re-audit, 26% of AXRs were not indicated (from 36% in the first audit). The non-indicated requests included abdominal pain, diarrhoea, megacolon and perforation.

Conclusions

Presentation and posters on AXR indications improved the appropriateness of AXR requests. Therefore, having regular teaching and the reinforcement of an AXR poster can further improve the appropriate use of AXRs.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

213 Perfecting pain relief: fifth cycle of a quality improvement project into the use of fascia iliaca blocks in fractured neck of femur patients in a district hospital

C Randall ¹, F Edokpayi ², F Rayan ², B Guhan ², S Shyamsundar ²

Abstract

Introduction

Neck of femur (NOF) fractures in the elderly are extremely painful making the provision of early and adequate analgesia a priority. This can be achieved through fascia iliaca block (FIB). In our district hospital, a quality improvement project was undertaken involving ongoing auditing of the administration of FIB preoperatively to all fractured NOF patients. The first audit conducted in October 2020 showed an uptake of FIB in 13.1% of the eligible population. The fifth cycle commenced in November 2021 after an educational workshop was conducted for junior orthopaedic trainees.

Methods

Medical notes for NOF fracture patients admitted from January to March 2022 were examined and the administration of FIB was recorded. If a patient was on long-term anticoagulation, or if they had a local contraindication, this was also recorded.

Results

Sixty-six NOF fracture patients were admitted during this time; 36 (54.5%) received FIB. Of those who did not receive FIB, 9 patients (13.6%) were on anticoagulation therapy, 1 (1.5%) had a local contraindication, 6 (9.09%) refused and 16 (24.2%) had no clear documentation to whether FIB was given.

Conclusions

This cycle has shown there has been an increase in FIB uptake by 41.4% since 2020. This is attributed to increased awareness in the department through the workshop. However, this cycle has highlighted that documentation of FIB must be improved. It is essential that FIB data for all patients are available to confirm the success of interventions. After this cycle, we plan to improve the NOF fracture documentation pack to make it easier to document FIB.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

214 Absence of coding in an outpatient paediatric orthopaedic department: where does the money go?

C Randall ¹, M Dhingra ², HH Chong ², M Baba ², S Syamsundar ²

Abstract

Introduction

Paediatric orthopaedic conditions are often managed in the outpatient department (OPD) setting in our district hospital. In June 2021, OPD tariff rates were based on attendance only. Because of the lack of official coding for these minor procedures, the hospital receives neither financial benefit nor evidence for a formal auditing process. This project aims to examine the procedures performed in the OPD and create a coding pathway to understand the financial implications of coding for our department.

Methods

Paediatric orthopaedic interventions were collated and grouped in a 6-month period, and a clinical outcome form was created accordingly. After consulting with the coding department, a cost analysis of prospective earnings was conducted, as well as comparisons with current standard tariff rates for OPD attendance.

Results

From January to June 2021, 100 interventions were performed in our OPD, including 21 clubfoot serial castings, 70 serial castings for pathology such as tip-toe walkers, 6 Botox injections in spastic contracture limbs and 3 Pavlik harnesses for developmental dysplasia of the hip. With the assistance of coding department, a new paediatric procedural coding form was created with 14 relevant interventions listed. A loss of £6,110 was calculated due to tariff rates being solely attendance based compared with interventional based.

Conclusions

Paediatric orthopaedic OPD should have clinical coding outcomes in place for each intervention performed to ensure that the hospital trust receives appropriate financial commission. To ensure this, the OPD will now use the coding form and we aim to audit its use.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

215 Being clear: a quality improvement project of total knee replacement operation documentation against GIRFT guidance in a district hospital

C Randall ¹, M Baba ², S Shyamsundar ²

Abstract

Introduction

Accurate and detailed documentation of operations is essential to ensure effective team communication and optimisation of the postoperative care of patients. Getting it Right First Time (GIRFT) guidance for knee arthroplasty aims to guide surgeons to achieve this. This quality improvement project aimed to audit the documentation of operation notes in our district hospital for total knee replacements (TKR) against this guidance.

Methods

From June to October 2021, 40 TKR operation notes were download from Bluespier and analysed for the clear documentation of 14 selected standards from GIRFT guidance, including preoperative and intraoperative examinations, implant trials and postoperative care plans. The percentage of operation notes that included these standards was recorded. The results were presented at the departmental meeting and a TKR operation template was created and shared with registrars and consultants to improve the postoperative documentation. A re-audit was conducted from January to April 2022 of 29 TKRs.

Results

There was an average increase in operation notes that mentioned 8 of the 14 standards by 15.1% compared with the first audit. Three standards were present in 100% of operation notes in both audits. There was an average decrease of 2.9% in operation notes that mentioned 3 standards.

Conclusions

This project has shown the presence of a template led to an improvement in the inclusion of eight key standards from GIRFT, making TKR operation notes more detailed. In the future, we want to continue to distribute the template and refine it further based on clinical opinion and GIFRT guidelines to ensure optimum documentation.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

218 Use of apixaban vs enoxaparin in elective total hip and total knee replacement: postoperative outcomes

B Phillips ¹

Abstract

Introduction

Venous thromboembolism (VTE) is recognised as a significant postoperative complication in elective total hip and knee arthroplasty (incidence of 2.7%). Whiston Hospital’s anticoagulation policy for postoperative hind limb arthroplasty was changed from enoxaparin 40mg OD to apixaban 2.5mg BD as per National Institute for Health and Care Excellence guidelines. The aim of this retrospective study was to compare the effectiveness of enoxaparin vs apixaban when considering VTE incidence, wound complications, haemoglobin drop and length of hospital stay.

Methods

Retrospective data were collected between March and December 2015 from all patients receiving an elective total hip (THR) or knee replacement (TKR) at Whiston Hospital. Data were gathered from patients notes, available investigations and postoperative follow-up documentation.

Results

Overall, 202 patients were included in this study. There was found to be no statistical difference between apixaban and enoxaparin with regard to VTE incidence (n = 5 vs n = 1 respectively, p = 0.10). Average length of stay was 4.75 vs 5.6 days (apixaban vs enoxaparin, p = 0.06). There was no statistically significant difference in the drop in haemoglobin between patients who received either anticoagulant (apixaban 28.65g/dl vs enoxaparin 28.95g/dl, p = 0.37). Using combined data for TKR and THR, apixaban showed an increase in postoperative wound complications (n = 19 vs n = 13, p = 0.24) that was not statically significant; however, when evaluating THR data alone, apixaban was found to have a significantly higher wound complication rate (n = 14 vs n = 4, p = <0.05).

Conclusions

These results show apixaban to be as effective as enoxaparin in VTE prophylaxis. Apixaban and enoxaparin were comparable in all outcomes except for wound complications in patients who received apixaban following THR.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

220 Can flaps be used to treat chronic seroma’s?

B Phillips ¹

Abstract

Seromas following resection of large lower limb sarcomas or nodal clearance surgery can be difficult to manage. Non-surgical management of seroma consists of sclerotherapy or serial aspiration. Here we discuss two cases of chronic seroma treated successfully with a free and pedicle flap. Case 1 was a 41-year-old male who underwent resection of a myxoid liposarcoma arising from the peritrochanteric area. A chronic 5-year seroma developed. Attempts to drain/resect the seroma and allow the defect to heal by secondary intention with the aid of a vacuum-assisted closure dressing failed. A computed tomography (CT) angiogram was performed confirming the viability of the anterolateral (ALT) perforators. The site of previous radiotherapy was resected along with the seroma. Successfully reconstruction of the defect using a pedicle ALT vastus lateralis flap based on the descending branch of the circumflex femoral artery was performed. Case 2 was a 74-year-old male with confirmed axillary metastatic melanoma proceeded with a axillary dissection. A 7-month chronic seroma developed. Preoperative CT imaging identified adequate ALT perforator vessels and thoracodorsal recipient vessels. The ALT flap was raised with a single septal and intramuscular perforator. The flap was inserted utilising thoraco-dorsal artery and vein as well as serratus vein. For both cases the postoperative period was uncomplicated. Both donor site and flaps healed well, and the cosmetic outcome was satisfactory. Seroma re-formation did not occur.

A pedicle ALT vastus lateralis type myo-fascia cutaneous flap as well as a free ALT flap are appropriate options for treating chronic seromas following axillary dissection and sarcoma excision.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

221 Assessment of nasal bone fracture: a closed-loop audit

MNM Nordin ¹, K Narang ¹, G Reddy-Kolanu ¹

Abstract

Introduction

Patients with nasal bone fractures are commonly booked into a rapid-access clinic (RAC) within 7–10 days after injury, for an assessment for manipulation under anaesthesia (MUA). Slots for RAC are limited. Our aims were to improve the efficiency of RAC, by minimising inappropriate referrals, and to ensure adequate documentations during clinical assessment.

Methods

Retrospective analysis of a single cohort; patients who were booked in for nasal bone fracture assessment in RAC over 4 weeks, were followed up. Outcomes include the need for intervention, the documentation of symptoms and examination findings. Two cycles were completed. The following interventions were implemented: introducing a pathway for clinicians to book patients into the RAC, initial physical review by clinicians, utilising information leaflets and introducing a self-assessment pathway with telephone follow-up.

Results

The percentage of patients who did not require MUA improved from 68% (first cycle) to 56% (second cycle). The main symptom elicited in history taking – nasal obstruction (which will determine the need for MUA) – was documented in 94% of cases (first cycle) and this improved to 100% (second cycle). Documenting the presence of septal haematoma and septal deviation is essential. These were done in 72% of cases (first cycle) and this improved to 96% (septal haematoma) and 92% (septal deviation) of cases following interventions.

Conclusions

The interventions implemented led to positive outcomes; lower rates of patients who did not require MUA and improvement in the quality of documentations. A standardised pathway combined with guided teaching and training are essential to ensure appropriate assessment and treatment of nasal bone fracture and maintaining the efficiency of the RAC.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

224 Operative notes in neurosurgery: a clinical audit

D Jesuyajolu ¹, A Zubair ¹, T Grundy ¹, J Evans ¹

Abstract

Introduction

Operation notes made by the neurosurgery team are not standardised and some information (although non-critical) may be missing. We aimed to identify the areas where the operation notes in neurosurgery can be improved and to help devise a proforma unique and fit for entering operation notes for neurosurgical procedures.

Methods

The Royal College of Surgeons of England (RCS England) set out a guideline regarding good surgical practice. It highlights 18 key items that must be present in every good operation note. We carried out a retrospective audit of the operative notes in the neurosurgery department of Salford Royal, part of the Northern Care Alliance NHS Foundation Trust. The first cycle involved 53 notes and the second involved 50 notes.

Results

In the first cycle, half (50%) of the domains had very poor ratings and by extension poor compliance. Four domains had moderate compliance, and five domains had very good compliance. By the second cycle, improvements were seen in the following domains: date and time, signature, names of the operating surgeon and assistant, name of the theatre anaesthetist, operative procedure carried out, operative diagnosis, incisions, details of closure technique, operative findings, antibiotic prophylaxis, deep vein thrombosis prophylaxis and detailed postoperative care instructions.

Conclusions

The second cycle of this audit showed that there has been an improvement in the domains of the notes as recommended by RCS England and gives a good outlook towards sustenance of the change. This is very important in ensuring continual, adequate and optimal patient care.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

225 Changing times in head and neck surgery: one regional unit experience

SK Lim ^1,², D Dick ¹, R Ullah ¹

Abstract

Introduction

COVID-19 has affected the surgical environment in Northern Ireland. The aim of this audit is to determine the changing nature of head and neck surgery before, during and after the COVID-19 pandemic. The pandemic occurred from 2020.

Methods

All surgery performed under the otolaryngology department in Belfast, the head and neck regional centre for Northern Ireland, from 2019 to 2021 was gathered from a computer system, the Theatre Management System. The data were compared with data from a similar previous audit in 2009 to 2015. This analysis was performed using Microsoft Excel.

Results

There was a decrease in most of the head and neck procedures (endoscopy, laryngectomy, parotidectomy, laser laryngoscopy and thyroidectomy) during the pandemic. Almost no maxillectomy and rhinectomy are done in Northern Ireland because they have been replaced by functional endoscopic sinus surgery. However, there are more neck dissection cases because of the increase in selective neck dissection for thyroid malignancy.

Conclusions

COVID-19 pandemic has affected the head and neck department’s surgical workload. There will need to be an increase in the theatre list to replace the reduced operating theatre lists for head and neck cancers.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

226 Are we screening for infectious mononucleosis? A closed-loop audit

A Ijaz ¹, A Hurry ¹

Abstract

Introduction

Glandular fever, or infectious mononucleosis, is an infection most commonly caused by the Epstein–Barr virus with up to 95% of adults worldwide having been infected with this virus during their lifetime. It typically presents with fever, lymphadenopathy and sore throat, and is often indistinguishable from bacterial tonsillitis. Glandular fever is normally self-limiting, although recovery may take 6–8 weeks and more serious complications can occur such as hepatitis, upper airway obstruction and splenic rupture. Serological testing for glandular fever can help manage patient expectations of recovery as well as alter lifestyle behaviour such as avoidance of contact sports, alcohol and further spread. Additionally, it eliminates the need for antibiotics that are not indicated in glandular fever. We aim to ensure all patients admitted with a diagnosis of tonsillitis are screened for glandular fever.

Methods

Data for all patients admitted to ear, nose and throat (ENT) due to tonsillitis were collected in multiple phases in 2021 and 2022. Glandular fever, full blood count (FBC) and liver function test (LFT) results and inpatient duration were reviewed. This was raised at a departmental level and education was given before re-audit.

Results

Pre-intervention, 50% of patients received a glandular fever screen compared with 73% after. FBC was undertaken in 88% of patients pre-intervention vs 100% post-intervention. LFTs were taken in 81% of patients pre-intervention vs 88% post-intervention. On average, 29.4% of patients tested were positive for glandular fever.

Conclusions

Intervention did improve compliance with these guidelines. Greater compliance with glandular fever testing, will ensure that patients avoid unnecessary antibiotics, are given necessary additional advice and have appropriate recovery expectations.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

230 Time to hand therapy following hand trauma: a multicentre experience

F Banhidy ¹, N Banhidy ²

Abstract

Introduction

Hand trauma is a common injury with a potentially devastating physical, psychological and socio-economic impact. Delayed time to postoperative hand therapy is known to adversely affect hand function. This audit aims to assess the time frame in which hand trauma is managed at two hand surgery units against current British Society for Surgery of the Hand (BSSH) guidelines.

Methods

A random sample of 50 adult patients with hand trauma receiving operative management between 1 January 2022 and 1 February 2022 from both the Royal London Hospital (RLH) and the Royal Free Hospital (RFH) were selected for analysis. Data were collected on patient demographics, injury characteristics and time to follow-up (TTF) by hand therapy. Average time to hand therapy follow-up were compared between units and contrasted against BSSH standards.

Results

Average time to hand therapy for closed fractures was 8.8 days (RLH) and 5.9 days (RFH). TTF for open fractures was 13 days (RLH) and 5 days (RFH). TTF for flexor tendon injuries was 15.3 days (RLH) and 4.7 days (RFH). TTF for extensor tendon injuries was 9.8 days (RLH) and 5.4 days (RFH). TTF for nerve injuries was 14.5 days (RLH) and 4.6 days (RFH).

Conclusions

There are clear differences in average times to hand therapy between the two hand surgery units. Hand therapy follow-up is consistently faster on average in RFH compared with RLH. Identifying the risk factors for delayed time to hand therapy are key to improving follow-up times and is the focus of future research.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

231 Improving final-year students’ confidence in postoperative patient care

M Khan ¹

Abstract

Introduction

Postoperative care taught at medical school often focuses on the common complications of surgery; however, how to approach postoperative patients is often neglected. Within the previous cohort of Nottingham medical students, based at United Lincolnshire Hospitals NHS Trust, perception of confidence in approaching postoperative patients following standard postoperative teaching was low. Frameworks are one tool that can be utilised to help students to improve their confidence and knowledge in approaching the postoperative patient. Within this quality improvement project, the existing session was modified with the addition of a postoperative assessment framework with the aim of improving students’ confidence and knowledge.

Methods

Data were collected from students who self-scored in four domains, before and after the session, and the difference in scores between the original and modified session was compared. The four domains were: confidence in assessing a postoperative patient, knowledge in assessing a postoperative patient, confidence in managing a postoperative patient and knowledge in managing a postoperative patient.

Results

The changes in the session increased student confidence by 44% and knowledge by 26% when assessing a postoperative patient. The students’ confidence in managing a postoperative patient increased by 30% and their knowledge by 14%.

Conclusions

The results showed that when students were given a framework on how to assess a postoperative patient, they felt much more confident and knowledgeable on how to assess and manage postoperative problems. This shows that when giving students a framework to approach postoperative patients is a useful way to improve confidence and knowledge for when they start working as junior doctors.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

233 Improving trauma and orthopaedics surgical teaching in the post-COVID-19 era

R Hammond ¹, O Desouky ², Y Ibrahim ¹, A Doshi ³

Abstract

Introduction

We aimed to assess the learning needs of junior trainees and design a teaching programme to improve the quality of trauma and orthopaedics surgical teaching internationally.

Methods

A survey of trainees was conducted. It was completed by 470 trainees online. We designed an online course for trainees that focuses explicitly on clinical aspects of the job that are not taught elsewhere, with the premise of being ‘designed by juniors, for juniors’ and adapted based on feedback. Feedback was scored on a 1–5 rank scale with 5 being most positive and 1 being most negative. We used MedAll^® to stream the sessions. Our webinars were free and catch-up recordings were posted online.

Results

Some 522 people attended the online sessions and 470 (90.0%) attendees provided feedback. We have an increasing international audience with viewers from 48 different countries globally. Only 36.6% of viewers felt that their current level of trauma and orthopaedics teaching was ‘more than enough’ or ‘enough’, scoring 5/5 or 4/5, respectively; 33.0% of viewers felt ‘very unprepared’ (1/5) or ‘unprepared’ (2/5) for their trauma and orthopaedics placements. Mean pre-session topic confidence scored 2.9/5 vs post-session 4.5/5. (p = 0.0001*). The relevance of topics to training scored 4.4/5.0 on average. The online format of the teaching was ranked 4–5/5 by 83.0% of participants.

