Busy District General Hospital Research Articles

HPB P47 Management of acalculous cholecystitis: Experiences from a district general hospital

Abstract Background Acalculous cholecystitis (AC) is a serious inflammatory condition of the gallbladder with associated high morbidity and mortality. Definitive management of AC involves cholecystectomy and/or cholecystostomy in combination with antibiotic therapy. Due to the lack of consensus regarding the optimal management of AC leading to possible variability in clinical practice, this study aims to review the management of AC in this busy district general hospital. Methods Data were collected retrospectively on consecutive patients with diagnosis of cholecystitis from March 2018 to March 2020. The data was analysed and patients with confirmed gallstones on imaging and no clinical/radiological signs of cholecystitis were excluded. In this two-year study period, a total of 61 patients were treated for AC. Results Twenty-eight patients were managed conservatively with antibiotics (median age of 68 and median ASA of 2). Thirty-three patients were offered definitive management; cholecystostomy (2 inpatients), laparoscopic cholecystectomy (9 inpatients and 13 elective patients), 5 remain on the waiting list for surgery and 4 declined surgery. Among patients who were offered definitive management, the median age was 62 and median ASA was 2. Seven patients developed complications of AC; 2 patients underwent acute laparoscopic cholecystectomy, 2 patients were offered elective laparoscopic cholecystectomy after having a cholecystostomy, 1 patient underwent cholecystostomy, 1 patient was offered elective laparoscopic cholecystectomy after antibiotic treatment and 1 patient was treated with antibiotics alone. 30-day readmission rate was similar between patients with conservative management (5 patients) and definitive management (4 patients). Conclusions With similar re-admission rates, this small study suggests that definitive management options may not be superior to antimicrobial therapy alone and demonstrates that management can be tailored according to clinical needs. A larger prospective study is recommended to fully assess the efficacy and safety of laparoscopic cholecystectomy, cholecystostomy and antibiotic therapy in managing AC.

HPB P52 Presentation of acalculous cholecystitis - Are patients with acalculous cholecystitis critically unwell?

Abstract Background Acalculous cholecystitis (AC) is considered a life threatening inflammatory disorder of the gallbladder and is associated with high mortality and morbidity. Although it has been classically reported in critically ill patients with sepsis, trauma, burns and major surgery, AC has also been described in outpatient settings. This study aims to review the clinical presentation of AC in a busy district general hospital. Methods Consecutive patients diagnosed with cholecystitis between March 2018 and March 2020 were identified from electronic medical database. Patients with no clinical/radiological signs of cholecystitis and confirmed gallstones on imaging were excluded. Data related to presenting symptoms, National Early Warning Score (NEWS), intensive care admission and AC related complications were retrospectively collected and analysed. Results In this two-year study period, 61 patients were diagnosed with AC. Only 4 patients were seen in an outpatient setting. The primary presenting complaint for all patients was abdominal pain. Initial clinical presentation had a range of severity. Thirty-seven patients had NEWS of 0–1, 20 patients with NEWS 2–4 and 4 patients had NEWS >4. One patient required intensive care and another was transferred to a tertiary unit. A total of 7 patients developed complications of AC; 4 gallbladder perforations, 2 emphysematous cholecystitis and 1 gangrenous cholecystitis. There was one mortality. Conclusions The study shows that majority of patients with AC were not critically ill. Having observed complications of AC in 11.7% of patients, this study highlights the need to have a high index of suspicion for AC in patients without coexisting critical illnesses as well.

32. Facial cellulitis: an audit of the management

Cellulitis is a common soft tissue infection of the dermis and subcutaneous tissues. NICE guidelines recommend Co-amoxiclav as first line therapy for facial cellulitis adjecent to the nose and eyes. We reviewed prescribing practices in patients presenting with facial cellulitis or preseptal cellulitis in a busy district general hospital.

30. Audit of diagnostic accuracy of ultrasound guided fine needle aspiration and core biopsy of head and neck lumps

Image guided fine needle aspiration cytology and core biopsies are well established first line investigations for head and neck lumps due to ease of access, cost effectiveness, and low morbidity. Previous systematic reviews of the literature suggest that overall diagnostic accuracy for this technique is in the region of 90.7% however there was significant variability within the papers that were reviewed. We quantified the diagnostic yield of head and neck ultrasound guided fine needle aspiration cytology and core biopsies in a busy district general hospital.

