ASiT Conference Cardiff 2012 - Abstract Book

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ASiT Executive Conference Team 2012

Goldie Khera
ASiT President Bariatric Fellow, North Tyneside
ASiT Conference Organiser & Past-President Presidents Introduction Registrar, London General Surgery Dear members and guests,
A very warm welcome to Cardiff for the ASiT Conference. We are delighted to be in such an exciting and vibrant capital city! With nearly 600 delegates attending Jonny pleasure to be part of the team organising our this year, its been my absolute Wild ASiT Honorary in 1976. Dont forget that your ASiT largest meeting since ASiT was foundedSecretary & Sponsorship Co-ordinator General Surgery Registrar, it all ourselves! committee are all real-life surgical trainees and we doSheffield We have had a record-breaking 1,200 abstracts submitted this year, consequently the bar for oral or poster presentation has never been higher for ASiT and is living, breathing proof of the hard work and commitment that surgical trainees possess in abundance. Eight pre-conference training courses offer un-paralled financial and educational value and fantastic breadth of potential for skill acquisition on Friday 23 rd March. Robert Davies
Ed Fitzgerald
ASiT Honorary Treasurer As the UKs only pan-specialty surgical trainee meeting, our conference programme is designed to promote Vascular Surgery Registrar, West your future the cross-pollination of ideas and help you get the most out ofMidlands training. The conference covers a vast field of topics including the science behind your surgical training, whether your aim is for robotics and endoluminal surgery; remote and rural surgery; staying out of jail; understanding what it takes to become a Silver Scalpel Award winning trainer; climbing Mt Everest; Royal Surgical Presidential Question time, the surgical trainee@war and much in between. We have something to interest everyone this weekend!
This year it is an honour to host a range of eminent speakers of national and international renown, and we ASiT Vice-President hope you will join us in thanking them for giving up their time this weekend. We also thank our corporate General Surgery Registrar, Inverness patrons and sponsors for their continued support. It is their generosity that keeps our annual conference affordable for trainees. Please do find time to visit their stands and speak to them in person. We are also proud to raise funds during our conference for our nominated charity, the Royal Medical Benevolent Fund, in its 175th Anniversary year and we warmly welcome its patron Dame Hine. 150th Finally, we thank you for your interest and involvement in ASiT. Over the past 36 years of its existence ASiT Vice-President ASiT has continued to hold a unique position in the surgical community. The political and structural landVascular Surgery Registrar, London scape will inevitably continually change but we remain determined to stand up for trainees interests and strive for excellence in your surgical training. As an educational charity, independent of the Surgical Royal Colleges and other professional bodies, ASiT is now stronger than ever with Hornby members from UK and worldwide. We are humble enough, I Steve over 2,000 hope, to remember thatASiT Director of Education implicitly on your continued support and I encourour continued success depends age you once this weekender is over to encourage your colleaguesPeninsula involved. General Surgery Registrar, South West to become I look forward to personally meeting you over the next few days and anticipate a lively, entertaining and educational experience for all. Iechyd With da!
James Milburn
Joseph Shalhoub
Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Goldie Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Khera
President, Association of Surgeons in Training 2011-2012 Association of Surgeons in Training | 35 - 43 Lincoln's InnFields | London | WC2A 3PE | United Kingdom Laura Andrews Kristina Gloufchev Harriet Innes Tel: 0207 973 0302 | Fax: 0207 430 9235 | E-mail: info@asit.org
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thanks to the local ASiT Welsh Regional Representatives:
With thanks to the wonderful ASiT Conference Admin team: info@asit.org
am 2012 ASiT Executive Conference Team 2012

Goldie Khera
Ed Fitzgerald
ASiT Conference Organiser & Past-President General Surgery Registrar, London
Jonny Wild
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ASiT Honorary Secretary & Sponsorship Co-ordinator General Surgery Registrar, Sheffield
Robert Davies
ASiT Honorary Treasurer Vascular Surgery Registrar, West Midlands
James Milburn
ASiT Vice-President General Surgery Registrar, Inverness
Joseph Shalhoub
ASiT Vice-President Vascular Surgery Registrar, London
Steve Hornby
ASiT Director of Education General Surgery Registrar, South West Peninsula
Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor edd, Bangor Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff al of Wales, Cardiff Laura Andrews
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With thanks to the local ASiT Welsh Regional Representatives:
With thanks to the wonderful ASiT Conference Admin team: info@asit.org m: info@asit.org
Kristina Gloufchev Harriet Innes
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ASiT Conference | Cardiff | 23 - 25th March 2012

Goldie Khera
ASiTASiT Conference Programme2012 Executive Conference Team
Ed Fitzgerald
Jonny Wild
Robert Davies
James Milburn
Joseph Shalhoub
Steve Hornby
Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff

Laura Andrews Kristina Gloufchev Harriet Innes
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edd, Bangor al of Wales, Cardiff
tives:
m: info@asit.org
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Goldie Khera
Ed Fitzgerald
Jonny Wild
Robert Davies
James Milburn
Joseph Shalhoub
Steve Hornby

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Student / Foundation Year Session
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m: info@asit.org
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ASiT Executive Conference Team 2012 Conference Programme Extras!

Free Laparoscopic skills sessions ASiT President
Goldie Khera
Bariatric Fellow, North Room A Sat 24th and Sun 25th, all day - SyndicateTyneside Drop-in skills sessions on laparoscopic box trainers, hosted by Laprotrain.
ASiT Conference Organiser & Past-President RCS Research workshop General Surgery Registrar, London Saturday 24th March, 3pm-4pm - Syndicate Room G The Royal College of Surgeons of England are delighted to present a 1 hour session introducing delegates to Research. The session includes presentations on and the options available for acaJonny Wild demic and non-academic careers in research and surgery, the benefits of research and opportuASiT Honorary Secretary & Sponsorship Co-ordinator nities to ask plenty of questions. General Surgery Registrar, Sheffield To sign up to the session please visit the RCSEng stand, places limited to 20. Run by Mr Paul Sutton MRCS and Mr David Humes MRCS on behalf of the RCSEng.
Ed Fitzgerald
Robert Davies
WetLab Surgical Skills
Delia Smiths home recipe book for Surgeons: Surgical skills with a difference Demonstrations, teaching and surgical skills competitions, led by Mr David ORegan, to be held at ASiT Vice-President morning, lunchtime and afternoon refreshment breaks over both Saturday and Sunday, at the General Surgery Registrar, Inverness Wetlab stand number 20 in the Lower Hall. What I would like to demonstrate at the wet lab stand at the ASiT meeting are exercises that can be done by setting up your own - a Delia Smith home recipe book for surgeons. Please come along and try your hand with the new innovative tasks that will stretch your capabilities and help Joseph Shalhoub you understand how you hold and use instruments. ASiT Vice-President Vascular Surgery Registrar, London Surgical instruments are to be regarded as tools and an extension of the hand. How you hold them and how you use them needs to be practiced again and again. Tiger Woods did not become a champion golfer by just playing on golf courses. He has been practicing since the age of 4. The principle of a golf swing is, if you look after the swing the ball will go in the direction you intend it Steve Hornby to. Likewise, all needles are made on a curve. It is important to take the needle into and deliver it ASiT Director of Education out of the tissue on that curve. These simple skills can be practiced at home. The non dominant General Surgery Registrar, South West Peninsula hand should be holding a pair of forceps. It is important that surgical instruments are used as you would use a knife and fork. Do you practice using your non dominant hand and how can you reinforce the skills?
James Milburn
With thanks have local ASiT Welsh at the ASiT conference and invite you to come With this in mind we to theset up a wet lab hereRegional Representatives: Miss Rhiannon Harries, General Surgery Registrar, can replicate them at home. Roll up along and practice on work stations designed such that youYsbyty Gwynedd, Bangor Mr go! and have a Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff
David With thanks to the wonderful ASiTSurgeon ORegan, Consultant Cardiothoracic Conference Admin team: info@asit.org Laura Andrews Kristina Gloufchev Harriet Innes
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ASiT Pre-Conference Courses

Friday 23 March 2012
Every year ASiT organises a range of pre-conference courses for surgical trainees. In 2012 we will host events in Cardiff on Friday 23 March. These can be booked with conference registration and offer fantastic value for money. All include free entry to an evening drinks reception. Read on below for further details.
ASiT / BOTA Foundation Skills in Surgery Course
This popular one-day course will equip senior medical students and junior doctors with many of the fundamental techniques required for success the early years of surgery. Topics include sterile technique and gloving, safe surgical practice, suturing, knot-tying, applying a plaster and many more. This course is essential for trainees wishing to set themselves apart from the crowd, and will provide an ideal talking point for future selection into Surgery... A one-day hands-on skills course aimed at trainees who wish to develop core techniques in laparoscopic surgery. Through both lectures and practical sessions the course includes an introduction to laparoscopic surgery Instruments, ports, access and ergonomics, as well simulated laparoscopic appendicectomy, cholecystectomy and laparoscopic suturing.
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ASiT / Covidien Core Laparoscopic Skills Course
FRCS Critical Appraisal of Literature Course: Masterclass in Journal Club
This full-day pre-conference course aims to provide participants with a strategy for reading and critiquing surgical journal papers, with a step-by-step guide to analysing their methodology, statistics and findings. Participants will be sent a number of recently published journal papers (e.g. BJS, Annals of Surgical Oncology, World Journal of Surgery) immediately prior to the course to read in preparation. For those who wish, the course can include the opportunity to actively present and be questioned on a journal paper.
ASiT / SARS / BJS Research Skills Course
A course for anybody wishing to gain the skills essential for carrying out research studies from simple projects, to higher degrees & to improve the quality of their research and analysis. Run in association with the Society of Academic and Research Surgeons and the British Journal of Surgery, this course provides an overview of the field of academic surgery This course will be invaluable to surgeons at all stages of their training, both to those with a career interest in academic surgery, and those performing or considering a period of laboratory or clinical research. The focus is in providing practical advice on carrying out all types of surgical research.
ASiT GI Anastomotic Stapling and Energised Dissection Course
This one-day course offers an excellent hands-on practical guide to anastomotic intestinal stapling and energised dissection. It includes an overview of the array of stapling devices available to the general surgeon, the science of stapling and staple line leaks, instructions on how to select the best staple size for different tissues, small and large bowel anastomosis and an opportunity to practice on porcine bowel and synthetic substitutes.
edd, Bangor This one-day course will help you learn the basics or improve your skills at surgically-related art in this new al of Wales, Cardiff course by an expert tutor and artist. It introduces the students to the artistic canons of human proportion and how to apply these proportional systems to drawing the human form, including m: info@asit.org drawing from a life model and 3D model making.
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ASiT Surgical Art Workshop
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ASiT Executive Conference Team 2012 ASiT Conference Trainee Prizes

ASiT has again worked hard to organise a range of prestigious awards for the Annual Conference. The following will be awarded to the best abstracts in their respective categories. Goldie Khera ASiT President Bariatric Fellow, North Tyneside ASiT Medal Sponsored by Ansell, ASiTs most prestigious prize is awarded to the best presentation from a surgical trainee. This is selected from the highest scoring abstracts delivered as part of the ASiT Medal oral presentation session. The winner is presented with the ASiT Medal and invited to preEd Fitzgerald sent their work in the ASiT Session at the Association of Surgeons of Great Britain and Ireland International Surgical ASiT Conference Organiser & Past-President Congress. General Surgery Registrar, London
SARS / ASIT Academic & Research Surgery Prize
Awarded in conjunction with the Society of Academic and Research Surgery, this surgical trainee prize rewards high quality clinical and basic science research. The prize winner is selected followJonny Wild ing the SARS oral presentation session, and is judged by members of the SARS Council in conASiT Honorary Secretary & Sponsorship Co-ordinator junction with ASiT. The winnerSurgery Registrar, Sheffield General is invited to present their work in the ASiT Session at the Association of Surgeons of Great Britain and Ireland International Surgical Congress.
ASGBI / ASiT Short Paper Prize

Robert Davies Awarded in conjunction with the Association of Surgeons of Great Britain and Ireland, ASiT Honorary not qualifying for the ASiT Medal or the SARS/ this rewards the best oral presentationTreasurer Vascular Surgery Registrar, West awarded ASIT Academic & Research Surgery Prize. The prize is Midlands to the surgical trainee giving the best presentation in this session. The winner is invited to present their work in the ASiT Session at the Association of Surgeons of Great Britain and Ireland International Surgical Congress, and receives complimentary registration for the meeting.
ASiT / Elsevier Medical Student Prize ASiT Vice-President
James Milburn
General Surgery Registrar, Inverness The highest scoring abstracts with an undergraduate medical student as the first author are selected for the prestigious medical student prize presentation session. The prize is awarded to the medical student giving the best presentation in this session.
Joseph Surgeons ASiT / Royal College ofShalhoub of England Poster Prize
ASiT Vice-President Vascular Surgery Registrar, London Sponsored by the Royal College of Surgeons of England, this prestigeous prize is awarded to the highest scoring poster presented at the ASiT Conference. All abstracts selected for presentation as posters are assessed and marked over the course of the weekend. The ASiT / RCSEng Poster Presentation Prize of 200 is Steve Hornby awarded to the highest scoring authors. ASiT Director of Education General Surgery Registrar, South West Peninsula
IJS Case Report Prizes
Awarded in conjunction with the ASiT-affiliated International Journal of Surgery (IJS), With reward to two local ASiT case reports presented at the ASiT Conferthese prizes thanksthe the best surgical Welsh Regional Representatives: Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor ence. Elsevier's new PubMed-indexed online surgical journal International Journal of Case Reports is a companion journal to the IJS, and is dedicated to publishSurgery Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff ing case reports only. The winners will be invited to submit their full case reports for publication in With thanks to the wonderful ASiT Conference Admin team: fee will be waived. IJS Case Reports, and pending successful peer-review the 250+ publicationinfo@asit.org Laura Andrews Kristina Gloufchev Harriet Innes
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ASiT Surgical Specialty Prizes
ASiT has again worked hard to organise a range of prestigious awards for the Annual Conference. The following will be awarded to the best abstracts in their respective categories.
Orthopaedic Research UK Prize

Orthopaedic Research UK is an independent research foundation in the field of orthopaedic science. It was founded in 1989 by an orthopaedic surgeon, Mr Ronald Furlong, FRCS, and was previously known as the Furlong Research Charitable Foundation. The objectives of the Charity include the advancement of medical education and research. In particular the advancement of orthopaedic knowledge by funding research and training, along with encouraging cooperation between surgeons, scientists and engineers working in the orthopaedic field. Orthopaedic Research UK has established its rightful place as one of the most important names in orthopaedic research in the UK. This prize will be awarded for the best orthopaedic related abstract submitted to the ASiT Conference. The winner will receive 150 and a certificate from the Foundation.
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BASO~The Association for Cancer Surgery Prize

BASO~The Association for Cancer Surgery speaks as an umbrella organisation for surgical specialties treating people with malignant diseases. Their mission statement is to promote the science and art of cancer surgery, for the benefit of the patient, and to encourage and showcase cancer research for public good. The BASO~ACS Trainee Prize will be awarded for the best abstract relating to the "science and practice of cancer surgery". The winner will receive 200.
ALSGBI Trainee Prize

The Association of Laparoscopic Surgeons of Great Britain and Ireland is the premier professional association in the field of laparoscopic surgery. This prize will be awarded for the best transplant surgery related abstract submitted to the ASiT conference. The winner will receive 250, to be presented at the ALS Annual Conference.
AUGIS Trainee Prize

The objectives of the Association of Upper Gastrointestinal Surgeons (AUGIS) of Great Britain and Ireland are to improve the delivery, results and outcome of conditions of the oesophagus, stomach, duodenum, pancreas, liver and biliary tract requiring surgical treatment. The prize will be awarded for the best upper GI surgery related abstract submitted to the ASiT conference. The winner will receive 100.
tives:
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ASiT Executive Conference Team 2012 Specialty Trainee Group Prizes

ASiT has again worked hard to organise a range of prestigious awards for the Annual ConferASiT President ence. We are grateful for the support of several surgical trainee groups who are represented on Bariatric Fellow, North Tyneside ASiT Council. The following will be awarded to the best abstracts in their respective categories.
Goldie Khera
www.aotent.com General Surgery Registrar, London Awarded for the best ENT surgery abstract submitted to the ASiT Conference. The winner will receive 100. AOT is the Association of Otolarynologists in Training, representing ENT trainees.
ASiT-AOT Prize ASiT Conference Organiser & Past-President
Ed Fitzgerald
ASiT-Rouleaux Club Prize
Jonny Wild www.rouleauxclub.com Awarded for the best ASiT Honorary Secretary & Sponsorship Co-ordinator The winner will vascular surgery abstract submitted to the ASiT Conference. General Surgery Registrar, Sheffield receive 100. The Rouleaux Club represents trainees in vascular surgery.
www.surg-online.net Awarded for the best Robert Davies abstract submitted to the ASiT Conference. The winner urological surgery ASiT the Senior Urological will receive 100. SURG is Honorary Treasurer Registrars Group, representing trainees in urological surgery. Vascular Surgery Registrar, West Midlands http://plasta.org.uk Awarded for the best James Milburn plastic surgery abstract submitted to the ASiT Conference. The winner will receive 100. PLASTA is Plastic Surgery Trainees Association, representing plastic surgery. ASiT Vice-President www.thedukesclub.org.uk With the support of Association of Coloproctology of Great Britain and Ireland, this is awarded for the best colorectal surgery abstract submitted to the ASiT Conference. The winner will receive Joseph Shalhoub 100. The Dukes' Club represents general surgery trainees with a sub-specialty interest in coloASiT Vice-President rectal surgery. Vascular Surgery Registrar, London
ASiT-SURG Prize
ASiT-PLASTA Prize
ASiT-Dukes' Club / ACPGBI Prize
General Surgery Registrar, Inverness
ASiT-Mammary Fold Group Prize
www.themammaryfold.com Awarded for the best Steve surgery abstract submitted to the ASiT Conference. breast Hornby ASiT Director of Education General Surgery Registrar, South West Peninsula ASiT-BNTA Prize www.sbns.org.uk/site/1018/default.aspx Awarded for the best neurosurgery abstract presented at the ASiT Conference. The BNTA is the national neurosurgical trainees group, representing neurosurgery trainees at the With thanks to the local ASiT Society of British Neurological Surgeons.Welsh Regional Representatives: Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff

am 2012 ASiT Platinum Corporate Sponsor
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ETHICON PRODUCTS
ETHICON Products are delighted to be platinum sponsors of ASiT once again in 2012. ETHICON remain committed to Professional Education of surgeons in training through a 1st class training pathway. This pathway delivers in-depth training in hernia surgery, tailored to meet the needs of surgeons in their final 2 years of training. The objective is to enhance patient outcomes. For more information on the STEPS training pathway, please contact your local representative or Hernia Specialist. ETHICON Products P.O. Box 1988 Simpson Parkway Kirkton Campus Livingston EH54 0AB Tel: 01506 594500
tives:
m: info@asit.org
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ASiT Gold Corporate Sponsors ASiT Executive Conference Team 2012

COVIDIEN
ASiT President Covidien are proud to be associated once Bariatric Fellow, North Tyneside again with ASiT in 2012 for their annual conference in Cardiff. We have enjoyed a fantastic relationship with ASiT for many years, and look forward to strengthening this collaboration going forward. At Covidien were passionate about making doctors, nurses, pharmacists and other medical proEd they can be. fessionals as effective as Fitzgerald From Autosuture to Valleylab, from Kendall to Mallinckrodt, ASiT are known worldwide for uncompromising our industry leading brands Conference Organiser & Past-President quality. Through ongoing General Surgery Registrar, London collaboration with medical professionals and organisations, we identify clinical needs and translate them into proven products and procedures. Over the years, weve pioneered a number of medical advances including contrast media, pulse oximetry, electrosurgery, surgical stapling and laparoscopic instrumentation. Offering an extensive Jonny Wild product line that spans medical devices, imaging solutions, pharmaceutiASiT Honorary Secretary & Sponsorship Co-ordinator cals and medical supplies, we serve healthcare needs in hospitals, long-term care and alternate General and in the home. care facilities, doctors offices, Surgery Registrar, Sheffield Enjoy the conference! Covidien (UK) Commercial Ltd Robert Davies 4500 Parkway, Whiteley, Fareham, PO15 7NY ASiT Honorary Treasurer Vascular Surgery Registrar, West Midlands
Goldie Khera
THE MEDICAL PROTECTION SOCIETY
MPS - The right choice because we put members first
James Milburn MPS is the worlds leading medical defence ASiT Vice-President organisation, putting members first by proGeneral Surgery adviding professional support and expert Registrar, Inverness vice throughout their careers.
Our whole ethos is focused on what members need and doing our best to help them in whatever way we can. Members of MPS canASiT to fellow professionals with unrivalled specialist medicolegal experiturn Vice-President Vascular Surgery Registrar, 24/7. In addition, they have access to the best ence for confidential, personalised, expert advice London possible protection from the costs of clinical negligence claims. We are also committed to sharing our experience with members to help them avoid problems in the first place and provide the very best care for their patients. Steve Hornby ASiT Director of Education Our financial strength Generalwe will always be here for West Peninsula they need us and our means Surgery Registrar, South members when subscriptions are set fairly which means members only pay for the risk associated with their area of practice. The Medical thanks to Society With Protection the local ASiT Welsh Regional Representatives: 33 CavendishRhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Miss Square London, W1G 0PS Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Tel: 0845 718 7187 www.mps.org.uk With thanks to the member.help@mps.org.uk wonderful ASiT Conference Admin team: info@asit.org Laura Andrews Kristina Gloufchev Harriet Innes
Joseph Shalhoub
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ASiT Gold Corporate Sponsors
Ansell Healthcare Europe N.V. Riverside Business Park Spey House Boulevard International 55 1070 Brussels Belgium Tel: +32 (0) 2 528 74 83 Fax: +32 (0) 2 528 74 06 www.ansell.eu Ansell is a world leader in providing superior health and safety protection solutions that enhance human well being. With operations in North America, Latin America, EMEA and Asia, Ansell employs more than 10,000 people worldwide and holds leading positions in the natural latex and synthetic polymer glove and condom markets. Ansell operates in four main business segments: Medical Solutions, Industrial Solutions, New Verticals and Sexual Health & Well Being. Information on Ansell and its products can be found at: http://www.ansell.eu
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ASiT Silver Corporate Sponsors

ROYAL COLLEGE OF SURGEONS OF ENGLAND The Royal College of Surgeons of England is a standard setting body for Surgery in the UK. We support trainees throughout their careers from premedical students through to retiring consultants. We are able to provide information and guidance on Courses and Careers in Surgery. The Education department at the RCS run a number of courses across the UK for Medical Students upwards including a number of speciality courses. The Opportunities in Surgery Team provide careers support and advice to all groups and oversee the Women in Surgery and Affiliates projects on behalf of the RCS. The Royal College of Surgeons of England 35-43 Lincoln's Inn Fields London WC2A 3PE 020 7405 3474
tives: www.rcseng.ac.uk edd, Bangor al of Wales, Cardiff
m: info@asit.org
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ASiT Silver Conference Team 2012 ASiT ExecutiveCorporate Sponsors

Goldie Khera WESLEYAN MEDICAL SICKNESS
ASiT Conference Organiser & Past-President General Surgery Registrar, London Wesleyan Medical Sickness specialises in providing financial planning services for the medical profession. Our Financial Consultants are trained to understand the specific needs of hospital doctors and are dedicated to helping you plan for a more secure financial future. We understand that doctors have a unique career path with different financial needs at every Jonny Wild stage. As your financial circumstances change, so will our recommendations and we work hard to ASiT Honorary career. understand the issues that affect your Secretary & Sponsorship Co-ordinator General Surgery Registrar, Sheffield Working hard Throughout your career as a hospital doctor, people are constantly asking you for advice, but when do you get the chance to talk to a specialist about what you need? Our Financial Consultants can help with your professional and personal financial needs. Robert Davies We can advise on: ASiT Honorary Treasurer Income protection and life assurance Vascular Surgery Registrar, West Midlands Pensions, including the NHS pension scheme and retirement planning Savings and investments* Mortgages Schools and university fees planning Inheritance tax mitigation James Milburn Insurance* ASiT Vice-President
* Home, motor and travel insurance is arranged by Wesleyan for Professionals. Deposit accounts, loans and savings are provided by General Surgery Registrar, Inverness Wesleyan Bank.
Ed Fitzgerald Personal financial planning exclusively for hospital doctors
To arrange a no-obligation financial review call 0808 100 1884 or visit www.wesleyan.co.uk to find your local Financial Consultant
Joseph Shalhoub
Steve Hornby

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Other Sponsors and Exhibitors
SWANN-MORTON LTD.
Swann-Morton Limited Owlerton Green Sheffield S6 2BJ Telephone: +44 (0)114 234 4231 Email: info@swann-morton.com The Worlds leading surgeons can always rely on the consistent quality, precision and performance of surgical blades, handles and scalpels manufactured by Swann-Morton in Sheffield, England. With the pending implementation of the EU Directive on the prevention from Sharp Injuries in the Hospital and Healthcare Sector (2010/32/EU) Swann-Morton can offer in house training on good practice when fitting, handling and disposing of surgical blades and scalpels in the workplace. They also offer a number of products such as their single and multi use blade removers, Retractable Scalpels and the Cygnetic range which incorporate safety features that can support existing protocols and initiatives already established within the Hospitals. Launched in Autumn 2010 Cygnetic incorporates a lever system allowing safe and easy blade attachment and removal. For use in Orthopaedics and general surgery the handle can be disassembled by the decontamination and reprocessing centre for cleaning before reassembly for sterilisation and use in the next procedure. Never compromising their ongoing commitment to quality, Swann-Morton celebrates their 80th anniversary in July 2012. Full details of the company and products can be found at www.swann-morton.com where you will also find a range of training films and supporting literature.
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Other Sponsors and Exhibitors ASiT Executive Conference Team 2012

Goldie Khera
ASiT President Bariatric Fellow, North Tyneside AFRICA HEALTH PLACEMENTS Africa Health Placements (AHP) is a joint venture between the Rural Health Initiative (RHI) and Ed Fitzgerald Foundation for Professional Development (Pty) Ltd, with the shared aims of recruiting, orientating ASiT Conference the public & Past-President and retaining healthcare professionals inOrganiser healthcare sector in southern Africa. General Surgery Registrar, London AHPs operations are currently based in South Africa where the project was founded. Our recruitment is achieved through close working relationships with the National Department of Health, provincial health departments, government hospitals, NGO clinics and regulatory bodies, as well as with a number of institutions that support the pipeline of human resources for health. AHP fully Jonny Wild supports Doctors desiring placements in the Public Health Sector through the entire process of ASiT Honorary Secretary & placement support. finding jobs, to paperwork and orientation and post Sponsorship Co-ordinator General Surgery Registrar, Sheffield AHP is funded through a number of aid organisations, philanthropists and corporate donors, as well as through a growing base of for-profit recruitment activities, so our services are delivered free of charge to medical personnel. There are severe healthcare staffing shortages in Sub-Saharan Africa. These are exasperated by ASiT Honorary Treasurer the well-publicised brain drainSurgery Registrar, West Midlands are huge inequities within the Vascular situation. Shortages aside, there South African healthcare sector. The public sector, serving 80% of the population, only employs a quarter of the countrys doctors. Within the public sector, rural areas are suffering even more dramatically than their urban counterparts. Africa Health Placements markets to foreign- and local-qualified doctors, nurses and allied health James Milburn professionals in an attempt Vice-President public practice. This forms the core of AHPs operaASiT to draw them to tions. Africa Health Placements also works with aInverness General Surgery Registrar, wide network of partners in building retention and training programmes for healthcare professionals, running advocacy campaigns around the staffing crisis, interacting with international and regional bodies around healthcare capacity issues, supporting research into capacity development, creating innovative and effective documentaries and marketing campaigns, and, as such, is a leader in this field in Sub-Saharan Africa . The Project was started in Mid-2005 and has received much positive publicity and success since ASiT Vice-President then. For more information please visit: Registrar, London Vascular Surgery http://www.ahp.org.za/
Robert Davies
Joseph Shalhoub
Steve Hornby

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AO FOUNDATION The AO Foundation is a charitable organisation, which is dedicated to the promotion of excellence in surgery of musculoskeletal trauma. AOUK is the Anglo-Irish section of the foundation and through its education department delivers non-profit making courses in the UK & Ireland to train young surgeons and operating room personnel in the theory and practice of trauma and spine surgery. As well as its core activity of educating and training, AOUK promotes advanced educational courses for senior doctors, not only in the surgical specialties but in teaching techniques through AO Tips for Trainers. AOUK hold courses at principles & advanced levels in general trauma. Our specialty courses include: long bone, pelvic, hand & wrist, shoulder & elbow, foot & ankle, geriatric and paediatric. We also hold courses at principle and advanced level for cranio-maxillofacial surgeons & ORPs as well as specialty courses for CMF surgeons in neurotrauma. Spine courses at both principle and advanced level. Vet courses also at both principle and advanced level. The membership of AOUK consists of a group of established surgeons and ORPs who freely give their time to teach on the 30 courses that are run by AOUK annually. For further information please visit www.aouk.org
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TERRITORIAL ARMY MEDICAL SERVICES HEADQUARTERS 2 MEDICAL BRIGADE QUEEN ELIZABETH BARRACKS STRENSALL YORK YO32 5SW TEL: 0800 731 1201 EMAIL: 2MEDX-CVHQ-G1-Recruiting-SO2@mod.uk 2MEDX-CVHQ-Recruiting-WO@mod.uk Are you searching for something extra from your life a rewarding experience outside of normal working hours? You will find all this and more in the Territorial Army - Medical Services. We can offer a career to people who want to experience Army life but are unable to make a full time commitment. Wherever you find the Regular Army, you will find the Territorial Army - Medical Services assisting worldwide in providing critical medical support. The One Army concept brings Regular and Territorial servicemen and women together to work side by side providing specialist medical care during times of conflict, counter insurgency, peacekeeping and humanitarian operations.
The Territorial Army Medical Services is constantly recruiting medical professionals who want to gain more from life and enhance their own clinical and specialist development whilst creating a edd, Bangor military team ethic. al of Wales, Cardiff To discover how a career in the Territorial Army Medical Services can make a real difference to your life: m: info@asit.org Visit us at the Army Medical Services stand or FREEPHONE 0800 731 1201 for more information.
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British Journal of Surgery Goldie Khera Wiley-Blackwell ASiT President 101 George Street Bariatric Fellow, North Tyneside Edinburgh, EH2 3ES, UK Tel: +44 (0) 131 7184457 Fax: +44 (0) 131 2263803 E-mail: bjs@wiley.co.uk www.bjs.co.uk ASiT Conference Organiser Europe and one of BJS is the premier peer-reviewed surgical journal in & Past-President the top surgical periodicals in the world, with General Surgery Registrar,Its international readership is reflected in the an impact factor of 4.444. London prestigious international Editorial Board, supported by a panel of over 1200 reviewers worldwide. BJS features the very best in clinical and laboratory-based research on all aspects of general surgery and related topics. BJS has a tradition of publishing high quality papers in breast, upper GI, Jonny Wild lower GI, vascular, endocrine and surgical sciences. ASiT Honorary Secretary & Sponsorship Co-ordinator General Surgery Registrar, Sheffield ASiT members can take advantage of our unique trainee discount subscription to the BJS.
Ed Fitzgerald
See the ASiT website www.asit.org for further details. ASiT Honorary Treasurer Vascular Surgery Registrar, West Midlands COCHRANE COLLABORATION The Cochrane Collaboration, established in 1993, is an international nonprofit independent network of health-care professionals, researchers, and James Milburn consumers located in ASiT Vice-President more than 100 countries and consisting of more than 28.000 volunteers. General Surgery Registrar, Inverness The Collaboration is dedicated to developing and maintaining the accessibility of comprehensive, regularly updated critical systematic reviews of evidence from randomised clinical trials (RCTs) relevant to their speciality and interests. Conducting reJoseph Shalhoub search in a systematic way, the Collaboration thus aims to provide compiled scientific evidence ASiT Vice-President about the effects of healthcare to aid well informed health care decisions. Vascular Surgery Registrar, London So far, more than 4.800 Cochrane Systematic Reviews have been published in The Cochrane Library for the benefit of health care providers, policy-makers, patients, their advocates and carers. ASiT Cancer of Education The Cochrane Colorectal DirectorGroup, CCCG, was established January 27, 1998 and forms General Surgery Registrar, South West Peninsula one of the 52 collaborative review groups in The Cochrane Collaboration. The CCCG is sponsored by grants from The Capital Region of Denmark and private funds. The primary aim of the CCCG is to assist and support review authors in preparing, developing and updating Cochrane Systematic Reviews within the scopes CCCG, which besides colorectal cancer also comprises benignWith thanks conditions. Today, CCCG has more than 900 members. proctological to the local ASiT Welsh Regional Representatives: Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff
Robert Davies
Steve Hornby

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DOCTORS' SUPPORT NETWORK Doctors' Support Network (DSN) is a confidential peer support network for doctors who have experienced mental health difficulties. Doctors in difficulty often feel extremely isolated - support from other doctors is an invaluable part of recovery. All members have themselves been troubled at some stage in their lives; many have continued in medicine, some have pursued other options. We encourage members to open up about their experiences and help newcomers to see that things can and do get better. We have a 24h online forum and a helpline staffed by trained volunteer doctors, as well as some local meetings. www.dsn.org.uk
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ELSEVIER HEALTH Elsevier Health advances medicine by delivering superior education, reference information and decision support tools to medical students and medical professionals. Elsevier Health sponsors the 2012 ASiT Medical Student Prize.
HODDER ARNOLD Hodder Arnold offer a range of resources to cover every stage of your surgical career - from course textbooks and guides for revision and study to operative manuals and reference works. Examdoctor is an online exam revision resource to help medical students and junior doctors to prepare for their medical finals, Royal College and professional examinations. Examdoctor contains over 35,000 expert-authored questions and 20 different courses covering a wide range of specialties including the MRCS examination.
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LAPROSURGE ASiT President LaproSurge manufactures and supplies hospitals worldwide with Bariatric for laparoscopic applications. The high quality single-use devicesFellow, North Tyneside portfolio includes tissue retrieval systems, trocar and cannula sets, smoke filters, scissors, insufflation needles and many laparoscopic accessories. Founded in London inEd Fitzgerald 1998, LaproSurge supports partners and distributors in the UK and across ASiT Conference a close collaboration between Europe. Devices are manufactured from Organiser & Past-President leading surgeons and speGeneral Surgery Registrar, London cialists, ensuring clinical approval and excellence.
Goldie Khera
LAPROTRAIN
ASiT Honorary Secretary & Sponsorship Co-ordinator General Surgery Registrar, Sheffield Most simulators are inanimate or virtual limited in their use or expensive! Laprotrain is a fully functional, take home endoscopic trainer which provides a realistic simulated laparoscopic platform. It provides the perfect image and links directly to a TV! Laprotrain may be Robert Davies used with or without an assistant surgeon as the scope may be fixed or mobile in a moment. ASiT Honorary Treasurer Vascular Surgery Registrar, West Midlands This trainer works! It comes complete with on-line, step to step skills videos, available through our web site, www.lapsimtraining.com to take a complete novice to a competent technical level in a few months. Laprotrain can accommodate the use of predesigned skills sets, tissue, perfect the use of diathermy and harmonic scalpels for example. ASiT Vice-President Laprotrain has been adopted by the London Deanery, ASGBI, & the BSGE General Surgery Registrar, Inverness Key Features: Scientifically proven to improve skills Take home system Joseph Shalhoub Ease of set up ASiT Vice-President Office, home, OR, training lab Surgical warm up Vascular Surgery Registrar, London Ergonomically designed Robust High definition camera Steve No light source required Hornby ASiT Director of Education Unique posable camera mount General Surgery Registrar, South West Peninsula Allows assistant training Adjustable platform Realistic skin ports At Endosim we are committed toGeneralaffordable simulators into the hands of surgeons who are Miss Rhiannon Harries, getting Surgery Registrar, Ysbyty Gwynedd, Bangor training or up-skilling order your laprotrain now! Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff
Jonny Wild
James Milburn

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MHRA
The Medicines and Healthcare products Regulatory Agency (MHRA) is the government agency which is responsible for ensuring that medicines and medical devices work, and are acceptably safe. The MHRA is an executive agency of the Department of Health. Dr Nicola Lennard, MHRA Senior Medical Officer, and Mike Peel, MHRA Head of Device Education, will be on hand to discuss the MHRA and to promote our education packages and the Medical Device Driving Licence, a new initiative to support and promote learning and education.
For more information visit: http://www.mhra.gov.uk
inator ONEXAMINATION
onExamination from BMJ Learning, is a leading provider of online exam revision resources and since 1996 has supported over 167,000 medical professionals with their exam preparation. Trust the experts in medical exam revision to help you pass your medical exams. Use our peer reviewed, exam format questions that are pitched at the right level of difficulty to mirror the actual exam. Our focussed and efficient revision resources will support you towards exam success. All resources include; detailed explanations, links to further reading, performance feedback and mobile access.