Conclusions

Using technology has allowed us to reach a larger and more diverse audience than would have been possible with conventional face-to-face teaching. An innovative, online, clinically orientated course is an effective way to re-engage trainees and improve the quality of surgical education.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

234 Reduction in opioid-based patient-controlled analgesia decreases incidence of postoperative ileus for major elective colorectal procedures: single-centre prospective study

A Dereham ¹, S Mahmoud ¹, N Helmy ¹, E Janta ¹, P Hawkin ¹, E Davies ¹, T Raymond ¹, O Ryska ¹

Abstract

Introduction

We aimed to identify the incidence and risk factors for developing postoperative ileus (POI) in patients undergoing major colorectal procedures. We reassessed this after optimising analgesic control.

Methods

This prospective study included all patients undergoing major elective colorectal procedures at the Royal Lancaster Infirmary, University Hospitals of Morecambe Bay Foundation NHS Trust between 2018 and 2020. The initial patient cohort provided a baseline for risk factor identification (group A). Perioperative analgesia was then modified, transitioning from opioid patient-controlled analgesia (PCA) to fentanyl patches and non-opioid optimisation (group B). Group C comprised patients after the protocol was established.

Results

In total, 345 patients were included: group A, n = 97; group B, n = 129; and group C, n = 119. Baseline POI incidence was 44%. Significant risk factors were male gender (3.92 [1.41–10.9]), open procedure (3.29 [1.42–7.65]) and PCA use (2.64 [1.42–7.65]). There was a statistically significant reduction in PCA use from 65% in group A vs 32% (p = 0.0001) in group B vs 47% (p = 0.013) in group C. Fentanyl patch application increased from 40% in group B vs 83% in group C (p < 0.05). POI incidence decreased from 44% in group A to 38% (p = 0.524) in group B and 30% (p = 0.045) in group C. In addition, there was an observed successive decrease in length of stay (10.6 ± 11 days vs 9.2 ± 6.7 days vs 7.8 ± 5.3 days, p = 0.008).

Conclusions

Our study identified the incidence and risk factors for developing postoperative ileus following major colorectal procedures and indicates transitioning from opioid PCA to fentanyl patches and non-opioid analgesia may decrease postoperative ileus incidence and length of stay.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

239 ENT E-clinic: are we exhausting the resources?

A Jamalludin ^1,², M Zainaldeen ²

Abstract

Introduction

The ear, nose and throat (ENT) emergency clinic (E-clinic) provides rapid access for acute conditions to be managed in a timely manner, and is of high clinical value. However, a significant number of routine cases were referred. This led to inaccurate clinical settings and a waste of resources. The aim of this study is to audit referrals according to clinical priorities, ensuring the safety, quality and effectiveness of clinical practice.

Methods

A data sample (n = 467) from February 2022 to mid-June 2022 (18 weeks) was analysed using retrospective analysis. Data were collected from E-clinic records. Analysis was broken down into reason for and source of referral, outcome of the E-clinic and type of case (new or follow-up). Cases were categorised as: routine, meaning not requiring immediate treatment within few hours to days (mostly follow-up); and urgent, meaning the opposite (mostly coming from the emergency department/general practitioner). For accuracy, these categories were then subdivide into: urgent and new, urgent and follow-up, routine and new, and routine and follow-up.

Results

Results showed that 51% of cases referred to the E-clinic were follow-ups; of these, 51% were routine, and only 49% were urgent. Also of note, only 48% referred cases were new; new cases are supposed to make up a higher proportion of this service.

Conclusions

The audit showed a higher percentage of follow-up, routine cases referred to the service, which is not ideal. A closed-loop audit is suggested for improvisation, considering the use a standard referral proforma. This audit is also an opportunity to highlight the patient-initiated follow-up pathway, which empowers individualised care in a safe, flexible and cost-effective manners. This audit is of clinical importance in utilising valuable healthcare resources.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

241 How fast are surgeons?

H Selvachandran ¹, N Pranesh ¹

Abstract

Introduction

Timely assessment, decision making and treatment are important for surgical admissions. Inconsistency between the care of high-risk and lower-risk surgical patients has been identified by the Royal College of Surgeons of England who recommend hospitals should regularly assess performance in reviewing admissions to ensure safe care for all patients. The National Institute for Health and Care Excellence (NICE) recommends all emergency admissions require a consultant assessment within 14 hours.

Methods

Retrospective review of all emergency’s general surgical admissions over 7 days in two study periods. Time of consultant assessment and reasons for non-compliance were assessed. Evidence upon which the NICE recommendations are based was reviewed.

Results

From the 39 general surgical admissions in the first cycle, 30 admissions had a consultant assessment within 14 hours (77%; target 90%). Common reasons for delayed consultant assessment were low-complexity cases, poor documentation of actual time of review and theatre commitments. A standard operating procedure for delegated reviews of admissions that can be assessed and safely managed by surgical trainees (abscesses without sepsis, uncomplicated rib fractures and head injuries where the primary treatment decision is made remotely) and provision of additional IT equipment, were implemented prior to the second cycle. The second cycle results showed that 27 of 28 admissions received a consultant assessment within 14 hours (96%). The evidence on which NICE recommendations are based, focused solely on medical admissions with no evidence specifically for surgical admissions.

Conclusions

Compliance improved by implementing delegated reviews for appropriate admissions. The evidence behind the NICE recommendations does not account for differing responsibilities between medical and surgical consultants, and therefore should be adjusted by speciality.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

242 Intravenous iron therapy for iron-deficiency anaemia in preoperative colorectal patients: improving our pathways

L Mann ¹, L Alim ¹, J Bennett ¹, G Pocock ¹

Abstract

Introduction

It is well established that preoperative anaemia is associated with adverse patient outcomes. Data collected within a single National Health Service trust between January 2018 and February 2020 showed that 54% of colorectal cancer patients undergoing major resectional surgery were anaemic (haemoglobin [Hb] <130g/l), with only 50% receiving intravenous iron preoperatively. This quality improvement project aimed to increase the number of colorectal patients receiving iron transfusions by 50% in those undergoing elective resectional surgery over a 5-month period, by optimising identification and referral pathways.

Methods

A centralised pathway to identify iron-deficient patients was created in collaboration with the colorectal and endoscopy teams, recognising endoscopy as the earliest point of identification. An endoscopy checklist was created, acting as a memory aid for haemoglobin- and iron-level checks. This was presented at both teams governance meetings and adapted continually in response to feedback, before being distributed across four sites.

Results

Between March and July 2022, 18 anaemic patients were referred with suspected or confirmed colorectal malignancy. Seventeen were iron deficient with an average Hb of 101g/l. Following implementation of the endoscopy checklist, 89% received intravenous iron preoperatively with an average of 25 days from initial referral to infusion. Intravenous iron was infused on average 31 days prior to surgery with a mean Hb increase of 16%.

Conclusions

Facilitating system-wide change is difficult, often requiring a multidisciplinary team approach. This project demonstrated the real impact of a simple measure with future works focusing on multi-speciality implementation, building a case for a dedicated anaemia nurse to oversee the process.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

245 Do patients remember what they consent to? A quality improvement project

J Starup-Hansen ¹, I Allison ², K Charitopoulos ²

Abstract

Introduction

Procedural consenting is not merely signing a form, but rather an exchange of information from clinician to patient that facilitates informed decisions. Consent forms should serve as documentation of such discussions rather than a replacement for them. This quality improvement project sought to improve patients’ understanding of the procedures to which they had consented.

Methods

Twenty patients were interviewed in series, 6 months apart. Patients were asked about their satisfaction with the consent process and to recall the nature of their procedure, possible risks and intended benefits. In addition, physical consent forms were reviewed for the completion of the following sections: demographics, clinician details, nature of procedure, risks, benefits, provision of leaflet, translator, copy offered and legibility.

Results

The first audit found that 95% of consent forms met minimum standards. However, none (0%) documented leaflets, translators or copies offered to patients. Patient interviews revealed that 85% of patients could recall associated risks for their procedures. The most common suggestion was to allow more time for discussion and questions. Following education at a clinical governance meeting, there was reduced completion of basic minimum standard (85%) but improvement in the provision of translators and leaflets (15%), patient understanding of their consent forms (100%) and overall satisfaction (100%).

Conclusions

Patients do not always remember the risks and benefits of procedures. This can be improved by providing leaflets, translators and copies of forms to patients. Surgical consenting is shifting to electronic platforms. This improves convenience but must not detract from high-quality discussions with patients.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

247 Quality improvement project: medication Kardex compliance in an otolaryngology ward

SK Lim ^1,², C Diver ¹

Abstract

Introduction

This is a quality improvement project looking at the accuracy of allergy status documentation in a tertiary hospital, otolaryngology ward compared with the average ward in the same trust. The aim of this audit is to improve the practice of Foundation Year (FY) 2 doctors on the ward.

Methods

Data were collected from the medication chart on the ward and analysed using a Microsoft Excel spreadsheet. Several interventions were carried out monthly from February 2022 to July 2022, such as emails, reminders through text messages and a poster. The poster was circulated to all nurses on the ward and FY2 doctors who covered the ward, including specialties with outliers.

Results

The ward performance was below average in most of the months.

Conclusions

Despite all the efforts to improve performance, ward performance was still below average for the allergy status documentation. The prospective plan is to include this intervention in the twice-weekly FY2-led teaching.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

248 Antibiotic management of acute diverticulitis at a district general hospital

S Salsabil ¹, H Morsy ¹, A Rajput ¹

Abstract

Introduction

Audit to evaluate whether patients admitted to a district general hospital with acute diverticulitis were prescribed the appropriate antibiotics.

Methods

The first cycle of the audit was performed to assess compliance of antibiotic prescriptions for acute diverticulitis. Royal College of Surgeons of England (RCS Engl) and National Institute for Health and Care Excellence (NICE) guidelines were used as the standard criteria. This was carried out as a retrospective audit of patients admitted with computed tomography-proven acute diverticulitis over 3 months. Following the findings of the first audit, trust guidelines were introduced. Further interventions included posters and a junior doctor teaching session. A prospective re-audit was conducted over 4 months to assess improvement.

Results

The first cycle of the audit showed that the overall compliance with NICE and RCS England guidelines was 20.68%. Furthermore, we identified that there were no trust guidelines for antibiotics use in acute diverticulitis. Following the interventions, the re-audit results revealed that compliance with antibiotic prescription rose significantly to 61.4%.

Conclusions

This audit was able to identify poor compliance with appropriate antibiotic prescription in acute diverticulitis and the lack of a trust guideline. We were able to improve compliance, which resulted in improved management of acute diverticulitis; thus, demonstrating a positive impact on patient safety.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

249 Safe use of intraoperative tourniquets against BOAST guidelines

L AlSaket ¹, I Jaly ², I Sherif ³

Abstract

Introduction

The use of pneumatic tourniquets is a well-established practice in trauma and orthopaedics. The advantages include providing the surgeon with a clear, bloodless operating field and reducing intraoperative blood loss. Complications can not only have life changing consequences for the patient, but can also have an associated impact for the trust in terms of length of stay and cost of treatment. The aim of this study is to assess current practice with the use of tourniquets against newly released British Orthopaedic Association Standards for Trauma (BOAST) guidelines, looking at type/location of tourniquet applied; isolation method used; documentation of tourniquet time, pressure and method of exsanguination; and to educate about the recent BOAST guidelines for the safe use of intraoperative tourniquets to improve practice.

Methods

This is a retrospective study looking at cases in which tourniquet application was indicated. We identified patients who underwent upper or lower limb surgery at a level 1 trauma centre at the Queen Elizabeth Hospital Birmingham and who may require utilisation of a tourniquet. Patients’ clinical notes, including operation notes and documentation, were reviewed.

Results

In total, 143 cases were studied, with a median patient age of 47 years, including 109 cases of lower limb surgery and 35 cases of upper limb surgery. A tourniquet was used in 42 cases, 16 of which have pressure documented, and 16 have duration documented.

Conclusions

This study demonstrates that the use of intraoperative tourniquets requires improvement. Common practice is following the most recent guidelines, but documentation was lacking concerning the duration of tourniquet use and the pressure of the tourniquet used.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

250 Bypassing switchboard using the induction app: a quality improvement project

J Starup-Hansen ¹, I Kim ¹

Abstract

Introduction

Increasing modernisation and geographical dispersion have made it more difficult for loved ones to visit patients in hospital. This increases reliance on telephone communication and thus the hospital switchboard. As a result of increased pressure, switchboards are slowed, which increases waiting times for interdepartmental communication between hospital staff. Mobile applications such as the Induction Switch app exist to reduce reliance on the hospital switchboard by providing an independent directory. This quality improvement project audited the accuracy of the Induction Switch app and improved its ability to aid communication and reduce dependence on the switchboard.

Methods

The full directory of numbers available on Induction Switch for a district general hospital was audited by members of each department over a 1-month period. Numbers were tested for accuracy and relevance.

Results

In total, 599 numbers were available on the app: 38% (227) were accurate, 46% (276) were inaccurate, 16% (96) could not be verified and 22 additions to the directory were suggested. The directory was updated to reflect the most recent available numbers. To encourage regular up-to-date maintenance of the electronic database, the hospital switchboard is to be encouraged to provide a record of commonly requested numbers so these could be added to the directory.

Conclusions

This audit demonstrates that there is significant potential for improving the accuracy of the directory. If maintained, an external directory could reduce reliance on the hospital switchboard, aiding efficient interdepartmental communication with reduced friction. Further audits of the hospital switchboard are planned to monitor the waiting times experienced by hospital staff.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

257 New improvement on the approach to acutely unwell surgical patients: a clinical audit

L Alghazawi ¹, E Kalakouti ¹, P Rajagopal ¹, M Pai ¹

Abstract

Introduction

The Royal College of Physicians defines patients having a National Early Warning Score (NEWS) ≥ 5 as being at risk of deterioration, and recommend prompt identification and urgent clinical review. Following a serious incident in our department due to lack of documentation, we aimed to identify patients with NEWS ≥ 5 and assess and improve the documentation response pathway by doctors.

Methods

This study was a two-cycle audit in a single surgical ward. The first cycle analysed 36 events of NEWS ≥ 5, looking into the corresponding documentation by nurses and doctors, and the outcomes of those events over a 6-week period in 2021. A new surgical ward round template was applied and used thereafter. Subsequently, a second cycle was performed in 2022 and same analysis performed on the 52 events identified at that time.

Results

Whereas fully completed documentation of the response pathway by doctors and nurses was 64% in all events in the first audit, a marked improvement was seen in the second audit cycle to reach 73%. Moreover, 14% of nursing documentation was not met with doctor response documentation in the first cycle and this decreased to 7% in the second cycle (50% reduction). Finally, 5% of all events in the first audit had a late response by doctors, whereas no late responses were seen in the second audit.

Conclusions

The application of the new surgical ward round template at our department enhanced identification and response of doctors to patients having a NEWS ≥ 5 and hence improving patient care and safety.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

258 Consultant-led, structured simulation is the future for enhanced surgical training

MA Yehiyan ¹

Abstract

Introduction

Technological development has created opportunities as well as challenges for surgical training in all specialities. Surgery requires a wide range of skills and experiences to attain competency. The adverse outcomes of unskilled and inexperienced surgical techniques are detrimental to patient care. Newer approaches like laparoscopy and robotic surgery have a steep learning curve, requiring significant time and resource investiture. However, lack of dedicated teaching time, surgical tutors, operating time (particularly in the wake of COVID-19), and suitable cases are major obstacles faced by trainees.

Methods

Our trust has instigated a 4-hour weekly consultant-led surgical teaching session in our simulation lab. Trainees from all surgical specialities are encouraged, but any interested personnel from around the trust are welcome. Taught skills include suturing techniques, knot tying, minor surgeries, basic/advanced laparoscopic skills and in situ patient simulations. Sessions are task-orientated, based on Intercollegiate Surgical Curriculum Project competencies. These allow trainees to practise in a pressure-free environment and complete workplace-based assessments such as Case-based Discussion and Direct Observation of Practical Skills.

Results

The collected feedback demonstrates that trainees found the sessions useful for improving their surgical skills, were pitched at the appropriate level for them, were well organised, good fun and will invariably help them achieve their goals or competencies.

Conclusions

Consultant-led structured surgical simulation with dedicated sessions weekly is a promising way forward for surgical training in this modern era and should be integrated more into the curriculum. Improved access to dedicated simulation training should be encouraged for all surgical trainees.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

260 Magseed^® vs wire-guided localisation for non-palpable breast cancer: a single-centre two-phase cohort study

R Simson ¹, M Bramley ¹

Abstract

Introduction

Breast cancer is the most common cancer in the UK and with the introduction of screening, there has been in an increase in the number of non-palpable breast cancers. Magseed^® is a novel method that uses a magnetic seed, placed preoperatively under image guidance, that aids intraoperative localisation with use of the Sentimag^® probe. The aim of this study is to compare the newly adopted Magseed^® localisation technique with the traditional wire-guided localisation (WGL) technique with the primary outcome being margin positivity.

Methods

Data were retrospectively collected for all patients undergoing breast-conserving surgery for impalpable lesions in a single institution between January to June 2021 and January to June 2022. The first cohort of patients underwent WGL, and the second cohort underwent localisation with established Magseed^® technique.

Results

The two cohorts were similar in age, body mass index and use of neo-adjuvant chemotherapy. There was no difference in complexity of breast operations between the two cohorts. The mean weight of wide local excision specimens in the WGL cohort and subsequent Magseed^®-guided cohort were 34.6g and 27.5g respectively. Successful excision of margins was 16.9% with WGL and 12.1% with Magseed^®. A chi-squared test of independence showed that there was no significant association between localisation technique and margin positivity (p = 0.44).

Conclusions

In this study, Magseed^® localisation proved to be as safe and reliable when compared with the traditional WGL technique in terms of excision with tumour-free margins and specimen weight.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

262 Management of first-time shoulder dislocations in a level 2 trauma centre and compliance with the British Elbow and Shoulder Society guidelines

J Gill ¹, R Choudhury ¹, H Colaco ¹

Abstract

Introduction

This study investigates whether Basingstoke Hospital complies with British Elbow and Shoulder Society (BESS) guidance. For initial assessment, there should be detailed neurological and circulatory examination documented pre- and post-reduction and two x-ray views both pre- and post-reduction. For management, patients aged <25 years should be seen by a shoulder surgeon within 6 weeks, patients aged 25–40 should be seen within 3–6 months and patients aged >40 years should have early diagnostic imaging to look for a rotator cuff tear.

Methods

Some 81 patients who attended the emergency department with a first-time shoulder dislocation between October 2020 and October 2021 was identified. Parameters measured were: documentation of neurovascular status (NVS) pre- and post-reduction; whether two x-ray views were performed pre- and post-reduction; time taken to see a shoulder specialist; and whether imaging was performed in those aged >40 years.