A Quality Improvement Project to Improve Periprosthetic Fracture Management at District General Hospitals.

Introduction The incidence of periprosthetic femoral fractures (PPF) is expected to rise by 4.6% every decade over the next 30 years. The risk of mortality for patients who sustained a PPF was found to be similar to the mortality rate after a native hip fracture, and so The National Institute for Health and Care Excellence (NICE) guidelines advocate the timely management and mobilisation for patients with PPFs. Patient outcomes following these complex surgeries can be highly variable owing to the variability in regional practice and service delivery. This study aimed to review the management trend and outcomes of periprosthetic fractures (PPFs) involving hip and knee prostheses at a busy district general hospital in order to improve the overall efficacy in managing these complex fractures. Methods This retrospective study included 67 patients who presented to a single district general hospital during a two-year period. Data was collected on demographic profile, further onward referral to a tertiary centre, management (operative versus conservative), timing of surgery, complications, length of stay, implant survivorship, 30-day, one-year, and two-year mortality rate. Results Out of the total of 67 PPFs, 51 (76%) were managed operatively, and 16 (24%) were managed conservatively. Of the operatively managed PPFs, 49 (96%) were managed locally at the district general hospital, and two (4%) were managed at the tertiary centre. Eighteen patients (37%) underwent both revision and fixation, whilst 31 (63%) underwent fixation alone. The mortality rates at 30 days, one year, and two years were 10.4%, 20.9%, and 25.4%, respectively. For PPF patients managed operatively, the mean time taken from presentation to operation was 89.2 hours. The overall mean length of hospital stay for all patients was 23.6 days. Eight patients suffered complications. The implant survivorship at two years was 98%. Conclusion This study adds objective support for the successful operative management of PPFs at district general hospitals. However, improvement is required in service delivery and the efficacy of management. This could be achieved by a national database for PPFs, improved resource allocation, and prompt logistical support.

385 Service Evaluation of the Management of Acute Cholecystitis in the Royal Gwent Hospital Pre and During the COVID-19 Pandemic

Abstract Aim NICE guidelines set out the criteria for the treatment of patients with acute cholecystitis and the operative timescales for cholecystectomy. These targets were greatly affected during the Covid-19 pandemic. Therefore, we aimed to assess the impact that COVID-19 had on patients presenting with acute cholecystitis at a busy district general hospital. June 2020, compared with patients who presented with the same in June 2019. Method Patient cohorts were identified for matching seasons pre- and post-covid-19 (June 2019 and June 2020). Data of all patients who presented with acute cholecystitis was obtained using an electronic patient management system. Statistical analyses were performed using a Wilcoxon test. Results The results of the study indicate that waiting times post-covid are going down (p<0.05). Thus, days until cholecystectomy have decreased but the number of patients being operated on too has decreased thus further worsening waiting times for elective patients. The median and IQR's of days to surgery post-covid are 198 (121.5–278) and pre-covid are 251 (89.5–586.5). Presentations of gallstone complications almost doubled post-covid and the percentage of patients operated on decreased by over 20%. Conclusions It is clear from the data that the NICE guidance on the management of acute cholecystitis has been difficult to adhere to during the pandemic. While the time from diagnosis to operation has reduced post-covid the total number of operations has decreased drastically, putting further strain on elective waiting lists. This, inevitably, will result in further presentations of complications from gallstones and adverse patient outcomes.

363 A Comparative Analysis of Night-Time General Surgical Training

AimThe aim of surgical training is to ensure trainees acquire competencies to perform as a Day 1 Consultant. The last decade has seen the introduction of European Working Time Directive, NELA guidelines and the revised Junior Doctor Contract. All of these, as well as the COVID 19 pandemic, have caused concerns regarding training. Our aim was to examine any changes to night-time on call activity during this time.MethodWe retrospectively analysed prospectively collected data from 2011, 2018, and 2021, in a busy District General Hospital. The data collection period was 31 days, looking at night-time (8pm to 8am) operative experience, supervision, and non-operative activity. A regression analysis was conducted to compare outcomes. A qualitative survey was used to assess attitudes and confidence.ResultsOn average, trainees spent 11% of their time operating independently, 2% operating supervised, 11% attending trauma-calls and 73% clerking/non-educational activities. There was a significant difference between the hours spent on operative versus non-operative activity (P 0.00046) with no differences over the years. Junior trainees did not feel confident operating at night and only 33% of all trainees found night-time training effective.ConclusionsNightshifts comprise a substantial proportion of potential training opportunities and managing the unselected emergency take is one of the Capabilities in Practice. Effective solutions must be implemented to help improve night-time surgical experience and confidence in order for this time to be effective for training of both operative and non-operative competency attainment.