Our Surgical revision resources include: MRCS Part A Paper 1 and 2 FRCS General Surgery
Let us support you towards exam success with one of our many unique features, including: Work Smart Work by curriculum area to focus your efforts topic by topic. AdaptForMeTM Questions pitched to improve your learning faster. Group Learning Quiz format revision tool. Test your knowledge with our FREE sample questions. Visit us at Stand 13 or find out more at: onexamination.com/surgery
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OPERATION HERNIA ASiT President Operation Hernia is an independent UK charity and non-profit orBariatric Fellow, North Tyneside ganisation that delivers a surgical programme intended to treat and teach inguinal hernia surgery in low and middle income countries. Operation Hernia is committed to providing high quality surgery at minimal costs to patients that otherwise would not receive it.
Goldie Khera
Ed Fitzgerald It was initiated in 2005 in Takoradi, Ghana and now operates in four other countries of West AfASiT Conference Organiser in Malawi, Mongolia, Ecuador, Peru and rica (Nigeria, Ivory Coast, The Gambia, Cameroon),& Past-President General Surgery Registrar, London Moldova, and with plans for further expansion in 2012.
Surgeon Volunteers are drawn mainly from members of the European and American Hernia Societies, by Andrew Kingsnorth, Past-President of the European Hernia Society who also recruits volunteers, initiates and organises the missions. ASiT Honorary Secretary & Sponsorship Co-ordinator See www.operationhernia.org.uk for more information, to get involved or to make a donation. General Surgery Registrar, Sheffield
Jonny Wild
ORTHOPAEDIC RESEARCH Davies Robert UK
ASiT Honorary Treasurer Orthopaedic Research UK is a Surgery Registrar, West Midlands Vascular charitable organisation which funds high quality research into orthopaedic science. We are an independent body dedicated to advancing orthopaedic knowledge, not just by funding and publicising research James Milburn but also by organising training and events which promote colASiT Vice-President laboration between orthopaedic surgeons, scientists and engiGeneral Surgery Registrar, Inverness neers. We were established in 1989 by the orthopaedic surgeon Mr Ronald Furlong FRCS. Until 2011 we were known as The Furlong Research Charitable FoundaJoseph Shalhoub tion. ASiT Vice-President Vascular Surgery Registrar, London Since 2004 we have supported more than 80 projects, investing over 5.6 million and working alongside in excess of 30 of the UKs leading universities and research centres.
Steve Hornby Today we are one of the most significant funders of orthopaedic research in the UK and we are ASiT Director of Education pleased to sponsor the 2012 ASiT Orthopaedic Prize. General Surgery Registrar, South West Peninsula
For more information please visit our website: www.oruk.org

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PASTEST
Make sure you visit the PasTest stand to register your details and receive a free copy of Fast Track Surgery: General, Vascular and Urology! Every year PasTest helps thousands of trainee surgeons to achieve success in their MRCS A and B exams, and in ST1, ST3 and Consultant-level interviews, with a range of online resources, courses and books. MRCS A PasTest Online offers over 4,000 exam themed questions, eLectures and professionally filmed anatomy demonstrations given by Prof Harold Ellis. Access questions through our dedicated smartphone app for iPhone, iPad, Android and BlackBerry 7 devices. PasTest books for MRCS A include the extensive Essential Revision Notes for MRCS, and a wide range of question books for both Paper 1 and Paper 2. MRCS B Our highly recommended weekend course at Kings College London is held three times a year. Candidates start the weekend with targeted lectures covering exam technique and key revision areas, followed by Saturday afternoon and all day Sunday practicing with model and patient OSCE cases. OsceCases is our innovative online resource for MRCS B. Including over 250 exam-themed resources including filmed patient cases, spot diagnosis and examination demonstrations, OsceCases is free of charge to all course attendees, or sold separately for candidates who want truly flexible preparation for the OSCE. Essential Revision Notes for the MRCS B OSCE tells you everything you need to know to pass the OSCE, and is a great basis for revision from best-selling MRCS author Catherine ParchmentSmith. Interview Skills PasTests online interview skills site offers specialty and level specific questions for ST1, ST3 and Consultant surgical interviews with accompanying guidance notes and eLectures. Visit: www.pastest.co.uk WETLAB Wetlab is dedicated to hands on surgical training development and assessment, working closely with industry and National health service hospitals in Britain and Ireland together with the SCTS university. With over 10 years experience of supplying our award winning Wetlab services, we know what is required to make an event not only successful and memorable but a great opportunity to truly develop a delegates skills and knowledge.
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edd, Bangor Wetlab Ltd have quickly become renowned throughout the medical industry for what we do and al of Wales, Cardiff for what we can provide.
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For more m: info@asit.org information visit www.wetlab.co.uk

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RRSSC ASiT President We train: you gain skills, confidence and speed Bariatric Fellow, North Tyneside
Goldie Khera
RRSSC is a microsurgical training centre in the Netherlands (Almere, very close to Schiphol airport). In this well-equipped centre you can be trained in microsurgical techniques in a module Ed Fitzgerald specifically made for MD's., We also offer other modules for any experimental animal models you ASiT Conference Organiser & Past-President might need to perfect for your research projects. General Surgery Registrar, London Prof. Ren Remie, the course leader has more than 30 years of experience in teaching surgical and microsurgical techniques. RRSSC's mission, vision and Wild are: Jonny values ASiT Honorary Secretary & Sponsorship Co-ordinator Mission; To share Ren Remies experience andSheffield General Surgery Registrar, enthusiasm for setting and achieving ambitious levels of (micro)surgical skills. Vision; Teaching, training and consultancy tailored to your individual needs, with as many handson practical exercises for you as possible. Values; Encouraging ASiT Honorary Treasurer will benefit all involved back in your places of good surgical practices that work. Vascular Surgery Registrar, West Midlands Learning to do the right things in the best and most efficient ways, with the least tissue trauma, in the shortest possible times. Particular attention paid to good access, illumination and sequence of handlings (goal oriented), haemostasis, asepsis, and proper perioperative care. ASiT on the web: www.rrssc.eu Want to see more? Visit us Vice-President General Surgery Registrar, Inverness
Robert Davies
James Milburn
Joseph Shalhoub
ASiT Vice-President Vascular Surgery Registrar, London The Royal College of Physicians and Surgeons of Glasgow is the only multidisciplinary Royal College in the UK. Founded in 1599 and ASiTwith over 10,000 physicians, surgeons, dental professionals and spenow Director of Education General Surgery Registrar, has developed a reputation for providing high cialists in the field of travel medicine the College South West Peninsula quality, relevant, postgraduate education, continuing professional development and an array of examinations and assessment in key centres worldwide. In partnershipRhiannon Harries, General Surgeons of Great Ysbyty and IrelandBangor jointly re Miss with the Royal Colleges of Surgery Registrar, Britain Gwynedd, we are sponsible for settingBeamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Mr Andrew standards of surgical training and assessments and protecting professional integrity.
Steve Hornby

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The Royal College of Surgeons of Edinburgh is dedicated to the pursuit of excellence and advancement in surgical practice, through its interest in education, training and examinations, its liaison with external medical bodies and representation of the modern surgical workforce. The College prides itself on its rich heritage, its reputation for friendliness and innovation, and the individual attention given to all our College Fellows, Members and Affiliates throughout the UK and internationally. We offer representation of our trainees through an elected Trainee Member of Council, in addition to trainee representatives on the Colleges surgical specialty groups and meetings with trainee groups. We are also increasing trainee representation by reconstituting a Trainees Committee. Come and visit us in the Exhibition Hall (Stand 7) where representatives from the College will be available to talk with you about the range of College initiatives, events and benefits designed especially for trainees, from your first years after foundation training and passing your MRCS examination, right through to your appointment as a consultant. www.rcsed.ac.uk
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The Royal Society of Medicine is one of the largest providers of continuing medical education in the UK. Each year the RSM organises over 400 CPD accredited conferences, courses and meetings allowing doctors, dentists, veterinary surgeons, including students of these disciplines, and other healthcare professionals their continuing freedom to practise. RSM members enjoy exclusive member benefits including: 1. Access to one of the worlds leading medical libraries 2. Online access to hundreds of full text ejournals, ebooks and 7 medical databases 3. Opportunities to enter over 65 awards and prizes worth a total of 65,000 each year 4. Trainee specific meetings designed by trainees for trainees 5. Discounts (sometimes free) attendance at all RSM meetings 6. View, free of charge, over 170 videos of our key lectures at www.rsmvideos.com 7. Networking opportunities to meet senior healthcare professionals and opinion formers 8. Exclusive Members only club facilities when visiting London including lounge, caf/bar area, restaurant and private dining rooms 9. Exclusive accommodation at low prices RSM Young Fellow membership starts at just 9 a month. For more information and to join one of the worlds leading medical societies:
edd, Bangor Email: membership@rsm.ac.uk al of Wales, Cardiff Tel: 020 7290 2991 www.rsm.ac.uk/join
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ASiT Conference Speaker Biographies ASiT Executive Conference Team 2012

In alphabetical order, where supplied by speakers
Goldie Khera Rajesh Aggarwal MBBS MA PhD FRCS Tyneside Bariatric Fellow, North
Rajesh Aggarwal began his medical training at Selwyn College, Cambridge University and completed clinical studies at The Royal Free Hospital School of Medicine, London, graduating with Honours. Subsequently he has completed basic surgical Ed Fitzgerald training in London teaching hospitals, and a PhD thesis at Imperial College London entitled A Proficiency-Based Technical ASiT Conference Organiser & Past-President Skills Curriculum for Laparoscopic Surgery. His work has been published in General Surgery Registrar, London over 100 peer-reviewed papers, including Annals of Surgery, British Journal of Surgery and New England Journal of Medicine. In 2010 he has been elected to the prestigious National Institute of Health Research Clinician Scientist Fellowship, awarded by the Department of Health, U.K. ASiT President
Jonny Wild
Mr Ian W R Anderson General Surgery Registrar, Sheffield

FRCS, FRCP, FCEM, HON FACP
ASiT Honorary Secretary & Sponsorship Co-ordinator
Mr Ian Anderson, President of the Royal College of Physicians and Surgeons of Glasgow, is a graduate of the University of Glasgow where he Robert Davies studied between 1969 and 1975, graduating with commendation MB ChB in ASiT Honorary Treasurer 1975. Vascular Surgery Registrar, West Midlands He spent the bulk of his training years in the West of Scotland, having completed surgical training and then training in Accident and Emergency Medicine. He first took up his Consultant post in the Victoria Infirmary in Glasgow in 1984. In 1999, he was elected President of the then Faculty of Accident and Emergency MediJames Milburn cine, now College of Emergency Medicine. ASiT Vice-President General the Council of the Royal College of Physicians and Surgeons of Mr Anderson has served on Surgery Registrar, Inverness Glasgow continuously in various roles since 1993. He has been Treasurer, Visitor (President Elect) and finally, President, since November 2009. He has been a Director of The Medical and Dental Defence Union of Scotland for almost 20 years Joseph Shalhoub and in 2010, became Honorary Professor in the Institute for People-Centred Healthcare ManageASiT Vice-President ment at Stirling University Business School. Vascular Surgery Registrar, London
Dr Stephanie Bown LLB(Hons) MRCP DRCOG FFFLM Director of Policy, Communications and Marketing at the Medical Protection Steve Hornby Society. ASiT Director of Education General the interests of MPS and its members exterShe represents and promotesSurgery Registrar, South West Peninsula
nally to decision makers and a wide range of health and legal stakeholders. She works to establish MPS as the preferred choice of professional protection for doctors and other healthcare workers in Regional Representatives: With thanks to the local ASiT Welsh the markets in which MPS operates. Through her role at MPS Stephanie contributes Ysbyty Gwynedd, Bangor Miss Rhiannon Harries, General Surgery Registrar, to a number of working Mr Andrew Beamish, Clinical Research Fellow, involved in Hospital of Wales, Cardiff groups, expert panels and boards. She is also University developing MPS's medicolegal educational materials.

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Stephanie joined MPS in 1994 as a medicolegal adviser and developed a particular interest in disciplinary and regulatory case work. She completed an LLB in 1997 and subsequently qualified as a mediator. Stephanie later became MPS's Head of Medical Services (London). She spent over 12 years as a doctor in the NHS, in acute hospital medicine, then obstetrics and gynaecology before moving into general practice in South East London. Outside MPS, Stephanie is a foundation fellow and past vice president of the Faculty of Forensic and Legal Medicine.
Alison Carr
Alison Carr is Senior Clinical Advisor to the Medical Education and Training Programme of the Department of Health and a Consultant Paediatric Anaesthetist at Plymouth Hospitals NHS Trust. She has wide experience in medical education and training and workforce issues with previous roles including Deputy Postgraduate Dean in the South West Peninsula Postgraduate Deanery, Director of Phase 2 curriculum for the Peninsula College of Medicine and Dentistry and Education Director for the South West School of Anaesthesia. She has recently joined the Advisory Board of the Centre for Workforce Intelligence. As a Consultant Paediatric Anaesthetist, Alison has a special interest in the training of future surgeons!
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Philip Wai Yan Chiu MD, FRCSEd, FHKAM (Surgery)

Professor Philip Chiu is currently Professor of the Department of Surgery, Institute of Digestive Disease and Director of CUHK Jockey Club Minimal Invasive Surgical Skills Center, The Chinese University of Hong Kong. Professor Chiu graduated from the Faculty of Medicine, Chinese University of Hong Kong in 1994 with two scholarships. During his surgical training, he won the bronze prize of the best original research by trainee, Hong Kong Academy of Medicine. He became a fellow of the Royal College of Surgeons of Edinburgh and Hong Kong Academy of Medicine in 2001. He achieved doctorial degree (M.D.) at the Chinese University of Hong Kong in 2009. Dr. Chiu was the first to perform endoscopic submucosal dissection (ESD) for treatment of early GI cancers in Hong Kong. In 2010, he performed the first Per-oral Endoscopic Myotomy (P.O.E.M.) in Hong Kong. His research interests include upper gastrointestinal bleeding, esophageal cancer and thoracoscopic esophagectomy, novel endoscopic technologies for diagnosis of early GI cancers, ESD and development of novel endoscopic procedures as well as Natural Orifices Transluminal Endoscopic Surgery (NOTES). Currently he is vice president of Hong Kong Society of Upper Gastrointestinal Surgeons, council member of the Hong Kong Society of Digestive Endoscopy, and member of the American Society of Gastrointestinal Endoscopy. He is council member of the College of Surgeons of Hong Kong and deputy director of Department of Standard. He served as associate editor for Digestive Endoscopy, and peer reviewer for numerous journals including Gastrointestinal Endoscopy and Endoscopy. He was awarded outstanding reviewer for Gastrointestinal Endoscopy in 2008.
tives: Serving as a member of the team led by Prof. Joseph Sung, he was awarded State Scientific edd, Bangor Technology and Progress Award by the State Council of the Peoples Republic of China in 2007. al of Wales, Cardiff his research on Per Oral Endoscopic Myotomy was awarded best of DDW 2011 as well Recently as 1st runners up in the ASGE world cup of endoscopy.
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Dr Alison Cook
Director of External Affairs, RCS

Goldie Khera
Alison Cook joined the Royal College of Surgeons in 2007 and is responsible for directing College policy, communications and external affairs. ASiT President Alison worked as a journalist for the BBC for 10 years appearing on TV and radio Bariatric Fellow, in science and as a news correspondent, specialisingNorth Tyneside medicine, before moving to the Human Fertilization and Embryology Authority as their Head of Press in 2003. She co-ordinated communications campaigns on sex selection, embryo transfer and the granting of the first cloning licence.
Ed Fitzgerald Alison moved to the Department of Health and led on the White Paper consultation on health outASiT Our Care, Our Say delivering a ground breaking web cast of governside hospitals Our Health, Conference Organiser & Past-President General broadcast live to London ment policy making in action, Surgery Registrar,over 2.5 million viewers. She also designed and produced a three part public health campaign Small change, big difference for Number 10. Surgeon Lieutenant Commander Catherine Doran Jonny Wild
BA PGCAES FRCS (Gen Surg) RN ASiT Honorary Secretary & Sponsorship Co-ordinator General Surgery Registrar, Sheffield Catherine grew up in Northern Ireland and after graduating from Trinity College Dublin in Medicine pursued her surgical career as an SHO in Glasgow. Having been a member of the Royal Naval Reserves for a few years, she decided to transfer to a full time in the Royal Navy in 2002, and promptly spent a year at sea and being involved with the initial conflict in Iraq. Robert Davies ASiT Honorary Treasurer On return to shore-side, she continued Registrar, West Midlands Vascular Surgery her surgical training in Wessex and Severn regions. In 2008, she entered a two year research project at the Ministry of Defence Research Facility at Porton Down looking at the coagulopathy of trauma and spent two months based at the Military Hospital in Camp Bastion, Afghanistan. Currently Catherine is in her final year of training at the Oxford Radcliffe Hospital Trust. Outside work, her passion is escaping to sea on yachts. James Milburn ASiT Vice-President General Surgery Registrar, Inverness Dame Deirdre Hine DBE FFPH FRCP Deirdre Hine is a public health physician who qualified at the then Welsh National School of Medicine in 1961. She has had a career in both academic and Joseph Shalhoub NHS practice in Wales and in the Medical Civil Service. ASiT Vice-President Vascular Surgery Registrar, London She established the Welsh Breast Cancer Screening Service, before becoming Chief Medical Officer at the Welsh Office from 1990 to 1997. She is known widely for her copublication with Sir Kenneth Calman of the seminal Report on Cancer Services ( the Calman Hine report). ASiT Director of Education Since retirement as Chief Medical Officer in 1997 she has been Chairman of the Commission for Health Improvement, General Surgery Royal Society of West Peninsula President of the Registrar, South Medicine, President of the British Medical Association, Chairman of the BUPA Foundation and a Non-Executive Director of Dwr Cymru Welsh Water She is currently President of the Royal Medical Benevolent Fund, Chairman of the Wales Cancer Insititute Partners Forum and president of Age Cymru and has most recently With Review of the local ASiT Welsh Regional the H1N1 Pandemic, chaired the thanks to the UK Governments Response to Representatives: a Public Inquiry Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, of Older into an Outbreak of C.Difficile in Northern Ireland and a Review of the Care Bangor People in in Andrew Hospital Mr Wales. Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff
Steve Hornby

am 2012 James, at the age of 25, became the first ever Welsh woman to climb Tori
Mount Everest. Tori stars in the BBC documentary On Top of the World which was produced using video footage which she shot and directed whilst climbing Everest. Tori is a multi-talented individual with a passion for extreme adventure in sub zero temperatures. She grew up on a farm in Pembrokeshire (West Wales) where she claims to have gathered much of her toughness for venturing outside in all weather. After gaining a degree in Geography from Royal Holloway University, Tori spent three years working for the British Schools Exploring Society (BSES Expeditions) which is based at the Royal Geographical Society (RGS) in London. It was during her time working in the attic of the RGS that she became part of a team that was determined to make the record books. In May 2005 The Pink Lady PoleCats became the first ever all-female team to complete The Polar Challenge, a grueling 360 mile race to the Magnetic North Pole. Not only did The Pink Lady PoleCats finish the race in 6th position out of 16 teams, beating allmale teams along the way, but they also raced through polar bear territory, across constantly--shifting sea ice and battled against temperatures of --40C. Two years later, on 24 May 2007, Tori climbed to the summit of Mount Everest (8,850 metres/29,035 feet). In doing so, she became the youngest British female (at that time) and the first ever Welsh woman to reach the summit. In January 2010, Tori took to two wheels and cycled the length of New Zealand, a total of 2400 km, unsupported from north to south. Tori currently lives and works in Cardiff. She is a co-founder of the group Cardiff Explorers which launched 2010. She is an Honorary Patron for the Search & Rescue Dog Association (South Wales), a volunteer for the Duke of Edinburghs Award and BSES Expeditions and an Ambassador for Girlguiding UK. Her expeditions have raised over 40,000 for charity. Tori works for GE Aviation in Cardiff as the site s Community Liaison Leader. www.torijames.com Twitter: @torijtweets www.girlsbikenewzealand.com www.theaward.org www.bses.org.uk www.sardasouthwales.org.uk
Tori James Speaker & Adventurer
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Carol Makin PhD FRCS
1976 Graduated from Welsh National School of Medicine, Cardiff 1978-79 SHO Nottingham University Hospitals 1979-81 Registrar, Royal London Hospital 1980 FRCS England 1981-84 PhD Monoclonal antibodies for the study of epithelial and other cantives: edd, Bangor cers, University College, London & Cancer Research UK 1984-85 al of Wales, Cardiff Registrar, Westminster Hospital 1986-90 Lecturer & Honorary Senior Registrar, Royal Liverpool University Hospital 1990-10 m: info@asit.org Consultant General & Colorectal Surgeon, Wirral University Teaching Hospital 2004 Lean experience in applying manufacturing principles to healthcare
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2008-9 President Section of Coloproctology, Royal Society of Medicine, London 2009-10 Seconded to the NHS Institute for Innovation & Improvement, surgical lead for Day Surgery Cholecystectomy Project 2010- current position Consultant General & Colorectal Surgeon, Medical Specialist Group & Princess Elizabeth Hospital Guernsey, Channel Islands

Goldie Khera
ASiT President Along the way acquired a husband who is also a surgeon and 3 children a chemical engineer, a Bariatric Fellow, North Tyneside marketing and psychology expert, and a natural scientist currently studying physics in french at Grenoble University
Gordon McFarlane isASiT Conference Organiser & Past-President a Consultant Surgeon in Lerwick, Shetland Islands. He General Surgery Registrar, London graduated from Aberdeen University and continued training in general surgery in Aberdeen and Inverness, obtaining an FRCS in 1989. After a further 6 month post in Inverness as an orthopaedic registrar, he worked for 9 years as a surgeon in Chogoria, Kenya, a 300 bed rural church hospital. While there he undertook a ChM thesis on H. Pylori and gastric cancer. ASiT Honorary Secretary & Sponsorship Co-ordinator On returning to UK, he spent 4 years on the West of Scotland SpR rotation in General Surgery, General Surgery Registrar,Trainee with the North of Scotland Deanery. He the last year of which was as a Rural Surgical Sheffield was appointed to Gilbert Bain Hospital, Shetland in 2004. He is a Fellow of the College of Surgeons of East Central and Southern Africa, and a member of the Viking Surgeons club. He maintains an interest in rural surgical training and surgery in Africa. He is a member of the Christian Medical Fellowship and takes Davies role in his local church. He is married and has two sons, Robert an active both undergraduate engineers. Since moving to Shetland, hill climbing has been replaced by ASiT Honorary Treasurer squash during the winter months and sea kayaking in the summer. Vascular Surgery Registrar, West Midlands
Gordon A McFarlane ChM FRCS Ed Fitzgerald
Jonny Wild
Jessica Montori Giugiaro MD, PhD

Born in Rome, Italy. James Milburn High school dipoma (50/60) from the Liceo Linguistico Sperimentale Istituto Pio XII delle religiose dell'Assunzione of Rome. ASiT Vice-President General Surgery Registrar, Inverness Degree in Medicine from the University "La Sapienza" of Rome ( 110/110 and honours). Thesis published on the " Quaderni di Chirurgia". Maximum grades at the abilitation exam.
Joseph Shalhoub First qualified at the exam to enter the Specialization in General Surgery at the Department of ASiT Vice-President Surgical Sciences at the Policlinico Umberto I of Rome. Vascular Surgery Registrar, London Specialized in General Surgery (70/70 and honours). Chief year of residency at the Cleveland Clinic, Cleveland, Ohio, USA, and at Thomas Jefferson University Hospital in Philadelphia, Penn, USA. PhD in New Technologies in Surgery. Published many scientific articles and worked on the writing of some chapters of the surgical manuals (Paletto, Mazzeo). Steve Hornby ASiT Director of Education Partecipated in numerous medical conferences around West Peninsula General Surgery Registrar, South the world as lecturer, chairperson and organizor. Winner of the Premio Ruggeri. Winner of the SPIGC award for best lecture during the national meeting in 2004. Part of the Board of Directors of the Italian Young Surgeons Society SPIGC since 1997, Vice-President of the Italian Polispecialistic Young Surgeons Society SPIGC. With Living to the Italy, ASiT Welsh Regional Representatives: (2009/2012).thanksin Turin, local since 2002. Married to Fabrizio Giugiaro with three daughters: Flora ad Adele. Paolina, Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff With thanks to the wonderful ASiT Conference Admin team: info@asit.org
am 2012 Professor Dion Morton

Dion received his degree in Medicine from Bristol University in 1985. He was awarded an MD from Bristol University in 1993 and was appointed a Lecturer at Birmingham University in the same year. He was given an honorary consultant appointment at the University Hospital Birmingham in 1996. He was appointed Professor of Surgery in 2006, and is Director of the Birmingham Experimental Cancer Medicine Centre. He was appointed Director of Clinical Research at the Royal College of Surgeons of England in October 2011. For the NIHR, he chairs GRIST and the NCRI Surgical Colorectal Subgroup. His research interests are predominantly in clinical and translational research in colorectal cancer, but also encompassing the development of clinical trials in surgery. He leads a portfolio of national trials in colorectal cancer and research into cancer prevention.
David J. ORegan
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MBA MD FRSC C-Th David qualified from Southampton University in 1985. He started his career in general surgery but changed to Cardiothoracic Surgery in 1992. He obtained the Intercollegiate exam in 1999 and was awarded a Doctor of Medicine by Imperial College in 2000. He was appointed a Consultant Cardiothoracic Surgeon to Leeds Teaching Hospitals Trust in November 2000. He was awarded with distinction a Masters in Business Administration by Leeds University Business School in 2005. David changed his clinical practice on 29 January 2003. This has resulted in significant clinical and operational benefits and formed the basis of his MBA dissertation Why cant dinosaurs boogie? He has acted as lead clinician for the national Primary Care Development Team and SMART care program. He completed the Patient Safety Officer Executive Development Program at the Institute of Health Improvement in Boston 2008 and has travelled the USA to visit the hospitals at the leading edge of Quality and Safety. He is currently lead for Cardiac services in Leeds. He sits on the Patient Safety Steering Group (PSSG) for the trust and the Patient Level Information and Costing Systems (PLICS) board. He was a tutor and lead for the British Association of Medical Managers (BAMM) and has founded the UK Association of NHS Medical Executives (www.ukan.me) pronounced [you can] and together we will shape the business of health care. Linked in: http://uk.linkedin.com/pub/david-o-regan/8/b6/47a Twitter: @David_ukan
Ninos Oussi
Ninos Oussi attended the medical school at The Karolinska Institute, Stockholm, Sweden. Internship was carried out at Mlar County Hospital and he tives: continued with a combined Residency in General Surgery and Urology at The edd, Bangor Karolinska University Hospital and later Mlar County Hospital. Ninos Oussi is al of Wales, Cardiff a member of the Swedish Surgical Society since 2007. Former President of the Swedish Association for Younger Surgeons between 2008-2010 and also an m: info@asit.org ATLS instructor at The Karolinska Institute.
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His interest in medical education, international work and global health has lead him to take part in several projects around the world. Ninos Oussi has also volunteered as a medical consultant for the football team Assyriska FF in Sdertlje, Sweden between 2006-2011.