Results

In total, 19.8% of patients had detailed NVS pre-reduction, which dropped to 8.6% post-reduction; 96% had two x-ray views pre-reduction and 97.5% post-reduction; and 61% were referred to a shoulder specialist. All those aged 25–40 were seen within the recommended time frame. Some 67% of those aged <25 were seen within the 6-week target and 64% of those aged >40 were referred to a shoulder specialist. Eighteen patients (50%) aged >40 years were sent for further imaging: ten were found to have a rotator cuff tear, three of whom are awaiting surgery; the rest were managed conservatively.

Conclusions

NVS documentation needs to be improved, as does the follow-up time scale of those aged <25, who are at risk of recurrent dislocations, and those aged >40, who are high risk owing to rotator cuff tears. Referral for further imaging in those aged >40 was also poor.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

265 Increasing use of ENT emergency clinic and reducing reliance on emergency department

N Krishnakumar ¹, V Reddy ¹

Abstract

Introduction

Our ear, nose and throat (ENT) department traditionally undertook emergency clinics (e-clinics) four times a week in addition to seeing patients visiting the emergency department as ‘ENT expected’. An audit of 2019–2021 demonstrated that some patients visiting the emergency department could have been diverted to e-clinics. Following presentation of the audit at our clinical governance meeting, we increased the number of e-clinics to five times a week and proposed changes to management guidelines to reduce use of the emergency department. A re-audit of the number of the ‘ENT expected’ patients visiting the emergency department and the e-clinics after increasing the number of e-clinic days was subsequently carried out.

Methods

Retrospective analysis of cases presenting to e-clinic and to the emergency department as ‘ENT expected’ from May to July 2022 was compared with previous years.

Results

The re-audit demonstrated a significant increase in the number of patients seen: 380 patients from May to July 2022 compared with 324 patients over the same period in 2021. There was a substantial increase in the number of conditions like otitis externa (∼120 cases seen compared with 60 cases in 2021) and hearing loss (44 cases against 35 in 2021), which were seen more in the e-clinics after implementation of increased clinic capacity and changes to management guidelines.

Conclusions

Re-audit of e-clinic performance revealed that more patients were seen in the e-clinic who would otherwise have been seen in the emergency department hence reducing demand on the emergency department.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

268 Evaluation of patient satisfaction and safety perspective of elective hip and knee replacement during the COVID-19 pandemic

GAS Sidhu ^1,², S Mulay ²

Abstract

Introduction

During the first peak of the pandemic, the National Health Service stopped non-urgent care and all resources were diverted to perform life- or limb-saving surgery. New protocols including preoperative self-isolation, COVID-19 testing and surgery at ‘COVID-19-light’ or ‘green’ site were introduced to minimise the risk of viral transmission.

Methods

This is a prospective single-centre study of 100 patients who underwent elective hip and knee procedures between mid-June 2020 and mid-August 2020. A COVID-19-modified satisfaction questionnaire was used to assess patient satisfaction. The primary outcome was the rate of COVID-19 infection, while the secondary outcome was patient satisfaction of the service and their perception of safety prior to and during their hospital stay, and discharge.

Results

None of the patients contracted COVID-19 and only one patient needed to be transferred to the main hospital for further investigation to rule out pulmonary embolism; 3% were readmitted to the hospital after discharge. 70% of patients completed a satisfaction questionnaire on their first follow-up appointment 6 weeks after surgery. All the patients were happy with the length of their hospital stay and scored a mean of 8.6 on a satisfaction scale (0–10) regarding measures taken to minimise contracting COVID-19, the information given and quality of the service.

Conclusions

The development of a COVID-19-free pathway for elective orthopaedic patients resulted in great overall patient satisfaction, and a safe patient environment with zero COVID-19 transmission.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

272 How to improve fertility work-up in patients undergoing radical inguinal orchidectomy

E Pearson ¹, S Parker ¹, J Dockray ¹

Abstract

Introduction

Testicular cancer (TC) accounts for 1%–1.5% of all cancers in men. Many TC patients are of reproductive age and therefore the European Association of Urology (EAU) recommends fertility investigations prior to surgery.

Methods

A retrospective analysis of the fertility work-up of all radical inguinal orchidectomy patients undertaken in 2020 at a single centre was compared against EAU guidelines. The initial cycle studied 42 patients. A ‘uro-testicular proforma’, blood/ultrasound electronic order set and changes to the local sperm-banking process were implemented and communicated at an audit meeting. The prospective cycle studied 12 patients from December 2021 to the present.

Results

The initial cycle demonstrated that >50% (n = 23) of patients did not have clear documentation about their fertility considerations. None of the patients had the recommended fertility blood tests (testosterone, luteinising hormone and follicle-stimulating hormone) prior to their operation. The prospective arm had a 75% (n = 9) use of the new proforma; of which 100% (n = 9) had fertility considerations documented compared with 33% (n = 1) who did not use the proforma. Overall, 80% (n = 10) of patients had fertility bloods taken. All patients who requested sperm-banking in the prospective arm received it (33% [n = 4] of patients overall). Both cycles reassuringly reflected that sperm-banking did not cause a delay from referral to orchidectomy: a mean of 13 days for those who sperm-banked vs 15 days for those who did not.

Conclusions

An electronic proforma and blood order set can improve the management of fertility in TC patients and did not delay radical inguinal orchidectomy.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

274 Acute pancreatitis severity scoring and timely escalation: are we doing it right?

Y Shanmugharaj ¹, S Lee ¹, M Badawi ¹, A Rahman ¹, A Shalaby ¹, M Klimovskij ¹

Abstract

Introduction

Acute pancreatitis presents with sudden onset of severe abdominal pain and can be accompanied by severe local and systemic complications. Numerous scoring systems have been suggested to predict the severity of pancreatitis. Identifying the cause of pancreatitis guides the management plan and short interval cholecystectomy is recommended if indicated.

Methods

We collected data retrospectively from March to April 2022 for acute pancreatitis admissions (n = 29). We audited whether a score was documented in the first 24 hours of admission and whether the patients who were at risk escalated or were admitted to high dependency units in a timely manner as recommended by National Institute for Health and Care Excellence and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The data were presented in the local governance meeting, a new proforma was introduced and we re-audited our admissions between June and July 2022 (n = 26).

Results

Glasgow-Imrie score was documented in only 17% of patients in the initial cycle, which increased to 38% in the second cycle. In both cycles, none of the patients scored >2, however; in the initial cycle 10% of patients were escalated to the critical outreach team with 33% having no documented score despite escalation. None of the patients was escalated in the second cycle. Finally, in the initial cycle, 96.5% of patients had diagnostic imaging which dropped to 50% during the second cycle.

Conclusions

The introduction of a dedicated proforma helped guide the clerking doctor to follow the guidelines and act accordingly. We need to focus more on arranging diagnostic imaging and re-establishment of the hot gallbladder pathway which is on hold since the COVID-19 pandemic.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

276 Two-cycle audit on post-tonsillectomy analgesia

S Ojha ¹, M Thamer ¹, I Soltan ¹, T Sinclair ¹, M Saunders ¹, J Gaskin ¹

Abstract

Introduction

The aim of the study was to assess whether children undergoing tonsillectomy were receiving adequate analgesia postoperatively and compare this against national standards. Implementation of new ibuprofen dosage guidance, reducing opioid prescribing, and assessment of whether this impacts readmission rates for post-tonsillectomy pain and bleeding.

Methods

Retrospective audit of tonsillectomies performed over a 5-month period in 2021 and a prospective audit over the same period in 2022, with new ibuprofen prescribing guidelines (7.5mg/kg QDS compared with 5mg/kg TDS previously) and effect on reduced opioid prescribing.

Results

There were ∼ 110 tonsillectomies performed in each cycle. For the first retrospective cycle, 95% were prescribed inadequate ibuprofen, with a mean dose of 5.5mg/kg. All patients who were readmitted with pain/haemorrhage had ibuprofen prescribed at a TDS frequency. Five per cent of cases presenting with bleeding, none returned to the theatre. Coblation was used in 40% of cases (extracapsular and intracapsular). For the second prospective cycle, 95% of patients were prescribed the correct ibuprofen dosage of 7.5mg/kg QDS, with reduced opioid prescribing. No patients were readmitted with postoperative pain and only a low number of patients presented with post-tonsillectomy bleeds.

Conclusions

Changing the dosing of ibuprofen to 7.5mg/kg QDS and ensuring departmental consistency has resulted in adequate analgesia dosing with no admissions for poorly controlled pain post-tonsillectomy. We feel a secondary impact is on reduced bleeding rates.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

279 Are we assessing and documenting the mortality risk for patients undergoing emergency laparotomy?

A Arora ¹, S Palmer ¹, V Velchuru ¹

Abstract

Introduction

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published its perioperative care report in 2011, recommending that mortality risk should be made explicit to all patients, and clearly documented in the consent form and medical records. Similar recommendations have been made by the National Emergency Laparotomy Audit (NELA) and General Medical Council. The primary aim of this audit was to identify whether mortality risk was documented in the consent forms of patients undergoing emergency laparotomy at James Paget University Hospital, Great Yarmouth, UK and the secondary aim was to check the quality of consent forms.

Methods

Retrospective data collection, a review of consent forms on electronic health records, was done for patients who underwent emergency laparotomy in March and April 2022 to evaluate whether mortality risk had been documented and to check the quality. The target for documentation standard was 100% as per NCEPOD and NELA guidelines.

Results

A total of 19 patients underwent emergency laparotomy and mortality risk was documented in just 21%, which is far from the 100% standard. In terms of quality of consent forms, most of the sections were completed correctly except the job title of the responsible healthcare professional which was missing in six consent forms.

Conclusions

Our audit shows a weak rate of mortality risk documentation in consent forms, so interventions included education of surgical team at the weekly departmental teaching and proposal of a procedure specific consent form. Although approval for procedure specific form is still in process, a second audit cycle will be undertaken in October to evaluate the results of educational intervention.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

281 An audit of driving practices in cardiac surgery: adherence to DVLA regulations in patients undergoing cardiac surgery in Aberdeen Royal Infirmary between March and June 2022

AR Abdel-Fattah ¹, S Singh ², H El-Shafei ²

Abstract

Introduction

Driving regulations for patients undergoing cardiac surgery are outlined by the Driver and Vehicle Licensing Agency (DVLA) to ensure road-user safety. We sought to assess the compliance with DVLA regulations in cardiac surgery patients in Aberdeen Royal Infirmary (ARI) and implement changes accordingly.

Methods

Patients visiting ARI outpatient cardiothoracic clinics between March and June 2022 were surveyed using a questionnaire. Data on patient demographics, past medical and social history, clinician advice and type of vehicle (group 1 [cars/motorcycles] vs group 2 [heavy-goods, passenger-carrying or on-road farm vehicles]) were collated. Adherence to disease-specific driving regulations was assessed against the DVLA government guidance. Data were analysed using SPSS software.

Results

Eighteen patients were included (mean age, 68.3 years; group 1 drivers, 18/18; group 2 drivers, 6/18). Most patients were either retired (n = 7) or worked in agriculture (n = 5). Eighty-three per cent were smokers. The survey revealed that 6/12 group 1 (50%) and 2/3 group 2 (66.7%) drivers post-coronary artery bypass grafting and 11/17 group 1 (64.7%) and 3/5 group 2 (60%) drivers post-aortic or mitral valve replacement continued to drive within 4 weeks. This is despite the requirement to delay driving for 4 weeks post-surgery in group 1 drivers and the licence-revocation requirement in group 2 drivers. No patient fulfilled requirement to notify the DVLA, regardless of vehicle-type or type of operation.

Conclusions

Adherence to DVLA regulations in ARI patients undergoing cardiac surgery can be improved. To improve adherence, clinicians will verbally emphasise the guidance given in a patient information leaflet, particularly for group 2 drivers. In addition, an outpatient clinic poster will be presented to highlight the DVLA guidance. The audit loop will be closed in October 2022.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

284 Short-term outcomes of colorectal cancer surgeries in octogenarians

N Angamuthu ¹, S Alagaratnam ¹, R Mirnezami ¹, O Ogunbiyi ¹

Abstract

Introduction

Advancing age, comorbid illnesses and diminishing physiological reserve pose unique challenges in the management of colorectal cancers.

Methods

A retrospective audit of current surgical practice and its outcome in colorectal cancer patients in their ninth decade of life was undertaken. Patient characteristics, comorbidities, multidisciplinary team decision, perioperative care and postoperative outcomes were analysed.

Results

From 50 patients (aged 80 and above), 37 were eligible records were reviewed. The average age was 83.35 years (range 80–88) with a male-to-female ratio of 1.3:1. Nine patients (24%) had rectal cancers and 28 (75.7%) had colon cancers (14 right, 2 transvers, 1 left and 11 sigmoid).

The common comorbidities noted were hypertension (22, 59.5%), atrial fibrillation (6, 16%), deep vein thrombosis, chronic kidney disease and pulmonary embolism (3 each, 8%). Six patients underwent emergency surgery and 31 had elective surgery. Twenty-five (67.5%) surgeries were performed laparoscopically with a conversion rate of 32% (8/25). The majority of patients (25/37, 67.5%) had an American Society of Anesthesiologists grade of 2. Average length of stay after a curative surgery was 11.5 days (range 5–49) with an intensive care unit (ICU) stay of 2.1 days (range 0–14). A morbidity rate of 59% (22/37) and a mortality rate of 5% (2/37) rate were noted. Major adverse events were noted in four patients (2.7% Clavien–Dindo III, 2.7% Clavien–Dindo IV and 5.4% Clavien–Dindo V).

Conclusions

Age per se should not be a deterrent to undertaking curative resections for eligible patients with colorectal cancer aged 80 and above. A multidisciplinary approach to perioperative care and a planned postoperative ICU stay before step-down to the wards potentially helps to minimise adverse outcomes.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

285 Laparoscopic adrenalectomy in day surgery: cost-effectiveness and patient experience

K Alexandrou ¹, G Galata ¹, A Al-Lawati ¹, P Klang ¹, A Jawaada ¹, F Dunsire ¹, J Hubbard ², J Preece ², A Aldrees ², KM Schulte ^1,³

Abstract

Introduction

Laparoscopic trans-peritoneal adrenalectomy (lapADX) has a variable length of stay between institutions that is safe and affordable. The COVID-19 epidemic has increased waiting list numbers for elective surgery and the demand for hospital beds, and necessitated the implementation of steps to reduce nosocomial exposure. As a response, we explored outpatient primary hyperaldosteronism surgery.

Methods

Forty-seven patients underwent lapADX between September 2021 and June 2022 as a part of a prospective study that gathered a substantial amount of data. A survey of patients was undertaken to evaluate patients’ perceptions. Data collected on costs were retrieved from National Health Service management systems.

Results

Average patient age was 50 ± 4.5 years and 61.7% were male. Thirty-nine patients (82.97%) did not fulfil the rigorous criteria for day surgery; however, they were all discharged from the hospital within 24 hours (27/39, 69.23%) or 24–48 hours of surgery (8/39, 20.51%). Eight patients (17.02%) were admitted in the day surgery pathway. Of these, seven (14.89%) were discharged the same day. One patient was erroneously admitted to the day surgery pathway, had lapADX performed and was admitted for observation overnight. There were no complications or readmissions within 30 days.

Conclusions

When the appropriate patients are selected and the proper protocols are in place, lapADX can be performed safely in the outpatient setting. The day surgery pathway has enormous potential to address clinical demands in contemporary settings with limited access to inpatient surgical care and greater resource constraints. It has been demonstrated to be both cost-effective and achieve patient satisfaction.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

289 Impact of COVID-19 on operative timing for plastic surgery hand trauma in a plastic surgery tertiary referral centre

L Ishak ¹, R Bramhall ¹

Abstract

Introduction

The aim of this study was to evaluate the impact of COVID-19 on operative timings for hand trauma in a plastic surgery tertiary referral centre.

Methods

Data were collected retrospectively on 80 patients who underwent surgical management of hand trauma in a plastic surgery tertiary referral centre in Scotland. Forty patients were in the pre-COVID-19 group (January to March 2019) and 40 were in the post-COVID-19 group (January to March 2022).

Data included operative timings for closed hand fractures (19 pre-COVID-19, 17 post-COVID-19), digital nerve injuries (8 pre-COVID-19, 6 post-COVID-19) and tendon injuries (13 pre-COVID-19, 17 post-COVID-19). Parameters included: operative delay time, whether delays were related to COVID-19 and adherence to British Society for Surgery of the Hand (BSSH) operative timing requirements.

Results

In the post-COVID-19 group, the mean number of days between decision to operate and the operation date was longer than in the pre-COVID-19 groups for hand fractures (3.9 vs 2.5, p = 0.0503), nerve injuries (3.8 vs 1.8, p = 0.3062), tendon injuries (2.2 vs 1.4, p = 0.016) and overall (3.3 vs 1.9, p = 0.0024). In the post-COVID-19 group, BSSH operative timing requirements were not met in a higher proportion of patients than the pre-COVID-19 group for hand fracture fixations (15% vs 0%, p = 0.231), nerve repairs (13% vs 0%, p = 1) tendon repairs (15% vs 0%, p = 0.1793) and overall (15% vs 0%, p = 0.0214). The delay in management was related to COVID-19 in all patients whose operative timings did not meet the BSSH requirements.

Conclusions

COVID-19 has significantly impacted operative timing for hand trauma and adherence to BSSH operative timing requirements. Further studies are needed to evaluate the impact of vaccination-based triaging on recovery of services.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

292 Extended VTE prophylaxis for emergency major cancer surgery in secondary care: clinical audit

S McCafferty ¹, M Gami ²

Abstract

Introduction

Venous thromboembolism (VTE) is a common and dangerous complication in post-surgical patients. The risk of such events is further increased in cancer patients, particularly those undergoing major cancer surgery. The National Institute for Health and Care Excellence (NICE) recommends extending VTE prophylaxis to 28 days post-surgery in those receiving major cancer surgery. Compliance is high in elective cases but often is low in emergency cases. The aim of this audit is to determine the compliance to the NICE guideline regarding extended VTE in emergency laparotomies.

Methods

A retrospective cohort of 464 patients undergoing emergency laparotomy with intra-abdominal cancer was collected. Baseline characteristics, pathology report, operation and extended VTE prophylaxis status was recorded. Data were recorded and analysed with Microsoft Excel.

