General Surgery Research Articles

Prognostic Factors of Acute Intestinal Obstruction in the General Surgery Department of the Ignace Deen National Hospital

Introduction: The aim of this work was to highlight the prognostic factors of acute intestinal obstruction in the general surgery department of the Ignace Deen National Hospital, Conakry University Hospital. Methods: This was a prospective descriptive study of six months from January to June 2021 on patients admitted and operated on in the general surgery department of the Ignace Deen National Hospital for acute intestinal obstruction. Results: Acute intestinal obstructions represented 10.1% (n = 102) of abdominal surgical emergencies (n = 1005). The mean age was 47.64 ± 19.16 years with extremes of 1 and 86 years. The sex ratio was 1.37 in favor of men. The location of the obstacle was high (58.8%), low (33.3%) and mixed in 7.8%. The strangulation mechanism was the most frequent 92.3%. Necrosis 27.5%. An intestinal resection was performed in 37.3%. Septic complications were 14.1% including parietal suppuration 7.6%. The average hospital stay was 13.25 days. Overall mortality was 15.6% (n = 16). This was statistically correlated with strangulation (p = 0.015), intestinal necrosis (p = 0.004), delay in consultation (p = 0.000), age (p = 0.008) and delay in treatment (p = 0.021). Conclusion: Acute intestinal occlusions are a common medical and surgical emergency. Morbidity and mortality remain high and often linked to age, delay in consultation, mechanism, and the occurrence of necrosis, which are prognostic factors that are mostly modifiable. Management requires multidisciplinary collaboration or resuscitation plays a prominent role.

Predicting prolonged postoperative ileus in gastric cancer patients based on bowel sounds using intelligent auscultation and machine learning

BACKGROUND Prolonged postoperative ileus (PPOI) delays the postoperative recovery of gastrointestinal function in patients with gastric cancer (GC), leading to longer hospitalization and higher healthcare expenditure. However, effective monitoring of gastrointestinal recovery in patients with GC remains challenging because of the lack of noninvasive methods. AIM To explore the risk factors for delayed postoperative bowel function recovery and evaluate bowel sound indicators collected via an intelligent auscultation system to guide clinical practice. METHODS This study included data from 120 patients diagnosed with GC who had undergone surgical treatment and postoperative bowel sound monitoring in the Department of General Surgery II at Shaanxi Provincial People's Hospital between January 2019 and January 2021. Among them, PPOI was reported in 33 cases. The patients were randomly divided into the training and validation cohorts. Significant variables from the training cohort were identified using univariate and multivariable analyses and were included in the model. RESULTS The analysis identified six potential variables associated with PPOI among the included participants. The incidence rate of PPOI was 27.5%. Age ≥ 70 years, cTNM stage (I and IV), preoperative hypoproteinemia, recovery time of bowel sounds (RTBS), number of bowel sounds (NBS), and frequency of bowel sounds (FBS) were independent risk factors for PPOI. The Bayesian model demonstrated good performance with internal validation: Training cohort [area under the curve (AUC) = 0.880, accuracy = 0.823, Brier score = 0.139] and validation cohort (AUC = 0.747, accuracy = 0.690, Brier score = 0.215). The model showed a good fit and calibration in the decision curve analysis, indicating a significant net benefit. CONCLUSION PPOI is a common complication following gastrectomy in patients with GC and is associated with age, cTNM stage, preoperative hypoproteinemia, and specific bowel sound-related indices (RTBS, NBS, and FBS). To facilitate early intervention and improve patient outcomes, clinicians should consider these factors, optimize preoperative nutritional status, and implement routine postoperative bowel sound monitoring. This study introduces an accessible machine learning model for predicting PPOI in patients with GC.

Evaluating the SAFE Tool’s Impact on Documentation and Patient Safety During Structured Ward Rounds in General Surgery: A Retrospective Study

Evaluating the SAFE Tool’s Impact on Documentation and Patient Safety During Structured Ward Rounds in General Surgery: A Retrospective Study

Emergency neurosurgery for traumatic brain injury by general surgeons at local hospitals in Sweden: a viable option when time is brain.