Goldie Khera
Norman Williams
ASiT President Consultant colorectalBariatric Fellow, North Tyneside surgeon Professor Norman Williams became College President in July 2011. He is Professor of Surgery and Director of Innovation at the Academic Surgical Unit of Barts and The London, Queen Marys School of Medicine and Dentistry. His main clinical interests are sphincter preservation and reconstructive surgery, and his scientific interests are concentrated Ed Fitzgerald on GI motility and anorectal physiology. ASiT Conference Organiser & Past-President General Surgery Registrar, London Professor Williams was elected as a Council Member and Trustee of the College in 2005, and most recently chaired the Research and Academic Board, the Invited Review Mechanism and was Lead for the National Fellowship Scheme. Prior to being elected as College President, he was President of the Society of Academic & Research Surgery and President of the national patient charity, The Ileostomy & Internal Pouch Support Group. Professor Williams has also been Jonny Wild Chairman of the UKCCCR committee on Colorectal Cancer, President of European Digestive ASiT Honorary Secretary & Sponsorship Co-ordinator Surgery, President of The International Surgical Group and Vice Chairman of The British Journal General Surgery Registrar, Sheffield of Surgery. Professor Williams is joint editor of Bailey and Loves Short Practice of Surgery, co-author of Surgery of the Anus, Rectum and Colon and is a trustee of Bowel & Cancer Research. He is a Fellow of the Academy of Medical Sciences, an Honorary Fellow of The American Surgical Association, Robert Davies and in 2011 gave theASiT Honorary Treasurer prestigious Hunterian Oration at the College and was awarded the Cutlers Surgical Prize. Vascular Surgery Registrar, West Midlands
Sue Woodward
Chair of the Patient Liaison Group
Sue joined the PLG at the RCS Eng in April 2008 and became Chair in JanuASiT Vice-President ary of this year. She General Surgery Registrar, Inverness starting her working life in the pharmaceutical industry gave her an interest in patient and patient care which she has developed in a variety of ways. Sue spent 16 years developing and coordinating phase 2/3 clinical trials Joseph Shalhoub across Europe phase, in a variety of therapeutic areas. Following this she beASiT Vice-President came involved in a small developing a small business and the launch of a medical charity. CurVascular Surgery Registrar, London rently she works in the commercial sector in the regulation of drug safety as well being involved in her local education community. Sues professional and her personnel experiences of the NHS have given her an interest in the patient perspective particularity in the patient pathway, accessibility of high quality appropriate Steve Hornby services to all patients and patient safety. ASiT Director of Education General Surgery Registrar, South West Peninsula
James Milburn

am 2012 Medal: 0127 ASiT
ASiT Oral Prize Conference Abstracts
FREE TISSUE TRANSFER OF A TRANSDUCED FLAP AS A VEHICLE FOR GENE AND VIRUS THERAPY OF CANCER Rohit Seth1, Aadil Khan1, Tim Pencavel1, Kevin Harrington1, Paul Harris2 1 Institute of Cancer Research, London, UK 2 Royal Marsden Hospital, London, UK Introduction: Free flap is an integral part of the surgical management of cancer, but serves no direct function in treating the malignant disease. However, the field of gene therapy has opened up the possibility of genetically modifying free flaps while they are detached from the patient (ex vivo period). Aim: To establish a working tumour model, in Fischer 344 adult male rats, assessing the ability to treat microscopic residual disease [MRD], following cancer resection. Materials and Methods: The Superficial Inferior Epigastric Artery (SIEA) was used in Fischer 344 Adult male rats. A reliable tumour cell line (rat glioma) was established in an isolated vascular territory [IVT]) and also to mimic MRD. Adenovirus encoding a thymidine kinase gene was transduced into the flap and Ganciclovir (50 mg/ml) was given systemically. Therapeutic efficacy was determined by the level of tumour growth/regression that occurred. Results: This study demonstrated a significant delay in tumour growth, within the IVT (p=0.004) and in MRD model (p=0.0005); a significant increase in survival (p=0.0010) and a significant difference in time to reach measurable tumour growth (p = 0.0001). Conclusion: Free flaps can be used as vehicles to transmit gene therapy onto a resected tumour bed, thereby treating MRD. ASiT Medal: 0279 MATRIX METALLOPROTEINASE 9 (MMP-9) PROMOTES TUMOUR PROGRESSION AND METASTASIS IN PATIENTS WITH COLORECTAL CANCER - A POTENTIAL NOVEL THERAPEUTIC TARGET? Arfon Powell, Lynsey Bennett, Clare Orange, Paul Horgan, Joanne Edwards University of Glasgow, Glasgow, UK Introduction: MMP-9 degrades connective tissue and is possibly responsible for colorectal cancer progression and metastasis. This study examines the relationship between MMP-9 expression, clinicopathological factors and survival. Methods: Immunohistochemical analysis of MMP-9 expression was performed on a tissue microarray (TMA) of paraffin embedded tissue from 237 patients undergoing potentially curative resection. Clinicopathological data including components of the Peterson index (PI) and Klintrup score was available for analysis. Results: High MMP-9 expression correlated with higher lymph node ratio (LNR) (P=0.015), vascular invasion (P<0.001) and higher PI (P=0.015). Minimum follow-up was 46 months; with 70 cancer deaths. On univariate survival analysis MMP-9 (P<0.001), higher T stage (P=0.004), higher LNR (P=0.004), vascular invasion (P<0.001), higher PI (P<0.001) and low Klintrup score (P<0.001) was associated with poor survival. On Cox multivariate analysis, high MMP-9 (Hazard Ratio 3.80 (95%CI 2.03-7.13);P<0.001), higher PI (HR 2.79 (95%CI 1.584.91);P<0.001) and low Klintrup score (HR 3.49 (95%CI 1.65-7.40);P<0.001) were independently associated with cancer-specific survival. High MMP-9 expression retained prognostic significance (P<0.001) in node negative patients. Conclusions: MMP-9 plays an important role in colorectal cancer progression and metastasis. The mechanisms underlying MMP-9 expression may offer a novel therapeutic target for patients at risk of recurrence.
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ASiT Medal: 0326 IMAGING ASSESSMENT OF DESMOID TUMOURS IN FAMILIAL ADENOMATOUS POLYPOSIS: IS STATE OF THE ART 1.5T MRI BETTER THAN 64-MDCT? Santosh Bhandari1, Ashish Sinha1, Anika Hansmann1, Arun Gupta1, David Burling1, Robin Phillips1, Susan Clark1, Vicky Goh2 1 St Mark's Hospital, Harrow, Middlesex, UK 2 Mount Vernon Hospital, Northwood, Middlesex, UK Aim: Desmoid tumour is a common extra intestinal manifestation of patients with familial adenomatous polyposis (FAP). We aimed to determine whether MRI provides equivalent or better assessment of desmoids than CT, the current first-line investigation. Patients and Methods: Following ethical approval and informed consent, FAP patients with known desmoid underwent contrast enhanced 64-MDCT and 1.5T-MRI. The number, site, size, local extent, tumour signal intensity and desmoid to aorta enhancement ratio (ER) were analysed. Results: MRI identified 23 desmoids in 9 patients 9 intra-abdominal desmoids (IAD), 10 abdominal wall desmoids (AWD) and four extra-abdominal desmoids (EAD). CT only identified 21 desmoids one EAD and one tives: edd, Bangor AWD were not identified. The two modalities were equivalent in terms 2of defining local extent of desmoid. There 2 was no al of Wales, Cardiff difference in median desmoid size 56.7 (range 2-215) cm on MDCT and 56.3(3-215) cm on MRI (p=0.985). The mean MRI-ER 1.12 (standard deviation 0.43) was greater than CT-ER 0.48(0.16) (p<0.0001). High signal intensity on T2-MRI was associated with increased MR-ER (p=0.006). m: info@asit.org Conclusions: MRI is superior to MDCT for the detection of desmoids in FAP. Coupled with the advantage of avoiding radiation, it should be considered as the primary imaging modality for young FAP patients.
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ASiT Medal: 0853 A RANDOMIZED CONTROLLED TRIAL EVALUATING ENDOSCOPIC AND LAPAROSCOPICTRAINING IN SKILLS TRANSFER FOR NOVICES PERFORMING A SIMULATED NOTES TASK Jean Nehme, Mikael Sodergren, Colin Sugden, Raj Aggarwal, Sonja Gillen, Hubertus Feussner, Guang-Zhong Yang, Ara Darzi. Imperial College, London, UK Background: The NOSCAR white paper lists training as an important step to the safe clinical application of Goldie Khera NOTES. The aim of this randomized-controlled-trial was to evaluate whether training novices in a laparoscopic or ASiT President endoscopic simulator-curriculum would affect performance in a NOTES simulator-task. Methods: Thirty novices Bariatric Fellow, to three-groups: no-training (n=10), endoscopy-training (n=10), and were randomized North Tyneside laparoscopy-training (n=10). All participants completed a simulated-NOTES-task on the ELITE (EndoscopicLaparoscopic Interdisciplinary Training Entity) model. Performance was assessed as time taken to complete individual-steps, overall-task time and number of errors. Results: The endoscopy-group was significantly faster than the control-group at accessing the peritoneal cavity (median 27 versus 78 sec; p=0.015), applying diathermy to the appendix (median 103.5 versus 173 sec; p=0.014), and navigatingEd Fitzgerald (median 76 versus 169.5 sec; p=0.049). Endoscopy participants comto the gallbladder ASiT Conference time than the Past-President pleted the full NOTES procedure in a shorter Organiser & laparoscopy group (median 863 versus 2074 sec; p<0.001). General Surgery Registrar, London Conclusion: This highlights the importance of endoscopic-training for a simulated NOTES task that involves both navigation and resection with operative maneuvers. Although laparoscopic training confers some benefit for operative steps such as applying diathermy to the gallbladder fossa, this was not as beneficial as training in endoscopy.
Jonny Wild ASiT Medal: 0868 ASiT Honorary Secretary & Sponsorship THE DEVELOPMENT OF A NOVEL TENDON AUGMENTATION GRAFT Co-ordinator Zafar Ahmad, John Wardale, Roger Brookes,Registrar, Sheffield General Surgery Neil Rushton University of Cambridge, Cambridge, UK Introduction: Rotator cuff tears remain a problem, with massive rotator cuff tears having a failure rate of repair of up to 90%, despite new surgical techniques. Tissue engineering techniques offer the possibility of generating pre -injury tendon tissue. We present the development of a novel tendon augmentation graft made of extruded collagen graft used with tissue engineering techniques to overcome this challenge. Methods: In-vitro: Sheep Robert Davies tenocytes were placed on the augmentation graft with and without Platelet Rich Plasma ASiT Honorary Treasurer (PRP). An evaluation of collagen production, cell proliferation, and cell adherence of the material was done over a 3 week period In-vivo: Vascular were operated on withWest Midlands and reattachment of the infraspinatus 24 sheep Surgery Registrar, the detachment of the sheep. The repair groups were divided as follow: (1) Control (2) Extruded collagen graft (3) Biphasic collagen scaffold (4) Biphasic collagen scaffold with platelet rich plasma. The sheep were harvested at 12 weeks. Results: In-vitro: The sheep tenocytes are indeed able to adhere, proliferate on the novel material. However the use of platelet rich plasma has lead to an even higher level of cell proliferation and collagen production In-vivo: The outcomes show that the material integrated and enhanced the tendon repair. Immunohistochemistry James Milburn will be presented.
ASiT Medal: 1122 EXPRESSION OF TOTAL VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) AND INHIBITORY ISOFORMS OF VEGF IN HEAD AND NECK SQUAMOUS CELL CARCINOMA Mark Wilkie1, Shilpa Santosh2, Maxine Emmett3, Rowan Pritchard-Jones3, Terence Jones3 1 Department of Otorhinolaryngology Head and Neck Surgery, Royal Liverpool University Hospital, Liverpool, UK, 2Department of Pathology, University Hospital Aintree, Liverpool, UK, Joseph Shalhoub 3 Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK ASiT Vice-President Aims: Angiogenesis is an absolute requirement for tumour survival and progression, of which vascular endotheVascular Surgery Registrar, London lial growth factor-A (VEGF-A) is a potent stimulator. Alternative splicing, however, results in a family of highly anti -angiogenic endogenous sister isoforms (VEGFxxxb), not yet investigated in head and neck squamous cell carcinoma (HNSCC). We investigated whether VEGF isoform expression was altered in HNSCC and compared this with clinicopathological outcomes. Methods: Ninety-three HNSCCs (29 larynx, 38 oropharynx, 26 hypopharynx) were studied. Tumour sections Steve Hornby were assessed by immunohistochemistry with total VEGF (panVEGF) and VEGF xxxb-specific antibodies, and analysed by 2 assessors ASiT Director of Education (blinded). General Surgery Registrar, in hypopharyngeal tumours (ANOVA p<0.01) and was Results: PanVEGF expression was significantly reducedSouth West Peninsula significantly associated with increasing T stage in laryngeal tumours but not for other sites (p<0.05). Significant correlations were demonstrated for panVEGF and VEGFxxxb:panVEGF expressions and length of overall survival (p<0.05 and p<0.0001, Pearson). No significant differences were demonstrated in panVEGF, VEGF xxxb, or expression ratio thanks b:panVEGF) when correlated for presence Representatives: With (VEGFxxxto the local ASiT Welsh Regional of lymph node metastasis, extra-capsular spread, Miss Rhiannonor recurrence. vascular invasion, Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Conclusions: Total VEGF expression appears upregulated in HNSCC, particularly in advanced laryngeal tu Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff mours. Increased relative expression of inhibitory VEGF isoforms may be a biological marker of enhanced survival and merits further large-scale investigation.

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ASiT Medical Student Prize: 0075 XENOTRANSPLANTATION: HUMAN T-CELL PROLIFERATION AND EFFECTOR MOLECULE PRODUCTION FOLLOWING XENOSTIMULATION Gaurav Gulsin1, Dirk Van der Windt2, Camila Macedo2, David Cooper2 1 The University of Aberdeen, Aberdeen, UK 2 The Thomas E. Starzl Transplantation Institute, Pittsburgh, PA, USA Aim: To investigate human T-cell proliferation and effector molecule production in response to xenostimulation byvarious pig peripheral blood mononuclear cells (PBMCs). Method: Flow cytometric analysis of mixed lymphocyte reactions was performed. Human PBMC responders were co-cultured with wild-type (WT) pig PBMCs, galactosyl transferase knockout (GTKO) pig PBMCs and human PBMC controls for five days. Proliferation of responder T-cells was traced using carboxyfluorescein diacetate succinimidyl ester assays and effector molecule production assessed by labelling with specific antibodies. Results: T-cell proliferation was greatest with WT pig stimulators (42.7%) and lowest with human stimulators (9.4%), with GTKO pig stimulators in between the two (28.9%). Proliferation of responder CD8+ cells was twice that of CD4+ cells (overall 36.4% CD8+ versus 17.6% CD4+). Effector molecule (GranzymeB, Perforin and Interferon-) production was similar regardless of the stimulator cells, although CD8+ T-cells expressed a greater proportion of these effectors. Conclusions: Absence of the Gal sugar on pig stimulator cells decreases the proliferative response of T-cells to these cells, suggesting a role for Gal in cell-mediated xenograft rejection. Furthermore, both proliferation and effector molecule production are higher among CD8+ T-cells than CD4+ T-cells. These findings may guide clinicians seeking to prevent acute cellular xenograft rejection in the future. ASiT Medical Student Prize: 0220 ASSESSMENT OF PERIOSTIN AND TRANSGLUTAMINASE 2 AS POTENTIAL BIOMARKERS IN OESOPHAGEAL ADENOCARCINOMA Chudy Uzoho, Fergus Noble, Andrew Bateman, Mattheiu Derouet, Tim Underwood University of Southampton, Southampton, UK Aim: To model biomarker identification, we evaluated POSTN and TG2 as they have been shown in various cancers to correlate with cell survival, invasion, and resistance to chemotherapy. Methods: Using primary OAC tissue (chemotherapy responders ((TRG 1-3), n=30), non-responders ((TRG 4-5) n=30), and chemonaive (n=30; 8 matched normal oesophagus, 6 metastatic lymph nodes)) protein expression of TG2 and POSTN was assessed by immunohistochemistry (weakly positive (0-5%), positive (5-50%) and strongly positive (50-100%)) and correlated to clinicopathalogical data. Results: POSTN and TG2 was positive or strongly positive in 90% and 76% of OAC tumour compared to only 13% and 13% being positive in matched normal oesophagus (p=0.015, p=0.009). POSTN is expressed at a higher level in non-responders compared to responders (p=0.014) as well as TRG (p=0.040). Low levels of POSTN expression (0-5%) correlates with improved survival. Conclusion: The positive expression of POSTN and TG2 in oesophageal cancer with limited expression in normal oesophageal tissue suggests a functional role in OAC and provides biomarker potential. The significant correlation of POSTN with TRG suggests POSTN may be clinically useful in predicting response to neoadjuvant chemotherapy.
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al of Wales, Cardiff
ASiT Medical Student Prize: 0226 A GENERATION OF LAPAROSCOPIC NEPHRECTOMY: STAGE SPECIFIC SURGICAL AND ONCOLOGICAL OUTCOMES FOR LAPAROSCOPIC NEPHRECTOMY IN A SINGLE CENTRE Alexander Laird, Grant Stewart, Jim Zhong, Jensen Ang, Antony Riddick, David Tolley, Alan McNeill University of Edinburgh, Edinburgh, UK Introduction/Aims: To determine the stage-specific operative, post-operative and oncological outcomes, for patients undergoing laparoscopic radical nephrectomy (LRN) for renal cell cancer (RCC) in a single centre. Methods: From December 1997 to July 2011, data was collected prospectively for 397 consecutive patients undergoing LRN for pathologically confirmed RCC. Follow-up data was completed retrospectively. Patients were listed chronologically and split into 3 equal groups. Results: There was no difference in age and gender between the 3 groups. The number of LRNs conducted for locally advanced (T3/4) disease (37, 27, 56) significantly increased (P < 0.001) but remained similar for localised (T1/2) disease (95,106, 76). Surgical outcomes (operation time, blood loss etc) improved for localised disease (P < 0.05) and remain unchanged for locally advanced disease. There was a significant difference in overall survival (80.7%, 52.7%, 50.7%), cancer-specific survival (96.8%. 77.4% and 52.7%) and progression free survival (83.5%, 56.4%, 39.8%) between patients with T1, T2 and T3 disease (p<0.001). Conclusion: Operative outcomes following LRN for localised RCC have improved over time. LRN is increasingly undertaken for locally advanced disease which is acceptable from operative, post-operative and oncological tives: edd, Bangor standpoints. This is likely due to increased experience and operative ability to tackle more complex cases. ASiT Medical Student Prize: 0286 HARMONIC SCALPEL VS. ELECTROCAUTERY DISSECTION IN MODIFIED RADICAL MASTECTOMY: info@asit.org RANDOMIZED CONTROLLED TRIAL Salma Khan, Shaista Khan, Ghulam Murtaza, Naveed Haroon
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Aga Khan University Hospital, Karachi, Pakistan Aim: To compare outcomes between harmonic and Electrocautry dissection in adult female patients underwent modified radical mastectomy (MRM). Method: All adult females who underwent MRM during May 2010 to July 2011 were randomized to either intervention A harmonic scalpel or B electrocautery. The outcomes were estimated blood loss, operating time, drain volume, seroma, surgical site infection and postoperative pain. Comparison of groups were done with T-test for Goldie Khera continuous and chi-square for categorical variables. Multiple linear regression was done to control the effect of age, BMI, breast volume,ASiT President tumor size and neoadjuvant chemo radiotherapy. Bariatric were recruited. Both the groups were comparable for baseline variables with Results: In each group, 75 patientsFellow, North Tyneside age of 48.514.5 and 50.512.2 years, respectively. Harmonic dissection yielded better outcomes as compared to electrocautery with lower EBL (18292 vs. 10062, p-value: 0.00), operative time (18736 vs. 19144, pvalue: o.49), drain volume (1035413 vs.631275, p-value: 0.00), drain days (174 vs. 123 p-value: 0.00), seroma formation (21.3% vs. 33.3%, p-value: 0.071), surgical site infection (5.3% vs. 23%, p-value: 0.006) and postoperative pain ( 3.41 vs. 1.80.6, p-value: 0.00). Ed Fitzgerald Conclusions: Although the harmonic didn't reduce the operative time, however, it significantly reduced postoperative discomfort and ASiT Conference Organiser & Past-President morbidity to the patient.
ASiT Medical Student Prize: 0361 PENOSCROTAL MEDIAN RAPHE DEVIATION MAY BE A NEW CLINICAL SIGN IN HYPOSPADIAS Laura D Ashton1, Christopher G Wallace2, Milind D Dalal2 1 University of Manchester, Manchester, UK 2 Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK Hypospadias congenital Jonny Wild anomaly is defined by a dystopic urethral meatus with/without chordee and prepucial ASiT observed abnormal deviation of the penoscrotal median raphe (PMR) amongst hooding. We have additionally Honorary Secretary & Sponsorship Co-ordinator hypospadiacs. Aim: To investigateSurgery Registrar, Sheffield previously unreported association between General the potential significance of the hypospadias and PMR deviation. Methods: Prospectively, 30 healthy male infant controls were examined for PMR deviation. Preoperative photographs of 46 hypospadiacs were assessed retrospectively for the same. These groups were statistically compared. Results: PMR deviation was, significantly (p<0.001), twice as common in hypospadiacs (38/46; 83%) than conRobert Davies trols (13/30; 43%). Incidence of PMR deviation was not affected by Duckett/Hadidi severity of hypospadias. ASiT Honorary Treasurer Conclusion: PMR deviation appears to be a significant clinical sign in hypospadias. Importantly, it is easily disVascular Surgery Registrar, West Midlands cernable even in the mildest forms of hypospadias (that are often diagnosed late) without requiring prepucial retraction. Thus, it could increase sensitivity of hypospadias detection by paediatricians during neonatal checks. Whether PMR deviation should be acknowledged as part of hypospadias spectrum requires further large-scale research (currently underway), but would have important implications for hypospadias epidemiologic, etiologic and pathogenesis studies as well as for further aesthetic refinement of hypospadias reconstruction by correcting abnormal PMR deviation.
General Surgery Registrar, London
ASiT Vice-President ASiT Medical Student Prize: 0477 General Surgery Registrar, Inverness THE DEVELOPMENT OF A VIRTUAL REALITY COLONOSCOPY TRAINING CURRICULUM Mahua Bhaduri, Colin Sugden, Rajesh Aggarwal, Ara Darzi Imperial College London, London, UK Colonoscopy success in colorectal cancer prevention is dependent on operator competence in polypdetection.Virtual-reality(VR) colonoscopy is a reliable method of teaching the psychomotor skill required for colonic intubation. Pathology-detection simulated-training has not been extensively studied; thus we have developed Joseph Shalhoub 20 novel VR polyp-detection tasks. We will assess their construct-validity, novice learning-curves and define ASiT Vice-President benchmark criteria. Vascular Surgery Registrar, London 15 novices, 10 intermediate/experienced colonoscopists were recruited. All participants performed 4 repetitions of two types of VR-simulated models:clean and dirty colon. Additionally, 10 novices performed 12 more repetitions for learning-curve analysis. Tasks required participants to extubate the colon, detect abnormalities and cauterise them. Both clean and dirty colon models distinguished between initial skill-levels of the novice and experienced colonoSteve Hornby scopists in pathology-detection metrics:number of abnormalities located (clean-p=0.000,dirty-p=0.0001), number ASiT Director of Education of polyps located (p=0.001,0.004) and number of angiodysplasias(p=0.0001,0.0037).Median scores of the exGeneral Surgery Registrar, benchmark criteria. Both perienced cohort in validated metrics determined the South West Peninsula models showed statisticallysignificant learning-curves for pathology-detection metrics (p<0.05).By the end of the programme, novices had progressed towards experienced benchmarks. Learning-curve plateaus occurred at third/fourth attempts for all pathology-detection metrics. This study represents the first colonoscopy simulator study focused Representatives: With thanks to the local ASiT Welsh Regional on VR pathology- detection teaching. The training Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor increase in tasks showed excellent construct-validity. Learning-curve analysis demonstrated significant skill after repeated training;proving that targeted VR simulator-training can improve novice proficiency in mucosal Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff inspection.
James Milburn
With thanks to the Prize: 0126 SARS Academic and Researchwonderful ASiT Conference Admin team: info@asit.org MAGNESIUM SULFATE ATTENUATES LOCAL ANAESTHETIC INDUCED CHONDROTOXICITY Laura Andrews Kristina Gloufchev Harriet Innes
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Joseph Baker1, Pauline Walsh1, Damien Byrne2, Kevin Mulhall3 University College Dublin, Dublin, Ireland 2 Orthopaedic Research and Innovation Foundation, Dublin, Ireland, 3 Mater Misericordiae University Hospital, Dublin, Ireland Purpose: Local anaesthetic has been reported to have a potentially detrimental effect on human chondrocytes. Magnesium may be an alternative analgesic agent following arthroscopy. We aimed to report on the effect on chondrocyte viability of adding magnesium to commonly used local anesthetic agents. Methods: Human chondrocytes were grown under standard culture conditions. Cells were exposed to either bupivacaine (0.125, 0.25, 0.5%) or ropivacaine (0.1875, 0.375, 0.75%) for 15 minutes with or without the addition of magnesium (10, 20, or 50%). Untreated cells served as controls. The MTS assay was used to assess for cell viability 24 hours after exposure. One-way ANOVA were used to test for statistical significance. Results: Magnesium alone was no more toxic than normal saline (P>0.3) compared to untreated cells. The addition of magnesium to the local anesthetic agents resulted in greater cell viability than when cells were treated with local anaesthetic alone (bupivacaine (P<0.001), ropivacaine (P<0.001)). Conclusion: We have showed that cell viability is improved with the addition of magnesium to local anaesthetic compared to local anesthetic alone. These findings offer support to an alternative analgesia following arthroscopy although the optimum doses and combinations of local anaesthetic and magnesium are yet to be shown.
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SARS Academic and Research Prize: 0440 A COMPARISON OF THREE TENDON-TYING TECHNIQUES FOR USE DURING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION Richard Walter, Benjamin Bradley, Samuel James, David Isaac, Michael Hockings Department of Trauma and Orthopaedics, Torbay Hospital, Torbay, UK Aims: This study uses an animal model to examine the strength of three different suture-to-tendon attachment techniques for use during passage of hamstrings graft through the tibial tunnel in ACL reconstruction. Methods: Forty-eight fresh porcine digital flexor tendons were fixed at one end. A suture was attached to the free end of each tendon using either a) Whipstitch b) Modified Prussik knot c) The Smith and Nephew Whipknot TM device. The suture was loaded with 2.5N increments until structural failure. Load at failure and time taken to attach suture to tendon were recorded. Results: Mean load at failure was 112N (standard deviation 9.7) for whipstitch, 111N (26.5) for modified Prussik, and 136N (15.9) for the WhipknotTM. The WhipknotTM device was significantly faster than the Prussik knot technique (8.8s vs 15.8s, p<0.01), which in turn was faster than whipstitching (15.8s vs 121.5s, p<0.01). Discussion: All three techniques provided sufficient strength for attaching a suture to the graft tendon during anterior cruciate ligament surgery. Whilst whipstitching is the most commonly used method, the modified Prussik technique can be recommended for its significant speed advantage. The Whipknot TM device, whilst both strong and fast, is more costly than the other two techniques. SARS Academic and Research Prize: 0696 MACROPHAGE MIGRATORY INHIBITORY FACTOR (MIF) SECRETION BY MESENCHYMAL STEM CELLS (MSC) AND COLORECTAL CANCER (CRC) CELLS IN 3-DIMENSIONAL CULTURE Niamh Hogan1, Roisin Dwyer1, Myles Joyce2, Michael Kerin1 1 Discipline of Surgery, National University of Ireland, Galway, Ireland, 2 Department of Colorectal Surgery, University College Hospital, Galway, Ireland Aims: High serum MIF levels positively correlate with an increased risk of metastasis in CRC patients. MSCs are multipotent stromal cells known to home to CRC and integrate into the tumour architecture. This study aimed to investigate interactions between MSCs and human CRC cells in three-dimensional culture. Methods: Cultures were established of CRC cell lines (HCT-116/HT 29) alone, or in combination with MSCs or normal fibroblasts (WI 38). Conditioned media containing all secreted factors was harvested at day 1, 3 and 7, and MIF levels quantified using ELISA. Results: MIF was secreted by all cell populations examined, with the highest levels secreted by the invasive HCT -116 cells (4-92ng/mL over time). MSCs and WI38 cells secreted similar levels of the cytokine at Day1 (18ngmL), with WI38 secretion increasing significantly at later timepoints. Upon co-culture of either CRC cell line with MSCs, a net decrease in MIF secretion (21 -90% decrease) was observed. Interestingly, co-culture with WI38s had the opposite effect, suggesting an MSC specific phenomenon. Conclusions: This data highlights distinct effects of MSCs on the CRC tumour microenvironment. Considering the role of MIF in inflammation and the known link between inflammation and colorectal cancer, further investigation is warranted.
SARS Academic and Research Prize: 0698 STATINS ENHANCE VEIN RECANALISATION AND REDUCE VEIN WALL INFLAMMATION FOLLOWING edd, Bangor VENOUS THROMBOSIS Sobath al of Wales, Cardiff Premaratne, Steven Grover, Prakash Saha, Ashish Patel, Bijan Modarai, Matthew Waltham, Alberto Smith Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedim: info@asit.org cal Research Centre at Kings Health Partners, London, UK Background: Statins exhibit anti-inflammatory, pro-angiogenic and pro-fibrinolytic effects that may affect thromPage 4
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bus recanalisation and organisation. Methods: Venous thrombi were induced in BalbC mice by a combination of reduced flow and endothelial injury. On day-1, mice were randomised to 3 groups (n=7/gp). Atorvastatin (30mg/kg or 3mg/kg) or vehicle (methylcellulose) was given daily for 7 days by gavage. On day-7 thrombi were harvested and paraffin sections obtained at defined intervals. Vein recanalisation, thrombus volume, nucleated cell counts, macrophages (MAC-2) and neutrophils (NIMP-R14) content in the thrombus and vein wall were measured. Goldie Khera Results: Vein recanalisation was greater following high-dose Atorvastatin (0.500.13mm3) compared with lowASiT 3, 0.270.13mm3, P=0.002 ANOVA). Neovascular channel number within the dose or vehicle (0.290.11mmPresident Bariatric Fellow, North Tyneside thrombus was significantly higher in both treated groups (5.00.44 [high-dose]; 5.14.5 [low-dose], vs 3.14.40 [vehicle], P=0.009). Thrombus volume, nucleated cell count, MAC-2 and NIMP-R14 staining was similar for all three groups. Vein wall nucleated cell count was lower in treatment groups (63774 [high-dose]); 64975 [lowdose] vs control (102360, P=0.001). MAC-2 (0.41%0.04, 0.45%0.04) and NIMP-R14 (3.92%0.38, 3.76% 0.48) staining was significantly lower in the vein wall of statin treated groups compared with vehicle (0.97% 0.05, P<0.001; 7.33%0.36, P<0.001). Ed Fitzgerald Conclusions: Atorvastatin enhanced recanalisation and inhibited vein wall inflammation associated with wall fibroASiT Conference Organiser & Past-President sis.
SARS Academic and Research Prize: 0903 MIRNAS: SMALL MOLECULES, BIG PLAYERS IN TAMOXIFEN RESISTANCE IN BREAST CANCER Nuala Healy1, Rachel Schiff1, CK Osborne2, Michael Kerin2 1 NUI Galway, Galway, Ireland 2 Baylor College of Medicine, Houston, Tx, USA Jonny Wild Aim: The aim of this study was to identify and evaluate miRNAs that are dysregulated in tamoxifen resistance. ASiT was performed on lysates Sponsorship Co-ordinator Methods: A microarray analysisHonorary Secretary & obtained from the MCF7 breast cancer cell line (ER+/ PR+/HER2-). Parental MCF7 cells Surgery Registrar,estrogen deprivation (ED) conditions for 48 hours prior to General were cultured under Sheffield short or long-term treatment with tamoxifen, estrogen or ED. Validation of microarray data was performed using RQ-PCR. Functional analysis of cell growth and apoptosis was performed following knockdown of miRNAs using insitu cell cytometry (Celigo). Results: 58 out of 999 miRNAs were identified to be significantly altered across the various treatment and resistant groups (p<0.001). 23 miRNAs were observed to be upregulated and 41 downregulated in tamoxifen resistance. Microarray resultsRobert Davies RQ-PCR. A reduction in cell growth was observed in tamoxifen rewere confirmed by ASiT Honorary Treasurer sistant cells following miR-1285 and miR-181c knockdown. Apoptosis was induced upon knockdown of miRVascular Surgery Registrar, West Midlands 1285. Evaluation of predicted targets of miR-181c was performed using RQ-PCR. Conclusion: This study has identified a number of miRNAs that are dysregulated in association with tamoxifen resistance in breast cancer, two playing a role in cell growth. Modulation of such miRNAs may offer novel therapeutic strategies in overcoming such resistance. SARS Academic and Research Prize: 1038 James Milburn UNDERSTANDING THE DYNAMIC HAEMATOPOIETIC AND MESENCHYMAL STEM CELL CONTRIBUTION ASiT Vice-President TO THE TUMOUR MICROENVIRONMENT OF CHOLANGIOCARCINOMA General Surgery Registrar, Inverness Andrew Robson, Kay Samuel, Antonella Pellicoro, John Iredale, Stuart Forbes University of Edinburgh, Edinburgh, UK Background: Intrahepatic cholangiocarcinoma (ICC) is an aggressive malignancy of biliary epithelium with increasing global mortality. ICC is characterised by a pronounced inflammatory stroma of tumour-associated myofibroblasts, macrophages and immune cells. We aimed to define the stem cell source of these components. Methods: Tumours were Joseph Shalhoub our thioacetamide (TAA) rat model of ICC. Bone marrow (BM) studied in humans and transplants were performed: ICC was then induced in sex-mismatched and GFP+ BM transplant recipients. Extra ASiT Vice-President -hepatic derivation of cells was tracked over time using Y-Chromosome FISH and GFP+ together with dual imVascular Surgery Registrar, macrophages and neutrophils. Flow cytometry of BM munoflourescence for biliary epithelium, myofibroblasts, London and stem cell culture of BM mesenchymal cells (stro-1+) enabled quantification of GFP+ donor reconstitution of the haematopoietic and mesenchymal stem cell compartments in recipients. Results: BM transplantation successfully reconstituted haematopoietic and mesenchymal stem cell compartments. In tumours, macrophages and neutrophils were overwhelmingly GFP+ve, whereas myofibroblasts, benign Steve Hornby and malignant bile ducts were GFP-ve. This demonstrates that haematopoietic cells migrate from BM to contribASiT Director of Education ute to tumours whereas mesenchymal and epithelial cells are locally derived within the liver. This was confirmed General Surgery Registrar, South West Peninsula by independent cell tracking of Y-Chromosome. Conclusions: Understanding the dynamic haematopoietic and mesenchymal contribution to ICC tumour formation informs therapeutic development. ASiT Short Paper Prize: 0061 local ASiT Welsh Regional Representatives: With thanks to the THE OPEN BLAST PELVIS: THE BURDEN OF MANAGEMENT. Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Scott Evans, Arul Ramasamy, Jon Kendrew, Julian Cooper Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff University Hospitals of Birmingham, Queen Elizabeth, Birmingham, UK Aim: First study to evaluate casualties with an open pelvic blast injury. With thanks study of a prospective combat trauma registry. UK Service Personnel sustaining Methods: Retrospective to the wonderful ASiT Conference Admin team: info@asit.org open pelvic fractures from an explosive mechanism Gloufchev from Aug Innes Laura Andrews Kristina were identified Harriet2008 - Aug 2010.
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Results: 29 casualties survived with an open pelvic ring fracture following explosion. The median NIS score was 41. Mean blood requirements in the 1st 24 hours was 60.3 units. 6 casualties had an associated vascular injury, 7 had a bowel injury, 11 had a genital injury and 7 had a bladder injury. 8 fractures were managed definitively with external fixation, and 7 fractures required ORIF, with 4 requiring removal of metalwork for infection. Faecal diversion was performed on 9 casualties. Median length of stay was 70.2 days, and mean operative time was 29.6 hours. 1 casualty was managed solely by the orthopaedic team. 19 requirined at least three different surgical specialty input. At mean 20.3 months follow-up, 24 were able to ambulate, and 26 had clinical and radiological evidence of pelvic ring stability. Conclusions: Open blast pelvis represents the extreme end of trauma necessitating intense resource allocation. We do not feel faecal diversion is required in all cases.
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ASiT Short Paper Prize: 0167 PERI-OPERATIVE PAIN AND PATIENT SATISFACTION FOLLOWING OPEN MESH REPAIR OF PARAUMBILICAL HERNIA UNDER LOCAL ANAESTHESIA: THE WEST SUFFOLK EXPERIENCE Philip Bennett, Balendra Kumar, Eamonn Coveney West Suffolk Hospital, Suffolk, UK Aims: To assess peri-operative pain(PoP) and satisfaction with experience(SE) in patients having open mesh repair of para-umbilical hernia(PAH) under local anaesthesia(LA). Methods: All patients requiring PAH repair under a single consultant between 01/01/2010-30/11/2011 were eligible to participate. Patients chose either general anaesthetic(GA) or LA repair. LA patients used visual analogue scales to record PoP and SE. Results: 63 patients underwent PAH repair(31GA; 32LA). There were no differences in patient age or gender between LA and GA repairs. LA patients had a lower body mass index (BMI) than GA(27.1[3.7] vs. 30.3[5.1], p=0.007). LA procedures took 24[17.5-30] minutes and used 25[20-32]ml LA solution. PoP was low (11[3-29]%) and SE was high(96[91-99]%). No differences were found in PoP, SE, procedural length and amount of LA infiltrated with increasing BMI. When comparing LA procedures performed by higher surgical trainees (HST) and consultant, HST took longer (30[25-36] vs. 20[16-24] minutes, p=0.0007), infiltrated more LA(34.5[26-47] vs. 20 [19-25.5]ml, p=0.0039), and patients experienced greater PoP(27.5[10-49.5] vs. 4[2-17]%, p=0.029), though this was still mild. There was no difference in overall SE(95.5[89-99.25] vs. 96.3[92.25-99]%, p=0.684) between HST and consultant. Conclusion: LA PAH repair is associated with low PoP and high SE in both HST and Consultant. ASiT Short Paper Prize: 0577 FLEXIBLE CYSTOSCOPY CLINIC PATIENT LED URINALYSIS Jamie Fairweather, Kohmal Solanki, Shayan Ahmed, Donna Tooth, Stuart Graham Whipps Cross University Hospital, London, UK Introduction: Flexible cystoscopy is the most commonly performed urological procedure in the UK, mostly performed as an outpatient. Many patients with pre-existing urinary tract infections (UTI) are cancelled on attendance, resulting in decreased clinic utilisation. Methods: A prototype reagent strip for urinalysis was designed, testing for only Nitrites and Leucocytes. This was adapted from a commercially available reagent strip. A diagrammatic, patient information sheet was designed. Prospectively 50 patients attending Flexible cystoscopy clinic were given an urinalysis strip, information sheet, asked to follow the instructions and state if they had a UTI. Their urine was also tested with multi-reagent urinalysis strips of the same type using an electronic urinalysis machine. The results were compared. Results: Of the 50 patients assessed, age range 22 - 96 years (mean 64.4, median 67), 47 (94%) patient's responses matched the electronic urinalysis results. There were 2 false positives and 1 false negative, representing a sensitivity of 77.8% and a specificity of 97.9%. The p value <0.05 using the Fisher's exact test. Conclusion: This study demonstrates that Patient led urinalysis using simplified urinalysis strips is a possible screening tool for diagnosing UTI's. This could be adapted to at home patient performed urinalysis, ultimately decreasing cancellations
ASiT Short Paper Prize: 0595 METASTATIC CUTANEOUS SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK: CHARACTERISTICS OF THE PRIMARY AND POOR PROGNOSTIC FACTORS David Walker1, Rajeev Mathew1, Tatiana Gutierrez1, Reza Nouraei1, Patrick McCabe2, Stephen Whittaker1, Silvana Di Palma1, Robert Sudderick1, Lisa Pitkin1 1 Royal Surrey County Hospital, Guildford, UK 2 Surrey Clinical Research Centre, Guildford, UK Aims: To describe the high risk features of primary head and neck cutaneous squamous cell carcinoma (cSCC), and to identify prognostic and treatment related factors that influence outcome. tives: edd, Bangor Methods: 10 year retrospective review of patients treated at a regional head and neck centre. The influence of selected al of Wales, Cardiff factors on disease-specific survival was analyzed using the Kaplan-Meier actuarial method and log-rank test. Results: 69 patients; M:F 5.9:1, median age 81 (range 41-99). Primary lesion location; ear (35%), anterior scalp m: info@asit.org frontotemporal (17%), 12% were immunocompromised, 88% moderately or poorly differentiated and (17%) and 78% >4mm deep. Margins were involved in 37% of excisions and close (0.2-4mm) in 51%.
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Median time to metastasis was 10 months (range 0-72months). Parotid and cervical nodes were involved equally (74% of cases). Multivariate analysis showed immune status, surgical margin and extent of parotid surgery (p<0.05) influenced disease-specific survival. 5-year actuarial estimates of recurrence and disease-specific survival were 47% and 45% respectively. Conclusions: Most cSCC developing regional metastasis are >4mm deep, moderately/poorly differentiated and have inadequate resection margins. Immunocompromised patients with regional metastasis have a particularly poor outcome. In this theGoldieUK review in the literature, we re-emphasise the importance of adequate surgilargest Khera ASiT President cal margins in primary cSCC.