Results

Of the 464 patients who underwent an emergency laparotomy, 68.3% received 28 days of VTE thromboprophylaxis as stipulated in the NICE criteria, 14.6% received VTE prophylaxis, but for less than the required 28 days and 17.1% received no thromboprophylaxis on discharge. The audit has found that the overall compliance to the NICE guideline on extended VTE prophylaxis for major cancer surgery is 68.3%. This falls short of the minimum standard of 100%.

Conclusions

The results of this audit have shown that there is a deviation from the guidance laid out in the NICE criteria regarding VTE prophylaxis following major cancer surgery.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

293 Educational impact of simulation teaching on junior doctors within general surgery

J Garner ¹, J Butler ¹

Abstract

Introduction

Simulation is a tool to develop clinicians’ assessment, management and communication skills. Scheduling simulation teaching for junior doctors and creating scenarios relevant to general surgery can be challenging. The aim of this study was to run a simulation teaching programme and measure the educational impact of this.

Methods

Three 1-hour sessions were organised with high-fidelity simulation models for junior doctors from general surgery. The scenarios were: sepsis, Advanced Trauma Life Support (ATLS) and postoperative complications. This was followed by feedback and a general discussion about the case. Anonymous online surveys were conducted before and after to measure confidence and knowledge and the usefulness of teaching.

Results

Ten junior doctors completed the questionnaire before teaching and 16 completed it afterwards. Before teaching, seven rated their confidence in assessing unwell surgical patients as average, two good and one excellent. After teaching, 11 rated this as good and 5 excellent. For knowledge in this domain, one junior doctor rated it borderline, four average, four good and one excellent. After teaching, 1 rated it as average, 11 good and 4 excellent. All students either agreed or strongly agreed that the teaching was useful, engaging and would recommend it to their peers. They all agreed or strongly agreed that simulation was an effective way to learn.

Conclusions

The results have shown that both confidence and knowledge of assessing unwell surgical patients improved significantly because of these simulation sessions. All found it engaging and would recommend this teaching to their peers. Therefore, simulation is a feasible and worthwhile method of teaching for junior doctors in general surgery.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

294 Effectiveness of extracorporeal shockwave lithotripsy in the treatment of renal and ureteric calculi

A Sahu ¹, R Varma ¹, W Mahmalji ¹

Abstract

Introduction

Extracorporeal shockwave lithotripsy (ESWL) is a non-invasive technique for the treatment of calculi. Literature has shown ESWL to have a lower rate of effectiveness compared with more invasive techniques such as flexible ureteroscopy and percutaneous nephrolithotomy. However, ESWL remains the only method that is non-invasive and therefore further research is needed to increase the rate of effectiveness of ESWL. Our aims are to identify the rate of successful treatment of patients and to identify common characteristics within those successfully treated.

Methods

Data were prospectively collected between 1 April and 1 November 2021. In total there were 55 patients: 34 were treated for renal calculi and 21 were treated for ureteric calculi. Data were stored and analysed using Microsoft Excel 2016 software.

Results

Overall, 83.8% of patients presenting with renal or ureteric calculi underwent successful treatment with ESWL. In patients presenting with renal and ureteric calculi who were successfully treated within four sessions or fewer, the average stone size was 9 and 8mm, respectively; average Hounsfield Units were 784 and 831, respectively; and average skin-to-stone distance was 9.98cm and 11.19cm respectively.

Conclusions

ESWL was generally successful in patients presenting with renal or ureteric calculi that are on average <10mm. ESWL is an effective intervention with a lower rate of failure than previously presented in the published literature. Reasons may include advancements in technology, improved operator technique and improved patient selection criteria.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

295 General surgery and surgical skills teaching series: an evaluation of the impact of face-to-face and virtual surgical lectures during the second COVID-19 wave

A Arora ¹, B Kumar ¹

Abstract

Introduction

The General Surgery and Surgical Skills teaching series was a regional teaching programme founded by a team of Foundation Year (FY) doctors at Norfolk and Norwich University Hospital in collaboration with Norwich Surgical Training & Research Academy (NoRSTRA). The programme was founded because the level of surgical teaching, including practical skills, at medical school, especially with placements being affected by the COVID-19 wave last year, often led junior doctors to feel poorly equipped to deal with the demands of surgical rotations. The aim of this teaching series was to equip medical students and FY doctors with core surgical knowledge and skills to better prepare them for a more successful rotation during their surgical jobs.

Methods

Virtual sessions and limited face-to-face sessions were run every Wednesday and attended by junior doctors and medical students across the east of England with anonymous feedback being collected after every session evaluating various parameters pre- and post-session. The sessions were also recorded and uploaded on the NoRSTRA website to facilitate remote learning and revision.

Results

Some 59% of attendees felt confident about the topic taught after the session and 30% felt very confident, compared with 1% prior to the teaching. Going through the responses received in relation to what the participants found particularly good, most participants appreciated the clinical relevance of topics, thorough explanations, and interactivity.

Conclusions

Cancellation of hospital placements during the second COVID-19 wave had an impact on the confidence of new graduates and this teaching series succeeded at equipping future junior doctors and new graduates with core surgical knowledge and skills essential for their surgical jobs.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

296 Informed consent: time to go digital

MI Hussain ¹, A Coombs ¹, D Dann ¹, C Lameirinhas ¹, Simon Toh ¹, E St John ^1,²

Abstract

Introduction

Informed consent is an essential requirement for those undergoing an invasive procedure. Innovations in digital consent aim to enhance the consent process and improve shared decision making. Our aim was to evaluate the traditional paper-based consent process against the introduction of digital consent at a representative acute National Health Service (NHS) trust.

Methods

A prospective service evaluation (SBRIH19P3055) was performed between May and August 2022 at Portsmouth Hospitals University NHS Trust. Paper-based consent forms were analysed from patients who had undergone surgery in a wide variety of specialties, and this was compared with patients who had used the Concentric digital consent process (https://concentric.health). Forms were scored for completion, accuracy and legibility. Data were analysed using Microsoft Excel.

Results

In total, 500 consent forms (n = 250 paper, n = 250 Concentric) were evaluated. Illegibility was prevalent for paper consent forms, 21% of ‘name of procedure’ and 29% of ‘risks’ compared with 0% for digital consent. Whereas 90.5% of Concentric patients received a copy of their digital consent form with embedded information links, only 15% of patients received a copy via the paper-based process. Three per cent of paper-based consent forms reported 15 or more risks in comparison with 82% on Concentric, 69% of paper consents were gained on the day of surgery in comparison with 12% on Concentric and 32% of patients remotely consented using Concentric compared with 0% with paper.

Conclusions

This study demonstrates that digital consent is associated with improved legibility, a higher number of documented risks, forms are shared more with patients and it allows for remote workflows.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

297 Audit of compliance of NICE and ACPGBI guidelines in management of acute diverticulitis

N Angamuthu ¹, C Hart ¹, R D’Souza ¹, O Ogunbiyi ¹

Abstract

Introduction

Acute diverticulitis (AD) is a common surgical emergency that varies in management despite National Institute for Health and Care Excellence (NICE) and Association of Coloproctology of Great Britain and Ireland guidelines (ACPGBI).

Methods

A retrospective audit of patients seen and managed as AD by the emergency surgical team over a 18-week period was performed. Clinical presentation, investigations, management, length of stay (LOS), morbidity and mortality were analysed. Colonoscopy requests and 30-day readmissions rates were also reviewed.

Results

Fifty AD patients were treated by the emergency surgical team. The average age was 60.7 years (range 28–91) with a male-to-female ratio of 1:1.5. Forty-nine (98%) patients underwent a computed tomography scan at admission. The majority (70%) of patients were of modified Hinchey grade Ia (others were: Ib, 18%; Iia, 2%; and Iib, 8%). AD was noted as being common in the left colon (82%) followed by right colon (18%). Five patients underwent emergency Hartmann’s procedure (two laparoscopic and three open). The mean white cell count × 10⁹/L (WCC) was 12.49 (range 6–22) and C-reactive protein mg/L (CRP) was 97.28 (range 1–338). Forty-eight hours after admission, the operative group had a mean WCC of 12.2 (range 6–19) and CRP of 240 (range 57–525). The average LOS was 5.2 days (range 1–47). Few (11%) patients with modified Hinchey Ia cases were managed without admission; 51% of the Ia subgroup had a LOS of 1–2 days. In total, 81% of the patients with uncomplicated AD had colonoscopy arranged at discharge.

Conclusions

A review of colonoscopy indications in uncomplicated AD would help in reducing the number of colonoscopies. A surgical hot clinic would potentially reduce the current admission rates of uncomplicated AD.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

300 Understanding nil-by-mouth in surgical patients

V Balasubaramaniam ¹, A Hellbig ¹, L Henderson ¹, N Vinod Kumar ¹

Abstract

Introduction

Surgical patients awaiting an operation need to be kept nil-by-mouth (NBM) and as such, doctors and nurses need a clear understanding of what this constitutes. A thorough understanding of the fasting guidelines before surgery will prevent patients from fasting for a prolonged period, which will impact the quality of care given to patients. This quality improvement project (QIP) has two main aims. First, to educate staff members on fasting guidelines with an emphasis on: (1) the difference between solids/clear fluids/free fluids and recommended fluids allowed; the period of recommended fasting; complications of prolonged fasting; and types of medication that should be given and withheld in fasted patients. The second aim is to improve the quality of care provided to patients who are kept NBM.

Methods

Questionnaires were distributed to doctors and nurses working in the surgical wards to assess background knowledge and understanding. Two plan–do–study–act cycles were undertaken, including education for doctors and nursing staff, and poster prompts in surgical wards.

Results

A total of 18 doctors and 18 nurses participated in the first cycle, and 20 doctors and 20 nurses participated in the second cycle. There was a significant improvement in the knowledge and understanding of staff members regarding preoperative fasting protocol. For doctors and nurses, there was an improvement from 57.91% to 87.9% and 57.5% to 78.1%, respectively.

Conclusions

This QIP has provided further support for staff members in managing surgical patients who are kept NBM. Ongoing education will help to improve their knowledge, thus leading to a superior quality of care provided to patients.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

301 Management of paediatric burns: a comparison of different treatment strategies

H Khan ^1,², R Risquet ^1,³

Abstract

Introduction

The aim of this study was to analyse different management strategies in the surgical treatments of paediatric burns, to help formulate a gold-standard management plan to improve outcomes and reduce complications.

Methods

Stoke Mandeville Hospital is a regional specialist burns unit where the majority of cases requiring surgical management of burns are dealt with on-site. Thus, we retrospectively collected and evaluated data of paediatric burns cases between April 2021 and March 2022 using Evolve and cross-referencing with paper notes and International Burn Injury Database (iBID). Cases were subgrouped into conservative and surgical management; focusing on surgical management alone, we measured outcomes including the type of injury, length of stay, complication and return to theatres.

Results

We identified 223 patients who underwent surgical management of burns between the ages of 0 and 15.73 years. The most common injuries were scalding (57.9%) and contact (28.7%). Some 169 patients had total body surface area (TBSA) burns of <3%, 60 patients had TBSA between 3 and 9.9%, 4 patients had TBSA >10%; 16% was the highest TBSA of burn. The most common treatment was debridement/de-roofing (80%), debridement and split skin grafting (10%), and debridement and epiprotect (4.5%). Infection was the main source of complications, with 5/180 cases in the debridement group and 3/43 cases in the skin graft group. However, this was not statistically significant as the Fisher’s test p-value is 0.1843 which is greater than p < 0.05.

Conclusions

Management of burns encompasses numerous factors with several surgical treatment options. With our cohort, there was not a statistical difference between each method, therefore a future evidence-based approach is recommended including qualitative data and a comparison of outcomes between each surgical method.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

302 Improving access to diagnostic imaging of acute renal colic patients in a district general hospital

I Kar ¹, P Krishnakumar ¹, G Nawaz ¹, K Qayum ¹

Abstract

Introduction

Renal colic generally describes an acute and severe loin pain caused when a urinary stone moves from the kidney or obstructs the flow of urine. It is a common presentation to the emergency department. As such, National Institute for Health and Care Excellence (NICE) guidelines mandate radiological imaging within 24 hours of presentation in all acute renal colic cases. This project aims to review and improve the access to diagnostic imaging to make an early diagnosis and to provide appropriate management.

Methods

This retrospective, prospective, cross-sectional study involved data collection from emergency department attendees diagnosed with renal colic (n = 45) over a 1-month period in December 2021. For each patient, the time and date of diagnostic imaging was reviewed to assess concordance with NICE guidelines. The local renal colic pathway was updated to mandate imaging within 24 hours of presentation. Following this intervention, the data were prospectively re-audited for 2 months.

Results

Forty-five patients presented to the emergency department with renal colic over a 1-month period (December 2021); 77.70% (n = 36) had imaging within 24 hours. Of these, 34 patients had a computed tomography scan. The remaining two patients had an ultrasound scan. Following intervention and subsequent re-audit over the following 2 months, there was a significant improvement in the department. Of 66 patients, 86.30% (n = 57) had radiological investigations within the first 24 hours.

Conclusions

Although the implementation of new trust guidelines improved access to diagnostic imaging, more awareness of the new trust renal colic pathway would further enhance compliance with NICE guidelines.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

303 Venous thromboembolism prophylaxis in a busy plastic surgery department: a closed-audit loop

J Feathers ¹

Abstract

Introduction

Venous thromboembolism (VTE) is an extremely common, yet reversible cause of patient morbidity and mortality in a hospital setting. National Institute for Health and Care Excellence (NICE) guidelines state that all surgical patients admitted to hospital should have a VTE risk assessment conducted. Our closed-audit loop aims to assess the completion of VTE risk assessment in patients admitted to a busy plastic surgery and regional burns centre.

Methods

We retrospectively analysed data between August and September 2021. Our findings were presented at the monthly departmental meeting and actions were implemented. Staff awareness was increased, and visual reminders were set up on the ward. We then undertook a re-audit in January 2022. All inpatient medical notes were reviewed, along with risk assessment charts and prescriptions. We compared our findings with both NICE and local guidelines. All patients admitted under plastic surgery were included. Paediatric patients aged under 16 were excluded from the study.

Results

VTE risk assessment evaluation forms were completed in 53% of patients. After implementation of recommendations and re-audit this increased to 95%. Pharmacological VTE was correctly prescribed in 77% of patients in our first audit. This improved to 94% on re-audit. Mechanical VTE was correctly prescribed in 53% of patients, this decreased to 48% on re-audit.

Conclusions

The implementation of visual reminders on the ward, along with increasing staff awareness regarding VTE prophylaxis has significantly improved risk assessment and subsequent VTE prophylaxis prescription in our department. This in turn will reduce the risk of unnecessary inpatient death and morbidity.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

304 Stoma reversals: an overlooked issue in NHS waiting lists and how to overcome

KK Oo ¹, R Codd ¹

Abstract

Introduction

Operative management of rectal cancer often requires temporary or permanent stoma formation. Delay in stoma reversal is associated with poorer functional results and an increased risk of complications. Many surgical societies, including the Royal College of Surgeons of England, produced guidance at the beginning of COVID-19 pandemic that recommended considering de-functioning stomas to mitigate risks of anastomotic complications. The study aimed to assess the impact of COVID-19 on diverting ileostomy rates, reversal rates and waiting times in elective rectal cancer surgery.

Methods

Consecutive elective anterior resections for rectal cancer were identified from the prospectively maintained database of a single colorectal multidisciplinary team between January 2018 and December 2021. The database was analysed to reveal operative approach, type of stoma, waiting time from initial surgery to stoma reversal and reasons for delayed closures.

Results

A total of 167 patients (70 pre-pandemic) and (97 pandemic) were included. An increase in the proportion of diverting stomas was observed in the pandemic group (58.8%) compared with the pre-pandemic group (38.6%). A threefold increase in the end-of-year waiting list for ileostomy reversal was noted between December 2019 (n = 17; pre-pandemic) and December 2021 (n = 47; pandemic). Reasons for delay included ongoing oncological treatment (34%), theatre capacity (20%), clinic capacity (26%) and access to water-soluble enema (9%).

Conclusions

The COVID-19 pandemic has been associated with increased diverting ileostomy rates among elective rectal cancer patients. A threefold increase in the stoma reversal waiting list poses logistical challenges at different levels. This study has highlighted potential bottlenecks to develop locally tailored pathways to prioritise timely reversal.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

307 Improving the basic biochemical evaluation of patients presenting with acute renal colic in a district general hospital

I Kar ¹, P Krishnakumar ¹, G Nawaz ¹, K Qayum ¹

Abstract

Introduction

Renal colic is a common presentation to the emergency department, with an annual incidence of 1–2 cases per 1,000 people, and recurrence rates are high. Some 82.5% of stones are composed of either calcium oxalate or calcium phosphate and 10% of stones are composed of uric acid. The British Association of Urological Surgeons have mandated the evaluation of serum calcium and urate levels. This project aims to review and improve the biochemical evaluation of these patients to make an early diagnosis and provide appropriate management.

Methods

This retrospective, prospective, cross-sectional study involved data collection from emergency department attendees diagnosed with renal colic (n = 45) over a 1-month period in December 2021. For each patient, blood work was reviewed to assess whether the sample included serum urate and calcium levels. Local guidelines were updated to accommodate the evaluation of serum urate and calcium. Following this intervention, the data were prospectively re-audited for 3 months.

Results

In total 45 patients presented to the emergency department with renal colic over a 1-month period (December 2021). Of these, 5.6% (n = 3) had serum calcium evaluated and 2.2% (n = 2) had serum urate evaluated. Following intervention and subsequent re-audit over the following 3 months, there was a significant improvement within the department with 22.7% (n = 20) having serum calcium evaluated and 15.9% (n = 14) having serum urate evaluated.

Conclusions

Although the implementation of new trust guidelines improved the evaluation of serum calcium and urate significantly, more awareness of the new guidelines (eg, presentation at grand round) would further enhance the basic metabolic evaluation of these patients.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

308 Postoperative note documentation in trauma and orthopaedics

Z Bholah ¹, H Youssef ¹, C Pasapula ¹

Abstract

Introduction

Review the adherence of postoperative documentation in the trauma and orthopaedics department with the current Royal College of Surgeons of England (RCS England) guidelines. Implement measures to improve postoperative documentation which will consequently increase patient safety.