Timing of surgical evacuation of mass lesions in traumatic brain injury (TBI) is crucial. However, due to geographical variations, transportation time to the nearest neurosurgical department may be long. To save time, general surgeons at a local hospital may perform the operation, despite more limited experience in neurosurgical techniques. This study aimed to determine whether patient outcomes differed between those who had undergone emergency neurosurgery at local hospitals by general surgeons vs. at university hospitals by neurosurgeons. A nationwide observational study was performed using data from the Swedish Trauma Registry (SweTrau) between 2018 and 2022. A total of 565 TBI patients (local hospitals, n = 21; university hospitals, n = 544) who underwent intracranial hematoma evacuation within 8h after arrival at the hospital were included. Data on demography, admission variables, traumatic injuries, and outcome (Glasgow Outcome Scale [GOS]) at discharge were evaluated. Favourable vs. unfavourable outcomes were defined as GOS scores of 4-5 vs. 1-3. Compared with those treated at university hospitals, patients treated with intracranial hematoma evacuation at local hospitals had lower median Glasgow Coma Scale (GCS) scores (8 vs. 12, p < 0.001), higher rate of acute subdural hematomas (86% vs. 77%, p < 0.001), and lower rate of contusions (14% vs. 53%, p = 0.01). Being operated on at a local hospital was independently associated with higher mortality (p = 0.03) but with a similar rate of favourable outcome (p = 0.74) in multiple logistic regressions after adjustment for demographic and injury-related variables. Although a slightly greater proportion of patients who underwent emergency neurosurgery at local hospitals died, there was no difference in the rate of favourable outcome. Thus, in patients with impending brain herniation, when time is of the essence, evacuation of traumatic intracranial bleeding by general surgeons at local hospitals remains a highly viable option.

A Novel Curriculum for Surgical Oncology Fellowship Training in West Africa.

Low- and middle-income countries (LMICs) lack the surgical capacity to contend with the growing burden of cancer care. West Africa is particularly affected, where limited cancer surgery is performed primarily by general surgeons without any subspecialty training. As a first step to develop surgical oncology capacity in the region, the West African College of Surgeons (WACS) in partnership with the Global Oncology Group at Queen's University, Canada, co-created a novel surgical oncology fellowship training program. Curriculum development began with a literature review of publications, global position statements, and curricular documents from surgical oncology societies and accreditation bodies. The results were reviewed by the WACS team members to reach consensus on the competencies and objectives of the program based on the perceived needs and available resources in West Africa. Iterative discussions between the Queen's Global Oncology Group and WACS leadership led to the creation of the surgical oncology curricular documents. A curriculum tailored to the West African context was developed to deliver essential knowledge, skills, and competencies for surgical oncologists in the region. The curriculum focuses on the six core domains of general surgical oncology, highlighting specific knowledge base and procedural skills within each clinical domain. Educational activities were outlined and the curriculum format, delivery, and trainee assessment were also described. A surgical oncology curriculum developed specifically for the West African context will enhance the capacity for cancer surgery in the region. This curriculum may serve as a model for future surgical oncology program development in LMICs.

GIANT LUMBO-SACRAL TUMORS

Objectives Despite comprising just 8% of all spinal tumors, sacral tumors present a long list of issues that should be taken in consideration when neurosurgical approach is tempted. Their unique anatomic location, close relation with neural structures and pelvic organs and high-vascularity are just a few nuances of these type of conditions. This paper outline the importance of a good preoperative and intraoperative management in order to facilitate the maximum recovery of the patients. Material and Methods This paper analyses retrospectively a series of 2 cases of giant sacral tumors (&gt;100 cm3) that were operated in our clinic in 2024 by a multidisciplinary team (neurosurgeons and general surgeons). Follow-up data were obtained from the charts and medical records. All the lesions were localised under L4 vertebra with invasion of sacrum. Results Our first case was a 47-years old man who accused diffuse mild lumbar pain for more than 2 years, but acutely aggravated in the last months with lumbosacral radicular pain, palsy of the inferior lumbar nerves, urinary incontinence and paraesthesia. MRI showed a giant L5-S2 mass and biopsy diagnostic was myxopapillary ependymoma. Second case was of a young woman with lumbosacral radicular pain debuted a few months ago, whose clinical state worsened rapidly becoming paralytic of lower limbs. MRI showed a giant sacral mass with invasion of the pelvic musculature and surrounding the iliac vessels (intraoperative aspect: sarcoma). Both patients ameliorated postoperatively, and are currently enrolled in a recovery program. Sub-total resection and near-total resection were obtained. Conclusions Sacral tumors exhibit a challenge in the field of spine surgery being clinical silence over a period of months and years, and then followed by gross deficit. We diagnosed sacral tumors based on clinical, radiographic and laboratory aspects. Prognostic factors were preoperative clinical status and gross-total resection.

Impact of structured checklist-based preoperative counseling versus standard counseling on postoperative patient-reported outcomes after elective surgery.