Bariatric Fellow, North Tyneside
ASiT Short Paper Prize: 0774 PUBLISH OR PERISH HOW TO AVOID PERISHING Alex Torrie, James Berstock, Elizabeth Hayward, Gordon Bannister Department of Orthopaedics, Southmead hospital, Bristol, UK Aim: To determine whether the senior author had a significant influence on the probability of achieving publicaEd a peer-reviewed journal. tion of your research paper inFitzgerald ASiT Conference Organiser & Past-President Methods: An observational study of all 54 orthopaedic registrars in the Severn deanery. All papers identifiable on Pubmed by each registrar were documented. The number of senior author papers was also identified. Logistic General Surgery Registrar, London regression was assessed using Spearman correlation for year of training vs. number of publications, number of publications vs. average number of senior author publications and number of publications vs. number of collaborative publications with current rotational registrar. Wilcoxon rank-sum test assessed the difference between registrars with <5 or >5 publications. P=0.05 was considered statistically significant. Results: Year of training was significantly associated with the number of peer-reviewed publications (P=0.0394). Jonny publications and collaborative papers was highly significantly associated with Average number of senior author Wild ASiT Honorary Secretary & Sponsorship Co-ordinator rate of peer-reviewed publication (P=<0.0001). The number of senior author publications was significantly different between registrars with <5 andSurgery Registrar, Sheffield a median number of senior author publicaGeneral >5 publications (P=0.0111), with tions of 16.5 and 46.2 respectively. Conclusion: To improve your probability of achieving a peer-reviewed publication you should engage in research with a senior author who has >46 peer-reviewed publications. ASiT Short Paper Prize: 0936 Robert Davies A NOVEL APPLICATION OF LEARNING CURVE ANALYSIS FOR A BASIC TASK IN SINGLE-INCISION ASiT LAPAROSCOPIC SURGERY Honorary Treasurer Vascular Surgery Registrar, West Purkayastha, Thanos Athanasiou, Ara Darzi, Mikael Sodergren, Colleen McGregor, Hugo Farne, Sanjay Midlands Paraskevas Paraskeva Imperial College, London, UK Aims: There is currently no objective quantification of the temporal changes in performance associated with a novice surgeon learning SILS operative tasks. Analyzing learning curves allows us to objectively quantify performance. James Milburn Methods: 36 surgically-naive medical students were randomized to complete the validated peg transfer task over ASiT Vice-President 50 repetitions using either 1) conventional laparoscopic set-up 2) SILS set-up with straight instruments 3) SILS General Surgery set-up with articulated set-up with articulated instruments or 4) SILSRegistrar, Inverness instruments after having reached proficiency using a conventional laparoscopic set-up. The data was analysed using univariate and multivariate regression models, and by fitting an inverse curve to derive measures for the asymptote and rate of learning of each group. Results: There was a significant increased overall proficiency between the group trained in conventional laparoscopy and all other groups (p<0.01), with no difference between the other groups. Conclusions: The results Joseph Shalhoub the proficiency reached using a conventional laparoscopic setof this study indicate that up cannot be matched using a SILS configuration for the novice surgeon, and that the choice of straight or articuASiT Vice-President lated instruments as well as previous laparoscopic training does not confer an advantage in this basic task.
Vascular Surgery Registrar, London
Steve Hornby