Methods

Two cycles of this audit were performed. In the first cycle, data were collected from 50 elective and emergency cases, between 14 and 27 September 2021. The analysed data were presented in our local governance meeting to raise awareness among surgeons and trainees. We printed out copies of the RCS England guidelines, had them laminated and hung them on the wall just in front of the computers to act as a visual aid in trauma and orthopaedics theatres where surgeons usually document postoperative notes. After 6 months, we collected data again from 40 postoperative notes from 1 to 15 April 2022. The collected data were tabulated and compared with the ones from the first cycle.

Results

There was a significant improvement in percentage adherence across multiple criteria, including details of closure from 70% to 98%, blood loss from 2% to 23% and antibiotics prophylaxis from 82% to 98%. There was a slight decrease in percentage adherence in the documentation of anaesthetist name from 82% to 70%.

Conclusions

Overall, there was a significant improvement in the percentage adherence of postoperative documentation with the RCS England guidelines. However, some criteria require further improvement. Indeed, the importance of clear documentation is crucial to ensure patient safety.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

309 Traumatic brain injury management in a district general hospital: are we communicating effectively with the tertiary centre?

A Shaharudin ^1,², T Siempis ^2,³

Abstract

Introduction

Most mild traumatic brain injury (TBI) cases are managed locally with guidance. At Northampton General Hospital (NGH), TBI are discussed with neurosurgery in Coventry. Currently, there are no clear guideline regarding conservatively managed TBI. This audit looks at the awareness of local clinicians on essential information required for conservatively managed TBI.

Methods

Essential information was discussed and agreed on with neurosurgery in Coventry. These are baseline Glasgow Coma Scale (GCS), management of anticoagulation, further imaging requirement, anti-convulsant prescription and necessary follow-up. TBI cases at NGH from January to May 2022 were identified through the electronic records. Referrals on referapatient.org were reviewed, looking at the management plans from referrals to see the adequacy of initial information provided. A questionnaire was then circulated to clinicians involved in managing TBI locally to assess awareness of essential information required for local management.

Results

Thirty-nine cases of TBI were identified. On initial referral, 100% of cases had baseline GCS recorded, 20% had provisional anticoagulant restart dates, 74.3% had advice on further imaging, 23% received instructions on anti-convulsant and 25.6% on further follow-up. Twenty-two local clinicians were then recruited to assess awareness on essential information; 73% felt that there is no clear guideline available. There was poor awareness regarding the importance of anticoagulation restart (18%), need for repeat imaging (32%) and anti-convulsant prescribing (18%).

Conclusions

This audit shows ineffective communication with a tertiary centre during initial referral for conservatively managed TBI. We are creating a checklist together with neurosurgery in Coventry to ensure that all essential information is obtained to assist local management.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

318 Audit on national outcomes of surgical hip fracture management over a 5-year period in the UK

WC Kim ¹, AW Chan ², E Choi ³, S Hoh ⁴, CR Im ⁵, J Lam ⁶, DR Lee ⁶, CF Mok ⁶, V Soh ⁷

Abstract

Introduction

Hip fractures are a debilitating condition, becoming more prevalent in recent years because of the ageing population. This major public health issue has an estimated annual cost of £1 billion because it requires prompt surgical intervention and rehabilitation. This study aims to analyse the outcomes of surgical treatment and incidences of different surgical options for hip fractures.

Methods

Data were extracted from the National Hip Fracture Database, looking at hip fractures in patients aged ≥ 60 years in the UK. The monthly 30-day mortality rate, average hospital length of stay (LOS), and adherence to National Institute for Health and Care Excellence (NICE) recommendations for different hip fracture patterns between 2016 and 2020 were analysed. Statistical analysis was performed with a single factor analysis of variance and Tukey’s post-hoc testing.

Results

There was a significant increase in mortality between 2018 and 2020 (1.91% difference, p < 0.05). The average hospital LOS decreased in 2020 compared with 2016 (2.74 days, p < 0.01). Over the 5-year period the number of cemented arthroplasties and intramedullary nails for subtrochanteric fractures increased from 86.16% to 92.67%, and 84.36% to 89.83% respectively (p < 0.01), whereas the percentage of intertrochanteric fractures managed with sliding hip screws (SHSs) decreased from 76.86% to 67.35% (p < 0.01).

Conclusions

Improved postoperative outcomes have been seen with adherence to NICE guidelines; however, the decline in the use of SHSs suggests an advancement in surgical paradigm, based on clinical experience and novel implant designs, which may lead to lesser complications and shorter operations.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

322 Quality consent: an essential pillar in surgery

A Dadhich ¹, JJR Muthiah Raj ¹

Abstract

Introduction

The aim of this study was to assess the quality of consent form completion in comparison with standard consent form guidelines.

Methods

We carried out an audit loop based on data collected from June 2021 to March 2022. It was carried out on vascular surgery inpatients. The group selected were elective vascular surgeries. The patients were randomly selected based on their capacity to consent following standard vascular procedures consent form guidelines. Data collection was based on whether a consent form was signed, who signed the consent form, were all the complications mentioned and were there any postoperative complications?

Results

In the first cycle of the audit, the important outcome was that none of the consent forms had all the complications mentioned as per the guidelines. Among these consent forms, 50% were signed by speciality registrars, 25% by consultants and 25% were signed by both the registrar and the consultant. The implemented change was the introduction of printed stickers with all the complications mentioned. In the second cycle after implementation of the change, the proportion of missed complications was reduced to 25%.

Conclusions

Implementation of printed stickers ensured the quality of consent and reduced missed complications due to human errors. A proper consent process is essential to ensure that patients understand treatment options and the alternatives together with the risks, benefits and likely outcomes of any proposed treatment. It also helps the healthcare system financially by reducing the burden of medicolegal cases and bridges the miscommunication gap.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

324 Patient-related outcome measures logbook: a convenient way for ear, nose and throat trainees and surgeons to record their PROMs

H Siddique ¹, R Maweni ¹, M Todd ²

Abstract

Introduction

Patient-reported outcome measures (PROMs) are brief standardised tools designed to capture health-related quality-of-life outcomes from the perspective of patients and/or caregivers, with the objective of allowing greater clinician understanding of the effects of disease and treatments on patients’ lives.

Methods

An online easy-to-follow logbook has been designed to facilitate the processing of PROMs to a secure database set. The website consists of standardised well-known PROM questionnaires such as ‘SNOT-22’, capturing the health-related quality-of-life of patients/caregivers.

Results

PROMS have been used in the performance assessment of healthcare systems, benchmarking of healthcare organisations, quality improvement and progress monitoring as well as serving as treatment outcomes in clinical research. Evidence shows that the systematic use of information from PROMs leads to better communication and decision making between doctors and patients, with improvement in patient satisfaction. This creates potential for improved patient outcomes and fine-tuning of training to trainees.

Conclusions

PROMs are not used routinely. Even in otorhinolaryngology, where we benefit from having multiple validated tools for commonly encountered conditions. One of the main reasons identified is a lack of convenience, with many clinicians stating that collecting PROMs would add to their workload. The PROMs logbook has been created as a solution to make PROMs collection more convenient and to allow ear, nose and throat trainees and their trainers access to feedback directly from patients. Future development will be targeted at facilitating the delivery of personalised emails to patients and creating a searchable doctor list within the database.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

326 An audit: perioperative management of anticoagulation and antiplatelet therapy for local anaesthetic skin lesion patients within a plastic surgery department

KH Lim ¹, R Hand ², D Dewar ¹, B Strong ¹

Abstract

Introduction

There are substantial numbers of surgical patients on anticoagulant or antiplatelet treatment. Owing to the risk of haemorrhage or thrombosis perioperatively, thorough discussions between the surgeon and patient should be conducted regarding withholding or continuing their anticoagulation or antiplatelet therapy before surgery. Furthermore, said decisions and their rationale should be clearly documented. This audit aimed to assess the compliance with our department’s anticoagulation guideline for local anaesthetic (LA) surgery patients, and the quality of documentation.

Methods

We evaluated all plastic surgery patients listed for LA procedures from March to May 2022. Patients’ comorbidities, drug history, intended surgical procedure, decisions surrounding preoperative anticoagulation management and quality of documentation were assessed. Data were collected from patients’ surgical booking forms and clinic letters.

Results

A total of 35 patients were identified. A majority of patients (n = 21, 60%) were on antiplatelet therapy, followed by novel oral anticoagulant (n = 10, 29%) and warfarin (n = 14, 11%). There was clear documentation regarding the decision to continue or stop anticoagulation or antiplatelet therapy for 27 (77%) patients. A further nine patients (25.7%) also had the respective decision rationale documented in their clinic letters. There were variances in anticoagulation management found in two patients (5.7%) who consequently did not have the rationale documented.

Conclusions

Our audit showcased good adherence to the department’s guidelines on perioperative management on anticoagulation therapy. Most clinic letters included the surgeon’s decisions regarding perioperative anticoagulation management. Nonetheless, we plan to re-audit after raising awareness of the department’s anticoagulation guidelines, and the importance of complete documentation.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

327 Assessing the completion rates of discharge advice letters in the Welsh Burns and Plastic Surgery Centre

K Khan ¹, A Jawad ¹

Abstract

Introduction

Discharge advice letters are essential in contributing to a continuation of patient care in the community and in outpatient settings. It is good medical practice to aim for the completion rates within 24 hours of patients being discharged from hospital. The Welsh Centre for Burns and Plastic Surgery is a busy department with a high turnover of patients with varying degrees of complexities and comorbidities. Therefore, we aimed to audit the efficacy.

Methods

A retrospective study was conducted over a 6-month period between 2021 and 2022 in a tertiary burns and plastic surgery centre to assess completion rates within 24 hours of patients being discharged from the department. Hospital digital software was used to record patients’ location, length of stay and subspecialty. Subspeciality departments included paediatrics, trauma and elective patients.

Results

Some 1,037 electronic discharge summaries were assessed. The completion rate within 24 hours of discharge was 45% across the department. Elective patients who were discharged had the highest rate of completion of 60%, with paediatric 28% and trauma 32% patients having the lowest average rate.

Conclusions

There is significant deficiency in the timeliness of completion rates of discharge summaries within the department. Replication of this study and comparison of other surgical specialties is recommended. The rate of completion can be multifactorial and awareness should be spread to juniors and hospital staff to increase efficiency. High turnover rates and complex surgical issues can delay summary completion rates templates and posters should therefore be developed to increase completion rates.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

328 Aesthetic clinic management software: can we improve patient safety?

J Kamal ¹, D Zargaran ¹, A Mosahebi ¹

Abstract

Introduction

To evaluate the features of clinic management software (CMS) used by aesthetic clinics including complication capturing tools and create a framework with the aim of improving patient safety and compliance with GMC guidance.

Methods

Market research was conducted on 18 aesthetic-specific CMS to assess which have the following features: e-prescribing, secure internal messaging, patient portals, photo upload, facial charting, business reports, tablet/mobile application, video consultation tool, audit trails, patient record access restrictions and complication capturing tools. We also evaluated CMS costs and their user profile.

Results

Five CMS had complication capturing tools, two of which audited its use. Seven CMS stated that most of their users were doctors and nurses. Nine CMS had patient record access restrictions, whereas three did not. Ten CMS had an audit trail for, for example, documentation and patient record access, whereas two did not have an audit trail.

Conclusions

Many CMS are available, with a wide variety of features, some overlapping. The 2013 Keogh review revealed there are no central collections of data on complications following cosmetic interventions. We propose that CMS capture complications and audit this to provide a data pool for complications. Our research shows that currently CMS are not capturing complications well enough. In line with the above and General Medical Council (GMC) guidance, we propose a framework for CMS with the following features: complication capturing tools, for example a patient complaints portal for reporting adverse effects and auditing this regularly, e-prescribing, audit trail, data encryption, user restrictions and consultations template in line with GMC guidance.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

329 Is your breakthrough opiate breaking through?

A Shaharudin ^1,², A Pabari ^2,³

Abstract

Introduction

There are numerous situations in which prescribers prescribe morphine. Often no justification is seen in the way the dose and frequency are written up. The National Institute for Health and Care Excellence (NICE) guideline recommends an oral morphine dose of one-sixth to one-tenth of the total daily oral morphine dose, to be taken when required. This audit aims to look at compliance of inpatient breakthrough morphine prescribing, concurrent simple analgesia and laxatives prescription.

Methods

Inpatients on regular opiates were identified on all wards at Northampton General Hospital in a spot-check from August 2021 to July 2022. Prescription as needed (PRN) morphine was assessed from drug charts. Prescriptions of simple analgesia and laxatives to the same patients were also reviewed. Posters were then distributed to all prescribers via email and placed in all wards. Two cycles of data collection were undertaken to assess compliance in prescription.

Results

Forty-five inpatients on regular opiates were identified during cycle 1. Of these, 15.6% had a correct prescription of PRN morphine, 55.6% were on regular analgesia and 51.1% had concurrent laxatives prescribed. Cycle 2, carried out following the distribution of posters, identified 30 inpatients who met the study criteria. Of these, 36.7% had a correct prescription of PRN morphine, 93.3% were on regular analgesia and 70% had laxatives prescribed.

Conclusions

Improvements were seen in all aspects. However, correct PRN morphine in patients on regular opiates remains poor. This is important because patients postoperatively or palliative patients need adequate breakthrough pain medication. Educating prescribers will help improve patient care and is also cost-effective in the long run.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

330 Minor operations with minor complications: an audit of postoperative complications in plastic surgery

D Bhojwani ¹, D Adegbie ¹, F Begum ¹, S Murphy ¹, M Daruwalla ¹

Abstract

Introduction

Minor operating procedures (MOPS) at Lister Hospital refer to a range of superficial procedures undertaken by the plastic surgery department under local anaesthetic. These include simple excision biopsies, small skin grafts and local flaps.

Methods

A retrospective closed-loop audit was completed to review the number of postoperative complications from minor operations following an educational initiative about aseptic technique and sterile preparation.

Results

A total of 131 and 134 procedures were audited from a 2-week period in October 2020 and October 2021, respectively. Type of procedure, body area and incidence of complications were recorded using a combination of paper notes and electronic software (ICE, Nerve Centre and eTrauma). Results of the first audit were presented within the department prior to the re-audit to raise awareness about reducing complications. The results showed a 6.1% complication rate in 2020 compared with a rate of 1.5% in 2021. Complications included surgical site infections, wound dehiscence and the persistence of foreign body materials.

Conclusions

The re-audit was also presented a departmental audit meeting and confirmed the success of education to reduce postoperative complications in MOPS.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

332 Outcomes of sublay mesh repair in ventral abdominal hernia: a retrospective study

K Noureldin ¹, M Issa ²

Abstract

Introduction

Ventral hernia repair is one of the challenging surgical operations over time. It is suggested that sublay mesh repair has the lowest rate of recurrence and surgical site infection in open anterior abdominal hernia repair. This study aimed to analyse the pros and cons of sublay mesh use in ventral hernia repair to evaluate the significance of this technique as a treatment modality. Length of hospital stay (LOS), acute postoperative complications and recurrence rate were the main areas of investigation.

Methods

This was a retrospective study was on 79 patients with ventral hernias who were underwent (electively) sublay mesh repair over a period of 3 years. Fit patients with first-time ventral hernias (primary and incisional) were included. Recurrent hernia, associated decompensated cardiopulmonary disorders and bleeding disorders were excluded. The project performa includes patient demographics, operative details, LOS, postoperative complications and follow-up, up to 12 months.

Results

All patients underwent open mesh repair using the sublay technique. Ventral hernia was five times more common in females than males. Mean age at presentation was 44.8 years. Mean operating time was 67 minutes and mean LOS was 1 day. Para-umbilical and incisional hernias represented the majority of cases. A component separation approach was added in three cases (3.7%). Simultaneous cholecystectomy was performed in two cases (2.5%). Only six cases (6.3%) developed wound-related complications, whereas two cases (2.5%) had a recurrence.

Conclusions

Sublay mesh repair is favourable for ventral abdominal hernia reconstruction. It is associated with a smooth and short hospital stay and the least incidence of complications and recurrence.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

333 Perioperative antibiotic prescription for appendicectomies QIP

J Garner ¹, J Butler ¹

Abstract

Introduction

An audit investigating the management of patients who had complications after an appendicectomy found that perioperative antibiotic prescriptions could be improved. This aim of this quality improvement project (QIP) was to increase compliance of antibiotic prescriptions to World Society of Emergency Surgery Jerusalem guidelines (2020); a single dose of preoperative antibiotics should be given to all patients and patients with uncomplicated appendicitis should not be given postoperative antibiotics.

Methods

An education drive to raise awareness of appropriate antibiotic treatment for appendicitis was commenced and involved presentations during teaching, emails and posters. The information department was contacted, and 27 patients who had an appendicectomy between 10 May and 28 June 22 were identified. Data were collected retrospectively by analysing the patient’s online records regarding antibiotic prescriptions.

Results

Sixteen patients had simple appendicitis and 11 had complicated appendicitis. Seven per cent of patients in the previous audit had a complication, whereas none of the patients in this cycle of the audit had a complication documented. Overall, there was an improvement in preoperative antibiotic prescription from 84.2% to 88.9%. All patients with complicated appendicitis received postoperative antibiotics appropriately. However, 68.8% (11/16) of patients with simple appendicitis received postoperative antibiotics, which goes against recommendations.

Conclusions

This education drive improved antibiotic prescriptions for patients with appendicitis. An area of further development is antibiotic prescription for patients with simple appendicitis. These patients should all have at least one dose of preoperative intravenous co-amoxiclav and should not require postoperative antibiotics.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

335 A review of the management of foreign body removal in children’s ears in a tertiary hospital

C Woo ¹

Abstract

Introduction

Foreign bodies in children’s ears are a common presenting complaint to emergency departments. Most patients are managed in emergency ear, nose and throat (ENT) clinics, but some may require surgical removal under general anaesthetic (GA). This audit reviews whether there are any factors that may predict which children may require the latter.

Methods

This was a retrospective study that looked at patients presenting to ENT clinics from 1 October 2021 to 14 May 2022 inclusive. Any patients who presented with a foreign body in the ears and were seen at the SOS clinic were included in the audit. Patient demographics such as age and type of foreign body were documented. Outcome was then defined as whether the child was successfully managed in clinic or had to be listed for removal in theatre.

Results

In total, 22 patients presented in 8.5 months to the SOS clinic with a foreign body in the ear, ranging in age from 2 to 11, with a median age of 6. The foreign bodies were documented as crayon (18%), plastic bead/coin (36%), Play-Doh (9%), paper (14%), pebble (9%), rice (4.5%) and unidentifiable (9%). Only 4/22 patients had their foreign body removed successfully in clinic, with the majority 82% requiring removal under GA. There was no difference in age, gender or material in the patients who had their foreign body removed successfully in clinic.