Surgery, even on an elective-basis, often induces significant stress in patients, characterized by preoperative anxiety and heightened stress levels due to anticipation of the unknown. However, the primary objective of preoperative counseling is to mitigate these concerns, particularly when delivered in a structured and comprehensive manner. While previous research has highlighted the beneficial impact of preoperative counseling on patient-reported outcomes, none have specifically explored the implementation of a structured checklist-based approach during counseling sessions. To bridge this gap in the literature, our study aims to investigate the effects of implementing a checklist-based structured counseling approach on patient-reported outcomes following elective surgery. In this prospective cohort study conducted over one year from January to December 2023, a total of 600 patients undergoing elective surgery across three specialties-orthopedic surgery, general surgery, and urology-were examined. The patients were divided into two groups: an intervention group consisting of 300 patients and a control group with an equal number of patients. The study evaluated three key outcomes-postoperative pain, anxiety, and satisfaction-at three specific time points following surgery: 24h, 48h, and 72h. Patients receiving structured checklist counseling showed significantly lower pain scores (24h: 6.6 vs. 7.03, p = 0.041; 48h: 5.62 vs. 6.55, p = 0.029; 72h: 2.54 vs. 2.90, p = 0.035) and anxiety scores (24h: 8.58 vs. 9.25, p = 0.039; 48h: 7.50 vs. 8.45, p = 0.030; 72h: 4.53 vs. 5.98, p = 0.031), as well as higher satisfaction scores (24h: 5.99 vs. 5.06, p = 0.043; 48h: 6.99 vs. 6.02, p = 0.033; 72h: 9.10 vs. 8.20, p = 0.039) compared to controls. These improvements were consistently significant across all three surgical specialties studied (p < 0.05). The structured checklist-based counseling method proves to be effective and essential. This method is associated with reduced postoperative pain and anxiety levels, along with increased patient satisfaction, when compared to the standard approach. Prospective non-randomized study, Level II.

A04 - EGS Evidenced competency in benign biliary surgery amongst UK general surgeons at certification: A JCST/ISCP study

Abstract Background Symptomatic gallstones are the most common reason for evaluation by an Emergency General Surgery (EGS) service, with laparoscopic cholecystectomy (LC) being performed by most general surgeons. Previous studies show that most LCs in the United Kingdom (UK) are performed by colorectal surgeons (CR). Emergency cholecystectomy requires advanced skills including intra-operative assessment of the bile ducts, and the ability to perform intra-operative cholangiogram (IOC) is part of the procedure-based assessment (PBA) that evidences competency for certificate of completion of training (CCT). This study aims to assess documented evidence of competency in benign biliary surgery amongst general surgeons in the UK. Method PBAs relating to LC and CBD exploration (CBDE) were retrieved for all UK general surgeons who received CCT between 2016 and 2021 from ISCP (702; 285 (41%) colorectal; 212 (30%) Upper GI (UGI)). All eLogbook entries relating to LC +/- IOC +/- CBDE were also retrieved. Subspecialty interest was determined from Part 2 of the FRCS examination. Competence (Level 4) as well as a granular assessment of IOC and CBDE was compared amongst trainees, taking into account their subspecialty interest. Results 11,733 LC and 553 CBDE assessments from 160,570 LC +/- IOC +/- CBDE procedures recorded on eLogbook were retrieved. Knowledge of IOC indication was assessed in 467 (94%) surgeons, but performance was only assessed in 380 (75%) surgeons. Median satisfactory IOC performance assessments was 3 (2-5). UGI were more likely to do this than colorectal (4 (2-7) vs 2 (1-4) P &amp;lt; 0.001). Satisfactory CBDE was achieved by 86 surgeons (12 CR and 74 UGI). 486 surgeons (97% CR; 94% UGI) received Level 4 (independence) despite never achieving satisfactory ability to perform IOC. Conclusion Competency in acute biliary surgery for general surgeons at certification is extensively assessed using PBAs. Cholecystectomy training and assessment in the UK does not seem to include intraoperative bile duct anatomy assessment or treatment of CBD stones. Assumed competency in cholecystectomy by trainers in the UK does not seem to include the need to do this, as 97% of CR and 94% of UGI trainees achieve documented competence without the ability to perform IOC. This may have an impact on EGS service delivery of acute and emergency gallbladder surgery including the ability to deal with difficult cases.

Risk factors for surgical site infection after general surgery in HIV-infected patients: a retrospective study.