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ASiT Poster Prize Conference Abstracts Oral Prize Conference Abstracts
BASIC SCIENCE INCLUDING ANATOMY
0470 SRC KINASE: GOOD OR BAD IN PROSTATE CANCER? Brian Stewart1, Jenniffer Willder1, Craig Robson2, Paul Horgan1, Joanne Edwards1 1 Institute of Cancer Sciences, University of Glasgow, Glasgow, UK, 2 Northern Institute for Cancer Research, Newcastle, UK Aim: To assess expression levels of c-Src and activated Src in 2 demographically separate hormone-nave prostate cancer cohorts and determine their influence on patient survival. Method: Immunohistochemistry using validated antibodies to c-Src and SrcY419 (the classical activation site) was used to determine expression levels of these proteins in prostate cancer tissue. The semi-quantitative weighted histoscore was used to assess expression levels and expression was correlated with survival. Results: In cohort 1 (n = 175 patients), high levels of tumour membrane c-Src expression were associated with decreased cancerspecific survival (6.3 v 8.3 years, p<0.0001). In cohort 2 (n = 92 patients) the reverse was apparent with patients with low levels of membrane c-Src expression exhibiting decreased cancer-specific survival (8.1 v 13.5 years, p=0.029). Additionally in cohort 2, low levels of membrane SrcY419 were associated with decreased cancer-specific survival (8.8 v 14 years, p=0.031). Conclusions: The role of Src kinase in the oncogenesis of prostate cancer is complex and varying levels of activation may occur at different stages of the disease process. The differences observed in the relationship between patient survival and Src kinase expression in the two cohorts may be linked to demographic, epidemiological and clinical factors. 0502 THE ROLE OF OSTEOPONTIN IN PAPILLARY THYROID CARCINOGENESIS Rohit Srinivasan1, Zaruhi Poghosyan1 1 Cardiff University, School of Medicine, Cardiff, UK 2 Cardiff University, Department of Medical Genetics, Haematology & Pathology, Cardiff, UK Aim: Papillary thyroid cancer (PTC) is the most prevalent form of thyroid cancer. OPN is thought to promote tumorigenesis by interacting with CD44, integrins and Met receptors. The study analysed the reasons for loss of tumour cell motility and invasiveness in a human PTC cell line (K1) with OPN knockdown. Method: K1 and a derivative stable lentiviral-mediated shRNA knockdown of OPN in K1 (OPNsh) cells underwent a regimen, either untreated or treated (hepatocyte growth factor (HGF), OPN or hyaluronan (HA)). Western Blot analysis was undertaken to analyse expression and phosphorylation events. Results: OPNsh cells showed higher levels of Met receptor expression than K1 cells; Met showed phosphorylation in the absence of OPN. Paxillin phosphorylation was enhanced in all untreated and treated K1 cells compared to OPNsh cells. Phosphorylation of cofilin in both cell lines showed notable changes. Conclusions: A decrease in Met levels in OPNsh cells does not seem to be the reason for loss of invasiveness but there may be impairment of Met receptor activation. The absence of OPN seemed to demonstrate an important effect on the activation paxillin and cofilin. This suggests a vital role for integrins in the loss of tumour cell invasiveness and motility in OPNsh cells. 0562 PARENTERAL NUTRITION IN ROUTINE SURGICAL PRACTICE - ROOM FOR IMPROVEMENT Shi Ying Hey, Andrew J Robson, Lesley-Ann Reekie, Satheesh Yalamarthi Department of Surgery, Queen Margaret Hospital, Dunfermline, UK Aims: Parenteral Nutrition (PN) administration in carefully selected surgical patients maximises recovery protocol. PN provision was compared against the European Society of Parenteral and Enteral Nutrition (ESPEN) 2009 guidelines to identify areas for improvement in clinical practice. Methods: A prospective study based on collected PN referral forms was conducted between January and June 2011. Results: Fifty-one patients received PN (29M: 22F). ESPEN criteria concluded 44/51 (86%) referrals were appropriate, whereas 7/51 (14%) were inappropriate since caloric intake were sufficient enterally. Of the 51 patients, 43/51 (84%) were postoperative cases where PN was used in: 23 with peri-operative complications, 12 who were unable to feed enterally, 5 as additional nutritional supplementation, and 3 with short bowel syndrome. In 8/51 (16%) non-operative individuals, gastrointestinal dysfunction led to PN use. PN was administered centrally in 30/51 (59%) and peripherally in 21/51 (41%) of patients. The median range for duration of PN was 46 days. The overall complication rate of PN administration was 24%, including line infection in 11 (22%), and pneumothorax in 1 (2%). Conclusion: Judicious usage of PN improves outcomes for surgical patients. As complication rates remain high, formal training on PN have been instituted locally and re-assessment of outcomes is awaited.
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0707 IS THE RULER IN DIGITALISED RADIOGRAPHS ACCURATE? A STUDY WITH QUESTIONNAIRE SURVEY Vijay Rajamani, Vasanth Ramsingh, Russell Walker Nevill Hall Hospital, Abergavenny, UK Objective: The aim of this study is to assess the opinion of practicing orthopaedic surgeons and radiology consultants with regards to the use of the ruler in digitalised radiograph. Methods: We compiled a questionnaire on the accuracy, magnification percent and positional variation of the measurements used in digitalised radiographs. Forty one orthopaedic surgeons and fourteen radiologists participated in our survey. We used digitalised ruler in the radiographs of 116 patients who undergone hemiarthroplasty of the hip and compared the head measurements with the actual size. To determine the positional variation, we compared the measurements of the nail diameter in radiographs of 33 patients taken on two different occasions. Results: Sixty nine percent of the orthopaedic surgeons and fifty percent of the radiologists believed that the ruler measurement was not accurate. Measurements of the prosthesis head in radiographs have shown that there is a magnification of 18 to 32%. Thirty two tives: percent of surgeons and 42% of radiologist believed that there is no positional variation. edd, Bangor Conclusion: Most of the orthopaedic surgeons believed that digitalized ruler is not accurate but half of the radiologist believed them to be accurate. al of Wales, Cardiff Our study has shown that the digitalized ruler is not accurate and have variable magnification with positional variation. 0792
R SHIVER m: info@asit.org ME TIMBERS: CLINICIANS DOING STATISTICS! A NOVEL APPROACH TO DATA ANALYSIS AND DATA VISUALISATION IN MODERN MEDICINE, AN EXAMPLE USING CHRONIC LYMPHOCYTIC LEUKAEMIA (CLL) DATA
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Steffan Evans, Stephen Man, Chris Pepper, Peter Giles Cardiff University School of Medicine, Cardiff, UK Aim: To analyse pre-existing clinical and laboratory data on CLL patients, explore relationships between immune cell markers and prognosis and find novel ways of presenting large, complex datasets in simple visual forms. Method: Data was analysed using the software environment R. Computer programming scripts were generated to analyse the dataset using multivariate analysis and 3D correlation graphs. Results: Three statistically significant (p<0.05) novel prognostic markers were discovered and trends towards significance were seen Goldie Khera in a further two. Four novel visualisations were produced depicting the change in immune cell populations with age and how these changes are distinct to those seen in CLL. ASiT President Conclusions: The five novel prognostic markers discovered have already led to new research threads and may have significant clinical Bariatric Fellow, in demonstrations to use. The four visualisations have already been used North Tynesidea lay audience. Computer programming and data visualisation is an under-exploited tool in all aspects of medicine. Although the quantity of literature has increased exponentially, methods of analysing complex data and presenting it in a simple, meaningful form is severely lacking. Although this project used CLL data, showing and explaining data to patients is part of the daily routine for the modern clinician, in all fields of medicine.
0929 Ed Fitzgerald CALOT'S TRIANGLE. A COMMON MISCONCEPTION OF BASIC ANATOMY ASiT Conference Organiser & Darmarajah Veeramootoo, Amanda Bond, Anthony Miles, Krishna Singh Past-President Worthing hospital, Worthing, UK General Surgery Registrar, London Aims: Dissection of the Calot's Triangle (CT) is regarded as the key component to a safe laparoscopic cholecystectomy. Yet, JF Calot in his doctoral thesis of 1891, named the boundaries of his triangle as: the cystic duct, the common hepatic duct and the cystic artery. This study aimed to review the medical literature on the description of CT. Methods: A focussed search was undertaken to evaluate the following: basic anatomy textbooks, surgical textbooks and Pubmed (articles about CT published in 2011). Results: Two commonly used textbooks (Last's and Gray's anatomy) inaccurately described the inferior border of the liver as one Jonny Wild boundary of CT instead of the cystic artery. Similarly, the oxford handbook of clinical surgery' and essential general surgical operations by Churchill Livingstone' made the same error. 17 peer reviewed articles were published describing CT. Only one correctly deASiT Honorary Secretary & Sponsorship Co-ordinator scribed the boundaries. 4 were inaccurate and 6 did not provide an anatomical description of the triangle. Of the remaining 6: 4 were General Surgery Registrar, Sheffield not accessible, 1 was in Serbian and 1 was a multimedia article. Conclusion: The cystohepatic triangle is a common misnomer for the Calot's Triangle. Recognition of this misconception will aid teaching and training towards performing a safe cholecystectomy. 1105 IRRIGATION OF SQUAMOUS CELL CARCINOMA WOUNDS TO PREVENT LOCAL RECURRENCE Stephen Goldie1, Scott Lyons3, Richard Price2, Fiona Watt3 Robert Davies 1 St John's Hospital, Livingston, UK 2 ASiT UK, 3Cancer Treasurer Addenbrooke's Hospital, Cambridge,HonoraryResearch UK, Cambridge Research Institute, Cambridge, UK Aim: Despite efforts to exciseVascular cell carcinomas with a margin of normal tissue, some tumours are incompletely excised or squamous Surgery Registrar, West Midlands cancer cells are "seeded" into the wound allowing local recurrence. Following surgical oncology procedures many operators irrigate wounds or body cavities with water rather than normal saline. The logic being that water will induce an osmotic shift of fluid into the cells, causing them to lyse. Methods: SCC cells labelled with a lentivirus YFP/luciferase reporter were grown at clonal densities on standard culture dishes and on top of de-epithelialised dermis (DEDs), to simulate the operative wound environment. Plates were irrigated with standard culture medium, water, normal saline and a 10% betadine solution. James Milburn Results: After 2 weeks, plates and DEDs were analysed for evidence of cell growth. Plates treated with water irrigation showed a decreased ability to form colonies, compared to those treated with culture medium or saline, however, substantial growth was still ASiT Vice-President present. Only the 10% betatine solution showed complete absence of cell growth. General Surgery Registrar, Inverness Conclusion: These experiments suggest that irrigating oncological wounds with water alone may not be sufficient to prevent seeding of tumour cells, and that irrigation with a betadine solution maybe a safer option. 1141 TARGETTING STEM CELLS IN SQUAMOUS CELL CARCINOMA Stephen Goldie1, Scott Lyons3, Richard Price2, Fiona Watt3 1 St John's Hospital, Livingston, UK Joseph Shalhoub 2 Addenbrooke's Hospital, Cambridge, UK ASiT Vice-President 3 Cancer Research UK, Cambridge Research Institute, Cambridge, UK Vascular therapies Registrar, London Aim: Cancer stem cells may evade currentSurgery and allow a cancer to re-grow. By targeting the tumour stem cell population, we may control the disease and cause less harm to the patient's normal tissues. FRMD4A has been shown to be more abundant in human keratinocytes with a stem-like phenotype, and highly over expressed in a panel of human SCCs. Methods: FRMD4A in human skin was studied using in-situ hybridization and immunofluorescence staining. Laser capture microscopy (LCM) was used to collect samples of the basal and granular layers of human epidermis in order to compare levels of FRMD4A by QPCR. In cell cultures derived Steve Hornby FRMD4A was stably knocked down using lentivirus shRNAs. The effect on funcfrom human HNSCCs tion was tested in vitro and in vivo by xenografting. ASiT Director of Education Results: Results of these studies revealed much higher levels of expression of FRMD4A in the basal layer compared to the granular layer of normal skin. Knockdown of FRMD4A disrupted normal cell-cell adhesion inPeninsula General Surgery Registrar, South West HNSCCs. Growth and invasion of the SCC lines in vitro and in vivo was reduced in the FRMD4A knockdowns. Conclusion: FRMD4A is a marker of stem cells in SCCs making it a potential target for future therapies. BREAST SURGERY With thanks
Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor 0056 A NOVEL Mr AndrewIN REPAIRING RECALCITRANT ABDOMINAL University Hospital of SURGERY USING MITEK TECHNIQUE Beamish, Clinical Research Fellow, HERNIAS POST BREAST Wales, Cardiff Laura Andrews Kristina Gloufchev Harriet Innes
to the local ASiT Welsh Regional Representatives:
BONE ANCHORS FOR SYNTHETIC MESH FIXATION Ali Ali, Charles Malata Department of Plastic and Reconstructive Surgery, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust., With thanks to the wonderful ASiT Conference Admin team: info@asit.org Cambridge, UK
am 2012
Introduction: Repair of recurrent abdominal hernias is a surgical challenge often presenting to plastic surgery as a last resort. Such recalcitrant hernias cause enormous morbidity and constitute a financial burden to the NHS. It is important to explore novel and potentially effective repair methods. We report on a technique utilising overlay prolene mesh fixed to bone using Mitek anchors. Methods: All recurrent iatrogenic abdominal hernias repaired by one surgeon (2003-2010) were reviewed. The indications, operative details and clinical outcomes were documented. Results: Seven patients (6F, 1M) aged 35-60 years had had a median of 3 hernia repairs prior to referral. The causes of herniation were incisional (5) and post-TRAM flap (2). The operations lasted a mean of 6 hours (r=3-10.5 hrs). There were no major postoperative problems although one patient requested removal of two of his eight Mitek anchors because of localised tenderness. Only one patient developed a recurrent lower abdominal bulge. Conclusion: Mitek bone anchor fixation of prosthetic mesh reinforcement of abdominal wall hernia repairs is an effective repair technique associated with low morbidity. This method of recalcitrant hernia repair may be a useful addition to the plastic surgeon's armamentarium.
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0098 DO WE NEED TO BIOPSY YOUNG WOMEN WITH CLINICALLY AND RADIOLOGICALLY BENIGN BREAST LUMPS? Kolitha Goonetilleke, Nikhil Sharma, Kiran Virdee, Martin Sintler, Deepak Vijayan Sandwell General Hospital, birmingham, UK Aims: Of all breast lumps in young women, very few are malignant. Some patients may not require all elements of triple assessment including those with clearly identified benign conditions with no other suspicious features identified clinically and radiologically. Aim of this study was to see if biopsy of clinically and radiologically benign breast lumps of women under 30 years is necessary. Methods: Retrospective study of women under 30 years presenting with breast symptoms between December 2000 to January 2010. Results: There were 864 patients. 612 had FNA and 252 CB. 544 met the inclusion criteria. There were 496 (U2), 39 (U3) and 9 (U3+) on ultrasonography. Of the 496 U2, 495 patients pathology was benign (B1/B2). All U3 patients pathology was benign. All U3+ patients pathology confirmed cancer. 9 cases of U4/5 all confirmed cancer on pathology.1 U2 was reported as a C4. Conclusions: 495 clinically and radiologically benign cases were proven to have benign disease on FNA/CB. If there is a discrepancy between clinical and radiological findings there should be a low threshold for biopsy. Otherwise it may be safe to opt out of needle biopsy as it avoids unnecessary morbidity and use of precious resources. 0106 A RETROSPECTIVE STUDY OF AXILLARY LYMPH NODE CLEARANCE FOR PATIENTS DIAGNOSED WITH EARLY BREAST CANCER AND AXILLARY LYMPH NODE INVOLVEMENT. Suet May Chan2, Vivien Ng1, Stephen Courtney1, Brendon Smith1, Hilary Umeh1, Pankaj Roy2 1 Royal Berkshire Hospital, Reading, Berkshire, UK, 2 John Radcliffe Hospital, Oxford, Oxfordshire, UK Aim: Axillary nodal status is the most important prognostic indicator that influences adjuvant therapy. Sentinel lymph node biopsy (SLNB) is the standard procedure performed to stage the axilla. The current standard is to perform axillary node clearance (ANC) if there is evidence of lymph node (LN) metastases. This study aims to assess the number of positive LN on ANC following a positive SLNB or biopsy on clinical/ultrasound assessment. Methods: Patients with ANC (January 2008 to December 2009) were identified along with LN yields on SLNB and ANC. Clinicalpathological parameters and treatment details were also collected. ANC was performed for three groups: SLNB + micrometastasis, SLNB + macrometastasis and positive axillary LN on clinical/ultrasound-guided biopsy. Results: 170 ANC were performed in the two-year period. More than 40% of patients with macrometastasis on SLNB had further positive LN on ANC. Only 8% of patients with micrometastasis were found to have residual axillary disease (p<0.001, Fishers exact test). Completion ANC did not provide any additional information to alter adjuvant treatment in patients with micrometastasis. Conclusion: The limited role of completion ANC in patients with SLNB + micrometastasis is highlighted and therefore is likely to have an impact on management of early breast cancer. 0112 FIVE YEARS AFTER INTRODUCTION, HAVE STANDARDISED REFERRAL FORMS REDUCED THE NUMBER OF INAPPROPRIATE REFERRALS TO BREAST CLINIC? Valentina Lefemine, Gary Osborn, Anne marie Mainwaring, Sumit Goyal Breast Centre, Cardiff, UK Introduction: In August 2005 new referral guidelines and updated referral forms were issued to GP's in Cardiff with the aim of reducing unnecessary referrals to breast clinic. An audit of 203 referral letters showed that 53% of patients were referred using the new style form. 55% of referrals were deemed inappropriate. After five years we aim to assess the impact of standardised referral forms on inappropriate referrals to breast clinic. Methods: A prospective audit of GP referrals to the breast clinic in June and July 2010 was performed. Results: 145 patients were included. 75% of patients were referred using the referral forms but 58% of these were filled incompletely. Concordance between GP and consultant findings was similar for written and form referrals (65% for breast lumps, 54% and 59% for pain and 100% and 57% for discharge respectively). Overall 8% referrals were deemed inappropriate using national guidelines, of which 7 (6%) used the standardised form and 5 (14%) were letters. All patients referred inappropriately had a normal diagnosis, none required a biopsy and all were discharged from clinic. Conclusion: After five years, the majority of referrals to the breast clinic are made using the standard referral form. The number of inappropriate referrals has fallen to 8%.
0113 MASTALGIA - ARE WE CARING IN THE COMMUNITY? Valentina Lefemine, Julie Cornish, Elle Javad, Walid Abou-Samra Glan clwyd Hospital, Rhyl, UK Introduction: Referral guidelines for mastalgia are well published. Breast pain with no other clinical concern should be managed initially in a primary care setting. Our aim was to look into the management of mastalgia in the community and have an understanding on tives: whether guidelines are followed. edd, Bangor Method: A questionnaire was posted to all GP surgeries that referred to our institution. Results: al of Wales, Cardiff 41 responses were received (34% response rate). 95% percent of GPs consulted 1-5 women with mastalgia every month. 24% of GPs were aware of referral guidelines for patients presenting with breast pain. 37% of GPs refer a patient with mastalgia to the breast clinic at their first presentation, mostly as urgent' or soon' referrals. All respondent GPs would initiate some form of management for mastalgia. m: info@asit.org Conclusion: Mastalgia is the commonest breast symptom presenting to general practitioners. Ignorance of national guidelines and fear
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of missing a breast cancer results in a large number of patients being referred to the breast clinic with significant resource implications. GPs should be encouraged to manage mastalgia in the community. We would advice breast specialists to assume a primary role in promoting knowledge and reassurance amongst GPs by means of leaflets, forums and meetings.
0132 PHYLLOIDES TUMOURS OF THE BREAST: A SINGLE CENTRE EXPERIENCE Valentina Lefemine, Gary Osborn, Verity Oloroso, Carrie Champ, Kate Gower-Thomas, Rhodri Williams, Eifion Vaughan-Williams Goldie Khera Royal Glamorgan Hospital, Llantrisant, UK Aims: Phylloides tumours (PT) are the most common non epithelial neoplasms of the breast and account for 1% of all breast tumours. ASiT President We aim to report our experience on the management of PT over an eight year period. Bariatric Fellow, North Tyneside Methods: A retrospective review of all patients diagnosed with PT in a single unit between January 2003 and December 2010 was performed. Results: 31 patients were included. 27 patients had symptomatic and 4 patients screen detected lesions. Diagnostic imaging showed benign features in 13 patients, equivocal features in 9 patients and features in keeping with PT in 9 patients. All lesions were biopsied but a preoperative diagnosis of PT was achieved in only 10 patients. 4 patients underwent mastectomy,27 patients had a wide local excision. Final histology revealed 23 benign and 8 malignant PT. All patients were followed up for 12 months; we had a 9.6% recurrence rate, mostly in patients with benign phylloides. Ed Fitzgerald Conclusions: PT of the breast are a diagnostic challenge. There is a lack of consensus on how to best manage these rare tumours and we would recommend a ASiT Conference Organiser & or large supposedly benign lesions . All patients should be low threshold for excising rapidly growing Past-President followed up as even benign phylloides can reoccur. Registrar, London General Surgery 0176 BREAST CANCER IN SYMPTOMATIC PATIENTS WHO HAVE NORMAL USS AND/OR MAMMOGRAM Andrew Mishreki, Syed Yousuf, Ranya Bafadal, Catherine Chikerema University Hospital North Durham, Durham, UK Aim: There is no data published on the incidence of patients who present to the breast clinic (with either a lump or thickening) and have normal findings on USS Jonny Wild and/or mammogram, however subsequently have biopsy proven cancers. The aim of our study was to determine this number in our centre. & Sponsorship Co-ordinator ASiT Honorary Secretary Method: We called all of the patient's notes who were diagnosed with breast cancer between 1 st April 2009 and 31st October 2011 in General Surgery Registrar, Sheffield our trust. We retrospectively reviewed all presenting complaints, radiology and histology findings, and multi-disciplinary team meeting decisions. Results: In total we found 319 patients who were diagnosed with breast cancer during this period. Out of these 17 had normal imaging initially, however had histologically confirmed breast cancer/in-situ cancer on FNAC/core biopsy of the symptomatic area. Conclusions: Our study has shown that patients who present with thickening or lumpiness of the breast should all have FNAC or core biopsy of the symptomatic area, even in the presence of normal USS and/or mammography. Robert Davies This highlight's the importance of a thorough triple assessment in all patients presenting to the breast clinic. 0236 Vascular Surgery Registrar, West Midlands IS THE BENEFIT OF INTRAOPERATIVE SENTINEL LYMPH NODE BIOPSY (SLNB) ANALYSIS USING ONE-STEP NUCLEICACID AMPLIFICATION (OSNA) NEGATED BY THE NEED FOR FURTHER BREAST SURGERY? Dionysios D. Remoundos1, Hannah A. Wilson1, Farid Ahmed1, Yoon Chia2, Giles H. Cunnick1 1 Department of General Surgery, Wycombe General Hospital, High Wycombe, UK 2 Department of Histopathology, Wycombe General Hospital, High Wycombe, UK SLNB is standard practice for axillary staging in clinically node-negative breast cancer patients. Traditionally, SLNB-positive patients James Milburn required delayed axillary lymph node clearance (ALNC). The development of intra-operative analysis methods, such as OSNA, has made single-stage procedures possible. However, some argue that their benefit may be negated by the need for further breast surASiT Vice-President gery. We aimed to assess the benefit of intraoperative OSNA compared to conventional SLNB analysis and delayed ALNC. General Surgery Registrar, Inverness 400 consecutive patients with clinically and radiologically normal axillary lymph nodes, who underwent mastectomy or breastconserving surgery for invasive cancer or multifocal DICS, in a single institution from May 2010 to November 2011, were included. Routine localisation and intra-operative OSNA analysis were performed. Patients positive for metastasis proceeded to ALNC at the same setting. Those requiring additional breast procedures were identified. 142 patients underwent an immediate ALNC. 14.6% of patients required re-excision breast surgery. Only 21.4% of OSNA-positive patients required further surgery. Despite the need for re-excision breast surgery in cases of positive margins, intra-operative OSNA analysis reduces the number of Joseph Shalhoub patients requiring further surgery by 78.6%. Offering a single operation is better for patients and the health economy, reducing waiting ASiT Vice-President times and expediting the start of adjuvant treatments. 0306 ULTRASOUND EVALUATION OF BREAST CANCER DEPTH. DOES THIS PREDICT THE LIKELIHOOD OF SUPERFICIAL MARGIN INVOLVEMENT? Lulu Tanno, Catherine Boffa, Gavin Royle, Rachel Oeppen, Ramsey Cutress Southampton University Hospital Trust, Hornby UK Steve Southampton, Aim: We determined superficial margin involvement (SMI) in patients undergoing breast conserving surgery (BCS) and assessed if ASiT Director of Education ultrasound tumour depth predicts the likelihood of SMI. Methods: A retrospective review of 201 BCS procedures undertaken in 2009. US report and images were used to determine the suGeneral Surgery Registrar, South West Peninsula perficial depth of tumours. Results: Tumour was present at one or more margin (including deep or superficial) in 41 (20%) cases and led to further surgery in 15 cases. A skin ellipse was excised in 76 (38%), and of these, no specimens had isolated SMI. In 2 cases skin involvement was clinically apparent pre-operatively. From those without skin resection the superficial margin was the only margin involved in 4 cases. In total there were 2 re-excisions forto the superficial margins, one following a skin ellipse and the other following no skin resection. The With thanks isolated local ASiT Welsh Regional Representatives: mean USS depth of the tumour in cases with SMI was 4mm whilst the mean depth of those without SMI was 10mm (p=0.002). Miss Rhiannon Harries, General Surgery Registrar, Ysbyty If USS depth is <5mm Conclusions: Isolated SMI is rare following BCS. US depth may be a good indicator of SMI. Gwynedd, Bangoran ellipse of skin overlying Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff the cancer should be considered rather than excision from a distant site. 0307 INTRA-OPERATIVE ULTRASOUND IS AN EFFECTIVE TECHNIQUE FOR EXCISION OF EARLY BREAST CANCER With thanks to the wonderful ASiT Conference Admin team: info@asit.org Jennifer Pollard, S Pathak, Anu Shrotri, CD Parmar, Lee Martin
ASiT Honorary Treasurer
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
University Hospitals Aintree, Liverpool, UK Introduction: Radio-guided occult lesion localisation (ROLL) has been used to excise impalpable breast lesions instead of wire-guided localisation. We hypothesise Intra-operative Ultrasound Marking (IUM) is as effective as ROLL for excision of ultrasound-detectable lesions and more cost-effective. Methods: Retrospective analysis performed on consecutive patients undergoing IUM WLE over 3 years. Baseline demographics, tumour size, margin clearance, histology and further procedures performed were analysed. Results: Sixty-six IUM WLEs were performed June 2008-November 2011 for non-palpable lesions, with 100% success rate for excision. Mean patient age 58-years (27-81 years). Mean radiological tumour size 13.5mm (4.5-28.4mm), mean invasive tumour size 18.7mm (3-77mm) and mean specimen weight 43.9 grams. 63 patients (95.3%) had clear radial margins (mean clearance 3.35mm, range 1.1-7mm). Three patients (4.7%) had positive margins for invasive malignancy. These results compare favourably with ROLL data. Conclusions: Our results demonstrate no malignant lesions were missed; therefore this procedure can be safely used to excise early, impalpable screen-detected breast cancers. It improves peri-operative patient journey; increases patient safety and convenience, whilst making savings in cost of nuclear medicine services. Furthermore, it can be performed in hospitals without a nuclear medicine department. Our recommendations are breast surgeons will need to undergo training in ultra-sound scanning.
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0318 MEDICAL ASTROLOGY: DEBUNKING THE MYTH FOR BREAST DISEASE Thomas Micic, Rachel Barnes, Kelvin Gomez Aneurin Bevan Health Board Trust, Abergavenny, South Wales, UK Introduction: Medical astrology predicts that disease is under the influence of astrological signs. Being born within the zodiac sign of Cancer is meant to increase your chances of developing diseases of the breast. Methods: A retrospective cohort of 1458 patients who presented with breast disease was derived from hospital admission data from a single Health Board from January 2008 to February 2011. Statistical confirmation of the dataset was performed using the Chi-Squared test. Results: Results showed that the probability of developing benign breast disease and being born within the zodiac sign of Cancer was 7.83% (Range 6.01-10.97% for the other zodiac signs); pre-invasive malignancy was 8.76% (Range 5.84-11.68% for the other zodiac signs); and for malignant disease was 9.25% (Range 7.71-9.91% for the other zodiac signs). There was no statistically significant difference between the Zodiac groups. Conclusions: The basis for medical astrology, as with astrology itself, is rooted in superstition and pseudoscience. Unfortunately, a proportion of patients presenting with breast disease still seek advice from medical astrologers, who may influence their treatment options. Our results show that there is no statistical difference. The authors hope that by debunking this myth, fewer patients will be adversely affected by inappropriate advice. 0331 HORMONE RECEPTOR STATUS OF BREAST CANCER IN PATIENTS OF DIFFERENT AGE GROUPS, LYMPH NODE STATUS AND TUMOR GRADE,AN EXPERIENCE AT KING FAHAD MEDICAL CITY(KFMC) Javeria Iqbal, Bandar Alharthi, Alam Ara, Mohammad Abukhatir, Yousaf Alabdulkarim King Fahad Medical City, Riyadh, Saudi Arabia Objectives: To see the relationship between receptor status(RS) and age of patients, tumor grade and lymph node involvement of breast cancer patients. Materials and methods: A retrospective review of all histopathology reports of breast cancer cases since 2007 till August 2011 was made .Pvalue <0.05 was considered significant. Results: 420 files were reviewed of which 75 were excluded due to incomplete data. We found that 63% of our patients were triple positive.35% were ER/PR Negative.54% ER/PR Positive and 11% were either ER or PR positive respectively. Patients >45yrs were usually ER/PR positive 72.7% as compared to patients of age <45yrs who had more ER/PR negative tumors 39.4 %.(p=0.044). On comparison of ER/PR status with grade we found that more ER/PR negative tumors were high grade as compared to ER/PR positive which were mostly low grade(P=0.001). We also found that HER2 positive tumors are mostly Grade III(57.8%) while those with HER2 negative are mostly low grade( 75%).(p=0.043).No significant correlation was found between RS and lymph node status (p=0.961) Conclusion: Most of our breast cancer patients are ER/PR positive and triple positive. Young patients tend to have more receptor negative tumors as compared to older patients. High grade tumors are mostly receptor status negative as compared to low grade ones. 0345 SAME DAY ADMISSIONS ARE KEY TO SAVING MONEY IN ELECTIVE BREAST SURGERY Usman Khalid, Nicola Woodcock, Pawel Pietrzak, Sumit Goyal The Cardiff and Vale Breast Centre, Cardiff, Wales, UK Aim: To evaluate our length of stay for Elective Breast Surgery and explore ways to increase our rate of Same Day Admissions (SDA's) and reduce costs. Method: Retrospective data on admission, discharge and day of surgery were collected for all patients who underwent Breast Surgery at Cardiff Breast Centre between April 2010 and March 2011. Results: 626 patients underwent Breast Surgery, with a median age of 57 and average length of stay 3 days. 28% of patients were admitted on day of surgery (62% of which day-cases), 71% day before surgery and 1% more than 1 day before surgery. Reasons for admission day before surgery were: Sentinel Node Radioisotope (RI) injection(50%), Wire insertion(6%), Normal Culture' within this trust for pre-operative assessment(44%). Conclusions: Based on a 200 cost per bed day, we estimated that our Trust could save 89,000 per year if all patients arrived on day of surgery. Ways to increase our SDA rate include: 1. RI injection day before surgery and admission on day of surgery; 2. Setup of a pre-assessment clinic - Clinic space, nursing staff and junior doctors are already set in place for this trust therefore only an additional cost of 10,000 per year would be required for a dedicated anaesthetist.
0383 ARE THE NUMBER OF LYMPH NODES EXCISED DURING AXILLARY NODE CLEARANCE SURGERY AFFECTED BY NEOADJUVANT CHEMOTHERAPY? edd, Bangor David Naumann, Martin Sintler Sandwell al of Wales, Cardiff and West Birmingham Hospitals NHS Trust, West Midlands, UK Introduction: Neoadjuvant chemotherapy may change the macroscopic architecture of lymph nodes (LNs) to such a degree that the number counted by a histologist following axillary node clearance (ANC) is lower than expected by the surgeon. We test the hypothesis that chemotherapy prior to ANC reduces the number of LNs. m: info@asit.org Methods: Retrospective study examining records for all patients undergoing ANC at a NHS Trust over a 17 month period. We com-
tives:
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pared the number of LNs counted on histological examination between the patient groups who had received neoadjuvant chemotherapy and those who had not, with further subdivision into groups who had undergone sentinel node biopsy (SNB) prior to ANC and those who had not. Results: There were 237 ANC operations including 98 ANC alone, 36 ANC following chemotherapy but no SNB, 61 ANC following SNB but no chemotherapy, and 42 following both SNB and chemotherapy, yielding 14.4 (6.5), 13.0 (5.8), 14.3 (5.1), and 15.1 (5.5) mean LNs respectively (p = 0.398). Conclusion: We find no statistically significant difference in the number of LNs from excised axillary tissues between patients who Goldie those who received neoadjuvant chemotherapy andKhera had not. Lower than expected number of LNs may not credibly be attributed to neoadjuvant chemotherapy. ASiT President
Bariatric Fellow, North Tyneside 0387 BLUE DYE DIRECTED AXILLARY NODE SAMPLING- REVISITING THE ROLE Rachel French, Vijay Kurup University Hospital North Tees, Stockton-on-Tees, UK Aim: To evaluate whether combination of Sentinel Lymph Node Biopsy(SLNB) using patent blue dye and four node sampling as a reasonable alternative to SLNB (dual technique), in early breast cancer as guidelines recommend. Methods: A retrospective study of SLNB using patent blue dye and four nodes sampling performed by a single surgeon from 2006-'11. Ed Fitzgerald All 245patients treated by WLE were included. SLN were localised by injecting 2 ml patent blue dye in the subareola with further Level ASiT Conference palpation. Node Past-President 1 sampling done to achieve a minimum of 4 nodes, byOrganiser &positive axillae were treated by radiotherapy or clearance as per MDT decision. General Surgery Registrar, London Results: The detection rate was 97.95% (240/245 patients). 41 patients had axillary metastases- 38 cases SLN positive and 3 Negative. False negative rate 1.5%, Sensitivity 92.7% and negative predictive value 98.5%. 21/41patients (51.2%) had only one node involved in their axilla. Axillary morbidity was minimal and recurrence nil at 5 years. Conclusion: Injection technique and experience of surgeon can lead up to 98% SLN detection using blue dye alone with comparable false negativity. Combining with four node sampling reduces the impact of false negativity and avoids unnecessary axillary clearance in single node disease (51.2%).
0432 ASiT Honorary Secretary & Sponsorship Co-ordinator TRIPLE NEGATIVE BREAST CANCER; BACKGROUND, TREATMENT AND FUTURE OPTIONS 1 General Surgery Registrar, Sheffield Rebecca Watts-Cherry , Eleri Davies2 1 Cardiff University, Cardiff, UK 2 Llandough Hospital, Cardiff, UK Aims: Identify a subgroup of patients who were diagnosed with triple negative breast cancer (TNBC) in Cardiff and Vale (CAV) in 2006 -2011, to enable an understanding of how TNBC patients present, what treatment is given and which patients had recurrences. Method: This was a retrospective study. The pathology database gave a list of TNBC patients. Using this information, the Clinical Portal and CANNISC databases allowed the Davies be completed, which was then analysed. All people diagnosed as having TNBC Robert proforma to in CAV in 2006 - 2011 were included. No age or gender restriction was imposed. ASiT Honorary Treasurer Results: 101 patients were included in the study, of these 77 (76%) are alive up to 5 years after. 11 (11%) developed recurrences and 7 (7%) developed metastasis.Vascular Surgery Registrar, West Midlands Of these 86% had grade 3 tumours (study average(sa)=79%), 86% had invasive ductal carcinoma (sa= 87%) and the average size was 54mm (sa= 33mm). 67 (66%) patients received chemotherapy which was found to enhance survival (p=0.003). Conclusion: TNBC disease is very responsive to chemotherapy agents, so must be given to all triple-negative patients as routine treatment irrespective to the histological result. The results obtained compare appropriately with the majority of studies already conducted. 0434 James Milburn IMAGING OF BREAST PATHOLOGY- IS ULTRASOUND ALONE ADEQUATE? Rebecca Griggs, Christina Harris, Michelle Mullan, Rachel Bright-Thomas ASiT Vice-President Worcestershire Royal Hospital, Worcester, UK General Surgery Registrar, Inverness Aim: Recently new guidelines for imaging of symptomatic breast problems in women aged 35-39 advocate ultrasound scan (USS) be adopted as the primary imaging modality, and that mammography (MMG) be reserved for those with suspicious/atypical examination or imaging. We sought to investigate the adequacy of USS alone in diagnosis of breast cancer. Method: All new patients aged 35-39 attending breast clinic from January 2008 to December 2010 who had a radiological investigation were included and those with cancer identified from radiology and histology records. Results: 542 patients were identified, 15 (3%) were men, 398 (73%) had a MMG, 285 also had an USS. 144 (27%) patients had an USS only. 28 were diagnosed with breast Shalhoub Joseph cancer. 17 cancers were investigated with MMG and USS, and in all of these the USS was graded U3/4/5 using the breast imaging reporting and data system (BIRADS) classification. One patient had USS only, and one MMG ASiT Vice-President only for diagnosis. There were no incidental findings of breast cancer on MMG. Vascular Surgery is as sensitive as MMG Conclusion: USS alone for women aged 35-39 yearsRegistrar, London for diagnosis of breast cancer. We suggest MMG be reserved for patients with uncertain or positive findings on USS. 0438 DIFFERENCES IN PATIENT EXPERIENCE AND UNDERSTANDING OF CONSENT WHEN CARRIED OUT IN CLINIC AND ON THE DAY OF SURGERY Steve Hornby Amy Lord, Shehryer Naqvi, Ramesh Babu, Richard Sainsbury ASiT St Mary's Hospital, Isle of Wight, UK Director of Education Aims: To assess patients subjective perception of consent and recall of information when comparing those consented in clinic with General Surgery Registrar, South West Peninsula those consented immediately before surgery. Methods: Prospective study of patients undergoing breast and general surgical operations. Patients were randomised to consent in clinic or consent immediately before surgery. Patients completed a post-operative questionnaire assessing satisfaction and recall of complications using a tick-box list of 16 common complications, 6 of which were correct for each operation. An overall score of correct minus incorrect answers wasto the local6. With thanks calculated out of ASiT Welsh Regional Representatives: Results: 27 patients were included, 17 consented immediately pre-operatively, and 10 in clinic (mean - 13 days pre-op). The mean Miss Rhiannon Harries, was 3 when consented on the day and 2.9 when consented in clinic. Subjective ratings overall score for recollection of complicationsGeneral Surgery Registrar, Ysbyty Gwynedd, Bangor of experience were not significantly different between the groups. Overall recall rates were better for general complications (96% Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff bleeding, 100% infection and 74% anaesthetic risk) than specific risks (25% seroma in breast patients). Conclusions: In our experience patients can be consented either in clinic or on the day of operation as there is no difference in their subjective perceptions or recall ofthe wonderful only small numbers have been assessed so far. info@asit.org With thanks to information. However ASiT Conference Admin team:
Jonny Wild
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
0457 IS MAMMOGRAM AN ESSENTIAL INVESTIGATION FOR DETECTING BREAST CANCER IN PATIENTS YOUNGER THAN 40 YEARS? Annabelle Williams, Rachel Hung, Yazan Masannat, Anil Desai, Prakash Sinha Princess Royal University Hospital, London, UK Aims: Breast cancer is the commonest female cancer diagnosed in the UK. In November 2010, the Best Practice Diagnostic Guidelines for Patients Presenting with Breast Symptoms' were amended. This study aims to evaluate the safety of the proposed changes that state mammography is no longer an essential first line investigation for women under the age of 40, with breast symptoms, Methods: A retrospective cohort study of 40 patients, from January 2007 to July 2011, with histologically confirmed breast cancer diagnosed when under the age of 40 was performed by comparing mammography and ultrasound results. Results: All patients presented with a symptomatic lump and underwent ultrasound scanning, mammography and core biopsy. No patient with a normal ultrasound was found to have an abnormal mammogram. In all 40 patients ultrasound scanning showed 100% sensitivity in identifying the breast lesions with 95% identified as indeterminate, suspicious or malignant radiologically. Conclusions: The new symptomatic breast guidelines are safe to implement, as ultrasound is an adequate first line investigation. If any suspicious ultrasound abnormality is detected then mammogram is essential for further assessment as this could demonstrate further pathological changes which may affect clinical management. This should lead to improved patient care and resource management. 0471 BREAST PAIN UNDER THE AGE OF 50: IS MAMMOGRAPHY REALLY NECESSARY? R E Foulkes, R Thomas, S Ghosh Nevill Hall Hospital, Abergavenny, UK Aim: The aim of this study was to assess whether routine mammography in patients presenting with painful breasts, and no palpable mass is necessary in those under the age of 50 years. Methods: All patients attending breast clinic between 1 st January 2008 - 31st December 2010 with breast pain only, undergoing mammography, were assessed. Patients were then divided into the under 50 and over 50 age group for comparison. Results: 315 patients were assessed, 168 (53%) were under 50 years old (mean 43). All had clinically normal breasts on examination. Six (3.5%) patients had indeterminate mammographic abnormalities in the under 50s age group, versus eight (5%) in the over 50s group. All had benign findings following further investigation. One (0.6%) patient in the under 50s group had a malignant mammographic abnormality - this was on the asymptomatic side in a 48 year old. In those patients over 50 years, three (2%) had malignant abnormalities on mammography, of which two were confirmed malignancies. Conclusions: Malignancy is rare in patients under the age of 50 presenting with pain only. In the setting of a normal clinical examination, routine mammography is not necessary, and may lead to further unnecessary investigations and anxiety.
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0571 MAJOR BREAST AND AXILLARY SURGERY FEASIBILITY OF A 23 HOUR PATHWAY Rachel Clancy, Roger Watkins Frenchay Hospital, Bristol, UK Aims: Length of hospital stay for mastectomy patients has declined. Hospital Episode Statistics data for 2010-11 showed the average length of stay is still almost four days. Without compromising clinical care the aim of this study was to evaluate the feasibility and safety of a new pathway aimed at discharging patients within 24 hours of surgery. Methods: From December 2008 suitable breast cancer patients requiring mastectomy and/or major axillary surgery were offered same day admission and discharge home within 24 hours. Results: 126 patients (mean age:60;range27-86) were included from 2008-2011. 99(79%) underwent mastectomy with either axillary node sampling (ANS) (10), sentinel lymph node biopsy (SNB)(59), axillary node clearance (ANC)(20) or no axillary procedure (10). 4 (3%) had bilateral mastectomy with either ANS(1), SNB(2) or no axillary procedure (1). (18%) patients underwent ANC with either wide local excision (4), repeat excision (1) or no breast procedure (18). 97(77%) patients were discharged within 24 hours. 24(19%) were discharged on second day and 4(3%) required a three night stay. One patient developed ventilatory problems post-operatively requiring transfer to ITU. None of the 97 patients required unplanned readmission. Conclusions: Major breast and axillary surgery can be safely performed with a minimal length of post-operative stay in suitable patients. 0589 ONE-STAGE DELAYED BREAST RECONSTRUCTION USING STRATTICE AND PERMANENT IMPLANT Victoria Bonello, Siva Gopalswamy, Sheikh Ahmad Royal Cornwall Hospital, Truro, Cornwall, UK Aim: This case series aims to determine the degree of patient satisfaction and complication rates associated with a novel method of one-stage delayed breast reconstruction. Method: Six patients underwent reconstruction, one of which was bilateral, over an eight-month period. StratticeTM was used to create a subpectoral/allogenic graft pocket capacious enough to accommodate a permanent implant, hence eliminating the need for further intervention following the index procedure. The creation of a neo-inframammary fold was essential to produce a natural looking result. A patient satisfaction questionnaire was conducted six months following the procedure. The complication rate was determined after review of case notes. Results: All patients showed satisfaction with the cosmetic outcome and especially with the ease of return to normal activities. One early post-operative complication was noted. This involved a small area of poor wound healing at the site of previous irradiation, necessitating excision of scar tissue. Conclusion: This case series has demonstrated that this new technique is an excellent option for patients wishing to undergo a less extensive form of delayed reconstruction. It is associated with less tissue disruption than other reconstructive procedures, hence reducing the length of recovery and complication rates whilst giving the reconstructed breast a natural appearance.
0600 GYNECOMASTIA: IS IT COST-EFFECTIVE TO INVESTIGATE ALL PATIENTS IN A FINANCIALLY RESTRAINED NHS? edd, Bangor Habib Tafazal, Hiren Chauhan, Mehboob Mirza Sandwell al of Wales, Cardiff General Hospital, Birmingham, UK Aim: Gynecomastia is a common condition, with many men being referred to the already busy rapid access breast clinic. As surgery for gynecomastia is classed as non-essential, is it cost-effective to investigate all patients? Method: Retrospective analysis of 97 patients referred from primary care. All patients were male, aged 17 to 89 years. The costs of the m: info@asit.org following investigations were calculated. Blood tests including LFTs, U&Es, TSH, FSH, LH, prolactin, testosterone, oestradiol, AFP,
tives:
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HCG and imaging in the form of mammography and ultrasound. Results: The cost of a complete set of blood tests for each patient, including staffing and reagents, totals 35. Mammography and ultrasound cost 110 each. 87% of the patients were investigated with blood tests; the majority of which were normal. 43% had a mammogram, 52% had an ultrasound. Neither breast cancer nor endocrine pathology was detected in any cases. Total cost of the blood tests was 3000; mammography costs were over 4500. Conclusions: Investigating all patients may not be cost effective but a selected combination of tests may be useful. We recommend that blood tests do not add value towards diagnosis and are an unnecessary additional cost to the already financially restrained NHS.