Conclusions

Despite requiring GA to have their foreign body removed, most patients should be seen in clinic first because this can prevent any unnecessary GA.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

336 Is there an acute rehabilitation need for limb sarcoma patients in the Welsh Sarcoma Service?

K Khan ¹, C Ford ¹, J Vass ¹, T Bragg ¹

Abstract

Introduction

Sarcoma is a rare type of malignancy. However, in 2020, 154 people in South Wales were diagnosed with soft-tissue sarcomas. Sarcoma affects a diverse age range of patients with non-existent to widespread comorbidities, and the extent of surgery and further chemo- and radiotherapy can be debilitating, requiring a strong multidisciplinary team to improve best patient outcomes. The aim of this study was to identify the acute physiotherapy needs of lower and upper limb sarcoma patients in Wales.

Methods

This was a retrospective study. The functional assessment of patients with limb sarcomas was carried out using Toronto Extremity Salvage Score questionnaires. This questionnaire assesses the baseline mobility and daily function of each patient. The questionnaire was done preoperatively and 6 weeks postoperatively, and scores were compared to assess an acute rehabilitation need.

Results

From 94 patients (23 upper limb and 71 lower limb) average baseline score was 75% function preoperatively for lower limb (LL) patients and 85% for upper limb (UL) patients. Six weeks postoperatively, the average baseline score was 55% (LL) and 70% (UL). The highest score rehabilitation needs postoperatively for patients was a 55% decrease in the ability to drive and a 60% decrease in working hours. Self-care and socialising also decreased by 50% postoperatively.

Conclusions

There is high demand for postoperative rehabilitation services including, physiotherapy and physiological therapies, in Wales. If needs are not met acutely this may lead to long-term and permanent mobility complications and worsening in quality of life.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

337 Managing primary Achilles tendon ruptures with functional bracing orthoses: experience at a North London district general hospital

L Zhu ¹, S Shah ², K Rajasekar ², S Janipireddy ²

Abstract

Introduction

The Achilles tendon is the strongest yet most commonly ruptured tendon in the body. Achilles tendon ruptures (ATR) have a peak prevalence in intermittently active patients in their third to fifth decades of life and are strongly associated with sport. There exists much debate surrounding the choice between operative and conservative management, and within this serial casting compared with functional bracing.

Methods

This single-centre prospective case-controlled quality improvement project of a district general hospital orthopaedics department followed consecutive ATRs managed by VACOped functional orthoses issued at fracture clinic between May and August 2021. Patients were followed up at 6 months to assess for re-rupture, and at 12 months via telephone for re-rupture and score on a validated quality-of-life instrument (Achilles Tendon Rupture Score).

Results

At 6-month follow-up, there were no reported re-ruptures following a median of four fracture clinic appointments, and a median of five physiotherapy sessions. The median time to discharge from orthopaedics was 9 weeks, and discharge from physiotherapy was 17 weeks. Follow-up was successful in 17/25 (68%) patients with mean duration since rupture of 12.8 months. There were no re-ruptures in patients who reported the highest residual limitation in activities that include running and jumping. Furthermore, patients reported high scores in symptoms including stiffness, decreased strength and fatigue. Reassuringly, reported limitation in activities of daily living were low.

Conclusions

This quality improvement project demonstrates positive outcomes with the use of functional bracing orthoses for the management of primary ATR.

Robotics and digital surgery

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

83 The transition from transoral laser microsurgery to transoral robotic surgery: does the patient pathway change?

JY Tan ¹, J Moor ¹

Abstract

Introduction

The incidence of oropharyngeal squamous cell carcinoma (OPSCC) is rising in the UK. Minimally invasive surgical techniques including transoral laser microsurgery (TOLM) and transoral robotic surgery (TORS) are becoming more well-established for primary surgical treatment of OPSCC, driven by the desire to reduce the treatment-related toxicity of chemoradiotherapy and functional morbidity of open surgery. The ear, nose and throat department of Leeds Teaching Hospitals has evolved in parallel with the advancement of these new surgical approaches. Our department has employed TOLM and now the TORS approach as primary surgery. This audit aims to compare the adjuvant treatment prescribing rates in patients with primary OPSCC who underwent TOLM or TORS.

Methods

We performed a prospective collation of patient-level data with retrospective case note review. These primary surgery cases of TOLM or TORS were identified at the weekly multidisciplinary team meeting. Numbers of patients undergoing no adjuvant treatment, adjuvant radiotherapy or adjuvant chemoradiotherapy were identified.

Results

Between October 2015 and November 2017, 37 patients underwent TOLM resection. Between December 2017 and March 2022, 90 patients underwent TORS resection. These data show that the transition from TOLM to TORS does not affect the treatment pathway in a statistically significant way.

Conclusions

A TOLM service would seem to be a good precursor for developing a new TORS programme. Units with an existing TOLM service, including patients and non-surgical members of the multidisciplinary team can be reassured that with the transition from TOLM to TORS as a primary treatment for appropriate OPSCC cases, prescribing rates for adjuvant treatments does not significantly change.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

137 Exploring the value of undergraduate competency-based surgical training through the MSc in Laparoscopic Surgery and Surgical Skills: an experimental and survey-based study

R Vyas ¹, B Patel ¹

Abstract

Introduction

The objectives of this study were to investigate the effect of early surgical training on surgical proficiencies and surgical interest in undergraduate medical students and whether further surgical training should be incorporated into the standard undergraduate medical curriculum.

Methods

An experimental approach with a supplementary survey (including a short knowledge quiz) was used with two groups: an intervention group taking the MSc in Laparoscopic Surgery and Surgical Skills, and a control group acting as a baseline. The primary outcomes were improvements in open suturing, laparoscopic suturing and surgical knowledge.

Results

In total, 29 participants were recruited, with 14 in the intervention group and 15 in the control. There was a significant difference in the mean total percentage score for open suturing (11.43%, 95% confidence interval [CI] 5.73 to 17.13, p = 0.0003), laparoscopic suturing (18.23%, 95% CI 12.94 to 23.92, p = 0.0001) and surgical knowledge (26.71%, p < 0.0001), showing a substantial improvement fulfilling the primary outcomes of the study. The survey responses (secondary outcomes) demonstrated an increased confidence in research skills, a push for further surgical education at the undergraduate level, reduced worries and concerns regarding surgery, and an increased interest in surgery. There was a little difference for confidence in surgical skill, knowledge and exposure to surgery.

Conclusions

This study suggests that surgical training at the undergraduate level holds significant value in various ways. Further surgical teaching should be incorporated earlier in the medical school curriculum, specifically to ensure that students have greater confidence to meet the expected General Medical Council outcomes for graduates.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

152 The impact of augmented reality training on laparoscopic appendectomy utilising objective performance metrics

D Rawaf ^1,^2,³, J Toms ³, M Sheikh ³, G Beghal ³, A Joynson ⁴, N Kaur ¹, E Street ¹, J Van Flute ¹

Abstract

Introduction

Utilising the LapAR™ by Inovus Medical, we supervised surgical trainees performing several augmented reality simulated appendectomies interspersed with LapPass tasks. Objective metrics measured include time to completion, distance travelled by instruments, instrument acceleration, hand dominance and instrument time in view. The study was undertaken at a National Health Service university teaching hospital in South London.

Methods

Comparison was made with a benchmark score set by an experienced minimally invasive surgery (MIS) surgeon. Subjective performance feedback was also provided by experienced surgeons using the work-based assessment (WBA) framework. During the course, benchmarks of both LapPass tasks and appendicectomies were set by each trainee in addition to an experienced MIS surgeon. Trainees were then asked to perform a series of tasks including further appendicectomies and LapPass tasks. Following this period of intervention, trainees were set a final benchmark to compare with their original.

Results

We found that the performance metrics improved when comparing initial and final benchmarks. In addition, the final benchmark metrics of the trainees were compared in a standardisation exercise with the benchmark set by the experienced MIS surgeon. Of note, time to completion and distance travelled were both markedly reduced following the intervention period. WBA review of performance demonstrated a marked improvement in surgical skill.

Conclusions

Augmented reality task training using a high-fidelity trainer such as the LapAR™ improves objective and subjective performance in simulated appendicectomy completion. It can be inferred that this technique improves the surgical learning curve while safely taking it away from the live patient.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

172 Learning with immersive virtual reality improves efficiency, confidence and knowledge of novice scrub nurses in learning skills for anterior approach total hip arthroplasty: a randomised controlled trial

T Edwards ¹, I Poole ¹, J Edwards ¹, F Kablean-Howard ¹, M Karia ¹, K King ², J Bliss ², A Liddle ¹, J Cobb ¹, K Logishetty ¹

Abstract

Introduction

Superior surgical team performance improves patient outcomes. Scrub nurses are pivotal team members yet have little structured training. Immersive virtual reality (iVR) simulation is an accessible technology allowing practitioners to practise skills without patient risk. This study examines the impact of iVR on novice scrub nurse skill, knowledge and confidence.

Methods

Sixty nursing students were included and randomised (1:1 ratio) to conventional or iVR training. Participants with prior nailing operation or iVR surgical simulation experience were excluded. Conventional training (derived through expert consensus) involved a 1-hour seminar and 2 hours of e-learning, teaching the operation equipment and sequence. The iVR training comprised three separate 1-hour sessions in which participants were scrub nurses within a virtual operation. iVR outcomes were time taken to complete the virtual operation and dominant hand motion. Real-world transfer was assessed through expert-derived knowledge test and self-perceived confidence/ability, measured using a validated 5-point Likert scale.

Results

Fifty-three participants completed the study (27 iVR, 26 conventional) with a mean age of 31 ± 9 years. There were no significant differences in baseline characteristics or knowledge scores between the groups (p > 0.05). Procedure time decreased across the sessions by 30.2%, dominant hand motion decreased 7.7%. The iVR group demonstrated superior improvement in knowledge from baseline (84.2% vs 47.2%, p < 0.0001) and in confidence identifying, understanding and assembling equipment compared with conventionally trained participants.

Conclusions

iVR training improves efficiency, knowledge and confidence for novice scrub nurses learning anterior approach total hip arthroplasty (AA-THA). This accessible, low-cost training modality could be integrated into scrub nursing curricula to address the training shortfall.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

176 Immersive virtual reality training is superior to conventional training for novice scrub nurses learning intramedullary tibial nail: a randomised controlled trial

T Edwards ¹, F Kablean-Howard ¹, I Poole ¹, J Edwards ¹, K King ², J Bliss ², A Liddle ¹, J Cobb ¹, K Logishetty ¹

Abstract

Introduction

Superior surgical team performance improves patient outcomes. Scrub nurses are pivotal team members yet have little structured training. Immersive virtual reality (iVR) simulation is an accessible technology allowing practitioners to practise skills without patient risk. This randomised study investigates the impact of iVR in training prospective scrub nurses to perform their role in intramedullary tibial nailing.

Methods

Sixty nursing students were included and randomised (1:1 ratio) to conventional or iVR training. Participants with prior nailing operation or iVR surgical simulation experience were excluded. Conventional training was a 1-hour seminar and 2 hours of e-learning, which taught the equipment and operation sequence. iVR training comprised three separate 1-hour sessions in which participants performed the operation virtually. Primary outcome was performance in a physical world practical assessment with real equipment, which tested the knowledge and skills needed for scrub nurses in the operation. The assessment was developed and validated using a modified Delphi method, with experts consisting of scrub nurses, surgeons and industry representatives.

Results

Fifty-three participants completed the study (26 iVR, 27 conventional), mean age 31 ± 9 years. There were no significant differences in baseline characteristics or knowledge test scores between the groups (p > 0.05). The iVR group significantly outperformed the conventionally trained group in real-world assessment, scoring 65.4% ± 17.7% vs 37.3% ± 15.9% (p < 0.0001).

Conclusions

iVR was superior to conventional training in teaching novice scrub nurses to perform their role for intramedullary tibial nailing. This accessible, low-cost training modality could be integrated into scrub nursing curricula to address the training shortfall.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

185 The impact of augmented reality training on patient treatment pathways

D Rawaf ^1,^2,³, E Street ¹, L Tenang ^1,², J Van Flute ¹

Abstract

Introduction

The aim of this study was to understand the impact of augmented reality (AR) training on patient and surgical outcomes.

Methods

Needham et al estimated costs of a laparoscopic appendectomy in 2007. Using this data, we estimate the financial impact the technology may have through improvement in surgical outcomes. The costs were estimated using the Personal Social Services Research Unit hospital and community health services index. Currently, median times for a laparoscopic completed procedure and a laparoscopic conversion are estimated to be 59 and 101 minutes, respectively. The median total hospital stay is 3 days, and 0.22% of patients will have bowel perforation. Currently, median theatre costs are £780 per patient, with ward costs of £776. Thus, the total inpatient cost for a laparoscopic appendectomy is £1,903. Using this estimate, we are able to calculate the possible cost savings per patient.

Results

The average cost in theatre is assumed to reduce from £780 to £702, and the cost of bowel perforations from £2,153 to £1,937. Thus, total cost difference per patient is estimated at £79. It should be noted that this cost difference assumes that all the benefit of the surgical technology will be realised in every procedure undertaken in theatre.

Conclusions

Assuming 150 trusts with a total of 10,000 surgeries a day (including the fixed costs of equipment), total cost savings in the first year will be £777,579 realised after the 115th surgery. In subsequent years, the cost savings will be £786,574 per trust. This process was peer-reviewed by the Inovus clinical excellence team and the British Medical Association.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

197 Improving the sustainability of ear, nose and throat surgery: the argument for reusable fibreoptic nasendoscopes

L Jegatheeswaran ¹, K Oungpasuk ², B Choi ³, S Gokani ¹, A Espehana ¹, TKP Naing ¹, O Burgan ¹

Abstract

Introduction

Fibreoptic nasendoscopy is a common procedure within the field of ear, nose and throat (ENT) surgery, performed primarily as a diagnostic and therapeutic tool within the upper aerodigestive tract. In recent years, a mixture of reusable and disposable fibreoptic nasendoscopes (FNEs) have become available for clinicians to use. Reusable FNEs are reprocessed after each use, whereas disposable FNEs are designed to be single-use only. Anecdotally, at the host institution, concerns were raised about the waste associated with disposable FNEs. This study primarily assessed Health Education England ENT trainees’ preferences on the qualities of disposable and reusable FNEs, for emergency on-call purposes. Secondary aims included: eliciting trainees’ views on ENT surgery and climate change; and creating a single-centre per-use cost analysis for disposable and reusable FNEs.

Methods

An online survey consisting of multiple-choice and Likert-scale questions was distributed nationally. Cost analysis was performed using 2021/2022 financial data from the host institution. A National Institute for Health and Care Excellence (NICE)-recommended 3.5% discount was applied to future costs occurring in the 5- and 10-year analysis.

Results

Twenty-four trainees responded nationally (8.1% response rate). There was no difference in overall satisfaction for disposable FNEs (p = 0.244). Reusable FNEs had a lower cost per use compared with disposable FNEs at 5 years (4.7% reduction) and 10 years (7.1% reduction). Among the trainees, 79.2% were supportive of climate-friendly initiatives within ENT surgery; only 25% felt supported by their departments in pursuing these initiatives.

Conclusions

Trainees’ satisfaction with disposable and reusable FNEs is similar. Cost analysis favours reusable FNEs long term at the host institution. Empowering departments and trainees to pursue climate-friendly initiatives should be encouraged.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

305 Examining the discourse around surgical innovation on Twitter

N Alford ^1,², C Hoffmann ^3,⁴, R Macefield ^3,⁴, K Avery ³, S Potter ^4,⁵, N Blencowe ^4,⁶

Abstract

Introduction

Innovation is crucial to advancing surgical practice. Dissemination of new information from innovation is done through traditional channels (peer-reviewed publications, etc). These methods are limited because innovative procedures evolve quickly and undergo modification. Surgeons have used Twitter to disseminate real-time information. Therefore, Twitter represents an important method for sharing learning. The extent of the utility of Twitter for disseminating information about surgical innovation, however, is unknown. The aim of this study was to examine: (1) how Twitter is being used to share information about surgical innovation; and (2) current practices of information sharing (including content and type of data).

Methods

Online software (Mediatoolkit) was used together with keywords related to ‘surgery’ and ‘innovation’. Searches were limited to the period 21 September to 21 October 2021. Tweets were classified by the type, for example advertising or promoting. Metadata (eg, Tweet, source) was examined.

Results

A total of 954 tweets were captured, of which 238 were relevant to surgical innovation. Tweets were classified into four categories (advertising conferences, marketing new products, promoting self/colleagues and sharing information). A total of 110/238 (42%) tweets were categorised as sharing information about a surgical innovation, with most posted by US users. Some 76/238 (32%) tweets used Twitter as a promotional tool to endorse an innovation. General surgery was the most engaged speciality, totalling 60/137 (44%). Tweets with the most engagement discussed innovation in remote surgery (1,202,401 people) and orthopaedics (6,090).

Conclusions

The study demonstrates the practice of utilising Twitter to disseminate innovation. Twitter represents an important method of sharing information with inevitable implications for surgical innovations.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

312 Conventional, navigated or robotic total knee arthroplasty: is there a difference in the radiological and clinical outcomes?

L Al-Hilfii ¹, I Afzal ², H Mercalose ¹

Abstract

Introduction

Despite advances in navigated and robotic-assisted surgery, there has been no direct comparison. Our study reviewed a matched cohort of patients undergoing conventional, navigated and robotic-assisted total knee arthroplasty (RTKA) to identify whether there are differences in radiological and clinical outcomes in these techniques.

Methods

In each of the different surgical techniques there were 88 TKA procedures included. Patient cohorts were matched for valgus and varus preoperative deformity, grade of preoperative osteoarthritis and patient demographics; patient-reported outcomes and radiographic data were reviewed.

Results

Mean correction for tibiofemoral alignment for the RTKA was −3.58°, for the navigated assisted TKA (NTKA) was −5.00° and for the conventional TKA (CTKA) was −4.16°. Mean posterior slope was reported as 4.46°, 7.89° and 5.20°, respectively. An independent Kruskal–Wallis test comparing the posterior slope showed there was statistical significance (p < 0.005) between the different types of surgical techniques. There was no statistical significance between the groups for the Oxford Knee Score (OKS) and EuroQuol-5D (EQ-5D) scores, 6-week and 1-year outcome satisfaction. CTKA had the shortest length of stay (LOS), length of operation and lowest readmission rate. There was statistical significance between the groups for the length of operation (p < 0.005). There have been no major reported complications in any of the cohorts.