As the number of HIV-infected patients increased, the number of patients requiring general surgery has subsequently increased. However, impairment of immune function due to HIV infection increases the risk of postoperative surgical-site infection and significant harm to patient health. This study aimed to examine the risk factors for surgical-site infection after general surgery. The patients' data were from Zunyi fourth hospital medical information system. Machine learning based Boruta algorithm were used for variable screening. Univariable and multivariable logistic regression and restricted cubic spline analysis were performed to examine the relationship between significant variables and surgical-site infection. A total of 125 general surgery postoperative HIV-infected patients participated in the study. Surgical-site pathogen culture identified Escherichia coli, Klebsiella pneumoniae, and mixed bacteria as the three most common pathogens causing Surgical-site infection. Univariable and multivariable logistic regression analysis to adjust for risk factors identified type III surgical incision (OR = 9.92, 95% CI = 1.28-76.75) and elevated preoperative white blood cell (WBC) count (OR = 1.30, 95% CI = 1.12-1.51) as independent risk factors for postoperative surgical-site infection, whereas CD4 + T lymphocyte count greater than 400 cells/µL was identified as a protective factor (OR = 0.23, 95% CI = 0.09-0.60) while. The restricted cubic spline analysis results directly reflected the dose-response relationship between continuous variables and postoperative surgical-site infection. Type III incision and an elevated WBC count pose a higher risk of postoperative surgical-site infection. A CD4 + T lymphocyte counts greater than 400 cells/µL provided a protective effect of lower risk of surgical site infection. Preoperative serum neutrophil percentage, albumin level, red blood cell count, and serum urea level within a specific range were beneficial in reducing the risk of incisional infections. Our research provides a theoretical basis for clinical practice.

HPB SO02 - Cutting surgical site infection rates in perihilar cholangiocarcinoma with informed changes to perioperative antibiotic prophylaxis: A quality improvement project in a UK hepatopancreatobiliary tertiary centre

Abstract Background Perihilar cholangiocarcinoma (pCCA) is the most common cancer of biliary epithelia. While potentially curative, surgical resection is associated with high morbidity and mortality. Surgical site infections (SSIs) are common and pernicious. Preoperative biliary instrumentation is universal: to confirm histological diagnosis and deploy stents to relieve jaundice. Patients receive multiple antibiotic courses as periprocedural prophylaxis and to treat cholangitis. They are at high risk of harbouring bacteria not quelled by perioperative prophylactic antibiotics given for other general surgical procedures. Studying the biliary microbiome, this quality improvement project sought to reduce SSIs through informed changes to local guidelines on perioperative antibiotic prophylaxis. Method Health records of all patients undergoing resection for pCCA in a UK hepatopancreatobiliary centre from February 2009 to January 2024 were analysed retrospectively (n=118). For all patients, we routinely sent intraoperative bile swabs for culture and sensitivity. Informed by these microbiology results, multidisciplinary discussion led to changes to local guidelines in March 2019. Formerly, cefuroxime and metronidazole were given on anaesthetic induction, with subsequent antibiotic choice and duration according to surgeon preference. New guidance stipulated teicoplanin and piperacillin/tazobactam be given on induction and for 72 hours postoperatively. We studied the impact of these changes on SSIs within 30 days. Results 75 patients received cefuroxime and metronidazole; 43 patients were given teicoplanin and piperacillin/tazobactam after the policy change. Proportions of patients who developed any SSI substantially fell following the guideline change (55% v 28%; p=0.0049), primarily owing to reductions in intraperitoneal collections (39% v 21%; p=0.047). Rates of deep (8% v 2%; p=0.21) and superficial incisional infections (8% v 5%; p=0.49) were not significantly affected. Associated secondary outcomes were drops in post-hepatectomy liver failure (17% v 5%; p=0.047), and 90-day mortality (16% v 5%; p=0.067), albeit the latter was not statistically significant. Conclusion Invasive investigative work-up, disease complications and exposure to multiple courses of antibiotics prior to resection of pCCA subject patients’ biliary systems to colonisation with antimicrobial-resistant bacteria. We urge centres that undertake these operations to introduce intraoperative bile cultures as a part of routine practice to inform local guidance on perioperative antimicrobial prophylaxis. We demonstrated effective antibiotics in the perioperative period can have enormous benefits to patient outcomes.