Goldie Khera
0649 ASiT President A COMPLETE AUDIT CYCLE OF PREOPERATIVE SURGICAL SITE MARKING VERIFICATION CHECKLIST Bariatric Turton, K Horgan S Anwar, R Kurfi, SS Rajan, P Webster, PFellow, North Tyneside Department of Breast Surgery, Leeds General Infirmary, The Leeds Teaching Hospitals NHS Trust, Leeds, UK Aims: Correct preoperative surgical site marking is a major patient safety issue. The aim of this audit was to examine the compliance with preoperative surgical site marking verification checklist (PMVC) used at this trust. Methods: A prospective audit (101-patients) and a re-audit following staff education (125-patients) examined PMVC for correct written confirmation of: (a) side and procedure, (b) marking verification checks on ward (checks 1 and 2), and preoperatively in theatre (checks 3 and 4), (d) safety net signings if any of checks 1-4 were not completed (checks 5 and 6). Ed Fitzgerald Results: All patients had correct side and operation description listed. Ward documentation for checks 1 and 2 were complete in 100% ASiT Conference Organiser & Past-President and 97% in initial-audit, and in 100% and 98% in re-audit period, respectively. In theatre documentation for checks 3 and 4 were complete in 70% and 48% in initial-audit, and Surgery Registrar, LondonFurther safety net-checks 5 and 6 were not completed in General in 80% and 74% in re-audit period. either case (initial-audit=58%, re-audit=36%). No inadvertent side surgery error occurred in either cohort. Conclusions: A significant improvement in practice was demonstrated following staff education and regular close audit is necessary to ensure compliance to PMVC which is pivotal in preventing error. 0664 IMPACT OF PROPHYLACTIC ANTIBIOTICS ON THE INCIDENCE OF POST-OPERATIVE WOUND INFECTION AND SUBSEJonny Wild QUENT DELAY IN ADJUVANT THERAPY FOR BREAST CANCER Dilraj Bilku, Caroline Brammer ASiT Honorary Secretary & Sponsorship Co-ordinator Royal Wolverhampton Hospital NHS Trust, Wolverhampton, West Midlands, UK General Surgerystudies have shown rates of infection to be 3% to 30%. Wound infection results in Introduction: Breast surgery is considered clean but Registrar, Sheffield the delayed start of adjuvant breast cancer treatment. We therefore conducted an audit to analyse compliance with guidelines (SIGN guideline 84,104). Methods: 68 patients undergoing radiotherapy following wide local excision for breast cancer across four units were analysed. Data was extracted from treatment sheets, operation notes and anaesthetic charts. Results: Antibiotic prophylaxis was administered in 28 patients (41%) of which six (21%) developed wound infection. No antibiotics were given in 40 patients (59%) of which 20 (50%) developed wound infection. There was a delay in the initiation of radiotherapy in 31 Robert Davies patients. In two patients (7%) the delay was due to wound infection while in ten patients (32%) the delay was due to wound infection and adjuvant chemotherapy. ASiT Honorary Treasurer Conclusion: Wound infection following breast cancer surgery can have severe consequences by delaying the start of adjuvant chemoVascular Surgery Registrar, West Midlands radiotherapy and affect the outcome of patient. This audit indicates that prophylactic antibiotics substantially reduce the risk of postoperative wound infections in breast surgery and thus avoid delay in start of adjuvant treatment or any additional operation required for definitive treatment. 0747 ULTRASOUND MARKING OF THE WIRE-TIP PRIOR TO WIRE GUIDED WIDE LOCAL EXCISION SHOWS PROMISE IN IMPROVJames Milburn ING OUTCOME FOR IMPALPABLE BREAST CANCER Andy Kordowicz1, Susie Flexer1, David Sapherson2, Gary Dyke1 ASiT Vice-President 1 Department of Breast Surgery, Harrogate and District Hospital, Harrogate, North Yorkshire, UK, General Surgery Registrar, Inverness 2 Department of Radiology, Harrogate and District Hospital, Harrogate, North Yorkshire, UK Aim: We examined whether pre-operative ultrasound marking (PUM) of the wire-tip improved outcome for women undergoing wireguided wide local excision (WLE) of impalpable breast cancer. Methods: Between 01/2010 and 06/2011, 33 women underwent wire-guided WLE in our institution. Via a retrospective analysis of case-notes we identified patients who had undergone PUM of the wire-tip. Patient age, tumour characteristics, operating time, mass of specimen excised and further procedures (cavity-shave) were recorded. Results: 12 women underwent PUM of the wire-tip (group a), 21 women did not (group b). Both groups were well matched for age, Joseph Shalhoub histological grade of tumour and tumour size. The median mass of specimen excised was 48.5g(range 24-92g) for group a and 57g ASiT Vice-President (range 22-140g) for group b (p=0.14). Median operating time was 36.5mins(range 19-52mins) for group a compared to 41mins(range Vascular the patients in group a (0%) required 24-103mins) for group b (p=0.01). None of Surgery Registrar, London a further cavity-shave compared with 5 of the patients in group b (24%). Conclusions: PUM of the wire-tip shows promise as an adjunct in wire-guided WLE of impalpable breast cancer, reducing the mass of specimen removed (with obvious aesthetic implications), the operating time, and the number of repeat procedures to which the patient is subjected. 0782 Steve Hornby ANALYSIS OF SOCIAL STATUS AND BREAST CANCER PROGNOSIS USING WELSH INDEX OF MULTIPLE DEPRIVATION ASiT Director of Education AND ACORN CLASSIFICATION: DOES A GAP EXIST? Thomas Micic, Rachel Barnes, Kelvin Gomez General Surgery Registrar, South West Peninsula Anuerin Bevan Health Board Trust, Abergavenny, South Wales, UK Introduction: There has always been an implied association between poor health and social deprivation. Our study assessed whether a gap in patient outcome for breast cancer exists between different strata of society within a geographical region in Wales. Methods: A retrospective cohort of 745 breast cancer patients was recruited using cancer registry data from January 2008 to February 2011. Welsh Index of Multiple Deprivation (WIMD) alongWelsh Regional Representatives: With thanks to the local ASiT with 4 deprivation categories from the ACORN classification based on patient postcodes were used as a measure of deprivation. Nottingham Prognostic Index (NPI) was used as a marker of patient outcome. Results: Missof WIMD demonstrated no General with NPI (coefficient: 0.042, p: 0.25). Gwynedd, Bangor Analysis Rhiannon Harries, correlation Surgery Registrar, Ysbyty The incidence of breast cancer was highest (30%) in the Andrew Beamish,of patients (20%-26% for the remaining categories). The mean of Wales, Cardiff least Mr least deprived category Clinical Research Fellow, University Hospital NPI score was 3.1 for the deprived group (3.2 for other categories). 38% of the least deprived patients had an excellent prognostic outcome (32%-34% for other categories).11% of the least deprived patients had a poor prognosis (9%-11% for other categories). Conclusions: Ourthanks to the wonderful ASiT Conference Admin team: info@asit.org With results show no statistically significant difference in either the incidence of breast cancer or outcome from treatment of the disease between different strata of society.
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
0858 WHAT DO PATIENTS UNDERSTAND ABOUT OF THE ROLE OF HOSPITAL STAFF AND INVESTIGATIONS IN BREAST CANCER SERVICES? Rachel L O'Connell, Edward R St John, Nizar Din, Sidonie Hartridge-Lambert, Omotayo Johnson Ashford and St Peter's NHS Foundation Trust, Surrey, UK Aims: Patients' should be well-informed on the investigations they undergo and the roles of individual groups of healthcare professionals involved in their care. The aim of this study was to determine the level of knowledge in patients presenting to a breast unit. Methods: A written questionnaire was given to new patients in the breast clinic. Questionnaires were reviewed by two independent assessors. Results: 120 consecutive patients received the questionnaire; 7 declined or were unable to complete it. Mean age was 46.8 years, 97% (n=110) were female and 89% (n=101) spoke English as their first language. 88% defined surgeon' correctly whereas radiographer' and radiologist' were correctly defined by only 19% and 29% respectively. 26% correctly defined pathologist' and 41% oncologist'. Only 39% of patients could define mammogram' and 8% ultrasound'. 21% had an understanding of a multi-disciplinary team meeting'. Younger patients (age<50 years) had a worse overall understanding than older patients (36% v 41% correct, p=0.017) Conclusion: The majority of breast clinic patients have a poor understanding of the investigations they undergo and the role of medical staff involved in cancer care. Early education is essential, especially in this group of patients who may require multiple visits and investigations.
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0882 THE ROLE OF AXILLARY ULTRASOUND IN EARLY INVASIVE BREAST CANCER Liam Convie, Claire Jones, Carrie Moffitt, Mike Reilly, Janne Bingham Altnagelvin Hospital, Londonderry, UK Aim: Axillary node metastases influence the management of women with invasive breast cancer. Guidelines recommend axillary ultrasound for all patients, with fine needle aspiration (FNA) if abnormal. The study aim was to assess axillary ultrasound accuracy in a specialist breast centre. Methods: All cancer patients with early invasive breast cancer, from August 2010 to August 2011 inclusively, were identified. Patient demographics, axillary ultrasound and histology results were obtained. Mann Whitney U and Fishers Exact tests were used, with a p value of <0.05 considered significant. Results: 197 patients were identified; 9 were excluded due to incomplete data. All had axillary ultrasound; 31.0% were abnormal. 64.0% of abnormal lesions were malignant histologically. Ultrasound sensitivity and specificity were 60.9% and 82.5% respectively. Positive and negative predictive values were 65.0% and 79.8% respectively. Overall accuracy was 75.0%. The median (IQR) proportion of involved nodes was higher in those with a positive pre-operative ultrasound (50.0%(14.3-85.7%)vs.17.5%(8.242.5%);p=0.02), although harvested nodes was similar (17.0(11.0-23.0)vs.14.0(2.7-30.3);p=0.22). A lower proportion of patients with micrometastatic disease (35.7%) had a positive ultrasound compared to macroscopic nodal disease (85.7%;p=0.004). Conclusions: Ultrasound accurately assesses axillary lymph node status. Routine ultrasound should help avoid excessive axillary surgery. 0897 PREDICTING RESPONSE - THE USE OF NEOADJUVANT CHEMOTHERAPY IN BREAST CANCER A 5 YEAR REVIEW Eamon Francis, Aoife Lowery, Giueseppe Gullo, John Crown, James Geraghty, Denis Evoy, Enda W McDermott St Vincents University Hospital, Dublin, Ireland This study aimed to determine the rate of pCR following neoadjuvant chemotherapy, identify clinicopathologic factors associated with pCR and validate the efficacy of a published nomogram (Neo!adjuvant) (1) in predicting pCR . Data was collected on patients with breast cancer treated with neoadjuvant chemotherapy at SVUH from July 2006 to July 2011. Patient demographics, tumour clinicopathologic parameters and chemotherapeutic regimens were recorded. Response to neoadjuvant chemotherapy was assessed radiologically and pathologically. Where sufficient data was available the Neo!adjuvant nomogram was used to calculate the probability of pCR. Predictive accuracy was assessed by calculating the area under the receiver operating characteristic (ROC). 89 patients were treated with neoadjuvant chemotherapy during the study period. pCR was observed in 14%. Estrogen receptor (ER) negativity and Her2/neu receptor positivity were significantly associated with pCR (p<0.05). All tumours exhibiting a pCR were invasive ductal carcinomas. No invasive lobular carcinoma exhibited a pCR to neoadjuvant chemotherapy. The ROC of the validated nomogram in our breast cancer population revealed a value of 0.87. Clinicopathologic factors including ER and Her2/neu receptor status are associated with response to neoadjuvant chemotherapy. The Neo!adjuvant nomogram may be a useful tool in our population of breast cancer patients.
0920 BREAST RADIO-GUIDED OCCULT LESION LOCALISATION (ROLL): A GOOD ALTERNATIVE TO WIRE-GUIDED LOCALISATION Han-Sian Lee, Syeda Gilani, Noaman Sarfraz Warrington & Halton NHS Hospitals Trust, Merseyside, UK Aim: To assess the emerging role of radio-guided occult lesion localisation (ROLL) as a superior alternative to conventional wireguided localisation methods in the removal of impalpable breast lesions. This project assessed the excision margins and re-excision rates of ROLL and compared them to NICE-based wide local excision (WLE) standards. Method: Data was collected on a retrospective basis for all patients who underwent the ROLL-guided removal of screen-detected and incidental non-palpable breast cancers from July 2009 to July 2011. Benign tumours and lymphoma(s) excised using ROLL were excluded. Results: A total of 76 cases were examined. The re-excision rates using the ROLL technique with a < 2 mm excision margin stood at 7 cases (9.2%) overall, but this included 4 patients (5.2%) with multi-focal disease undergoing mastectomy. Only 3 patients (3.9%) required further WLE as the only procedure. This is well below the NICE guidelines of re-excision rates for WLE of 13 - 19% of similar margins. 57% of patients had the tumour size up-scaled from the ultrasonic measurement on final histology. tives: Conclusion: The ROLL technique for the management of non-palpable breast lesions does effectively show better results as comedd, Bangor pared to wire-guided procedures. Further research is necessary to establish the exact role of ROLL. 0981 WHEN SHOULD WE CONSIDER CONTRALATERAL PROPHYLACTIC MASTECTOMY IN BRCA1/BRCA2 NEGATIVE FAMILIAL BREAST info@asit.org CANCER PATIENTS? A STUDY OF HISTOPATHOLOGICAL PATTERNS Fatima Aloraifi, Trudi McDevitt, Nuala Cody, Marie Meany, Cliona de Baroid, Rosemarie Kelly, Adrian Bracken, Andrew Green, James
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Geraghty National Centre for Medical Genetics, Dublin, Ireland, Aims: Little is known on the management of BRCA1/BRCA2-negative familial breast cancer. This study aims to characterize histopathological data on these patients in order to help in predicting the likelihood of contralateral breast cancer. Methods: A 5-year retrospective study was performed on patients referred to the National Centre for Medical Genetics in Ireland from 2007-2011 for genetic testing. Clinical and histopathological reports were collected from high-risk patients (Manchester score >=16) negative to BRCA1/BRCA2 (N=179). Goldie Khera Results: 42/179 (23%) high-risk BRCA1/BRCA2-negative patients had bilateral breast cancer. 22/42 (52%) were moderate to high grade, 20/42 (47%) were ER+, 6/42 (14%) were HER2+ and 4/42 (10%) were triple negative. Interestingly, only 7/42 (16%) of these ASiT President tumours were lobular carcinoma. Bariatric Fellow, patients are considered high-risk and offered bilateral prophylactic mastectoConclusion: BRCA1/BRCA2-positive breast cancer North Tyneside mies. However, these patients only account for a small proportion of familial breast cancer. Despite intensive efforts, the discovery of additional breast cancer predisposing genes to account for the large proportion of familial breast cancer has so far been unsuccessful. Therefore, efforts should be made to create a scoring system to predict the likelihood of bilateral breast cancer in this patient group through histopathological data in a larger scale multinational study.
0992 Ed Fitzgerald COULD A PROPORTION OF FAMILIAL BREAST CANCER PATIENTS TESTING NEGATIVE TO BRCA1 AND BRCA2 IN FACT ASiT Conference Organiser & Past-President BE FALSE NEGATIVES IN THE REPUBLIC OF IRELAND? Fatima Aloraifi, Trudi McDevitt, Nuala Cody, Marie Meanie, Cliona de Baroid, Rosemarie Kelly, Adrian Bracken, Andrew Green, James General Surgery Registrar, London Geraghty National Centre for Medical Genetics, Dublin, Ireland Aim: The National Centre for Medical Genetics (NCMG) provides genetic testing for familial breast cancer patients throughout Ireland. We performed an audit of BRCA1/BRCA2-negative familial breast cancer patients and assessed their characteristics. Methods: BRCA1/BRCA2 genetic testing data was collected prospectively since the NCMG service was first introduced in 1998 to present. In addition, we collected histopathological data on patients from 2007 to 2011 and performed a literature review on BRCA1/ Jonny Wild BRCA2-positive breast cancer histological data from previous international reports to compare it with our Irish cohort. Results: Since 1998, 618 high-risk affected breast cancer patients & Sponsorship Co-ordinator ASiT Honorary Secretary were referred to the NCMG. Only 16% tested positive for BRCA1/ BRCA2 germline mutations. According to the literature, BRCA1-positive tumours tend to be triple negative and of high grade. In 179 General Surgery (15%) were triple negative, affected patients negative to BRCA1/BRCA2, 26/179 Registrar, Sheffield 41/179 (23%) were high grade and 10/179 (6%) were both. Conclusion: International statistics show that the susceptibility genes BRCA1 and BRCA2 comprise 25% of familial breast cancer. However, in Ireland, we show that only 16% are tested positive for BRCA1/BRCA2 mutations at the NCMG. Our next step will be to perform next generation DNA sequencing on invited participants in order to address this clinically important question. 1018 Robert Davies ROLE OF MRI IN INVASIVE BREAST CANCER D Oweis, P Rushton, V KurupASiT Honorary Treasurer North Tees and Hartlepool NHS Foundation Trust, Stockton, UK Vascular Surgery Registrar, West Midlands Aim: To study the effect of preoperative breast MRI on change of surgical management in invasive breast cancers. Methods: Retrospective study of patients(pts) with invasive breast cancer who underwent a preoperative breast MRI between Jan 09 and Dec11. Data collected included demographics, radiological investigations, surgical treatment &histology. Results: 79pts.with a mean age of 58.6years were included. 24 pts.underwent breast conservative surgery, 55 pts.had mastectomy. Mean histological tumour size was 32.5mm. There was a significant difference between MRI size of tumour (mean 36.5mm) and the histological size (mean 31.3mm) (p= 0.19). A significant difference was found between the mammogram(MMG)/Ultrasound(US) size (mean 19.7mm) and the MRI James Milburn size (mean 34.5mm). 31.2% had 2cm discrepancy between MMG/US and MRI and 56.2% had 1cm, 29.2% were multifocal. Discrepancy of 2cm between MRI and histology was seen in 19.2% and 1cm in 24.4%, 55.9% were multifoASiT Vice-President cal. 31pts (39.2%) had a change in the operative plan because of a new ipsilateral multifocality (16pts.), contralateral cancer (1pt) or General Surgery Registrar, Inverness larger cancer (12pts). Two pts had both a new multifocality and a contralateral breast cancer. 84% of those had lobular breast cancer. Conclusion: MRI plays a major role in detecting additional cancers/bigger size and in planning course of treatment especially in lobular cancers. 1052 WHAT IS THE COST-EFFECTIVENESS FOR MAMMOGRAMS FOR DETECTING BREAST CANCER RECURRENCE COMPARED WITH THOSE FOR BREAST Joseph Shalhoub CANCER SCREENING? Lydia Gabriel, Ellena Smith, Sunreet Randhawa, Katy Hogben ASiT Vice-President Imperial College NHS Trust, London, UK Vascular Surgery Registrar, London Background: There are limited NICE guidelines regarding follow-up after breast cancer surgery. At Charing Cross,London patients are followed up with yearly clinical and mammographic assessment for 5years. The aim of this audit is to determine if annual mammographic follow-up for breast cancer is cost effective compared to screening mammography. Methods: A retrospective audit,for breast patients cancer undergoing surgery during 2005 at Charing Cross Hospital,London. Data collected included operative procedures performed, length of follow-up, and recurrence (method of detection for recurrence) and survival rates. Data was compared to the pick-up rate NHS Breast Screening Programme(NHSBCSP) Audit2008-2009. Steve Hornby Results: 269patients underwent surgery from January-December2005, full data collection was possible on 213patients. Average follow ASiT 996mammograms(34860). During this time there have been 25deaths and 28recurrences. Of up was 4.68years, which equates to Director of Education the recurrences, 5were detected by followSurgery Registrar, South West Peninsulacancers from2008-2009. 199 followGeneral up mammogram only. The NHSBCSP detected 17,045 up mammograms(costing 6965) were required to detect one cancer, while 124 screening mammograms(costing 4340) were required to detect one cancer. Conclusions: Routine annual mammograms for breast cancer recurrence are less cost effective than those for the NHSBCSP. Stratified follow up or less frequent mammograms should be considered for detecting recurrence. 1057 Miss Rhiannon Harries, General Surgery BENIGN BREAST LUMPS REQUIRE BIOPSIES? DO YOUNG WOMEN WITH CLINICALLY AND RADIOLOGICALLYRegistrar, Ysbyty Gwynedd, Bangor Deepak Vijayan,Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Mr Kolitha Goonetilleke, Kiren Virdee, Nikhal Sharma, Martin Sintler Sandwell General Hospital, Birmingham, UK Aim: Women <25 years with clinically and radiologically benign breast lumps do not require a biopsy in accordance with RCR guideline 2010. With thanks to the wonderful ASiT Conference Admin team: info@asit.org Methods: A retrospective audit of all women under 30 years having a breast biopsy at SWBH NHS Trust between Jan 2000 and Dec
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
2010. Clinical, radiological and histological data were compared. Results: 864 patients were identified from the pathology database, 612 had FNAC and 252 had core biopsy. 544 patients had full data sets available for analysis. 91.2% (496) were p2 u2, all were confirmed b2 histology. 7.2% (39) were p2+ u3 with histology downgrading all of them to b2. 1.7% (9) were p3+ u3+ and histology graded them as b4+. 61.4% (334) of the dataset < 25years old. 10 cancers were detected, 1 <25 yrs (P2 U2), 9 >25yrs all suspicious clinically and radiologically. Conclusions: 91.2% of biopsies could have been avoided. Clinical and Radiological findings show a high correlation < 30 years. Only 0.18% (1) showed a discrepancy from the guidelines. 8.8% of the patients would have required biopsies in keeping with the guidelines; a substantial saving in psychological stress to patients, financial cost and manpower time.
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1071 IMPROVING THE SERVICE FOR PATIENTS WITH BENIGN BREAST BIOPSY RESULTS: LESSONS LEARNT FROM A BUSY DISTRICT GENERAL HOSPITAL Richard Boulton1, Shanjitha Kantharuban2, Ruth James2, Kian Chin2, Amanda Taylor2 1 North Middlesex University Hospital, London, UK, 2 Milton Keynes Foundation Hospital, Milton Keynes, Buckinghamshire, UK Aims: In 2005 the NHS Breast Screening Programme published guidelines recommending that 90% of breast biopsy results should be given to patients within a week. We set up a Consultant-led telephone biopsy results service in response to a recent questionnaire study that demonstrated 77% of our patients did not want a follow up appointment if their biopsy result was benign. Our experience and audit results are presented below. Methods: Retrospective analysis of 25 under 35 year clinic patients with benign histology between August 2009 and February 2010, and prospective analysis of 35 patients identified as suitable for telephone results in July 2010. Results: Between August 2009 and February 2010 the average wait from appointment to the patient receiving benign biopsy results were 25 days (16-61). 0% of patients were informed within a week. The average wait for results via telephone call was 6 days (2-12), with 88% (31/35) receiving results in 7 days or less. Conclusions: There was a significant reduction in patient wait for benign histology results after the introduction of a Consultant-led telephone service, which approached the NHSBSP target of 90%. This has reduced patient anxiety, clinic attendances and net departmental workload with resultant financial savings. 1077 AN ANALYSIS OF EMERGENCY ADMISSIONS RELATED TO PRIMARY BREAST SEPSIS: A THREE-YEAR STUDY George Kerans, Zoe Lin, Debasish Debnath, Lorna Cook, Isabella Karat, Raouf Daoud, Ian Laidlaw Frimley Park Hospital, Frimley, Surrey, UK Aim: Factors related to emergency admission of primary breast sepsis are not well known. We aimed to evaluate any such underlying factors. Method: Analysis of all emergency breast-related emergency admissions from 1st January 2009 to 31st December 2011 was performed retrospectively. Statistical analysis was performed using SPSS 16.0. Results: Some 140 breast-related emergency admissions took place over a three year period. A total of 89 admissions (59.7%) were due to primary breast sepsis (either cellulites or abscess, unrelated to any recent breast intervention). Patients with primary breast sepsis were significantly younger (40.916.1 years), compared to those who were admitted with other breast emergencies (such as haematoma, postoperative wound infection, pain, seroma, etc.) (53.415.0 years) [p<0.001]. Monthly occurrence of primary breast sepsis was highest in July (n=14) and lowest in September (n=3) [p=0.06]. Seasonal occurrences of primary breast sepsis were as follows- winter (18), spring (20); summer (29) and autumn (22) [p=0.29]. Conclusions: Incidence of primary breast abscess requiring emergency admission remained moderate and peaked in July and summer. Patients with primary breast sepsis were significantly younger than those without. These may improve our current understanding and have implications on service provision. 1079 AN AUDIT OF PRE-OPERATIVE AXILLARY ULTRASOUND ASSESSMENT IN BREAST CANCER Matthew Green, Ani Tencheva, Hemant Ingle, Jamie McIntosh Good Hope Hospital, Sutton Coldfield, UK Aim: To assess the sensitivity and specificity of pre-operative axillary ultrasound in predicting lymph node metastases in breast cancer. Method: A retrospective review of patients undergoing surgery for breast cancer over a 12-month study period was undertaken. Data was collected on pre-operative lymph node radiology, cytology and histopathology and correlated with post-operative histological nodal status. Out of 93 patients, 31 had radiologically abnormal axillary ultrasound scans (group 1) whilst 62 were normal (group 2). In group 1- 2 patients underwent ultrasound-guided biopsy of node, 3 underwent sentinel lymph node biopsy (SLNB), 28 underwent primary axillary node clearance (ANC) and 1 underwent secondary ANC (following SLNB). In group 2- 47 underwent SLNB, 15 underwent primary ANC and 11 underwent secondary ANC Results: In group 1, 87% of patients had involved nodes compared with 39% of patients in group 2. This data gives the sensitivity of ultrasound scan of the axilla as 52.9%, a specificity of 90.5%, positive predictive value of 87.1% and a negative predictive value of 61.3%. Conclusions: Isolated ultrasound assessment of axillary lymph nodes has an unacceptably low sensitivity, although specificity is high. Sensitivity may be improved by combining pre-operative imaging with guided lymph node biopsies.
1093 INVESTIGATING THE IMPACT OF NEOADJUVANT CHEMOTHERAPY AND HERCEPTIN ON THE SURGICAL MANAGEMENT OF PATIENTS WITH INVASIVE BREAST CANCER Terri McVeigh, Dhafir Al-Azawi, Karl Sweeney, Carmel Malone, Maccon Keane, Ray McLaughlin, Michael Kerin Galway University Hospital, Galway, Ireland Aims: Neoadjuvant Chemotherapy(NCT) is indicated in locally aggressive invasive breast cancers. The aims of this study are to audit the surgical management of patients managed with NCT, including Herceptin, in a tertiary referral centre in the west of Ireland, and to tives: assess the impact of receptor status on response to chemotherapy. edd, Bangor Methods: The cohort studied included all patients assigned to NCT between 1999-2010. Data regarding patient demographics, tumour characteristics, nodal management, final pathological score and outcome was obtained from a prospectively maintained database. al of Wales, Cardiff Analysis was completed using PASWv18. Results: 152 patients were assigned to NCT including 5 with bilateral disease. Following chemotherapy, 140 patients underwent Axillary Clearance(AXCn), of which 53 were negative. NCT was found to be effective in 77.9% of patients, 29.3% having a complete m: info@asit.org pathological response, and a further 48.6% having partial response. Breast Conservation was facilitated in 42 patients(28.57%). Lu-
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minal-A subtype was the molecular subtype most often associated with a poor response (30.14%), while all those positive for Her-2 receptor had at least a partial response, 50% a complete response. Conclusion: AXCn in this cohort remains controversial, with 38% of patients assigned to AXCn with no aditional positive lymph node yield. Those patients treated with chemotherapy targeting Her2-receptor had a better response than Her2-negative patients.
1127 INTRA-OPERATIVE RE-EXCISION OF MARGINS IN BREAST-CONSERVING SURGERY: HOW WELL ARE WE ABLE TO JUDGE Goldie Khera TUMOUR PROXIMITY? Lorna Cook, Debasish Debnath, Zoe Lin, Raouf Daoud, Isabella Karat, Ian Laidlaw ASiT President Frimley Park Hospital, Frimley, UK Bariatric (BCS), specimen Tyneside Introduction: In breast-conserving surgeryFellow, North margin involvement with tumour often necessitates re-operation. For this reason, extra margins are often taken at the time of primary operation. The aim of this study was to determine how often such reexcisions are appropriate. Methods: The records of 100 consecutive patients undergoing BCS for cancer during 2011 were analysed. Data was collected on demographics, tumours characteristics, surgery performed and final histology. Results: All 100 patients were female, median age 56 years (range 33-83 years). 66% had intra-operative re-excision of margins. In 26/66 (40%), re-excision was the correct decision. 25 of the 34 patients who had no extra margins taken at all were managed approEd Fitzgerald priately with the remaining 9 patients having close/positive margins. Unnecessary re-excisions were performed in 40/66 patients. The ASiT Conference Organiser correct intraoperative decision was therefore made in 51% of patients. & Past-President Conclusion: The decision regarding intra-operative margin re-excision was appropriate in just over half of all cases and a second opGeneral Surgery Registrar, London eration was avoided in 26%. However, in order to preserve as much uninvolved breast tissue as possible, further work should be done on methods to improve accuracy and to determine whether there are any patient, radiological or pathological predictors to guide intraoperative re-excision. 1181 FACTORS PREDICTING POSITIVE MARGIN STATUS IN BREAST CANCER PATIENTS UNDERGOING BREAST CONSERVING Jonny Wild SURGERY Euan Harris2, Andrew Lee1 ASiT Honorary Secretary & Sponsorship Co-ordinator 1 University of Dundee, Dundee, Tayside, UK 2 General Surgery Registrar, Glamorgan, Abertawe Bro Morgannwg University Healthboard, Swansea, West Sheffield UK Aim: To identify patient and tumour characteristics and techniques of surgical excision associated with a higher incidence of positive margins following breast conserving surgery. It was hypothesised an association between positive margin status and younger patient age, presence of in situ disease, high invasive tumour grade, high in situ disease grade, larger tumour size and localised wire localisation excision would exist. Method: 192 female patients undergoing breast conserving surgery between March 2009 and January 2010 were retrospectively indentified via postoperative pathology reports. A comparison of the incidence of positive and negative margins was conducted using Robert Davies CHI squared tests, odds ratios and 95% confidence intervals. Results: Of the variables that ASiT Honorary Treasurer were examined only tumour type proved to be statistically significant. The presence of in situ disease (P = 0.001), high grade of ductal carcinoma Surgery Registrar, West Midlands = 0.333) were observed to correlate with a Vascular in situ (P = 0.077), larger tumour diameter (P greater frequency of positive margins. Conclusion: With the exception of tumour type, this study failed to find a statistically significant association between positive margin status and the remaining variables examined; which is comparable to the inconsistent results presented in previous studies. CARDIOTHORACIC SURGERY
0022 ASiT Vice-President THE IMPACT OF CONCOMITANT ATRIAL FIBRILLATION ABLATION ON POST-OPERATIVE FLUID RETENTION General Surgery Registrar, Inverness David McGowan1, Jonathan Hyde2, Michael Lewis2 1 Brighton and Sussex Medical School, Brighton, East Sussex, UK 2 Brighton and Sussex University Hospitals NHS Trust, Brighton, East Sussex, UK Background: Atrial fibrillation (AF) ablation has been shown to cause alterations in fluid homeostasis hormones. This study investigated the clinical impact of concomitant AF ablation, with or without left atrial appendage removal, on fluid retention in the immediate post-operative period. Methods: A retrospective cohort study investigating adult cardiac procedures from 2006-2011. Recorded parameters included operaJoseph Shalhoub tion type, height, weight, kidney function, post-operative diuretic usage and post-operative weight gain. ASiT Vice-President Results: In patients receiving a concomitant AF ablation (n=89) the mean day-five post-operative weight gain was 2.77 Kg (+2.39), the mean weight gain in those notVascular concomitantRegistrar, London receiving a Surgery ablation (n=100) was -0.34 Kg (+2.84) (p<0.001). Patients receiving a concomitant AF ablation with LAA removal (n=59) had a mean post-operative weight gain of 3.28 Kg (+2.85), in those ablation patients not undergoing a LAA removal (n=30) the mean weight gain was 1.68 Kg (+2.43) (p<0.001). The AF ablation patients not undergoing a LAA removal had significantly greater weight gain than those who did not receive an ablation (p<0.001). Age, post-operative diuretic use and pre-operative BMI were not associated with significant post-operative fluid retention. Conclusions: Concomitant AF ablationHornby increase fluid retention and LAA removal increases this fluid retention further. Steve procedures These patients need to have their fluid status carefully monitored. 0071 General Surgery Registrar, South West Peninsula THE PERIOPERATIVE TRANSFUSION REQUIREMENTS OF OFF-PUMP VERSUS ON-PUMP CORONARY ARTERY BYPASS GRAFT SURGERY: A REVIEW OF FIVE YEARS OF PRACTICE Nicholas Bullock1, Paul Vaughan2, John Dunne2, Dheeraj Mehta2 1 Cardiff University School of Medicine, Cardiff, Wales, UK 2 University Hospital of Wales, Cardiff, Wales, UK With thanks to the local ASiT Welsh Regional Representatives: Aim: Whilst the transfusion of allogenic blood products is commonplace in cardiac surgery, its risks are becoming increasingly recognised. It Miss Rhiannon Harries, Generalcardiopulmonary bypass reduce the Gwynedd, Bangor transfusion. We has been reported that techniques avoiding Surgery Registrar, Ysbyty need for blood product sought to investigate this by comparing Clinical Research Fellow, University Hospital of Wales, Cardiff Mr Andrew Beamish, the perioperative red blood cell (RBC) transfusion requirements of patients undergoing offpump and conventional on-pump coronary artery bypass graft procedures at our centre over five years of practice. Method: All patients that underwent first-time isolated coronary artery bypass graft (CABG) procedures at our centre between 01/04/05 and 31/03/10 were considered for inclusion. Data wereASiT Conference Admin team: info@asit.org and With thanks to the wonderful collected retrospectively from departmental and blood bank databases analysed using SPSS statistical software. The primary outcome was receipt of allogenic RBC transfusion within the perioperative pe-
James Milburn
ASiT Director of Education
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
riod. Results: 2074 patients were included in the study (off-pump, n=569; on-pump, n=1505). Off-pump CABG was associated with significantly lower perioperative RBC transfusion requirements compared with the conventional on-pump procedure (21.1% versus 36.6% respectively, P<0.001). Additionally, in patients receiving perioperative RBCs, the off-pump technique appeared to be associated with a reduced number of units transfused, although this failed to reach significance. Conclusions: Off-pump CABG is associated with a reduction in perioperative allogenic RBC transfusion and its risks.
0078 GLOVE PERFORATION IN CARDIAC SURGERY-WHEN DOES IT OCCUR AND DOES IT MATTER? Kasra Shaikhrezai1, Maziar Khorsandi1, Maria Van Dalen2, William Walker1, Sai Prasad1 1 Royal Infirmary of Edinburgh, Edinburgh, UK, 2 Ruby Memorial Hospital, Virginia, USA Objectives: Glove perforation is a frequent occurrence in cardiac surgery. This study aimed to identify the principal aetiology of glove perforation during cardiac surgery. Methods: Prospective examination of 200 pairs of gloves worn by surgeons/assistants at the conclusion of 100 cardiac procedures undertaken via a median sternotomy. Gloves were filled with water to detect perforations. Sub-group analyses compared (a) perforations in gloves discarded before sternal closure with the fresh gloves worn, and (b) perforation rates in changed gloves after sternal closure. Results: Prior to sternal closure 42 (42%) surgeons and 86 (86%) assistants changed gloves. Eighty (80.8%) and 19 (19.2%) perforations were detected on the gloves of the surgeons and assistants respectively. Most perforations occurred on the right thumb of surgeons (n=18,22.5%). Glove features, number of needles and surgeons experience did not correlate with perforation rates (p>0.05). Changing gloves before sternal wiring did not reduce perforation rates (p=0.176). Wound infection occurred in 3 of 64 operations with glove perforation and 1 of 36 with no glove perforations (p=0.527). Conclusion: Sternal closure is the dominant cause of glove perforation in cardiac surgery. We would recommend double gloving before sternal wiring. We found no correlation between glove perforation and sternal wound infection. 0153 DOES EXPLORATIVE THORACOTOMY FOR NON-SMALL CELL LUNG CANCER (NSCLC) ADVERSELY AFFECT PATIENTS OUTCOME POSTOPERATIVELY? James Rigby, Aiman Alzetani, Adam Lea, Shilajit Ghosh University Hospital of North Staffordshire, Stoke-on-Trent, UK Aims: To determine our incidence of explorative thoracotomy for NSCLC and its influence on further management of patients & their survival. Methods: Retrospective review of patients referred for lung cancer surgery over 2.5 years. Clinical data were collected on radiological/ pathological staging and post-operative management including survival status. Results: Between January 2008-August 2011, 418 patients underwent thoracotomy for primary lung cancer, of which 27 patients (6%) had inoperable disease. Of the inoperable cases, 4 (15%) had a pre-explorative mediastinoscopy and 22 (81%) were investigated with PET studies. Sixteen patients (59%) had radiological-advanced stage (IIIA-). Inoperability was due to stage migration, N2 disease, tumour invasion or poor physiological status intra-operatively. Subsequent treatments included adjuvant (chemotherapy/ radiotherapy /combined) in 16 patients (59%) of which 12 (75%) are still alive with an average length of survival of 9 months. Conclusion: Our incidence of explorative thoracotomy is well within those reported in the literature. Over half of patients were still suitable for radical adjuvant treatment and 44% survived for an average 9 months post-surgery. Surgery should not be denied for advanced NSCLC to avoid depriving patients the benefit of curative resection and if resection cannot be achieved then some patients are suitable for adjuvant treatments. 0308 THE USE OF HOMOGRAFTS IN THE OPERATIVE MANAGEMENT OF INFECTIVE ENDOCARDITIS HAS LOWER SHORT AND MEDIUM-TERM MORTALITY AND IMPROVED OVERALL OUTCOME COMPARED TO PROSTHETIC VALVES Abderahman Kamaledeen1, Rizwan Q Attia2, James C Roxburgh2, Christopher P Young2, Christopher I Blauth2 1 King's College London, London, UK 2 Department of Cardiothoracic Surgery, St Thomas' Hospital, London, UK Aim: Infective endocarditis remains a challenging clinical entity, particularly with changing causative organisms. We aim to characterize the operative management, microbiology, operative mortality and long-term survival in a contemporary cohort of patients having surgery for IE. Methods: We reviewed the records of 125 consecutive patients who had surgery for IE over five years (2006-2011), at a large tertiary cardiovascular centre. The valve prosthesis, causative organism, in-hospital morality, long-term survival and need for repeat surgery were examined. Results: Cumulative Kaplan-Meier survival was 86.8% at one-year and 67.8% at five years. 101/125(80.8%) patients had isolated valve surgery, 13/125(13.6%) two valves and 7/125(5.6%) three valves. Of the aortic valve IE, 24/66(36.3%) patients had aortic homograft (LES 44.7%), 33/66(50%) had tissue valve (LES47.7%) and 9/66(13.6%) mechanical prosthesis (LES 23.3%). The use of Homograft as a valve substitute was more common in patients with annular involvement and intracardiac abscesses. In-hospital mortality for homograft was 4.5% vs. 8% for prosthetic valve p0.01. There were no re-infections in the homograft group vs. 4.5% for prosthetic valve p0.001. Conclusion: In patients having operation for infective endocarditis, homograft valve replacement provided excellent short and mediumterm outcomes with superior survival and freedom from re-intervention compared with prosthetic valve replacement
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0380 THE ROLE OF SURGICAL LUNG BIOPSY IN THE MANAGEMENT OF UNDEFINED PARENCHYMAL LUNG DISEASE Vivienne Blackhall, Felice Granato, Katrina Knight, Bernadette Quinn, Ali Jilaihaiwi, Alan Kirk, Mohammed Asif tives: Golden Jubilee National Hospital, Glasgow, UK edd, Bangor Aim: To examine whether surgical lung biopsy (SLB) is worthwhile in the diagnosis of undefined parenchymal lung disease (UPLD). Methods: al of Wales, Cardiff 113 patients over a two year period at a single institution underwent SLB for UPLD. Patient demographics, pre-operative diagnosis and treatment, surgical approach, number and site of biopsies, complications, length of postoperative stay and postoperative diagnosis and treatment were examined. Results: Fifty m: info@asit.org six patients were female and 57 were male. The median age was 59 years. Following biopsy, 27% of patients received no clear pathological diagnosis and 73% received a specific diagnosis. Of all patients, 42% had a change in their treatment following
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the procedure. We observed 5 (4%) perioperative deaths, 7 major complications (6%) and 8 minor complications (8%). The median hospital stay was 4 days. Conclusions: Surgical lung biopsy is a relatively safe procedure. Although it provides an accurate diagnosis for many patients, SLB can be inconclusive and can fail to provide a consistent change in patient management. It can be associated with a prolonged postoperative stay, resulting in an increased cost to the NHS. SLB should therefore be performed in a select group of patients with UPLD after discussion at a respiratory multidisciplinary team meeting.