Conclusions

Although technology may offer better short-term results based on the literature, our results show CTKA to have the greatest mean improvement in OKS and EQ-5D scores, lowest LOS, lowest length of operation and lowest 30-day readmission when compared with RTKA and NTKA.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

5 What is the best fixation technique for isolated talonavicular arthrodesis? A systematic review

V Arumugam ¹, S Ranjit ², S Patel ³, M Welck ³

Abstract

Introduction

Various fixation devices have been reported for talonavicular arthrodesis including screws, staples, plates, K-wires and intraosseous fix systems. This systematic review aims to compare outcomes between different fixation devices for talonavicular arthrodesis.

Methods

MEDLINE, Embase, CENTRAL and Google Scholar were reviewed for studies reporting on outcomes of different fixation techniques for talonavicular arthrodesis indicated for osteoarthritis, rheumatoid arthritis and post-traumatic arthritis from 1946 to 2021. The primary outcome measure was union rate. Secondary outcome measures included functional improvement, cost, quality of life and patient satisfaction.

Findings

Nine articles involving 141 cases of talonavicular arthrodesis were identified. Fusion rates were as follows: screw fixation (n = 75), 87.5% to 100%; staple fixation (n = 13), 100%; intraosseous fix systems (n = 16), 100%; and K-wire fixation (n = 2), 100%. One study utilised a dorsal locking plate with two supplemented compression screws (n = 9, fusion rate = 100%) and two studies used a combination of screws with staples (n = 26, fusion rate = 96%). Seven of 9 studies measured functional outcomes and pain relief with improvement demonstrated in all fixation techniques. Quality of life, satisfaction and cost were inadequately reported among the included studies. All studies were rated as serious risk of bias.

Conclusions

This systematic review consolidates the evidence for outcomes of different fixation techniques for talonavicular arthrodesis; however, a definitive judgement regarding the best fixation technique is unobtainable from current clinical evidence, owing to lack of high-quality studies. With review of biomechanical studies and the limited clinical data, fixation with plate plus screw is most promising and would warrant further comparative study.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

47 Simultaneous occurrence of subarachnoid haemorrhage and cerebral venous sinus thrombosis: a systematic review of cases

D Jesuyajolu ¹, O Olukoya ², T Moti ¹

Abstract

Introduction

Although the leading causes of subarachnoid haemorrhage (SAH) are aneurysm rupture and arteriovenous malformations, cerebral venous sinus thrombosis (CVST) can, in rare cases, be associated with SAH. We aimed to comprehensively review cases in which this uncommon phenomenon occurred and identify their peculiarities based on presentation and management.

Methods

To identify potentially relevant papers, the following databases were searched: PubMed and Ovid Embase. A complementary search of Google Scholar and African Journals Online was done. A grey literature search was also conducted on the Google search engine for any additional relevant papers. We were able to extract data regarding 33 cases from 29 identified studies.

Findings

The mean age was 46.6 ± 14.08 years and 17 (51.5%) were female; the female-to-male ratio is 1.1:1. Headache was by far the most common symptom (27 patients), followed by seizures in 14 patients. Four patients had loss of consciousness and five patients had some form of focal neurologic deficit. Twenty patients had CVST in at least two different sinuses. Of the different locations for the CVSTs, the superior sagittal sinus was the most common location (79%), followed by the transverse sinus (57.5%). Twenty-nine cases (89%) were managed with anticoagulation alone and one case had a mechanical thrombectomy first prior to anticoagulation.

Conclusions

We identified some peculiarities and challenges to the management of cases with simultaneous occurrence of SAH and CVST. Further research is needed to identify a causal relationship and to serve as a basis for the development of a standard management guideline across the board.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

49 Comparison of multiparametric magnetic resonance imaging with prostate-specific membrane antigen positron-emission tomography imaging in primary prostate cancer diagnosis: a systematic review and meta-analysis

Y Zhao ¹, B Simpson ², N Morka ³, A Freeman ⁴, A Kirkham ⁴, D Kelly ⁵, H Whitaker ⁶, M Emberton ^4,⁶, J Norris ¹

Abstract

Introduction

Multiparametric magnetic resonance imaging (mpMRI) has proven utility in diagnosing primary prostate cancer. However, the diagnostic potential of prostate-specific membrane antigen positron-emission tomography (PSMA PET) has yet to be established. This study aims to systematically review the current literature comparing the diagnostic performance of mpMRI and PSMA PET imaging to diagnose primary prostate cancer.

Methods

A systematic literature search was performed up to December 2021. Quality analyses were conducted using the QUADAS-2 tool. The reference standard was whole-mount prostatectomy or prostate biopsy. Statistical analysis involved pooling of the reported diagnostic performances of each modality, and differences in per-patient and per-lesion analysis were compared using a Fisher’s exact test.

Findings

Ten articles were included in the meta-analysis. At a per-patient level, the pooled values of sensitivity, specificity and area under the curve (AUC) for mpMRI and PSMA PET/computed tomography (CT) were 0.87 (95% confidence interval [CI] 0.83 to 0.91) vs 0.93 (95% CI 0.90 to 0.96, p < 0.01); 0.47 (95% CI 0.23 to 0.71) vs 0.54 (95% CI 0.23 to 0.84, p > 0.05); and 0.84 vs 0.91, respectively. At a per-lesion level, the pooled sensitivity, specificity and AUC value for mpMRI and PSMA PET/CT were lower, at 0.63 (95% CI 0.52 to 0.74) vs 0.79 (95% CI 0.62 to 0.92, p < 0.001); 0.88 (95% CI 0.81 to 0.95) vs 0.71 (95% CI 0.47 to 0.90, p < 0.05); and 0.83 vs 0.84, respectively. High heterogeneity was observed between studies.

Conclusions

PSMA PET/CT may better confirm the presence of prostate cancer than mpMRI. However, both modalities appear comparable in determining the localisation of the lesions.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

59 Efficacy of minimally invasive surgical techniques on hallux valgus: a systematic review

A Lisacek-Kiosoglous ^1,², A Georgiou ¹, S Antoniou ³, S Ristanis ⁴

Abstract

Introduction

The aim of this study was to systematically search the literature to evaluate the efficacy of minimally invasive surgery for hallux valgus with respect to surgical outcomes and patient-reported outcomes.

Methods

MEDLINE Complete, PubMed, Cochrane Library, SCOPUS, SAGE Journals and grey literature were searched. All studies published in English documenting surgical outcomes and patient-reported outcomes were included.

Findings

The literature search identified 2,558 abstracts, which were screened for eligibility, and 30 papers were identified as meeting the inclusion criteria. A total of 1,979 patients were treated over all the included studies. The surgical outcome measures reported by most papers included hallux valgus angle, distal metatarsal articular angle and intermetatarsal articular angle. Patient-reported outcome measures reported included the American Orthopaedic Foot and Ankle Society score, pain on a visual analogue scale and subjective patient satisfaction. All complications reported were extracted. Follow-up times ranged from 5 months to 10 years, with most papers reporting 12–24 months.

Conclusions

This review demonstrates the wide variety of procedures for hallux valgus. Overall, there is no sufficient data to suggest that one minimally invasive procedure is superior to another. We note that a larger number of studies reporting minimally invasive Chevron and Akin (MICA) and Reverdin–Isham procedures were present in the literature and the higher complication rate in the Reverdin–Isham compared with MICA. More controlled trials are necessary to further explore patient preference with each procedure, in particular with regard to longer term patient-reported outcomes.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

71 Foreseeing the future of cataract surgery training with virtual reality

B Yassa ¹, SP Glynou ¹, P Giannakis ^1,²

Abstract

Introduction

Cataract surgery is one the most common elective surgeries performed worldwide. One in three people over the age of 65 requires cataract surgery, so high fidelity is vital for all ophthalmology trainees. Virtual reality (VR) has been progressively popular in surgical training, including ophthalmology. VR is an emerging teaching tool to train and achieve proficiency in cataract surgery for ophthalmology trainees. Trainees enter a full-circle active learning experience that overcomes the barrier of VR by incorporating real-life sights and sounds. This review aims to explore VR on cataract surgery in correlation and in contrast to real-life cataract surgery performance.

Methods

PubMed, Embase and Cochrane Library were accessed using the keywords ‘virtual reality’ and ‘ophthalmology training’. In total, 284 publications were assessed collaboratively on Rayyan and were included if they met the inclusion criteria: talking about cataract surgery and VR training; exclusion criteria included publications that are editorials, letters to the editor. Twenty-three publications met the criteria and were included.

Findings

Of the 23 publications, 5 were situated in the UK, 5 were in Denmark and 7 were in USA.

Conclusions

Cataract surgery training is required to prepare competent future ophthalmologists in such a fundamental but vital expertise. VR simulators are an effective tool for evaluating student performance and establishing their skill level. They may also help improve surgical performance and patient outcomes in cataract surgery. In the future, it will be vital to employ technology improvements in simulators for teaching and research.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

79 Evaluating the effectiveness of mindfulness-based stress reduction (MBSR) programmes as an adjunct in the management of breast cancer: a systematic review and meta-analysis

L Jegatheeswaran ¹, B Choi ², H Rizki ³, A Chakravorty ⁴, E Babu ⁴, V Patel ⁴

Abstract

Introduction

Women with breast cancer have more lost disability-adjusted life years compared with any other type of cancer globally. Mindfulness-based stress reduction (MBSR) programmes have been identified as a possible effective adjunct in cancer treatment. This study aims to identify whether MBSR is a useful adjunct alongside standard care for women with a diagnosis of primary stage I to III breast cancer.

Methods

A search on MEDLINE and Embase was performed to identify appropriate studies to be included. Primary outcome measures included: quality of life, anxiety and depression, with secondary measures including fatigue, perceived stress levels, quality of sleep and pain.

Findings

A total of 14 studies were included with 1,951 patients. Significant short-term improvement occurred post MBSR in validated scores relating to quality of life (p < 0.001) despite high heterogeneity among the studies (p < 0.001; I² = 86%). There was significant short-term improvement post MBSR relating to depression (p < 0.001) and anxiety (p < 0.001) with minimal heterogeneity observed. Other outcome measures that demonstrated an improvement included perceived stress levels (p < 0.001) and quality of sleep (p = 0.01). Non-significant short-term improvements were noted in validated scores for pain (p = 0.38) and fatigue (p = 0.26).

Conclusions

This study demonstrates some clinical benefit for patients with primary breast cancer stage I to III, undergoing an MBSR programme. Future studies should be designed to evaluate its long-term impact. Furthermore, a consensus on utilising a standardised validated tool for each outcome measured, may reduce methodological heterogeneity among future studies.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

118 The epidemiology of trauma presentations to major trauma centres in England during the beginning of the COVID-19 pandemic: a systematic review

J Parker ¹, J Aamir ², P Byrne ³, L Mason ²

Abstract

Introduction

The beginning of the COVID-19 pandemic and the ‘lockdowns’ implemented in England caused unprecedented behavioural change. Research into how this impacted trauma presentations is needed to contribute to our understanding of how trauma epidemiology changed during this period. The primary objective was to determine whether the demographics of trauma patients changed during the lockdown period of the pandemic. The secondary objectives were to determine whether the volume of trauma or mechanism of injury changed during the lockdown period of the pandemic.

Methods

A systematic electronic review was conducted using PubMed, Science Direct, Ovid and SCOPUS databases. All studies with major trauma centre presentation data from the beginning of the pandemic, made comparison with a pre-pandemic trauma presentation cohort and that used quantitative data were included.

Findings

Sixty-one studies were screened with five retrievable studies meeting the inclusion and exclusion criteria. Five studies with 2,106 patients were considered. The reduction in the volume of trauma presentations ranged from 18.2% to 46.5%. Injury mechanism as a proportion of trauma aetiology changed with road traffic collisions decreasing, and self-harm and interpersonal violence increasing. The number of women suffering penetrating injuries and partners perpetrating assaults increased. There was no significant change in patient age.

Conclusions

This review suggests there has been a reduction in the volume of trauma presentations to major trauma centres in England during the COVID-19 pandemic and changes in trauma typology. This study provides data for effective resource allocation in trauma care and public health interventions during pandemics.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

120 The effectiveness of endoscopic dilation and stenting in treating anastomotic strictures as a complication of oesophageal atresia repair

K Kabay ¹

Abstract

Introduction

Oesophageal atresia (OA) is a congenital anomaly in which the oesophagus does not fully develop. This is treated surgically, which can result in various complications. Anastomotic stricture is the most common postoperative complication, occurring in approximately one-third of patients. Furthermore, strictures are managed with procedural treatment with endoscopic bougie/balloon dilation or stenting. This review aims to evaluate the literature surrounding the use of dilation and stenting in treating anastomotic strictures post-OA repair, and to determine which method is the most effective.

Methods

A systematic review was undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Several electronic databases (MEDLINE and SCOPUS) were used in the literature search to identify articles that used dilation or stenting in treating anastomotic strictures post-OA repair. Moreover, a bias assessment of each study was conducted using the ROBINS-I tool.

Findings

Nine retrospective single-centred cohort studies were identified with five articles using dilation and four using stenting to manage strictures. Furthermore, 189/247 (76.5%) patients who underwent dilation were treated successfully. Meanwhile, 33/69 (47.8%) patients who were treated with stenting were successful; significantly lower than patients who were managed with dilation.

Conclusions

The studies highlighted that dilation is the most effective method of treating anastomotic strictures post-OA repair. Stenting was shown to produce more complications and be less successful in reducing symptoms. However, the low number of studies incorporated in this analysis limits these findings. Therefore, future research should be conducted on the use of stenting to further optimise the technique and indications for use to produce better patient outcomes.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

131 Ascending aorta pathology: open repair or endovascular?

S Cyclewala ¹, S Alwis ¹, Y Salmasi ², C Nienaber ¹

Abstract

Introduction

Open surgical repair is the established gold-standard treatment for ascending aortic (AA) pathologies. In recent years, endovascular stenting (TEVAR) of the AA has been attempted, but with only limited understanding of the outcomes. This study is aimed at systematically reviewing the literature to determine the safety and outcomes of endovascular stenting as treatment for the ascending aorta pathology.

Methods

A literature search was conducted in five online databases, incorporating cohort studies and case series of patients undergoing TEVAR for pathology in the AA region. Qualitative analysis of patient covariates and outcomes were measured using pooled meta-analysis. Meta-regression was used to assess the complication rates.

Findings

A total of 572 endovascular procedures were identified, of which 89% were elective aneurysm repairs and 11% acute aortic dissections. Pooled analysis revealed a procedural mortality of 4.19%. The incidence of endo-leaks was 17.6% and at long-term follow-up 17.1% required re-intervention. The incidence of neurological complications including major and minor strokes and spinal cord ischaemia was 6.8%. A meta-regression analysis revealed congestive heart failure as a predictor of postoperative endo-leaks. No other variable (age, gender, diabetes, peripheral vascular disease (PVD)) were shown to be predictive of endo-leaks postoperatively. The presence of diabetes as a covariate was found to be a predictor of lower rates of re-intervention.

Conclusions

Endovascular repair of AA aneurysms is a safe alternative to surgery in high-risk patients, although the risks of endorphin leaks and re-interventions are not negligible. This analysis indicates careful patient selection is needed, especially to ensure good patient outcome.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

147 Hyperthermic intraperitoneal chemotherapy in metastatic peritoneal neuroendocrine tumours

H Wilson ¹, R Freer ¹, R Mirnezami ¹

Abstract

Introduction

Since 1994, neuroendocrine tumour (NET)-derived peritoneal metastasis has been treated with complete cytoreductive surgery (CCRS). At times, this is combined with hyperthermic intraperitoneal chemotherapy (HIPEC) based on its evidenced impact on survival years in ovarian and peritoneal primary cancers. Despite its implementation in practice, there is a lack of validated evidence for its use.

Methods

A systematic search of PubMed, Cochrane, MEDLINE, Google Scholar and Ovid from 1980 to 22 September 2021 was performed. The search used the terms [‘HIPEC’ OR ‘Hyperthermic intraperitoneal chemotherapy’] AND [‘Metastatic peritoneal’ OR ‘Peritoneal Metastasis’] AND [‘Neuroendocrine tumour’] were searched.

Results

A total of 84 articles were identified using our search criteria. Following initial assessment using our exclusion criteria, 14 articles were rejected and 70 studies remained for full-text review. Following full-text review, 68 studies were rejected and 2 remained. A total of 155 patients received HIPEC in the two studies. Elias et al reported a 1-year disease-free survival (DFS) at 77% and 49% and a 2-year DFS of 49% and 17%, respectively. These outcomes were statistically significant (p = 0.02). The complication rate ranged from 39%–61%. There was no significant difference in the major complication rate between patients who did and did not receive HIPEC.

Conclusions

At present, there is insufficient literature to review the impact of the addition of HIPEC to CCRS in the treatment of peritoneal metastasis from NET. Individual trials to date have not demonstrated an increase in complication rates and therefore further randomised controlled trials would be beneficial to establish the optimal treatment for these tumours.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

186 Robotic appendectomy: a systematic review of feasibility

H Arang ¹, M El Boghdady ²

Abstract

Introduction

Acute appendicitis is known to be one of the most common abdominal surgical emergencies. Laparoscopic appendectomy is considered the gold-standard management. There has been an increasing trend in the routine use of robotic surgery in abdominal surgery. However, it remains underutilised in emergency surgeries. We aimed to systematically review robotic appendectomy (RA) procedures in elective and emergency settings and study its indications and feasibility.

Methods

A 20-year systematic review was performed in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was performed on PubMed, Science Direct and the Cochrane Library databases. For quality assessment, MERSQI score was applied. The research protocol was registered with PROSPERO register for systematic reviews (CRD42022324582).

Findings

A total of 1242 citations resulted from the systematic search, of which a final 9 articles were included in this study. A total of 174 procedures were included, 161 elective, 12 emergency and 1 interval RA. MERSQI mean score was 10.72 (sd = 2.56), with four high-quality, two moderate-quality and three low-quality studies. The endpoints across the studies were rate of conversion to open surgery, length of hospital stay, intraoperative blood loss and operative time.