BN SO50 - The Resurgence of Veress Needle Insufflation: An Evaluation of Efficacy and Safety of One Surgeon’s Practice

Abstract Background Veress needle insufflation has been established as a safe and effective method of establishing pneumoperitoneum for laparoscopic surgery, with comparable risk profile to open methods. However, the blind nature of the procedure with potential complications such as iatrogenic bowel and blood vessel injury has seen this technique fall out of fashion with general surgeons. This study reviews the safety and efficacy of a single surgeon’s practice using Veress needle insufflation for Laparoscopic surgical procedures. Method A retrospective analysis was conducted on minimally invasive procedures performed between January 2019 and June 2024. In our practice, a standard or bariatric Veress needle is placed in a small incision at Palmer’s point. A manometer test is performed with CO2 insufflation at a low flow rate and raising the abdominal wall. If a low pressure is established, then the flow is increased to achieve adequate pneumoperitoneum before introduction of a midline 5mm camera port. Primary outcomes of this study include rate of conversion to open techniques (either Hasson’s or open cut down) and any complications. Results Of the 702 cases reviewed, five patients (0.71%) required conversion to open insufflation techniques. Two (0.28%) had bleeding from the omentum, and one patient (0.14%) experienced inadvertent bowel insufflation which was managed conservatively with no long-term morbidity. Notably there were no port site hernias. Conclusion This study supports the continued use of the Veress needle as a safe and effective method of insufflation in laparoscopic surgery. It offers minimal incision size, easier access in high BMI patients, and an alternative when adhesions and scarring limit access. Furthermore, adopting this technique can be particularly useful for appropriate port placement in robotic surgery, making it a valuable tool for modern surgical practices.

HPB SO56 - Prompt prescription of fluids and analgesia for acute pancreatitis and evaluation of subsequent laparoscopic cholecystectomy: A Quality Improvement Project

Abstract Background Pancreatitis is a common presentation for General Surgery department nationally. Treatment of these patients are timely initiation of analgesia and fluid resuscitation. Patients with gallstone pancreatitis should have inpatient cholecystectomy as per the NICE Guidance. Delays in treatment of acute pancreatitis can worsen mortality and morbidity rates. We aim to assess if patients have been given fluid, analgesia, VTE prophylaxis promptly upon admission and if they had laparoscopic cholecystectomy in the index admission for those with gallstone pancreatitis. Method Single centre retrospective cohort of patients, above 18 years old, who presented to general surgery services from November 2022-23. Patients need to have radiological evidence of pancreatitis or raised amylase above 150. Patients were evaluated for prompt prescription of analgesia, fluids and VTE prophylaxis within 24 hours based on our ePrescription system. Evaluation of laparoscopic cholecystectomy service was also performed to assess if patients had the surgery during the indexed admission or within 30 days of discharge. Results 99 patients with median age of 60 was included. Only 3 patients required higher levels of care in HDU or ITU. The median length of stay was 5 days. 96% had analgesia prescribed, 91% had VTE prescribed but only 81% had fluids. Of those who did not have fluids within 24 hours, the average lenght of stay was 5.5 days and only 1 patient needed to be admitted to intensive care unit. 26 patients had gallstone pancreatitis but 15% had laparoscopic cholecystectomy performed. Our readmission rate was 6% and 30-day mortality was 1%. Conclusion Delays in the prescription of fluids and analgesia are still present, with a proportion of patients not getting the appropriate treatment for acute pancreatitis. We will use a tailored prescription set for acute pancreatitis to ensure prompt prescriptions are done for patients. This will be re-evaluated to assess its effectiveness. Further evaluation is required to look at reasons for patients not getting cholecystectomy promptly after admission for acute pancreatitis.

Tumor seeding across specialties: a systematic review

BackgroundUnderstanding shared characteristics underlying reported tumor seeding episodes can reveal when tumor seeding is most likely to occur and guide clinical decision making. Our goal was to systematically review tumor seeding across specialties and determine what types of instrumentation and primary tumor histology are associated with tumor seeding.MethodsA systematic review was conducted using PubMed and Web of Science, per PRISMA guidelines. Publications ranged from 1965 to 2022, and studies with five or more reports of seeding were included. Papers were sorted by specialty and assigned a PRISMA Level of Evidence, and data analysis was conducted based on whether each paper supported the clinical significance of seeding.Results7,165 papers were screened with 156 papers included for analysis. Overall, there were 8,161 cases of tumors seeding across specialties with the majority from general surgery, gastroenterology, and urology. Laparoscopy (n=1,561) and needle biopsy (n=3,448) were most frequently implicated, and carcinomas (n=5,778) and adenocarcinomas (n=1,090) were the most common primary tumor types.DiscussionUpon review of the most updated (2023) versions of the NCCN and NICE guidelines across all cancer types, there were identified gaps in the coverage of tumor seeding within these guidelines, with tumor seeding being entirely absent from certain guidelines and partially absent from others.ConclusionsGiven the high cumulative reports of seeding and the deadly and disseminated nature of secondary disease, it is important to consider seeding risk when manipulating tumors and to modify current cancer care guidelines (NCCN/NICE) to ensure that they appropriately address seeding risk.