Goldie Khera 0513 WHAT'S THE ROLE OF VENTRICULAR ENDOCARDIAL RECONSTRUCTION SURGERY IN 2011? A SINGLE CENTRE 7 YEAR ASiT President EXPERIENCE Bariatric Fellow, North Tyneside Rizwan Attia, Hannah Fleming, John Chambers, Fikrat Shabbo Guys and Saint Thomas', London, UK Aim: Surgical ventricular restoration in patients with coronary artery disease, post infarction left ventricular aneurysm or ischemic dilated cardiomyopathy is a viable treatment option,yet conflicting data currently exists.We evaluated the 7-year clinical experience of this procedure in our institution. Methods: From 2003 to 2010, surgical ventricular restoration was performed in 86 patients (M2.3:1F), mean age 64.5 years. All patients presented with angina, heart failure and/or ventricular tachycardia. Post-infarction left ventricular aneurysm was present in all Ed Fitzgerald patients and ischemic dilated cardiomyopathy with a large akinetic left ventricle in 11.6%. The preoperative left ventricular ejection ASiT Conference Organiser & fraction was 33.110 %. Multi-vessel disease was present in 93% patients.Past-President Results: All patients underwent endoventricular or circular patch repair. 94% had concomitant coronary revascularisation, median of 2 General Surgery Registrar, London grafts and 5% had mitral valve repair. Intra-aortic balloon pump was placed pre-operatively in 18.6% while 16.2% needed inotropic support for more than 24h.Postoperative stroke occurred in 1 patient. In-hospital mortality was 4.6%.All cause cardiovascular mortality at five years was 8.1%. Mean follow-up in operative survivors was 4.42.8years.Actuarial survival at 1,2 and 5 years was 90.6%, 87.9% and 79.1%. Conclusions: Early and long-term results are good in terms of survival and better when compared to ventricular resynchronisation therapy and medical management.
0567 ASiT Honorary Secretary & Sponsorship Co-ordinator A FIVE YEAR AUDIT STUDY ON DEEP STERNAL WOUND INFECTIONS AND ASSOCIATED DEHISCENCE POST MEDIAN General Surgery Registrar,FACTORS AND A PROPOSED MANAGEMENT STRATEGY STERNOTOMY: AN ANALYSIS OF PATIENT OUTCOME, RISK Sheffield Kenneth Porter1, Rujuta Ropeklar2, Pari Mohanna1 1 St Thomas' Hospital, London, UK 2 King's College Hospital, London, UK Aims: To audit risk factors, outcome and management of patients who developed post median sternotomy wound infections and associated dehiscence. Methods: In a five year retrospective study 6335 consecutive patients who underwent median sternotomies for coronary artery bypass Robert Davies grafts and aortic valve replacements were examined. ASiT Honorary Treasurer Results: There were 166 sternal wound infections (2.6%). 48 patients (0.76%) underwent treatments such as vacuum therapy and debridements for sternal dehiscence. Vascular Surgery Registrar, West Midlands Increased age, BMI, a lower ejection fraction and diabetes were risk factors for developing sternal wound infections requiring more radical treatments. 18 patients required sternal reconstruction in the form of a flap and on average were seen by plastic surgeons 13 days after the onset of dehiscence. In the reconstruction group each patient received on average 27 days of vacuum therapy and 3 debridements. Conclusions: All patients should be risk stratified for post median sternotomy wound infections. In patients with significant risk factors and infected sternal wound dehiscence combined plastic and cardiothoracic surgical input James should be undertaken from the outset. Milburn Aggressive and early one stage debridement and flap coverage should be considered in serious sternal wound infections associated ASiT Vice-President with dehiscence as it may negate the need for multiple debridements and prolonged vacuum therapy.
Jonny Wild
0614 SYNCHRONOUS CAROTID ENDARTERECTOMY FOR ASYMPTOMATIC CAROTID STENOSIS AND CORONARY ARTERY BYPASS GRAFTING IN PATIENTS WITH CONCOMITANT DISEASE - A LITERATURE REVIEW Frances Burrell Glasgow Royal Infirmary, Glasgow, UK Aims: This literature review investigates the outcomes of synchronous coronary artery bypass grafting (CABG) and carotid endarterecJoseph Shalhoub tomy (CEA) for concomitant disease in neurologically asymptomatic patients. ASiT Vice-President Methods: An electronic OVID Medline database search using the following criteria: "asymptomatic", "carotid stenosis", "carotid enVascular Surgery Registrar, London darterectomy", "CEA", "coronary artery bypass", "CABG" gave a total of 56 articles. Stroke and mortality rates were calculated and compared to CABG alone in patients with carotid stenosis. Fishers exact test was used to calculate significance. Results: Incidence of stroke was significantly less in asymptomatic patients undergoing synchronous surgery compared to symptomatic patients, 1.7% versus 13.2%, risk 0.13 (95%confidence interval 0.08-0.21, P=<0.0001). There was a small significant decrease in stroke risk in patients undergoing synchronous surgery compared to CABG alone, 3.4% versus 5.8% , risk 0.92 (CI = 0.86-0.99, P=0.0123), but this was insignificant when limited to asymptomatic patients. There was a trend of increased mortality in symptomatic Steve Hornby patients and in synchronous surgery which was not statistically significant. ASiT Director of Education Conclusions: This study suggests synchronous surgery decreases stroke risk in patients with carotid stenosis compared to CABG alone, but mortality benefit and benefit toSurgery Registrar,remains unclear. Peninsula symptomatic patients have worse General asymptomatic patients South West Neurologically outcomes compared to those with asymptomatic carotid stenosis. 0892 WEIGHT REDUCTION PRIOR TO ELECTIVE CORONARY REVASCULARIZATION IN EXTREMELY OBESE PATIENTS IMPROVES CLINICAL OUTCOMES With thanks to the local ASiT Welsh Regional Representatives: Remananda K Pai, Natasha Prior, Christopher M R Satur Miss North Staffordshire, Stoke on Trent, Surgery Registrar, Ysbyty Gwynedd, Bangor University HospitalRhiannon Harries, GeneralUK Introduction: 20% of patients undergoingClinical revascularization [CABG]University Hospital of Wales, co-morbidities in Mr Andrew Beamish, coronary Research Fellow, in the UK are obese, with associated Cardiff cluding diabetes, hypercholesterolemia poor mobility, and smoking. They present a high risk for CABG. We examined the impact of diligent preoperative risk modification on postoperative outcomes. Methods: We instituted a closely the wonderful risk reduction focusing on weight loss, cessation of smoking and diabetic conWith thanks to monitored regimen of ASiT Conference Admin team: info@asit.org trol, in extremely obese patients [BMI>40] requiring elective CABG [Group WL] and examined their outcome compared to less obese
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
patients outside the study group [Group OE]. Kruskal Wallis and Anova method was used for statistical analysis. Results: A 8.9% weight loss was achieved safely in the 13 patients [Group WL] over 202 days, with a fall in BMI from 43.9 [+ 3.7] to 40.1[+3.4]. Four patients quit smoking and tight glycemic control was achieved in 8 diabetics before surgery. In spite of the poorer patient profile, patients in group WL did better with lower incidence of mediastinitis, wound infection, early mobilization and hospital stay compared to Group OE. Conclusion: Weight loss was safely achieved in extremely obese patients before planned CABG with tangible reduction of adverse postoperative outcomes and promises a better result in this high risk cohort of patients.
0983 THE OUTCOME OF CARDIAC SURGERY IN OCTOGENARIANS: A 13 YEAR EXPERIENCE Ghazi Elshafie, Omar Nawaytou, Taha Binesmael, Ana Lopez, Dheeraj Mehta University Hospital of Wales, Cardiff, UK Aim: Advanced age is associated with increased risk in cardiac surgery and more octogenarians are being referred for interventional procedures for structural and ischemic heart disease. The aim of this study is to evaluate our surgical outcome in octogenarians following cardiac surgery. Methods: Between January 1998 and May 2011, we identified 530 octogenarians who underwent cardiac surgery. The mean age was 82.3 +/- 2.4 years with a logistic EuroSCORE of 16.39 +/- 14.63. 135 patients (25.5%) underwent isolated coronary artery bypass grafting (CABG), 357 patients (67.3%) had aortic or mitral valve procedures. Results: The in-hospital mortality was 6.0%. Major complications included stroke in 0.8%, new haemofilteration in 9.1% and permanent pace maker insertion in 5.8% of patients respectively. Median postoperative stay was 13 days. The overall actuarial survival at 1, 3 and 5 years was 87.4%, 80.0% and 75.2% respectively. The actuarial survival at 5 years for the isolated CABG group, aortic valve replacement group and mitral valve group was 82.8%, 74.7% and 74.0% respectively. Conclusion: In our experience, cardiac surgery in octogenarians has excellent early and long-term survival. Morbidity rates are acceptable. We conclude that cardiac surgery should not be discounted in octogenarians on the basis of age alone. 1004 CORONARY ARTERY BYPASS GRAFTING ON DIALYSIS-DEPENDENT CHRONIC RENAL FAILURE PATIENTS: SHORT AND LONG-TERM OUTCOMES, A 12 YEAR EXPERIENCE Ghazi Elshafie, Omar Nawaytou, Taha Binesmael, Ana Lopez, Dheeraj Mehta University Hospital of Wales, Cardiff, UK Aim: Performing coronary artery bypass graft surgery (CABG) on dialysis-dependent end-stage renal disease patients is still a subject for debate. This study focuses on the short and long term outcomes of dialysis-dependent patients undergoing CABG. Methods: Between October 1998 and December 2010, we identified 65 dialysis dependent patients who underwent CABG in our institution. The mean logistic EuroSCORE was 17.07 +/- 20.62. 38 patients (58.5%) underwent isolated CABG and 27 patients (41.5%) had concomitant procedures. Results: The total in-hospital mortality was 7.7%. Major complications included reintubation in 4.6% of patients. None of the patients had new post-operative stroke. The median postoperative stay was 14 days. The overall actuarial survival at 1, 3 and 5 years was 80.0%, 64.3% and 49.8% respectively. The actuarial survival at 5 years for the isolated CABG group, aortic valve replacement group and mitral valve group was 51.8%, 52.5% and 40.4% respectively. Conclusion: Cardiac surgery can be performed in end stage renal disease with acceptable morbidity and mortality. The relatively decreased long term survival is only a reflection of their high natural attrition state and cardiac surgery should not be discounted solely on this foundation. 1065 ANTIPLATELET THERAPY FOLLOWING CORONARY ARTERY BYPASS GRAFT SURGERY Amir Sepehripour, Nikolaos Koumallos Wythenshawe Hospital, Manchester, UK Aim: The most recent American College of Cardiology Foundation/American Heart Association guidelines for coronary artery bypass graft surgery (CABG) recommend the initiation of Aspirin (100-325mg) within 6-hours post-operatively and indefinite continuation, supported by class 1A evidence. This study aimed to evaluate adherence to these guidelines in our cardiac unit. Method: A retrospective analysis of 100 consecutive patients undergoing CABG was conducted, analysing antiplatelet agents, dosing and timing of administration. The findings and recommendations were presented at local level. A prospective analysis of a further 100 consecutive patients undergoing CABG was conducted, analysing the above primary outcomes. Results: The retrospective analysis revealed the following therapies: Aspirin 75mg-73%, Clopidogrel 75mg-5%, Aspirin+Clopidogrel 75mg-15% and Aspirin 300mg-7%. Initiation of therapy within 6-hours was not observed in any patient. The prospective analysis revealed the following therapies: Aspirin 75mg-61%, Clopidogrel 75mg-4%, Aspirin+Clopidogrel 75mg-7% and Aspirin 300mg28%. Initiation of therapy within 6-hours was observed in 16%. Conclusions: There is strong evidence to support the early initiation and continuation of high-dose antiplatelets following CABG however these guidelines are not strictly adhered to. We have demonstrated with closed audit and re-education an improvement in a simple yet prognostically significant process of care, and consequently an enhancement in clinical practice.
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1092 LASER THERAPY FOR TRACHEOBRONCHIAL TUMOURS, DOES IT HELP? Janan Jeyatheesan, Mohammed Hawari, Henry Carslake, Maninder Kalkat Heartlands Hospital, Birmingham, UK Aim: Neodymium:yttrium aluminium garnet (Nd:YAG) laser therapy has been used for many years as part of palliative treatment of advanced tumours involving the tracheobronchial tree. We aim to review our practice and assess the safety of the procedure and its effectiveness. Method: Patients who underwent laser therapy for airway tumours between January 2008 and December 2011 were retrospectively reviewed. Collected data was analyzed using SPSS 20. Results: 38 patients; 15 females and 23 males, with mean age 64; range 35-84 years, underwent laser treatment. 76.3% were primary tives: lung tumours and 23.7% were metastatic. 10 were tracheal only, 6 tracheobroncheal, 15 right bronchus and 7 left bronchus. 42.1% edd, Bangor had external compression in addition to the endoluminal component. 65.8% of patients had significant improvement of their symptoms or radiological resolution of collapse, 13.2% had partial improvement while 21% had no improvement. None had complications related al of Wales, Cardiff to laser. Overall 1 and 2-year-survival was 20.1% and 10.7% respectively. There was no statistically significant survival difference between metastatic and primary lung tumours (p-value 0.423), or between endoluminal tumours and those with external compression (p-value 0.449). Conclusions: Laser is a safe and good option in palliation of blocked airways. Most patients get symptomatic and m: info@asit.org radiological improvement.
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1131 DOES SURGERY HAVE A ROLE IN LIMITED SMALL CELL LUNG CANCER? Khalid Mujahid, Mohammad Hawari, Babu Naidu, Maninder Kalkat, Simon Trotter Regional Centre for Thoracic Surgery, Heartlands Hospital, Birmingham, UK Aims: We looked at patients who underwent lung resections with a post-operative histological diagnosis of small cell lung cancer. Our aim was to identify which group in this category had a survival benefit from surgery. Methods: A retrospective review was performed between January 1996 and August 2011. All patients with histopathological diagnosis Goldie Khera of small cell cancer were identified and followed up. Survival data was analysed using Kaplan Meier and Cox regression. Results: 32 patients were identified. 19 males (59%). Mean age 65.9 (SD 8.6). 11 patients (32%) had a diagnosis of small cell on froASiT President zen section. 18 (60%) were stage I, 8 (26.7%) stage II, 4 (13.3%) stage III. Nodal status was N0 (22), N1(6), N2(2). Overall 1, 2 and 5Bariatric Fellow, North Tyneside year-survival was 74.3%, 50.1% and 41.8%. Patients with T1 disease had better 2 and 5-year-survival (76.2% each) compared with T2-4 disease (36.8%, 18.4%), p-value 0.014. However, there was no 2 and 5-year -survival benefit for nodal status in N0 (55.4%) versus N1 and N2 (37.5%, 18.8%) disease (p-value 0.146). Conclusions: There is a survival benefit for patients undergoing lung resection for T1 small cell lung cancer. Further studies are needed to evaluate positive proognostic factors in patients with limited disease.
1168 Ed Fitzgerald SURGICAL MANAGEMENT OF RHEUMATIC MITRAL VALVES ASiT Conference Organiser & Past-President Khalid Mujahid, Mohammad Hawari, Sunil Bhudia, Ramesh Patel Department of Cardiothoracic General Surgery Registrar, London Surgery, University Hospital of Coventry and Warwickshire, Coventry, UK Aims: Evaluate which prognostic factors affected long term outcomes in mitral valve repair and replacement. Methods: Retrospective review of our database. 470 patients underwent surgery between 1994 and 2010. Morbidity and mortality were evaluated using Kaplan-Meier analysis and Cox regression. Results: Mean age was 65 years, 80% were females. Preoperatively, 76.8% were treated for congestive heart failure (CHF) and 53.2% had recent deterioration of symptoms. 42.1% had moderate to poor LV function. 12.1% had mitral stenosis, 21.9% had regurgitation and 66% had mixed disease. 43.6% were repaired and 56.4% replaced. 16.8% were urgent cases. 30d mortality was 8.1%. Jonny survival Factors that significantly affected 5-year Wild included recent deterioration (p-value < 0.001), presence CHF (p-value 0.017), CRF or Creatinine >200 mol/l (p-value <0.001), preoperative dysrhythmia (p-value 0.038), poor LV (p-value <0.001), urgent status (p-value ASiT Honorary Secretary & Sponsorship Co-ordinator <0.001), postoperative renal impairment or need for dialysis (p-value <0.001). Valve repair or replacement did not affect long term General Surgery Registrar, Sheffield survival, p-value 0.155. Overall 5-year and 10-year survival for all patients was 82.7%, and 78.5% respectively. Conclusions: Both mitral valve repair and replacement carry similar long term outcomes regarding survival. However CHF, dysrhythmia, and renal failure carry worse prognosis and should be actively managed preoperatively especially in elective cases. CASE REPORTS
0135 ASiT Honorary Treasurer SUB-TOTAL SCALP RECONSTRUCTION AND CRANIOPLASTY FOR LARGE COMPLEX CALVARIAL DEFECTS; A CASE REPORT Vascular Surgery Registrar, West Midlands James Russell1, David Izadi2, Paul Wilson2 1 University of Bristol, Bristol, UK, 2 Frenchay Hospital, Bristol, UK Background: Reconstructive surgery of the scalp and cranium aims to establish both normal function and aesthetic outcome after disfigurement. Following excision of a basal cell carcinoma with bony involvement, an acrylic cranioplasty is often used to restore the bony defect. This is subsequently covered with an appropriate flap. Method: We present the caseJames Milburn who underwent resection of a large basal cell carcinoma involving the parietal of an 82-year old woman region of the scalp and underlying bone. This was reconstructed using a novel method of acrylic cranioplasty and coverage of the ASiT Vice-President defect using a single anterior-based transposition flap. General Surgery Registrar, Inverness Results: The use of local flaps generally leaves a dog-ear at the base of the pedicle. In this case, the dog-ear is planned for removal at two months post-surgery to achieve a satisfactory aesthetic outcome. There were no other complications at six weeks. Conclusions: We have presented a modification to a well-known cranioplasty technique and the planning and demonstration of a subtotal scalp reconstruction. Whilst recent reports have emphasised the use of free tissue transfer for large scalp defects, this example demonstrates the effectiveness of local flap techniques. This reduces surgical time and donor-site morbidity in the elderly or otherwise infirm patient. 0181 ASiT Vice-President ATROPINE SULPHATE: RESCUE THERAPY FOR FAILED PYLOROMYOTOMY Vascular Surgery Registrar, London Richard Owen1, Sarah Almond2, Gill Humphrey2 1 Leighton Hospital, Crewe, UK 2 Royal Manchester Children's Hospital, Manchester, UK Infantile hypertrophic pyloric stenosis (IHPS) is a common condition which presents with non-bilious vomiting and failure to thrive secondary to gastric outlet obstruction. In the UK, management is by fluid resuscitation followed by pyloromyotomy. Incomplete myotomy complicates 0.3% of cases necessitating further surgery and exposing the patient to further risk. Steve Hornby Medical management of IHPS with antimuscarinics to promote pyloric relaxation is a well described treatment modality that is used as ASiT Director of Education first line therapy in some countries. The use of this technique is limited by the need for extended hospital admission with parenteral nutrition administration. General Surgery Registrar, South West Peninsula We describe a case of IHPS complicated by incomplete pyloromyotomy and subsequently managed successfully by atropine sulphate therapy. To our knowledge, there are no published data reporting this novel application antimuscarinic therapy. We have found atropine to be an effective rescue therapy in this circumstance, leading to rapid resolution of symptoms without the risks of early surgical re-exploration. 0247 AUTOLOGOUS RECONSTRUCTION OF ADULT AURICULAR DEFECT WITH PRELAMINATED FREE COMPLEX Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor RADIAL FOREARM FLAP: ANAndrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Mr EXAMPLE OF A TISSUE ENGINEERED FLAP Jim Zhong, Ken Stewart University of Edinburgh, Edinburgh, UK A 45 year old man suffered ato the amputation of the ASiT and alkali burns to his face following a traumatic accident in a factory. With thanks subtotal wonderful left ear Conference Admin team: info@asit.org Conventional methods could not be used due to extensive scarring to his scalp. A reconstruction with ipsilateral costal cartilage cov-
Robert Davies
Joseph Shalhoub
Laura Andrews
Kristina Gloufchev
Harriet Innes
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ered with a free radial forearm fascial flap and a split thickness skin graft harvested from the scalp was undertaken, followed by release of the reconstructed ear and elevation with a combination of a further cartilage graft, the deep temporal fascia and a further split skin graft. Infection to the cartilage, after partial flap necrosis, resulted in a less than desirable aesthetic appearance of the ear which prompted further revision. The second attempt used a tissue expanded prelaminated flap (TEPLF) in the right forearm. This was microsurgically moved to his head as a free tissue transfer 6 months later. After 4 years of multiple operations and revisions the overall outcome was satisfactory. This highlights the importance of tissue expansion in flap prefabrication, a developing technique, as issues such as thick skin encountered in previous cases of prelaminated flaps are addressed. TEPLFs may be valuable for ear reconstruction when local skin is not available or viable. 0263 AN ATYPICAL CAUSE OF LEG SWELLING Suchira Sarkar, Andrew Sandison East Sussex NHS Trust, Eastbourne, UK Infected popliteal artery aneurysms are unusual. Mycobacterium malmoense is an atypical mycobacterium that has not been described previously as a cause of aneurysm formation.150 isolates a year in England, Wales and Northern Ireland are made of this organism and 90% of these come from the lungs, 65% from males and 85% from patients aged 45 years or older. If pathogenic, it usually causes lung disease and can also cause cervical lymphadenopathy. There are isolated reports about joint infection and tenosynovitis. In the 1980's it was most often reported in immune-compromised individuals. Currently patients most susceptible are those suffering with chronic respiratory illness followed by cancer. In this case report we describe the clinical presentation, investigations and management of a 74 year old Caucasian gentleman who presented with a aneurysm of the popliteal artery secondary to Mycobacterium malmoense. This is the first reported case of a mycotic popliteal aneurysm secondary to Mycobacterium malmoense. We have reviewed the literature and highlight the change in profile of pathogens causing infected aneurysms. In the future with an increasingly aging and immune-compromised population infected aneurysms must be considered in the diagnosis of a pulsatile swelling.
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0480 RAPUNZEL SYNDROME MIMICKING APPENDICITIS Josef Taylor, Frank McDermott, Matthew Bowles Derriford Hospital, Plymouth, Devon, UK Case: We present the case of a 12-year-old girl with a trichobezoar extending into the terminal ileum presenting with right iliac fossa pain (RIF). The patient had a complex social background and had been diagnosed with anorexia nervosa. At presentation she was tender in the RIF with raised inflammatory markers. Open appendicectomy revealed a normal appendix but firm intestinal contents from the stomach to the terminal ileum. Enterotomy revealed a trichobezoar which was removed via the enterotomy and a gastrotomy. Background: Trichobezoars are rare and caused by the ingestion of the patient's own hair. They are nearly always found in female adolescents with psychiatric problems and present with oesophago-gastric obstruction. On the very rare occasions when the bezoar extends into the small bowel it is termed Rapunzel syndrome'. This has a wider scope of presentation including obstruction, pancreatitis, perforation, intussusception and appendicitis. Diagnosis is based on clinical suspicion with characteristic radiology. Treatment is endoscopic, laparoscopic or by laparotomy. Prevention is by cutting hair short and treatment of the underlying trichophagia. Antidepressants have been used with success. Conclusion: Trichophagia causing Rapunzel syndrome is a differential to be borne in mind in young female psychiatric patients presenting with abdominal symptoms. 0512 SPINAL CORD ISCHEMIA FOLLOWING TRAUMA TO AN AXILLARY-BIFEMORAL SYNTHETIC GRAFT Sayinthen Vivekanantham, Gokulan Phoenix, Saroj Das Imperial College London, London, UK Introduction: Although rare, spinal cord ischemia (SCI) is a devastating complication of post-vascular surgery with consequences including paralysis and even death. We present a case of spinal cord ischemia following compromise to an axilla-bifemoral graft- a previously unpublished finding. Case study: A 55-year-old female with a background of peripheral vascular disease, hypertension and insulin-dependent diabetes underwent a femoral-femoral graft in 2000. She re-presented 11-years later to the vascular services with symptoms of bilateral intermittent claudication. Following the discovery of an occluded graft, an elective left axilla-bifemoral bypass with Dacron was performed. The patient was discharged following an uneventful post-operative stay. However, immediate re-admittance was necessary due to graft haemorrhage following accidental blunt trauma to the left axilla. The patient went on to develop sensory and motor loss below the level of T11 associated with bladder and bowel dysfunction. A MRI Spine was suggestive of SCI. Clinical and investigative findings resulted in thrombectomies of graft, superficial femoral and profundus femoris arteries. Two months post-insult, the patient has regained good sensory and motor function through intense rehabilitation. Discussion: Early surgical intervention and rehabilitation had prevented permanent paralysis in a patient with SCI secondary to transient arterial hypotension caused by graft haemorrhage.
0525 SUSTAINED BILATERAL MIDDLE EAR EFFUSIONS POST ORTHOGNATHIC SURGERY SUCCESSFULLY TREATED WITH GROMMET INSERTION: A CASE REPORT Ashwin Algudkar, Bernard Lim, Kathleen Fan, Robert Bentley King's College Hospital, London, UK A 22-year-old woman underwent a Le Fort I maxillary osteotomy to correct a class III malocclusion. Post surgery the patient commented on reduced hearing in both ears. On examination both tympanic membranes appeared congested suggestive of middle ear tives: effusions. Nasendoscopy showed rhinitic nasal mucosa. Pure tone audiometry (PTA) revealed mild bilateral conductive hearing loss edd, Bangor with tympanometry revealing flattened (type B) traces on both sides confirming bilateral middle ear effusions. The patient al of Wales, Cardiff underwent bilateral grommet insertion under general anaesthetic approximately 30 months after the onset of her auditory symptoms. She was also commenced on nasal steroids to treat her rhinitis. The patient was reviewed back in clinic 6 weeks after grommet insertion. Her hearing had returned to normal and this was confirmed on PTA. Orthognathic m: info@asit.org surgery is known to cause auditory system dysfunction but in most cases this is short term and does not require intervention. This is thought to be due to post-operative oedema, haematoma and changes in the musculature around the Eustachian tube.
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To our knowledge there are no reports of auditory dysfunction persisting 2 years after orthognathic surgery. In this case the patients rhinitis may have contributed to sustained Eustachian tube dysfunction leading to middle ear effusions. 0532 SAPHENOUS PATCH GRAFT OF A RUPTURED, NON-ANEURYSMAL, ABDOMINAL AORTA Thomas Brogden Institute of Naval Medicine, Gosport, Hampshire, UK Goldie Khera Aim: The aim is to report a rare case of a non-aneurysmal ruptured abdominal aorta, presumed mycotic, in a 44 year old male and its novel management to allow the dissemination of surgical experience. ASiT President Method: A case of a ruptured non-aneurysmal aorta which was thought to be mycotic was encountered as an emergency and repaired using a long saphenous vein Bariatric Fellow, Northalong with the repair technique is presented and the current literature re(LSV) patch graft. The case, Tyneside viewed. Results: No similar cases were identified in the literature as were no reports of similar patch grafts of aortas using LSV. With no similar cases the evidence for management of mycotic disease was reviewed in terms of mycotic aneurysm management, for the nonaneurysmal aspect literature on perforating atherosclerotic ulcers was examined. A general consensus of literature supports endovascular repair in both situations (if only for temporising), however, the key limitation is lack of evidence for longevity with endovascular techniques. Ed Fitzgerald Conclusion: With lacking evidence for repair techniques in non-aneurysmal aortic ruptures in young patients the LSV patch is a surgiASiT Conference months requiring Past-President cal option. In the case presented a leak occurred after 2Organiser & further intervention. This complication should be noted when confronted with similar situations. General Surgery Registrar, London 0548 TORSION OF A WANDERING SPLEEN: A CASE REPORT Swethan Alagaratnam, Andrew Choong, Kevin Lotzof, Richard Bird Department of Vascular Surgery, Barnet General Hospital, London., London, UK Aim: We describe the complications of a wandering spleen which is the abnormal positioning of the spleen away from the left upper Jonny Wild quadrant. Methods: Retrospective case ASiT Honorary Secretary & Sponsorship Co-ordinator report. Results: We describe the case of a 29 year old lady, initially presenting with a 1 year history of chronic upper abdominal pain. OutpaGeneral Surgery Registrar, Sheffield tient investigations included ultrasound and CT imaging of her abdomen which confirmed the presence of a wandering spleen which was centrally located. Upper gastrointestinal endoscopy identified Helicobacter pylori gastritis, and she was treated with appropriate eradication therapy leading to resolution of symptoms, and therefore discharged. 1 year following discharge from clinic, she presented to A&E with acute exacerbation of the upper abdominal pain and became septic during the admission. CT imaging demonstrated fat stranding around an enlarged spleen with a suspicion of an underlying splenic volvulus. An urgent laparotomy confirmed the findings of an engorged and gangrenous spleen with a 720o torsion of the splenic pedicle, and therefore a splenectomy was performed. Following an uneventful post operative course and four months post discharge, she is now symptom free. Robert Davies Conclusion: Elective splenopexy should be offered for patients identified to have a wandering spleen due to the high risk of complicaASiT Honorary Treasurer tions associated with conservative management. 0587 A PREVIOUSLY UNDOCUMENTED COMPLICATION OF AUTOLOGOUS CHONDROCYTE IMPLANTATION Anja Saso1, Parag Raval1, Ben Caesar2, Andrew Williams2 1 Imperial College, London, UK 2 Chelsea and Westminster Hospital, London, UK There is currently no gold-standard surgical treatment for isolated and full-thickness cartilaginous damage to the knee joint. Such an injury can cause considerableJames Milburn morbidity, diminish quality of life and potentially lead to joint degeneration and osteoarthritis, with associated pain and loss of function. Autologous Chondrocyte Implantation (ACI) is an increasingly popular surgical intervention. This is a ASiT Vice-President two-stage procedure whereby healthy autologous cartilage is first harvested from a less weight-bearing area of the articular surface. In General Surgery Registrar, Inverness vitro-derived chondrocytes are subsequently injected as a suspension into the defect area, using a variety of existing methods. Systematic analysis of the efficacy and safety of ACI interventions has been limited. Indeed, detailed literature reviews of the incidence and nature of poor ACI outcomes have only begun to emerge recently. There is nothing in the literature, to date, associating avascular necrosis (AVN) of the knee with ACI. We report the case of a middle-aged gentleman who, several years after ACI surgery to the right knee, developed changes within the femoral condyle suggestive of AVN. Subsequent management included restoration of the articular surface using a contoured articular resurfacing implant. Therefore, we propose that AVN of the knee should be considered as another potential complication of ACI. Joseph Shalhoub 0632 Vascular Surgery Registrar, London A RARE CASE OF OTORRHOEA CAUSED BY A TRAUMATIC PAROTO-AURAL FISTULA Mathuri Sakthithasan, Assia Ghani, Chris Ayshford Worcester Royal Hospital, Worcester, UK Aim: We present an extremely rare case 57 year old man with left gustatory otorrhoea secondary to a traumatic external auditory meatus (EAM) salivary fistula and describe a novel management technique not previously reported in the literature Method: We reviewed the patient's notes and clinical investigations, and performed a literature search of traumatic EAM salivary fistula Steve Hornby and its management. ASiT Director of Education Results: The patient presented with left sided gustatory otorrhoea following a facial injury 18 months previously. Biochemical analysis of the otorrhoea fluid was strongly positive for amylase. A superficial parotidectomy Peninsula used and intra-operatively he was General Surgery Registrar, South West approach was found to have a paroto-aural fistula caused by complete dissociation of the tympanic bone from the EAM cartilage. A Sternocleidomastoid (SCM) flap was interposed to interrupt the communication between the parotid gland and the ear cartilage. The patient had immediate and sustained resolution of otorrhoea Conclusion: EAM salivary fistula are extremely rare. Management strategies can vary and range from ligation of the parotid duct to total parotidectomy. SCM flap interposition is a ASiT Welsh Regional effective. With thanks to the local novel technique that is simple and Representatives:
Vascular Surgery Registrar, West Midlands
ASiT Vice-President
Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor 0775 HOW TO LOCATE AND TREAT LYMPHClinicalA NOVEL METHOD USING PATENT BLUE V DYE of Wales, Cardiff Mr Andrew Beamish, LEAKS: Research Fellow, University Hospital AND FLOSEAL Andrew Choong1, Swethan Alagaratnam1, Georgios Akritidis1, David Floyd2, Muhammed Al-Dubaisi3, Alexander Loh1 1 Department of Vascular Surgery, Barnet General Hospital, London, UK, 2 Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK, With thanks to the wonderful ASiT Conference Admin team: info@asit.org 3 Department of Breast Surgery, Barnet General Hospital, London, UK Laura Andrews Kristina Gloufchev Harriet Innes
am 2012
Aim: Lymph leaks following vascular groin dissections are a challenging postoperative complication for both patient and surgeon. A multidisciplinary team consisting of breast, plastics and vascular surgeons present this method for managing lymph leaks. Method: A 35 year old man developed a lymph leak following left sided varicose vein surgery involving a traditional sapheno-femoral junction high tie and great saphenous vein stripping. The leak did not resolve following a trial of conservative management and reexploration of the groin incision. Our technique involved injecting 1ml of patent blue V dye intra-dermally into the 1st dorsal web space of the left foot. Manual calf compression was undertaken whilst carefully observing the groin, and the site of the leak was ligated when the dye was seen appearing. Calf compression was repeated to confirm ligation of the leak site. The groin cavity was then filled with Floseal and the groin then closed in 2 layers. Results: The leak settled post procedure and on four months follow-up, the lymph leak had completely resolved. Conclusions: To our knowledge, this is the first description of using this technique which is simple and easily reproducible for patients with complicated lymph leaks refractory to conventional therapy.
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0965 A CASE OF CHEMICAL ASSAULT IN HONG KONG (CASE REPORT) Billy Ching Leung, Andrew Burd Barts and The London, London, UK Aim: To raise awareness of the unique protocol developed in Hong Kong for acute management of acid assault burns Background: In Hong Kong, acid-assaults are more common compared to other developed countries. A unique protocol had been developed to deal with the immediate injury. Case: A 16-year-old girl was assaulted by her ex-boyfriend. She suffered an 8% TBSA burn to her face, upper-limbs and back. Immediate lavage was commenced at the local hospital prior to transfer to the Burn Centre in PWH. She was immediately transfered to theatres for shaving of her burns to punctate bleeding. She then underwent 48-hours of saline-soaks with 2-hourly changes prior to definitive treatment of grafting. Discussion: Conventional strategies involved persistent lavage for 2-3 days, followed by delayed shaving and grafting. Outcomes often poor with disproportionate need for reconstructive procedures compared to thermal burns. Since introducing the new protocol 3-years ago, outcomes have improved and can be quantitatively assessed in terms of decreased reconstructive need. Conclusion: The benefits of the urgent reduction in chemical load is intuitively obvious and by shaving only to punctuate bleeding vital tissue is not removed. Whether trying to prove benefit in terms of an RCT is now ethically questionable. 1050 ABERNETHY MALFORMATION WITH DUPLICATE GALLBLADDER, POLYSPLENIA AND MALROTATION OF THE GUT Martin Nnaji, Haritharan Nageswaran, Paul Burn, Christopher Vickery Taunton and Somerset NHS Foundation Trust, Taunton, Somerset, UK Background: Congenital extrahepatic portosystemic shunt - the Abernethy malformation - is a rare anomaly. We present a 26 year old male with right upper quadrant pain also found to have an absent portal vein, double gallbladder, double spleen, right-sided pancreas and malrotation of the gut. Method: A search was made on Pubmed for literature on Abernethy malformation and these were examined for associated abnormalities similar to those found in our patient. Results: Abernethy malformation is extremely rare. Type I describes a complete absence of the portal vein as in our patient but is more common in females. It is also associated with other abnormalities including polysplenia, cardiac anomalies as well as malrotation . Type II is commoner in males, describing a partial shunt and rarely associated with other malformations. Hepatic neoplasms are a common finding in patients with CEPS. No case with associated double gall bladder was described. After routine imaging, no definite cause for the patient's abdominal pain was found. However, several liver lesions were noted and are currently being investigated. Conclusion: A very rare case of Abernethy malformation with associated polysplenia, malrotation and we report, to our knowledge, the first instance of an associated double gallbadder. 1089 A TRANS-RECTAL, RETROPERITONEAL PARA-AORTIC LYMPH NODE DISSECTION USING NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES) IN A PORCINE MODEL AM Howell, MH Sodergren, J Clark, D Noonan, J Teare, GZ Yang, A Darzi Imperial College, London, UK Background: Retroperitoneal lymph node dissection is employed in high-risk clinical stage 1 nonseminomatous germ-cell tumours to detect metastases. Current methods include open and laparoscopic approaches. Transvaginal NOTES para-aortic lymphadenectomy for gynaecological malignancy has been described. We present a novel trans-rectal approach. Methods: Under ethical approval and home office license, a para-aortic lymphadenectomy was performed in an anaesthetised 55kg pig in the supine position. A rectal port was placed and the retroperitoneum was accessed through a 2inch incision in the posterior rectal wall using a flexible endoscope. The retroperitoneal space was opened using blunt dissection and CO2 insufflation. The right kidney, right renal vein and inferior vena cava were easily identified. A para-aortic lymph node was removed using conventional flexible endoscopic instruments. Results: A para-aortic lymph node was successfully excised and the histology was confirmed microscopically. Operating time was 27mins without injury to other structures encountered. Subjectively, access was straightforward and the retroperitoneal structures clearly visualised. The animal was euthanized at the end as per the experimental protocol. Conclusion: It is feasible to obtain para-aortic lymph nodes using a trans-rectal, retroperitoneal NOTES approach in the porcine model. This approach could provide an alternative diagnostic option for patients with suspected retroperitoneal pathology. COLOPROCTOLOGY
0019 MEASURING THE QUALITY OF COLONOSCOPY AT A DISTRICT GENERAL HOSPITAL IN SOUTH EAST ENGLAND: ADENOMA DETECTION RATES AND WITHDRAWAL TIMES edd, Bangor Roland Fernandes, Lawrence Toquero, Devleen Mukherjee QEQM Hospital, Margate, UK al of Wales, Cardiff Aims: The aim of our audit was to ascertain the adenoma detection rate and withdrawal time in a district general hospital, to allow comparison with the national NHS guidelines and improve service development. Methods: m: info@asit.org Data was collected over a 5 month period commencing in June 2011. Data was excluded if the colonoscopy was part of surveillance or was a repeat colonoscopy. Correlation was made with subsequent histological findings.
tives:
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Results: Data was collected for 134 patients that met the eligibility criteria. The mean age of those undergoing colonoscopy was 71 years, (age range 49-88 years) The male to female ratio was 75:59. The majority of colonoscopies were performed by consultants 59%, with the remaining being performed by specialist nurses 17% and registrars 9%. The adenoma detection rate in our sample was 28%. The mean extubation time was 8 minutes. The adenoma detection rates were statistically higher for specialist nurses than both consultants and registrars ( p<0.005). Conclusions: Adenoma detection rates are important quality control markers for colonoscopy centres. In our sample, although the extubation times were in accordance with national guidelines, our adenoma detection rate was lower than expected. Our results also Goldie Khera provide further evidence in support of specialist nurse endoscopists.