695 Improving Consent Forms for Laparoscopic Cholecystectomy; a Visual Consent Form Toolkit

Abstract Aim Laparoscopic cholecystectomy is a common elective operation with significant complication risks. GMC guidance on consent emphasises informed consent, and failure to warn patients of significant complications can lead to medico-legal implications. We aimed to assess the quality of risk documentation for laparoscopic cholecystectomies performed at our trust. In particular, we aimed to assess improvement since previous cycles after circulation of our boutique ‘Visual Consent Form Toolkit’, an easily accessible resource for risks associated with common procedures. Method Consent forms for 49 elective laparoscopic cholecystectomies performed at a busy district general hospital between September and November 2021 were retrospectively analysed. Risk documentation was audited against a standard of 15 common complications associated with laparoscopic cholecystectomy. Results There was significant improvement across the board. Risks previously documented at 100% remained at this level (infection & bleeding). Those previously well-documented showed further improvement (CBD injury, bile leak, damage to local structures, open conversion & VTE). Of those not previously well-documented (the rest), all except two (diarrhoea & pancreatitis) showed improvement. In particular anaesthetic risks, which was emphasised in our toolkit, saw the largest improvement. Conclusions Risk documentation on consent forms has overall considerably improved with the circulation of our ‘Visual Consent Form Toolkit’. More risks now fully or partially meet the expected standard. From those risks not meeting the expected standard despite numerous audit cycles, we understand that surgeons do not feel these risks should be documented in all situations for all patients, and therefore that an expected standard does not necessarily apply for these risks.

WE5.9 Management of acute abdominal pain in children at District General Hospital (DGH)

Abstract Introduction Children with acute abdominal pain are frequently seen in paediatric A&E at DGH. Acute appendicitis is the most common surgical cause of acute abdominal pain in children. Diagnosis and management can be a problem in the absence of paediatric surgical unit Methods A retrospective study was conducted at a busy DGH where general surgical department is routinely involved in the management of acute abdominal pain in children. 6 months data was collected from 01/06/21 to 30/11/21. Results 381 patients (5–16 years) attended paediatric emergency with complaint of abdominal pain. 24% referred to surgeons (females 53%, mean age 10.9 years). All Presented with pain in RIF, migratory pain was in 42%. Nausea and vomiting were reported in 38%, loose stools in 10.8% and loss of appetite in 21.7%. Duration of pain vary between 24 hours to 3 weeks. WCC was raised in 32% patients, US was performed in 21.7%, CT scan in 5.4%, MRI 1%, and 1% had both Ultrasound and MRI. 46.7% did not have any radiological investigations. Appendectomy was performed in 21% (19) patients including laparoscopic in two. Duration of stay range from less than 24 hours to 5 days. 46.7% were discharged within 24 hrs of review, 21.7% stayed for one and only 2% stayed for five days. 1 patient was readmitted following a post operative collection that was managed conservatively. 2 referred to tertiary paediatric unit for complicated appendicitis. Conclusion This data proves that paediatric patients with suspected appendicitis can be safely managed in a surgical unit at DGH.

Acute extracorporeal shockwave lithotripsy for ureteric stones - 7-years' experience from a busy district general hospital.