Conclusions

RA can be considered a safe and feasible technique with minimal blood loss and without conversion. The operating time and hospital stay were within acceptable limits. Future studies are recommended to further evaluate RA with a focus on its application during emergency settings and on its cost-effectiveness.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

198 A case report on metastasis of prostatic carcinoma into a known intracranial meningioma

R Porag ¹, SMM Hashmi ¹, K Ghosh ¹

Abstract

Surgical excision of a meningioma surprisingly revealed a metastatic prostate adenocarcinoma infiltrating it. Tumour to intracranial meningioma metastasis is a fairly uncommon finding. So far, including this case, only nine case reports on the topic have been published. The purpose of this study is to present and discuss a similar case scenario for better understanding of the incident. A 72-year-old man with known prostatic carcinoma on radiotherapy was seen by neurologists with 6 weeks history of shuffling gait, recent behavioural change, lack of concentration and memory problems. Imaging revealed a large (6.5cm) right frontal mass with wide base on the inner table of the right frontal bone extending up to midline. The mass was unusually heterogeneous, but the axial T2 images show convincingly that it was extra axial. It was initially thought to be a meningioma and after multidisciplinary team discussion, embolisation and subsequent image-guided tumour resection was done. Frozen section reported meningioma with necrosis. However, the final histopathology report showed an unusual lesion compromising both meningothelial meningioma (World Health Organisation grade 1) and a metastatic prostate carcinoma colliding with the latter, apparently infiltrating into the meningioma. Subsequent histopathology confirmed two separate pathologies of meningioma and an infiltrating metastatic prostate carcinoma. Postoperatively patient made an uneventful recovery and continues to be followed up by the oncologists. This case report highlights the rather rare and unusual way in which a metastatic lesion can behave and the need to keep an ‘open mind’ while dealing with them.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

232 Are direct oral anticoagulants (DOACs) of clinical use in stroke prevention in patients with AF after surgical aortic bioprosthetic valve implantation?

H Smith ¹, O Emanuel ², J Chan ³

Abstract

Introduction

Postoperative atrial fibrillation (POAF) is a serious problem in patients following bioprosthetic aortic valve implantation occurring in between 35% and 50% of cardiac surgical patients, and there exist no definitive guidelines on how these patients should be anticoagulated. POAF is associated with increased risk of early stroke, late stroke and mortality. This study aimed to answer the question ‘In patients who develop POAF following bioprosthetic aortic valve replacement, is a direct oral anticoagulant/new oral anticoagulant (DOAC/NOAC) superior to warfarin for achieving effective stroke prevention postoperatively?’.

Methods

A best evidence topic was written according to the structured protocol. A search was conducted using PubMed, MEDLINE, and papers were also recommended from journal club. The European Society of Cardiology 2020 atrial fibrillation management guidelines were consulted.

Findings

Seventy-seven papers were found using the reported search and recommendations from journal club. From these, five papers were identified that provided the best evidence to answer the question. Key pieces of information from the studies were tabulated including but not limited to study type, relevant outcomes, results and study weaknesses.

Conclusions

We concluded that apixaban, edoxaban and dabigatran show similar efficacy in reducing strokes/systemic emboli (SSE). Edoxaban is associated with less major bleeding than other NOACs. NOACs are as effective as, if not superior to warfarin in reducing SSE, but at the cost of an increased bleeding risk. NOACs are safe to use in larger studies to compare the efficacy of NOACs against one another and against current anticoagulation as stipulated by the European Society of Cardiology.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

240 The impact of bariatric surgery on nocturia symptoms: a systematic review and meta-analysis

B Choi ¹, L Jegatheeswaran ¹, C Baillie ¹, J Stevens ¹, K Ratnasingham ¹

Abstract

Introduction

Obesity is becoming increasingly common and is known to affect nocturia, one of the lower urinary tract symptoms (LUTS). Studies have previously shown a significant association between nocturia and body mass index (BMI) and this can have a significant negative impact on quality of life. Bariatric surgery has been shown to reduce LUTS, but this meta-analysis aims to specifically determine the effects of bariatric surgery on nocturia in both men and women.

Methods

MEDLINE and Embase databases and reference lists were searched that reported quantitative data via validated scoring systems such as the International Prostate Symptom Score (IPSS). The primary outcome was difference in nocturia scores before and after bariatric surgery. Secondary outcomes included BMI and total IPSS scores before and after bariatric surgery.

Findings

Some 522 patients across five studies were included in the analysis of this paper. Statistically significant decreases in nocturia scores were observed post bariatric surgery (pooled mean difference = 0.67; 95% confidence interval 0.24 to 1.10, p = 0.01; I² = 79%). Bariatric surgery also resulted in a statistically significant reduction of BMI. However, the total mean IPSS were not statistically significant following bariatric surgery.

Conclusions

Bariatric surgery can have significant improvements on nocturia symptoms in men and women with obesity. This would thereby reduce morbidity and improve quality of life following bariatric surgery.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

243 Microbiome modulation to reduce anastomotic leak after colorectal surgery: systematic scoping review

J Helliwell ¹, P Sciberras ¹, A Dosis ¹, J Burke ¹, D Jayne ¹

Abstract

Introduction

The role of the gastrointestinal microbiome in the development of anastomotic leak after colorectal resection is increasingly recognised. Modulation of the microbiome by eradicating specific causative organisms or their associated virulence factors represents a novel approach to preventing anastomotic leak. The aim of this review was to identify previous studies evaluating the impact of perioperative interventions on the gastrointestinal microbiome and anastomotic wound healing after colorectal surgery.

Methods

A systematic scoping review was performed. MEDLINE and Embase databases were searched between 1 January 1995 and 14 August 2022. Studies that assessed changes to the microbiome after a perioperative intervention in an animal model of intestinal surgery or a clinical study of colorectal surgery were eligible.

Findings

A total of 2,449 papers were inspected, and 22 were eligible for inclusion. Fourteen papers were studies using an animal model. Perioperative interventions within these studies associated with a reduction in collagenase/collagenolytic bacteria, increased microbial diversity and improved anastomotic healing included: dietary prehabilitation, probiotics, faecal transplantation, tranexamic acid and a polyphosphorylated polymer. Eight papers included human participants and evaluated the following interventions: probiotics, synbiotics and oral antibiotics. These were associated with a reduction in microbiome dysbiosis, but were not sufficiently powered to demonstrate differences in anastomotic leak rates.

Conclusions

Targeting the microbiome to improve anastomotic healing represents a promising strategy to prevent anastomotic leak, however there is currently insufficient evidence from human studies to facilitate translation into routine clinical practice.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

246 How to spot the recurring lumbar disc? Risk factors for recurrent lumbar disc herniation in adult patients with lumbar disc herniation: a systematic review and meta-analysis

AR Abdel-Fattah ¹, A Irving ¹, S Baliga ², P Bhatt ¹, P Myint ¹, K Martin ¹

Abstract

Introduction

Clinically important risk factors for recurrent lumbar disc herniation (rLDH) have been subject to growing controversy despite an increasing evidence-base. We conducted a systematic review and meta-analysis to identify risk factors for rLDH in adults after primary disc surgery.

Methods

A systematic literature search was carried out using Ovid MEDLINE, Embase, Cochrane Library and Web of Science databases from inception to 23 June 2022. Observational studies of adult patients with radiologically confirmed rLDH after ≥3 months of the initial surgery were included, and their quality assessed using the Quality In Prognostic Studies appraisal tool. Meta-analyses of univariate and multivariate data and a sensitivity analysis for rLDH post-microdiscectomy were performed.

Findings

Twelve studies (n = 4,497, mean age 47.3 years; 34.5% female) were included, and 11 studies (n = 4,235) were meta-analysed. The mean follow-up was 38.4 months. Mean recurrence rate was 13.1% and mean time-to-recurrence was 24.1 months (range 6–90). Clinically, older age (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.00 to 1.08, n = 1,014), diabetes mellitus (OR 3.82, 95% CI 1.58 to 9.26, n = 2,330) and smoking (OR 1.80, 95%CI 1.03 to 3.14, n = 3,425) increased the likelihood of recurrence. Radiologically, type 2 Modic change (OR 7.93, 95% CI 5.70to 11.05, n = 1,706) and disc extrusion (OR 12.23, 95% CI 8.60 to 17.38, n = 1,706) increased the likelihood of recurrence. The evidence did not support an association between rLDH and sex, body mass index, occupational labour/driving, alcohol consumption, Pfirmann grade or herniation level.

Conclusions

Older patients, smokers, patients with diabetes, those with type 2 Modic changes or disc extrusion are more likely to experience rLDH. Higher quality studies with robust adjustment of confounders are required to determine the clinical bearing of all other potential risk factors for rLDH.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

267 Free tissue transfer for the management of diabetic lower limb ulcers: a systematic review and meta-analysis

K Devetzis ¹, K Cox ¹, S Sousi ², SB Farzaneh ³, Q Young Sing ⁴

Abstract

Introduction

The micro- and macrovascular compromise stemming from diabetes, and the other common co-existing comorbidities, make the treatment of such ulcers notoriously challenging. Our aim was to better characterise the role and efficacy of free tissue transfer in the management of diabetic foot ulcers.

Methods

A systematic search of Embase, MEDLINE and Web of Science was carried out to identify studies in which free flaps were used in the management of diabetic lower limb ulcers (June 2022). Key search terms included: ‘diabetes’, ‘lower limb’, ‘ulcer’ and ‘free tissue transfer’. A random-effects meta-analysis was implemented to assess the efficacy of free flaps as a treatment based on complication and limb-salvage rates.

Findings

It total, 544 free flaps from 25 studies were included in the systematic review. The total complication rate was 26% (95% confidence interval [CI] 21 to 32, I² = 27%, p = 0.11). Rate of partial flap loss was 6% (95% CI 3 to 11, I² = 0%, p = 0.96) and complete loss rate was 4% (95% CI 2 to 7, I² = 0%, p = 1.0). The most commonly used flap was anterior lateral thigh (28%). Some 15% of patients underwent revascularisation prior to free flap. The amputation rate was 5% (95% CI 3 to 10, I² = 8%, p = 0.36) at the latest follow-up point of each study.

Conclusions

Free tissue transfer poses a viable treatment plan for the management of diabetic foot ulcers, with a low complication rate and a low amputation rate of the lower limb.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

269 The effectiveness of intraoperative margin assessment during breast-conserving surgery with the use of MarginProbe^® as an adjunct tool in reducing patient re-excision rates; a systematic review

C Rossou ¹, G Alampritis ¹, B Patel ¹

Abstract

Introduction

Various intraoperative techniques are available for breast surgeon use during breast-conservation surgery (BCS), in an effort to decrease positive surgical margins; however, these techniques have varying levels of evidence. The aim of this systematic review is to evaluate the efficacy of the relatively new intraoperative MarginProbe^® system as an adjunct tool during BCS in reducing patient re-excision rates.

Methods

A systematic review of the available literature was conducted from 2007 to March 2022, with 147 abstracts identified through literature search. After evaluation of eligibility criteria, 12 eligible articles were identified looking at our primary outcome of percentage reduction in patient re-excision rates using MarginProbe^®. Secondary outcomes such as breast cosmesis, volume of tissue excised, sensitivity and specificity were also analysed where possible.

Findings

An independent samples t-test for our primary outcome using a total of 2,680 patients eligible for statistical analysis, was conducted. Percentage reduction in re-excision rate with MarginProbe^® use was found to be statistically significant (p < 0.001) with a very large effect size (d = 1.826). Secondary outcome analysis showed no significant impact on cosmetic outcome and volume of breast tissue excised. MarginProbe^® device parameters showed a high sensitivity at the expense of a decreased specificity.

Conclusions

The systematic review of the available literature showed that MarginProbe^® is indeed a very effective intraoperative adjunct tool in breast conservation surgery that can reduce patient re-excision rates by more than 50%, with no adverse effects such as negative breast cosmesis and no significant increase of volume of tissue excised.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

277 The economic burden of lower gastrointestinal anastomotic leak: a systematic review

M Khalil ^1,², J Burke ^1,², C La Raja ², A Quyn ^1,², A Vargas-Palacios ¹, D Mead ¹, D Jayne ^1,²

Abstract

Introduction

Despite innovations in both surgical technique and perioperative care, anastomotic leak (AL) rate remains as high as they were 50 years ago: between 1% and 19%. Hospital readmission following AL creates a significant economic burden for healthcare services. The aim of this systematic review was to determine the financial cost of a lower gastrointestinal AL.

Methods

A systematic review was conducted (MEDLINE and Embase) from January 1946 to August 2022 (PROSPERO 42020190211). Studies that defined the financial cost of lower gastrointestinal AL were considered. Total, inpatient, index admission and readmission costs were calculated.

Findings

The search resulted in 579 articles; 66 articles were reviewed and 10 were included in the final analysis. Eight studies were based in the USA (80%) one study in the UK and the other in Italy. In total, 486,444 patients were included across the 10 studies; 27,338 (5.62% [4.45%–12.30%]) had AL within 30 days of colorectal surgery. Reported total hospital costs ranged between US$15,545 and US$72,905 (AL) vs US$7,491 and US$30,409 (non-AL). Length of stay was increased in eight of the ten studies by 9.96 days (11.88–30.28 days AL) vs (5–13.93 days non-AL).

Conclusions

AL demonstrates a significant economic burden to hospitals both in terms of driving resource utilisation and underestimation of remuneration tariffs. Focus on prevention of AL is critical. Further analysis of the cost–consequence with respect to quality-of-life years is required.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

282 Visual outcomes after endoscopic endonasal surgery: a single-centre retrospective analysis

R Porag ¹, AF Alalade ¹

Abstract

Introduction

Visual impairment is a common clinical feature of lesions in close proximity to the optic system, for example pituitary adenomas. Visual outcomes following endoscopic endonasal trans-sphenoidal surgery (EETS) vary greatly among patients, and several factors (tumour-, patient- and procedural-related) have been suggested as contributory factors. This study examined the visual outcomes following the endoscopic endonasal approach (EEA) for resection of sellar lesions. This was a single-centre, retrospective analysis of collected data. Patients identified as suitable for the study underwent a case note review at the neurosurgical unit at Royal Preston Hospital between 2016 and 2021. A total of 84 patients with pituitary adenomas and/or other sellar lesions who underwent EEA resection were identified. The mean age at diagnosis was 56.85 years (±15.72). The male-to-female ratio was 1.42:1 (54.7% male and 38.4% female). Preoperative and immediate postoperative visual assessments were collated and analysed.

Methods

EEA was performed in 84 patients with pituitary macroadenomas (n = 74, 88.09%), microadenomas (n = 6, 7.14%) and other sellar lesions (n = 7, 8.33%). Outcomes were assessed using formal visual examinations. Statistical analysis using multiple variables was conducted to determine the association between postoperative visual outcomes and explanatory variables.

Findings

The majority of patients reported improvement in vision (n = 43/82, 52.4%), no change was reported in 36.6% (n = 30/82), and 11% (9/82) of patients experienced worsening symptoms.

Conclusions

Large non-functioning pituitary macroadenomas, tumours with cavernous sinus invasion, and apoplexy on presentation were factors associated with worse visual outcomes. Overall, surgical resection of pituitary tumours and chiasmatic decompression during EETS provides patients with better postoperative visual outcomes.

Ann R Coll Surg Engl. 2023 Jan;105(Suppl 1):S3–S71.

320 Surgeon’s attitudes towards artificial intelligence: a literature review

TM Li ^1,², H Pearson ¹

Abstract

Introduction

The growing application of artificial intelligence (AI) within surgery has the potential to transform how surgeons work. With significant changes taking place, we find there is limited evidence investigating the attitudes of surgeons relating to AI. Establishing the concerns and expectations of the surgical profession is key to successfully adopting these technologies in day-to-day practice.

Methods

We completed a keyword search of PubMed and Ovid using ‘((artificial intelligent) AND ((surgery) Or (surgeon))) AND ((attitude) OR (knowledge))’. Our research returned 28 results, from which 21 papers were selected. These discussed the use of AI in the diagnosis of surgical conditions, surgical planning, intraoperative assistance, prediction of postoperative complications and attitudes towards AI.

Findings

Literature on surgeons’ attitudes towards AI is limited. Of the 21 papers returned in the review, only 4 focused on the attitude of surgeons towards AI in surgery (3 papers on neurosurgery and 1 on trauma surgery). All four papers reported participating surgeons as having some experience of utilising AI in surgical care. There were different opinions on the usefulness of the technology in surgical care. Surgeons reported support for training in AI applied to surgery. The ethical considerations of these technologies in surgery were emphasised.

Conclusions

We have identified a knowledge gap in the investigation of surgeons’ attitudes towards AI in surgery. We intend to further evaluate the current attitude of UK surgeons towards the use of AI in surgery with a national qualitative study which is under ethics consideration.

PERMALINK

e-Poster Presentations

2 Decompressive craniectomy and shunt-amenable post-traumatic hydrocephalus, a single-centre experience

D Jesuyajolu

T Moti

Z Abdullahi

A Alnaser

A Zanaty

T Grundy

J Evans

Abstract

Introduction

Methods

Results

Conclusions

3 Disproportionately increased incidence of anaplastic thyroid cancer in the North Yorkshire region: a UK tertiary centre study

A Adedeji

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C Ojo

A Coatesworth

F Agada

Abstract

Introduction

Methods

Results

Conclusions

8 Intrathoracic gastric volvulus in a neonate with Marfan's syndrome: a case report

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Abstract

24 Ultrasound vs clinical diagnosis: which is better in diagnosing acute appendicitis? A cohort study

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Abstract

Introduction

Methods

Results

Conclusions

25 Seasonal and cyclical patterns of young pedestrian injuries secondary to motor vehicles

A Akhtar

Abstract

Introduction

Methods

Results

Conclusions

30 Pyloroplasty reduces the need for pyloric dilation after oesophagectomy

S Han

C Yu

J Halle-Smith

M Siddaiah-Subramanya

Abstract

Introduction

Methods

Results

Conclusions

35 Comparison of outcomes of mini-sternotomy vs full sternotomy: a 10-year retrospective study

A Faraz

Y Tarar

Abstract

Introduction

Methods

Results

Conclusions

56 Intussusception in incisional hernia: a rare case and literature review

M Hassan

A Saad

M Jeilan

Abstract

57 The use of flexible nails in the treatment of paediatric long-bone fractures: experience at a Level 1 paediatric trauma centre

A Hunt

N Judkins

A Biggs

P Sedgwick

C Hing

A Yeo

Abstract

Introduction

Methods

Results

Conclusions

60 A rare case of adrenal extramedullary haematopoiesis in a Cypriot woman with β-thalassaemia