EDI&amp;S SO03 Replacing Single-use Chloraprep with Low Carbon Cost-effective Surgical Skin Preparation: A QI Project for Sustainability in Surgery

Abstract Background Operating theatre waste accounts for approximately 50% of all hospital waste produced in the NHS [1] and two-thirds of carbon contributions come from single-use items [2]. With a major goal of the NHS being net-zero, surgeons have a collective responsibility for reducing the carbon footprint through eliminating single-use equipment and plastic waste such as Chloraprep wands. The aim of this quality improvement project was to introduce the use of chlorhexidine solution poured into reusable gallipots and applied using reusable sponge-holders into local practice, which is more environmentally friendly, significantly cheaper and is the first-line skin preparation recommended by NICE [3]. Method Chloraprep use in consecutive operations performed by the trust in a month before and after the intervention was retrospectively collected and categorised based on specialties. The intervention was a series of local oral presentations, leaflets and posters to highlight the benefits of chlorhexidine solution over Chloraprep. The change in percentage of Chloraprep use in all cases completed in 1 month pre- and post-intervention was retrospectively collected and analysed. Further qualitative data was obtained through pre- and post-intervention surveys. Results There was a reduction in use of Chloraprep across all specialties targeted by the intervention, with 27% of cases pre-intervention and 24% of cases post-intervention using Chloraprep. The highest percentage reduction was seen by the local upper gastrointestinal surgery team (37%). The percentage reductions in the cases using Chloraprep 10 days post intervention were general surgery 9%, upper GI 3%, colorectal 1% and vascular 6%. The pre- and post-intervention surveys also showed a decrease in Chloraprep use from 94.1% to 80% and corresponding increased use of swabs and antiseptic solution. 100% of the responders agreed with using the sustainable option. Conclusion The educational intervention has proven to be effective in achieving the aims of this project. Critical analysis of the literature has shown no difference in surgical site infection rates between the two options [2]. However, there is a need for high quality trials that directly compare the clinical effectiveness of both methods of application. We hope to encourage surgeons and theatre staff to opt out of using Chloraprep and consider the use of swabs dipped in chlorhexidine alcohol solution. Thus, we recommend the re-usable low carbon low-cost alternative method and encourage efforts to promote sustainability in surgery.

EGS SO05 - Improving the Flow of Patients Attending Surgical Assessment Unit: Introduction of Ambulatory USS Slots - Closed Loop Audit

Abstract Background Modern emergency surgical service recognises that a significant proportion of patients presenting with acute abdomen can be diagnosed and treated in the ambulatory fashion. However, this approach requires multidisciplinary cooperation between the general surgery team and radiology department. We aimed to assess and improve the flow of patients presenting to Surgical Assessment Unit (SAU) with complaints of right iliac fossa (RIF) and right upper quadrant (RUQ) pain. Method We performed a retrospective analysis of all ambulatory patients returning to SAU of a District General Hospital with RUQ and RIF pain in January 2023. We measured the waiting time between the arrival to SAU and the time of USS. We presented the results in a local meeting and negotiated the introduction of two daily USS slots for SAU patients. We re-assessed the impact of the USS slots on waiting times in July 2023. Results In January 2023, 13 patients returned to SAU for USS. The minimum waiting time for this cohort was 59 minutes and the maximum waiting time was 3 hours and 39 minutes. The median was 2 hours and 15 minutes. In July 2023, 18 patients returned to SAU for USS. The minimum waiting time for this cohort was 4 minutes and the maximum waiting time was 2 hours and 20 minutes. The median was 1 hour and 5 minutes. There was an average reduction of 1 hour and 10 minutes in waiting time for USS. Conclusion The introduction of two USS slots per day for patients returning to SAU with RUQ and RIF pain resulted in a 48% reduction in waiting times. This improved the flow of patients, sped up the diagnosis and timely access to treatment, as well as significantly improved patients experience and satisfaction. We would recommend close co-operation between general surgery and radiology to allow timely access to imaging for patients presenting with acute abdomen to SAU.