To demonstrate the efficacy and cost-effectiveness of acute extracorporeal shockwave lithotripsy (ESWL) for ureteric stones we present our experience of ESWL in 530 ureteric stone cases, in the largest UK series we are aware of to date. ESWL is underutilised in ureteric stone management. The Getting It Right First Time (GIRFT) report showed just four units nationally treated >10% of acute ureteric stones with ESWL. Despite guideline recommendations as a first-line treatment option, few large volume studies have been published. Retrospective review of prospectively collected data between December 2012 and February 2020 was performed. Data relating to patient demographics, stone characteristics, skin-to-stone distance, and treatment failure were collected. Cost analysis was conducted by the Trust's surgical financial manager. Multivariable analyses were performed to assess for predictors of ESWL success. A success rate of 68% (95% confidence interval 64%-72%) at 6 weeks was observed (n = 530). The median (interquartile range) number of treatment sessions was 2 (1, 2). Stone diameter was observed to be a predictor of ESWL success. The small number of stones treated of >13 mm or >1250 HU had an ~50% chance of successful treatment. Acute ureteric ESWL was less costly than acute ureterorenoscopy, consistent with findings from previous NHS studies. Acute ESWL is a safe, reliable, and financially viable treatment option for a wider spectrum of patients than reflected in international guidelines based on our large, heterogenous series. In the coronavirus disease 2019 (COVID-19) era, with theatre access reduced and concerns over aerosol generating procedures, acute ESWL remains an attractive first-line treatment option.

P015 Rheumatology Patient Initiated Follow-Up (PIFU) in a busy urban district general hospital - a scoping exercise

Abstract Background/Aims A recent report from British Society of Rheumatology (2021) highlighted severe national shortages in the rheumatology workforce. Patient Initiated Follow-Up (PIFU) is an innovative strategy for stable patients, reducing the need for “routine follow-up”. PIFU allows patients to contact their local department and organise a clinical review if they have a disease flare. In our model, a back-up appointment is made to allow ongoing future management such as drug de-escalation. PIFU has been trialled successfully in other trusts, where 20% of follow-up patients were deemed suitable. Our aim was to perform a scoping exercise to determine if PIFU would be suitable for our multi-ethnic diverse cohort in a busy urban district general hospital. Methods PIFU inclusion, exclusion and disease-related criteria were developed with input from departments already running PIFU. Patients were considered for PIFU if over 18 years old with a diagnosis of stable inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, axial spondyloarthropathy) evidenced by low disease scores, no change in disease modifying drugs or steroid use in the last 12 months. Our criteria were applied retrospectively to all patients who attended consultant and registrar General Rheumatology clinics from 20th-31st January 2020. Data were collected on demographics, rheumatological diagnosis and suitability of eligible patients for PIFU. Results 340 follow-up patients attended clinic during the 2-week period, of which 136 did not have a rheumatological condition suitable for PIFU (including osteoporosis, osteoarthritis and connective tissue disease). 42 (20.6%) of the 204 patients with eligible conditions were deemed suitable for PIFU. This represented 12.4% of our total follow-ups. In our current practice, the routine follow-up for the 42 suitable patients was arranged for a median time of 9 months (IQR: 7.75-12 months). If PIFU patients were allocated a back-up appointment at 3 years, PIFU would represent a saving of 3 routine appointments per patient over 3 years. For a full-time consultant, seeing 40 follow-ups per week, this would save 4.9 appointments per week or 198 appointments per year. Conclusion 12.4% of our follow-up patients were deemed eligible for PIFU, which was lower than other trusts. This may be due to the low sample size or increased diversity and social complexity of our local population. Even with this lower percentage of eligible patients, PIFU may allow freeing of nearly five appointments per full-time consultant per week. PIFU may also empower patients to take ownership of their condition and enable confidence in self-management. If a PIFU service was set up locally, a robust pathway would be needed to ensure that patients could contact the department when required. The need for annual disease review would also need to be considered using primary care or IT solutions. Disclosure N. Mothojakan: None. L. St.Aimee: None. C. Quieros: None. N. Horwood: None. S. Levy: None. R. Sathananthan: None.

212 Analysing the coding and management of puerperal sepsis in a busy district general hospital- An audit

Introduction and aims of the study: The World Health Organisation defines maternal sepsis as life threatening organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion or the postpartum period. Timely recognition and diagnosis of maternal sepsis is crucial to improve outcomes. This audit aimed to review the management of puerperal sepsis cases and how to improve capturing the information through coding used at trust. Methods: Between September 2019 and August 2020, 20 women were flagged as having puerperal sepsis.

The weight is over – CT contrast dosing by weight, an easy application in a DGH setting

Background: Historically a fixed dose of intravenous iodinated contrast medium has been used for portal venous phase abdominal computed tomography (CT). However, with increasing body mass indices, the patient populations now scanned have a wider weight distribution than ever. This results in a subjective variation in abdominal organ enhancement depending on patient weight. Patients of low weight are felt to have examinations with excessive iodinated contrast, whereas those of large weight have examinations with insufficient iodinated contrast. There is good evidence in the literature to support weight-based contrast administration, but some of the published tables can be unwieldy. We wanted to create a table that is easy and efficient to use in a busy district general hospital (DGH) setting.

301 Blood Grouping and Save in Day Case Laparoscopic Surgery – Potential for Resource Savings?

Abstract Introduction Currently, patients listed for Laparoscopic cholecystectomy and Laparoscopic Appendicectomy undergo routine Blood Grouping and Saving (G&S) pre-operatively. Blood transfusion administration in this context is a rare occurrence. Processing of G&S samples takes approximately 45 minutes and costs £31 per sample. This excludes the phlebotomy and junior doctor resources for sample collection, which incurs additional costs. We retrospectively assessed the blood transfusion requirements in those patients who underwent either a laparoscopic appendicectomy or cholecystectomy in the last 18 months at a busy District General Hospital (Milton Keynes Hospital) to determine if there were any potential costs and resource savings that could have been made. Method Retrospective case notes analysis of patients who had laparoscopic cholecystectomy and laparoscopic appendicectomy from January 2019 to June 2020 focusing on timing of G&S, preoperative and postoperative haemoglobin, the timing of blood transfusion and the number of units transfused. Results Of a total of 613 patients, 323 patients had laparoscopic cholecystectomy. 256 (78.8%) of these had 1 G&S sample and 96 (29.7%) had 2 samples. 290 patients had laparoscopic appendicectomy. 190 (65.5%) of these laparoscopic appendicectomy patients had 1 G&S sample and 89 (30.6%) had two G&S samples. None of the 613 patients was transfused. The total cost of G&S was £22,196. Conclusions Our study illustrates that in this group there was no requirement for blood transfusion. Routine group and save samples result in a significant waste of resources and finances. Targeted groups and save samples should be reserved for high-risk groups only.

277 Implementation of the ROSA Robot in a DGH

Abstract Introduction The ROSA (Robotic Surgical Assistant) is designed to assist orthopaedic surgeons performing total knee arthroplasty (TKA). It is postulated that the real-time data provided by the ROSA robot aids the surgeon by providing objective values to bone resections and soft tissue balance, enabling better implant selection and positioning. This is thought to improve patient outcomes through reduced post-operative pain, reduced hospital stays and reduced revision rate. To date, the ROSA robot has solely been implemented in tertiary centres in the UK. This study investigates the implementation of the ROSA robot in a district general hospital (DGH) in a geographically isolated region of the UK. Method The ROSA robot was installed in St. Michael’s Hospital, Cornwall in July 2021. Prior to its clinical deployment, six surgeons undertook saw bone training. Following this, six ROSA-assisted TKAs were performed in six weeks between July and August 2021. Logistical challenges to implementation included difficulty in ROSA component delivery given geographical isolation, consultant training time dedicated to ROSA operation in the context of a busy DGH trauma rota and increased operative time during the learning curve. Conclusions Despite the challenges faced, we have demonstrated that ROSA can be implemented in a rural, geographically distanced DGH. Given the use of robotic assistance in other surgical specialties, this is an exciting prospect for elective knee surgery in the future.

The impact of COVID-19 pandemic on acute urology admissions in a busy district general hospital in the United Kingdom

Objective: Coronavirus disease 2019 (COVID-19) has had unprecedented effects on the healthcare system in the United Kingdom. The pandemic has impacted every service within secondary care, including urology. Our objective is to determine how COVID-19 has influenced acute urology admissions in a busy district general hospital in the United Kingdom. Patient and methods: Retrospective data of patients presenting acutely to the urology department were collected between 13 January to 22 March 2020 (pre-lockdown period) and 23 March to 31 May 2020 (lockdown period). The nature of referrals, types of admission encountered and management required in accordance with the new set of protocols established during the lockdown period were analysed and compared to the same data prior to UK lockdown. Results: Overall, 1092 patients were included in the study. An overall reduction of 32.5% was seen in the total number of admissions. A marked decrease was seen in non-urological pathology as compared to other categories. Urolithiasis showed the highest proportional increase. Treatment varied proportionately to the diagnosis, with conservative management accounting for the most likely treatment during lockdown. However, the proportion of patients requiring interventions during the lockdown period increased overall. No comparative differences were observed during the two periods in terms of source of referral, length of stay and patient age. Conclusion: The admission rate showed a decrease, with no significant difference in the nature and timing of presentation. Our department was able to continue providing effective management to patients presenting acutely during the COVID-19 outbreak.