EGS SO09 - Documentation Of Mortality While Consenting For Major Emergency Operation In General Surgery : Are We Informing Patients Or Just Impressing NELA? A Three-Cycle Clinical Audit

Abstract Background Approximately 30,000 to 50,000 emergency laparotomies are performed annually in the United Kingdom (UK), with an in-hospital mortality rate of 9.2%. The UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report from 2011 recommends that the risk of mortality should be explicitly discussed with patients and clearly documented on consent forms and in medical records. The purpose of our audit was to assess the frequency of documenting the risk of mortality in consent forms and to evaluate the reporting of corresponding discussions in the medical records of patients undergoing major emergency general surgical operations. Method Patients were identified from our National Emergency Laparotomy Audit (NELA) database, and data was collected retrospectively from our online medical records. We included procedures from NELA performed on patients aged 16 and older who had the capacity to give consent. The first audit cycle took place from April to June 2021, the second from March to May 2022, and the third from March to May 2023. The results of the first cycle revealed gaps in documentation, leading to the implementation of periodic reminders for surgeons during meetings and the use of posters to reinforce best practices. Results The 1st cycle included 40 cases, with 93% documented mortality in NELA, 40% in consent forms, and 35% documented discussion about mortality in medical notes. The 2nd cycle reviewed 38 cases, showing 92% documented mortality in NELA, 71% in the consent forms, and 42% of documented discussion about mortality in the medical notes. The 3rd cycle assessed 32 cases, with 90% documented mortality in NELA, 92% in consent forms, and 51% in the medical notes. The improvement in documentation of the risk of death in the consent forms was statistically significant across all three cycles (p &amp;lt; 0.0001). Conclusion The three audit cycles demonstrated that implementing periodic reminders and posters for surgeons significantly improved the documentation of mortality risk. Documentation rates in consent forms increased from 40% in the first cycle to 92% by the third cycle, and in medical notes from 35% to 51%. These interventions effectively enhanced compliance with best practices. However, continuous effort is essential to maintain this improved practice. Regular monitoring, ongoing education, and reinforcement strategies should be employed to ensure that the documentation standards remain high and continue to improve patient care and safety.

HPB SO58 - Reporting outcomes on the management of complex benign biliary pathology referred into a tertiary Hepatobiliary centre

Abstract Background Gallstone disease represents a significant portion of acute general surgery workload. Complex biliary pathology is a common cause of referrals to tertiary hepatobiliary (HPB) centres, however, there is a paucity in the literature regarding criteria for referrals and the outcomes from the management of these cases. The aim of this study was to report the outcomes of patients referred to a tertiary HPB centre in an acute setting from secondary care hospitals for management of benign biliary pathology. Method Patients who were transferred to the HPB unit at Manchester Royal Infirmary from secondary care hospitals in the North West of England between September 2022 and May 2024 for benign biliary pathology were included. Patients were identified from the electronic emergency transfer centre. Data was collected on the reason for referral and management at the HPB unit. Outcomes were reported as: admission to intensive care (ITU), length of stay in hospital, in-hospital mortality, Clavien-Dindo grading of surgical complications and re-admission to hospital. Data was retrospectively collected from electronic patient records. Results Twenty-three patients were included. The most common reasons for transfer included: biliary drainage for choledocholithiasis where endoscopic retrograde cholangiopancreatography (ERCP) was not feasible at the referring hospital (8/23); Mirizzi syndrome (4/23); emergency general surgery not offered at the referring hospital (3/23) and perforated gallbladder (2/23). Ten patients were managed surgically, five patients had ERCPs, four patients had radiological interventions and four were managed conservatively. Two patients were admitted to ITU, one patient died within admission and a second patient managed conservatively was re-admitted within 30 days. Post-operative morbidity rate was 30%. The median hospital stay was 12 days (2, 50). Conclusion Our data demonstrates that complex biliary pathology that has been referred into a tertiary HPB unit from secondary care hospitals has been managed safely, with low rates of morbidity and mortality. Patients who underwent cholecystectomies that were deemed to be high risk had a 0% mortality rate. This study adds to the body of evidence that centralisation of specialist services with a multi-disciplinary approach has led to better patient outcomes.

HPB SO60 - A Re-Audit: Radiological Investigations In Patients Diagnosed With Gallstone Disease

Abstract Background Gallstones disease is very commonly encountered in general surgery and often detected by different modes of imaging. NICE guidance advises offering liver function tests and ultrasound where gallstones are suspected. MRCP and EUS are then considered if gallstones have not been detected. However, ultrasound is not always offered first line in patient cases, for varying reasons. This retrospective audit aims to assess the different radiological investigations used in gallstones against NICE guidance and the reasons behind this. Method Data was collected from a cohort of 108 patients over a 2 month period, all diagnosed with gallstones. The data collected included information regarding their demographics and imaging used to diagnose gallstones, as well as the reasoning when the first line investigation was not used. These results were then presented at the local general surgery CGM, findings were also communicated to doctors within the hospital. The audit was then repeated a year later with a similar cohort of patients, to compare findings. Results Mean age of patients decreased from initial audit to reaudit periodFemale preponderance in both audit and re-audit cyclePatients more likely to have imaging when abdominal pain present AND deranged LFTs as opposed to just one of the twoComparing total number of scans: less patients are undergoing CT scans (44 in audit period vs 31 in re-audit period)- 30% decreaseDecrease in number of patients having CTAP as first mode of scan (38 in audit period vs 21 in re-audit period). Total of 45 % drop. Conclusion While ultrasound scan is the first line radiological investigation where gallstones are suspected, it is not always the first to be used. This is for a plethora of reasons, including:Differing clinical judgment/ diagnostic uncertaintyDifferent clinicians/ specialities booking investigationsUnawareness of NICE guidanceLogistical delay in ultrasounds However, it does appear there has been improvement in adherence to NICE guidance between first and second cycle. Other modes of awareness will be implemented to further improve this, including publishing further guidance about NICE protocol within the trust so this is more easily accessible to doctors.

BN SO10 - Virtual Reality in Acute Pain Management of Adult Surgical Patients: Literature Review

Abstract Background Pain is an unavoidable side effect of medical procedures. British Pain Society (BPS) reports almost 10 million people in UK suffer from pain everyday. BPS reported an estimated €5 million per year is spent on managing back pain alone. Pharmaceutical pain management is costly and can cause side effects. Virtual Reality (VR) is a novel technology used to alleviate pain. We performed a literature review to assess the current advances in the pain management using VR. Method A literature search was done on the use of VR for pain management across 4 databases (Pubmed, Medline, Embase and Cinahl) using key words virtual reality, acute pain, adult, surgery. 144 non-duplicated studies were found. 66 studies were excluded: 41 were non-acute pain related, 16 involved chronic pain, 9 involved paediatric population. 78 studies with the total number of 1514 patients (n=1514) were included. All studies used VR to relieve acute pain symptoms experienced while undergoing a procedure. The data included sample size, gender, age, specialty, VR type, pain scale, pain score before and after, interventions, key findings and limitation. Results VR was tested to control pain in general surgery, plastics, obstetrics and gynaecology, cardiothoracics, orthopaedics, urology, and dentistry. In benign UGI surgery, including fundoplication, paraesophageal hernia repair, esophageal myotomy, and pyloroplasty requiring an overnight stay, the use of VR reduced pain, anxiety and nausea. Overall, no adverse outcomes were reported. No difference in nausea and dizziness between VR and control groups was observed. Active software has been shown to be superior to the passive one. Complete immersion with visual and audio stimulation replaced by VR environment is important. The results were similar in different age groups. Conclusion There is a good body of evidence to support the use of VR in pain management in clinical practice. It acts as a good distraction tool. The use of VR was demonstrated to be beneficial in reducing postoperative pain in benign UGI surgery. However, the main areas of application would be in short procedures where it not only delivers better pain management but also increases patient satisfaction and decreases the need for pharmaceutical analgesia, thus bringing down the overall cost.

HPB SO73 - Histopathological Patterns in Emergency and Elective Cholecystectomy

Abstract Background Laparoscopic cholecystectomy (LC) is one of the most frequently performed general surgical procedures. In the United Kingdom, gallbladder specimens are routinely submitted for histopathological analysis to detect occult pathologies, such as carcinoma in situ and early-stage carcinomas. This study aims to assess the results of routine histopathological examination of LC specimens. Method A prospectively collected database of all LCs and laparoscopic common bile duct exploration (LCBDE) performed between August 2022 and June 2024 was analysed. The database was populated from a single benign biliary center by two specialized biliary surgeons. Electronic case notes were analysed for the demographics, indication(s), operative findings and the histopathological results. All gallbladder specimens were sent for histopathology analysis, irrespective of their gross appearance. Results Of the 201 eligible patients, 164 patients had histopathology results available. Median age was 56 years (IQR 41-66) and 100 (61%) were female. 72 (43.9%) were emergency cases. 48 (29.3%) had cholecystectomy, 70 (42.7%) also had intraoperative cholangiogram and 46 (28%) had LCBDE. Conclusion Chronic calculus cholecystitis was the most frequent histopathological finding, followed by acute on chronic cholecystitis and gangrenous acute cholecystitis. Dysplasia was identified in 1.8% of patients, warranting multidisciplinary team discussion. This study underscores the significance of routine histopathological examination after cholecystectomy, as early incidental detection of dysplasia and carcinoma can modify postoperative management and improve patient outcomes.