Short-Term Hip Fracture Outcomes during the COVID-19 Pandemic.

Introduction Despite many significant changes as a result of the coronavirus disease 2019 (COVID-19) pandemic, and reductions in overall trauma workload, patients with fragility hip fractures continued to present to hospital. As we plan for ongoing service provision during future waves of the pandemic, valuable lessons can be learned from patients that have been treated surgically during the “first wave.” Methods All patients admitted to our center (a busy District General Hospital in London, United Kingdom) with a hip fracture during a 13-week period representing the initial rise (“United Kingdom first wave”) in COVID-19 cases, from February 17 th to May 17 th , 2020 (study group) were compared with hip fracture patients from the equivalent 13-week period in February to May 2019 (control group). The primary outcome was 30-day mortality, and additional information was collected in terms of length of stay (LOS), SARS-CoV-2 antigen testing, and cause of death. Results During the COVID-19 study period, 69 patients were admitted with a hip fracture, compared with 70 patients in the control group ( p = 0.949). There was no significant difference in 30-day mortality between the two groups (5.8 vs. 7.1%, p = 0.747). Mean LOS was shorter in the COVID-19 period compared with the control group (11.6 vs. 19.6 days, p <0.001, effect size 0.572). Forty-six patients (66.7%) had a SARS-CoV-2 antigen swab test, as testing was not available in the early period, and 10 patients (14.5%) tested positive. None of the patients, who presented before the antigen testing was available, had clinical suspicion of COVID-19 retrospectively. Two “COVID-19 positive” patients (20%) died within 30 days of admission.Conclusion We report reassuring short-term results demonstrating no statistically significant difference in the 30-day mortality rate of hip fracture patients admitted during the United Kingdom's first wave of the COVID-19 pandemic compared to the equivalent period in the previous year. Hip fracture incidence remained stable, and LOS was reduced, likely due to recent departmental changes as well as a drive to discharge patients quickly during the pandemic. We agree with existing reports that elderly hip fracture patients with COVID-19 have a higher risk of perioperative mortality, however, our results suggest that overall mortality for the whole hip fracture population was similar to the previous year, in which deaths were more commonly attributed to respiratory infections associated with other pathogens. Further work may be needed to evaluate the outcomes during subsequent waves of the pandemic as mutations in the virus and conditions may affect outcomes.

P-P16 Management of acute pancreatitis in a busy district general hospital

Abstract Background Pancreatitis is a common surgical presentation and can be life threatening, with complications such as acute respiratory distress syndrome and necrosis occurring. Due to high hospital incidence, it is important to ensure patients are managed appropriately using available guidelines. This audit aims to assess the management of acute pancreatitis in a busy district general hospital and identify areas for improvement to better patient safety. Methods Only cases of acute pancreatitis were used in this audit. Case notes for the period between October and December 2020 were collected respectively. A data collection proforma was created using guidelines from the British society of gastroenterology for the management of acute pancreatitis. Data was then analysed using Excel. Results 23% of cases had documented scoring, with Glasgow-Imrie the only scoring tool used. 41% had documented oxygen saturation. 33% had been reviewed by alcohol liaison team for pancreatitis secondary to high alcohol consumption. No patients were given the guideline’s recommended rate of fluid resuscitation (5-10ml/kg/hr). All patients had amylase/lipase in their blood profile. 80% of patients had antiemetics prescribed should they require them, whilst 95% of patients had opioids prescribed for analgesia. 50% of patients were given antibiotics despite them not being indicated. 18% were kept nil by mouth (NBM) whilst having abdominal pain. Conclusions Our results suggest that guidelines for acute pancreatitis are not adequately adhered to. Many aspects of the guidance were not followed including documentation of oxygen saturation, antibiotic use, IV fluid resuscitation and alcohol liaison review for patients who required review. We have developed a proforma to use for the management of acute pancreatitis to ensure that cases are managed in accordance with evidence-based literature and to make the management of these cases easier. We will reaudit to analyse the effects of our intervention and determine whether there has been an improvement in the management of acute pancreatitis.

P-EGS23 Efficacy of Percutaneous Cholecystostomy and Timing of Tube Removal: An Observational Study from a busy District General Hospital

Abstract Background Percutaneous cholecystostomy (PC) has traditionally been reserved for high-risk patients with cholecystitis who are unfit for surgical intervention, or as a temporizing measure for septic biliary patients to relieve sepsis and symptoms. However, there are currently no guidelines regarding the timing of tube removal following PC. The aim of this study is to evaluate the timing of tube removal following resolving inflammation and patency of biliary ducts, and its associated risks. Methods Patient notes and imaging reports were retrospectively reviewed from those who underwent percutaneous cholecystostomy from January 2015-Dec 2020. Data collected included demographic details, symptom presentation, requirement of ITU admissions, details of cholecystostomy, post-operative complications from the tube, outcomes following PC, and mortality rates within 30 days of the procedure. Patients were graded by their severity of their cholecystitis according to the 2018 Tokyo Guidelines, and these were correlated with morbidity and mortality outcomes within 1 year of the procedure. Results There were 55 females and 65 males, with a mean age of 75.2 years (range 45-96 years). Approximately 45% of patients were diabetic and had comorbidities. On presentation, 54% (65/120) patients had elevated inflammatory markers (WCC/CRP), and 20% of patients had associated deranged liver function tests. Majority of patients had moderate or severe acute cholecystitis, with over 25% (31/120) of patients presenting with sepsis, and 6 required admission to intensive care. The median time from diagnosis of acute cholecystitis to percutaneous cholecystostomy was 8.5 days (range 1-64 days). Tube removal was performed after a median time of 31 days (range 1-142 days). Morbidity rate was observed to be 8-10%, comprising of complications such as tube displacement, leakage around the drain, bleeding and liver abscesses. Only 18.3% (22/120) of patients were deemed to be fit for further surgical intervention, of which 13 of those underwent a cholecystectomy thereafter. Unsurprisingly, 38% of these patients had recurrent biliary symptoms, and a 30% mortality rate. Conclusions Percutaneous cholecystostomy is a safe option in high-risk surgical patients for symptom relief, and is a crucial step in temporizing and de-escalating sepsis. However, this study suggests that timing of cholecystostomy removal is variable, and is associated with high morbidity. Consideration needs to be given to shorten the time to tube removal, to minimise risks, if certain criteria are met to ensure safety and efficacy.

SP4.2.7 Outcomes following reorganisation of colorectal cancer pathway using FIT testing and a locally developed risk stratification score in a busy District General Hospital in United Kingdom during the COVID-19 pandemic

Aims/IntroductionLimited availability of endoscopy and CT colonography led to significant pressures on the colorectal cancer pathway during the COVID-19 pandemic. Risk stratification was necessary to determine the order in which patients on the tracking list could access diagnostics. Based on national guidance, patient symptoms and FIT test results, we used a locally developed risk stratification score (RSS). The aim of this study was to evaluate the impact the RSS had on patient diagnoses over a period of 8 months MethodologyA prospectively maintained database was used to assess the outcomes. Based on their symptoms, patients on the colorectal 2ww pathway were invited to provide FIT samples if eligible. Diagnostics were prioritised using RSS. Results were analysed to assess how the cancer diagnostic yield during the pandemic compared to a similar period the year before. ResultsThere were 1133 patients referred on the colorectal 2ww pathway between May - December 2020. 884 of these patients had FIT testing and 249 were not eligible. Of the 69 colorectal cancers diagnosed, 25 were in the FIT group and 44 in those not eligible. The RSS stratified to high or indeterminate risk in the non-FIT group was 31 and 23 in the FIT group. Compared to the previous year’s number of 59 patients diagnosed between May - December 2019, no statistical difference was found.ConclusionOur study shows that FIT testing and RSS led to an equivalent pick up rate of colorectal cancer and can be utilised in clinical settings with limited resources.