ASiT President
0032 Bariatric Fellow, North Tyneside A META-ANALYSIS EXPLORING THE ROLE OF FLAVONOIDS AFTER HAEMORRHOIDECTOMIES Jenny Simper, Muhammed Siddiqui, Khalid Khalifa, Said Mohamed, Al-Mutaz Abulafi, Ian Swift Croydon Hospital, London, UK Aims: A meta-analysis of published literature examining the role of flavonoids in the post-haemorrhoidectomy period. Methods: Electronic databases were searched from January 1985 to October 2011. A meta-analysis was performed to obtain a summative outcome. Results: Eight studies involving 695 patients were analyzed. 347 patients were in the flavonoid group and 348 in the placebo group. Ed Fitzgerald There was no significant difference in pain at day 1 [random effects model: SMD=-1.07, 95% CI(-2.45, 0.32), z=1.51, p=0.13]. Pain ASiT Conference Organiser 95% CI(-2.10, -0.23), z=2.45, p=0.01] and approached signifiwas less after flavonoids on day 2 [random effects model: SMD=-1.17,& Past-President cance on day 3 [random effects model: SMD=-1.90, 95% CI(-3.84, 0.05), z=1.91, p=0.06]. Pruritis symptoms were less in the flavonoid General Surgery Registrar, London group up to 10 days after the operation [random effects model: SMD=-1.98, 95% CI(-3.81, -0.16), z=2.13, p=0.03]. There was some slight reduction in bleeding after flavonoids up to 10 days post-operatively [fixed effects model: SMD=-1.01, 95% CI(-1.46, -0.57), z=4.49, p=0.00001]. There was conflicting data on hospital stay. Conclusions: Flavanoids after haemorrhoidectomy may reduce pain, symptoms of pruritis and minor bleeding in the early postoperative period. Further randomized controlled trials especially after newer techniques for treating haemorrhoids.
Jonny Wild 0043 PREDICTING A PERFORATION INHonorary SecretaryTHE USE OF TOTAL Co-ordinator ASiT ACUTE APPENDICITIS - & Sponsorship BILIRUBIN LEVELS, CRP, WHITE CELL COUNT AND NEUTROPHILS General Surgery Registrar, Sheffield David McGowan1, Helen Sims1, Khawaja Zia2, Moktah Uheba2, Irshad Shaikh3 1 Brighton and Sussex Medical School, Brighton, East Sussex, UK, 2 Brighton and Sussex University Hospitals NHS Trust, Brighton, East Sussex, UK, 3 East Kent Hospitals NHS Foundation Trust, Canterbury, Kent, UK Aims: Identifying a perforated appendix early could reduce the impact this has on the patient. Bilirubin, CRP and white cell count have been shown to indicate perforation in acute appendicitis. Methods: A retrospective cohort study of Davies Robert appendicectomies investigating pre-operative bilirubin, C-reactive protein (CRP), White cell count (WCC), and neutrophil count and correlating these results with the histological investigation of perforation. Results: 1271 patients were ASiT Honorary Treasurer found to have appendicitis, 154 (12.12%) of which had a perforation. All biochemical markers were significantly raised in perforationVascularThe sensitivity and specificity of a Midlands (94.4% and 31.8%) and bilirubin (62.5% and (p<0.001). Surgery Registrar, West raised CRP 88.3%) were improved when results were combined as CRP >5 mg/L and bilirubin >21 mol/L - sensitivity = 60.5%, specificity = 91.6%. Sensitivity and specificity were reduced by incorporating WCC and neutrophils. Logistic regression analysis identified CRP as the most sensitive marker of perforation (OR = 1.064 (1.043-1.085)) (p<0.001), with bilirubin (OR= 1.005 (1.003-1.008)) also significant (p<0.001). Conclusions: Bilirubin and CRP are markers of perforation in appendicitis but are not accurate enough to be used diagnostically. In a patient with high clinical suspicion of acute appendicitis, raised CRP and bilirubin as tests are specific for a perforation, but are not James Milburn sensitive.
0047 General Surgery Registrar, Inverness COLONOSCOPIC TATTOOING OF COLORECTAL NEOPLASIA A CHANGE IN PRACTICE Jonathan Clarke, Adela Brigic, Adam Haycock, Siwan Thomas-Gibson St. Mark's Hospital and Academic Institute, London, UK Background: In concordance with the national guidelines, the St. Marks Hospital colonoscopic tattooing protocol stated that suspicious lesions should be tattooed, with the exception of those in the caecum and within 20 cm of the anal verge. Three tattoos should be placed (120 apart, close to the lesion) and distal to lesions proximal to the splenic flexure (SpFlx). Left sided lesions should have tattoos placed proximal to the Joseph Shalhoub lesion. Aims: To audit compliance with the tattooing protocol in patients undergoing surgery for colorectal neoplasia. ASiT Vice-President Methods: We reviewed endoscopy reports for the location of tattoos relative to the lesion and number of tattoos placed in all patients Vascular Surgery Registrar, London who had surgery over 12 months. Results: 114 reports were available and full compliance with the protocol was observed in 71 cases (62%). 19 cases (17%) were partially compliant and 24 cases (21%) were non-compliant. Incomplete documentation (22 cases) and inability to place tattoos proximal to obstructing lesions (19 cases) were the major causes of reduced compliance. Conclusions: Educational intervention is necessary to address poor documentation. However, changes to our protocol are also required. The new protocol recommends that all tattoos should be placed distal to the lesion, regardless of the anatomical position.
ASiT Vice-President
ASiT Director of Education 0051 DOES RIGID SIGMOIDOSCOPY HAVE A PLACE INRegistrar, South West Peninsula General Surgery THE MODERN OUTPATIENT COLORECTAL CLINIC? Mouhamed E El Sayad, Abidon Bamidele, Kawan Shalli, Emad Aly Aberdeen Royal Infirmary, Aberdeen, UK Background:Although flexible sigmoidoscopy is now used in most outpatient colorectal clinics, rigid sigmoidoscopy is still used in many other (OP) colorectal clinics. The aim of our study is to assess the efficacy of rigid sigmoidoscopy. Methods:Retrospective review of thepatients that attended OP Colorectal clinic who had undergone rigid sigmoidoscopy for colorecWith thanks to 103 local ASiT Welsh Regional Representatives: tal symptoms. Findings as well as requirement of further investigation were recorded. patients. Presenting symptoms were; change in bowel habit 47 (45.6%), PR Gwynedd, Bangor Results:103Miss Rhiannon Harries, General Surgery Registrar, Ysbytybleeding 33 (32%), rectal mass 8 (7.8%), Abdominal pain Andrew Beamish, Clinical Research Fellow, anaemia 1 (0.9%) and follow up patients 8 (7.8%). Finding Mr 4 (3.9%), faecal incontinence 1 (0.9%), tenesmus 1 (0.9%), University Hospital of Wales, Cardiff were; normal mucosa 62 (60.1%), inflamed mucosa 5 (4.9%), rectal polyp 2 (1.9%) and uninformative 34 (33.1%). Of the 103 patients, 68 (66%) required further investigations. 35 (34%) did not required further investigation. Amongst those who had a normal finding, on further investigation 16 (25%) had different pathologies. ASiT Conference Admin team: info@asit.org With thanks to the wonderful 3 (42%) out of 7 patients whom had abnormal finding on rigid sigmoidoscopy, no abnormality was detected on further investigation. Laura Andrews Kristina Gloufchev Harriet Innes
Steve Hornby
am 2012
Conclusions:Our study showed that rigid sigmoidoscopy was rarely useful in the OP clinic set up. Further investigations were almost always needed to complete the assessment of the patient.
0097 LYMPH NODE HARVEST IN COLORECTAL RESECTIONS: AN AUDIT AT A SOUTH-EAST ENGLAND COLORECTAL SURGERY UNIT COMPARING PERFORMANCE IN 2005 AND 2008 WITH ANALYSIS OF THE INFLUENCE OF KEY OPERATIVE FACTORS Khabab Osman, Catherine Pringle, Humphrey Scott Ashford & St Peter's NHS Trust, Chertsey, Surrey, UK Lymph node examination is vital in the staging of colorectal cancer and ultimately influencing decisions on post-operative management. The Association of Coloproctology of Great Britain and Ireland as well as the National Institute of Clinical Excellence recommend that at least 12 lymph nodes are examined per resection. Aim: This study assesses the performance of a large colorectal surgery unit in England against the above targets between 2005 and 2008 with an analysis of the influence of operator and patient variables. Method: A hospital database search was used to identify all patients who underwent colorectal cancer resections in the months of October in 2005 (n=51) and 2008 (n=69). Information was extracted manually from notes and computed. Results: A significant improvement was shown in lymph node clearance from 8.2 to 11.0 between 2005 and 2008 respectively (p=0.0019). No statistically significant difference between elective/emergency or open/laparoscopic resections was shown. The strongest improvement was found in open resections between 2005 & 2008 cohorts. Conclusion: The results of the study provide further cause to explore and discuss the reasons behind the apparent improvement in lymph node harvest and to determine the relative importance of surgical technique, histopathological techniques and other possible influential factors.
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0115 COLORECTAL RESECTIONS: EVALUATING SHORT TERM POSTOPERATIVE OUTCOMES IN LAPAROSCOPIC VERSUS OPEN SURGERY Ee Von Woon, Prem Ruben Jayaram, Pete Chong Universtiy of Glasgow, Glasgow, UK Introduction: Laparoscopic colectomies has become increasingly popular in the recent decade, however reluctance still exists to widely apply it for colorectal resections. This study aims to evaluate the postoperative outcomes of laparoscopic surgery(LS) compared to open surgery(OS) in our centre. Method: All patients who underwent colorectal resection from June 2010 to February 2011 were reviewed retrospectively from the hospital database. Parameters include length of postoperative stay, infective and non-infective complications. Result: Between June 2010 and February 2011, a total of 99 patients of median age 69(range 20-95) underwent colorectal resection. The most common indication was malignancy(66%). 56/99 cases were subjected to LS, and 43/99 to OS, with a number of 5 conversions. Median postoperative stay was 13 days. This was higher in OS(10) compared to LS(7). 45 positive cultures occurred in 31 patients. OS has a significantly higher(p=0.01) incidence of infection - 20/43(46.5%) patients compared to LS - 11/56(19.6%). Total non-infective complications was 29(29.3%). This difference was not significant between OS(14, 48.3%) and LS(15, 51.7%). Conclusion: LS demonstrated better postoperative outcomes compared to OS. As a result of this study, further reviews were conducted within the General Surgery department to explore the possibility of increasing usage of the laparoscopic method. 0118 THE ROLE OF FDG-PET CT IN COLORECTAL CANCER Sadaf Jafferbhoy, Adam Chambers, James Mander, Hugh Paterson Edinburgh Colorectal Unit, Edinburgh, UK Background: There is limited evidence to support the use of PET-CT in colorectal cancer. The aim of this study is to evaluate the clinical impact of PET scan in management of our patients. Methods: 1043 patients were identified from SCAN database over a 2 year period, from July 2009. 103 patients underwent a FGDPET CT in addition to conventional imaging. In this retrospective study, PET CT findings were compared with CT findings and the clinical impact was evaluated. Results: 27 patients (26.2%) had PET CT for pre-operative staging and 76 patients (73.7%) for disease surveillance.Based on PET findings, the management was altered in 21(77.7%) patients in pre-operative group with indeterminate CT findings. In the follow-up group,PET had a significant impact on management of 51 patients (67.1%), of which 39 had indeterminate CT findings.6 patients with a negative CT had recurrent disease and another 6 patients with resectable disease on CT had unresectable metastases on PET. On the basis of PET CT, surgery was avoided in 32 cases (31%) and 32 patients(31%) were offered curative resection. Conclusion: PET CT plays a significant role in management of colorectal cancer by avoiding unnecessary surgery or identifying recurrent disease at an early stage.
0161 AUDIT OF CT COLONOGRAPHY: DOES IT ANSWER OUR QUESTIONS? Aaron Rooney, Ananth Vijendren, Marion Obichere Luton and Dunstable NHS Foundation Trust, Bedfordshire, UK Aim: CT Colonography (CTC) is being increasingly used instead of colonoscopy as it is less invasive and detects extra-colonic abnormalities. It has 94.9% sensitivity and 99.7% negative predictive value for colorectal cancer. As it is frequently used in our hospital, we aim to assess a) Appropriateness of requests, b) Bowel preparation adequacy, c) Effectiveness in identifying abnormalities, d) Diagnostic value, e) Possible use as a screening tool and/or gold standard investigation Methods: All CTCs from 1.1.2011-31.7.2011 were identified. Data was collected on age, gender, responsible consultant, presenting complaint, bowel preparation, colonic and extra-colonic findings, other investigations and final diagnosis. Results: Most of the 182 CTCs performed were requested by colorectal surgeons and gastroenterologists. A minority were unsuitably tives: used to investigate anaemia and PR bleeding. Bowel preparation was adequate in 75% of CTCs, affecting diagnostic value in 3 cases. edd, Bangor Colonic abnormalities were detected in 50% of cases, extra-colonic in 67% and diagnosis reached in 70%. It had 100% sensitivity and 50% specificity for colorectal cancers and 94% sensitivity for diverticular disease. al of Wales, Cardiff Conclusion: CTCs have high sensitivity and low specificity as evidenced by NICE. We have recommended it as a screening tool and have altered the bowel preparation guidelines, and online CTC request forms to improve efficacy.
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0179 A CASE SERIES OF ENCAPSULATING PERITONEAL SCLEROSIS - A SINGLE-CENTRE EXPERIENCE Robert Spence, Keith Gardiner Royal Victoria Hospital, Belfast, Northern Ireland, UK Aim: Encapsulating peritoneal sclerosis (EPS) is a rare, life-threatening condition. It is characterised by a progressive, intra-abdominal inflammatory process resulting in fibrous tissue constricting viscera. We report the aetiology, management, and outcome of EPS in Belfast. Goldie Khera Method: All patients diagnosed with EPS in Belfast over the past 5 years are included. Presentation, aetiology, imaging, pathology, and outcome are reported. ASiT President Results: 7 patients were identified with EPS. 4 males, 3 females; mean age 53.6 years (range 33-69). Aetiology included peritoneal dialysis (3), radiation enteritisBariatric Fellow, North Tyneside (1), peritoneal dialysis and radiation enteritis (1), tuberculosis, cirrhosis, and beta-blocker use (1), infected aortobifemoral graft (1). Of the 7 patients, 5 underwent surgery. Median pre-operative and post-operative hospital stay: 25 and 62 days respectively. 3 patients required total parental nutrition (TPN) pre-operatively, 3 patients post-operatively; with 4 of the 7 patients discharged on TPN. 5 out of 7 (71.4%) patients are alive at median follow-up of 24 months. There was no 30-day in-hospital mortality. Conclusions: Patients often require nutritional support before and after surgery. Peritoneal dialysis is a major risk factor for developing EPS but other aetiologies should be considered. These patients are complex and best managed in a specialised unit with access to Ed Fitzgerald nutritional support.
0198 General Surgery Registrar, London LONG-TERM SURVIVAL OF PATIENTS WHO UNDERWENT PALLIATIVE STENTING FOR OBSTRUCTING COLONIC CANCERS A Gungadeen, NL Wong, FG Bergin, SM Plusa, JM Hanson, JY Graham, HJ Gallagher Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK Aims: Stenting has been shown to be effective in relieving obstruction by colonic cancers. This study was designed to analyse the long -term survival of patients who underwent such stenting as a palliative measure. Methods: Single-centre prospective data was collected from 2003 to 2011. Information about the procedure was obtained from patient case notes and only patients Jonny Wild who underwent colonic stents as a palliative measure for obstructing cancers were included. Dates of death were retrieved from a national database, and post-stenting survival was calculated and analysed by age groups. ASiT Honorary Secretary & Sponsorship Co-ordinator Results: A total 130 colonic stents were performed. 81 patients (31 female and 50 male, median age of 72) underwent palliative stentGeneral Surgery months (range 0.1-68 months). 14 patients were alive at the time of the study. ing. The median post-stent insertion survival was 7.6Registrar, Sheffield Older age groups and females had lower median survival in this study. Conclusions: Colonic stents are associated with good long-term survival and are a good option to relieve malignant colonic obstruction. Older patients have lower survival rates post-stenting, probably owing to increased frailty and co-morbidities. It would be helpful to compare the survival of stented patients with those who undergo surgery to palliate acute obstruction. 0225 Robert Davies EARLY STOMA CLOSURE FOLLOWING DEFUNCTIONING FOR LOW ANTERIOR RESECTION - A FEASIBILITY STUDY ASiT Vimalachandran, C McFaul M Elmasry, N Eardley, M Johnson, D Honorary Treasurer The Countess of Chester hospital, Chester, UK Vascular Surgery Registrar, West Midlands Aim: To determine the feasibility of performing an early contrast enema, and then close the stoma as soon as possible without causing excessive morbidity/mortality. Methods: Prospective 1 year study (June 2010-June2011).All patients having a low anterior resection with defunctioning stoma had a contrast enema requested for 4 weeks following surgery, and if no leak listed for early closure. Primary end points: time to contrast enema, time to stoma closure, morbidity, mortality, delay in starting adjuvant chemotherapy. Secondary end point: radiological leak rate James Milburn Results: 15 patients were included. Median time from resection to contrast enema: 29 days. 5 patients were not suitable for early closure (3 because of a radiological leak). 10 patients underwent early closure. Median time from resection to closure: 46 days in those ASiT Vice-President due to have adjuvant chemotherapy (n=4) and 67 days in those who did not need adjuvant chemotherapy (n=6). No morbidity/ General Surgery Registrar, Inverness mortality following stoma closure. Conclusion: We demonstrated a reduction in time to stoma closure with no short term morbidity/mortality. Costs of stoma care are estimated to be ~3000 per year and so reducing time to stoma closure may result in significant financial savings (~30000 in our small group). 0228 CHARACTERISATION OF INDETERMINATE HEPATIC LESIONS IN COLORECTAL CANCER Joseph Shalhoub Shelly Griffiths, Irshad Shaikh, Emily Tam, Henk Wegstapel ASiT Vice-President Medway Maritime Hospital, Kent, UK Background: Management of Vascular Surgery Registrar, London cancer (CRC) is challenging. Current NICE guidelines indeterminate hepatic nodules (IHN) in colorectal recommend referral to specialist units. We aimed to study whether certain patient and disease based factors can be used to give guidance with regards to further investigation, treatment and outcome of these lesions. Methods: Data was collected via a 2-year retrospective case-note review of 539 patients discussed locally with a confirmed diagnosis of CRC and IHN on CT scan. Results: 20 (3.7%) were found to have IHN. Of the 15 patients who had further imaging at the time of detection (USS, MRI, PET), it Steve Hornby was possible to determine the nature of 11 (73%) of these. Eight patients (40%) were later found to have malignant liver lesions (median follow-up 330 days). ASiT Director of Education nodule on initial detection and EMVI positive tumours, although Malignancy was more likely with a larger significance was not reached General Surgery Registrar, South West Peninsula (p<0.1). Conclusion: This study demonstrates the difficulties of determining the nature of IHN using either patient or tumour characteristics. Significant factors appear to be a larger nodule at detection and EMVI positive tumours. Further studies are needed to elucidate any possible factors relating to the nature of these lesions. 0235 With thanks to the local ASiT Welsh Regional Representatives: ONE-STOP COLORECTAL CLINICS: IS THIS THE WAY FORWARD? Miss Rhiannon Harries, Sayeed, Ruth Tipling, Registrar, Moustafa Mansour, Saadia Saqlain, Hannah General SurgeryKhalid Canna Ysbyty Gwynedd, Bangor Inverclyde Royal Hospital, Greenock, Scotland, UK Research Fellow, University Hospital of Wales, Cardiff Mr Andrew Beamish, Clinical Aim: It has been proven that earlier colorectal cancer detection is associated with better outcome. The aim of our study was to assess the outcome of our One-Stop Colorectal Clinic Service in terms of completion rates, incidence of positive findings and average number of visits from referral to diagnosis. With thanks to the wonderful ASiT Conference Admin team: info@asit.org Method: Retrospective data of patients referred to our One-Stop Colorectal Clinic was collected from January 2010 to December 2010.
ASiT Conference Organiser & Past-President
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
A standard pro-forma sheet was generated including patient's age, reason for referral, procedure done, quality of bowel preparation, completion to caecum, findings and final outcome. Results: 146 patients were reviewed. Caecal intubation was achieved in 127 patients (87%). 65 patients (45%) had no abnormality detected and were discharged after a single visit. 7 patients (5%) had colorectal cancer. 47 patients (33%) had benign polyps and further surveillance colonoscopy was arranged later according to pathology results. Conclusions: One-Stop Colorectal Clinics are potentially efficient and effective in reducing the number of visits from referral to diagnosis. This was reduced to one visit for those with normal colonoscopies and two visits for those diagnosed with cancers. Fewer visits are associated with more convenience and lower costs. Savings can be used to improve other aspects of the colorectal service provided.
0269 GASTROINTESTINAL STROMAL TUMOUR OF THE RECTUM: A REVIEW OF SURGICAL TREATMENT, OUTCOMES AND THE ROLE OF IMATINIB M.J. Wilkinson, J.E.F. Fitzgerald, D.C. Strauss, A.J. Hayes, J.M. Thomas The Royal Marsden Hospital NHS Foundation Trust, London, UK Aims: Gastrointestinal stromal tumours (GISTs) of the rectum are rare, accounting for only 0.1% of all rectal tumours. This study investigates the presentation, management and outcomes of rectal GISTs at a specialist unit. Methods: Retrospective cohort study analysing a prospectively maintained database at a tertiary referral centre from Jan 2001 - Jan 2012. Results: A total of 14 patients (6 female, 8 male), presented with a primary rectal GIST. Commonest presenting symptoms were rectal bleeding (n=6) and tenesmus (n=6). Median tumour size at presentation: 8cm (range 2 - 12cm). 12 patients received neoadjuvant imatinib; median reduction in tumour size 2.8cm (range 0.5 - 5.6cm); p = 0.001. Surgical resection was performed in 6 of the 14 patients (2 patients declined surgery and 6 are continuing imatinib to downsize). Complete macroscopic clearance was obtained in 100% of patients. On follow up, 12 patients are alive without metastases: median follow-up 31.3 months. There were 2 deaths from unrelated causes. The remaining 5 patients operated on are disease free (median DFS = 36.2 months). Conclusions: Biopsy is essential in establishing the diagnosis. Neoadjuvant imatinib substantially downsizes rectal GISTS which may permit less invasive surgery. Favourable outcomes can be achieved for rectal GISTs in specialist centres. 0283 A PROPOSED STANDARD FOR PRE-OPERATIVE LAPAROSCOPIC COLORECTAL CANCER RESECTION ENDOSCOPIC TATTOOING. IDENTIFICATION OF MODIFIABLE PRACTICES AT AN ENHANCED RECOVERY CANCER CENTRE Ajay Sud, Arkeliana Tase, Elinor Baker, Santanu Bhattacharjee, Shiva Dindyal, Stefano Andreani Whipps Cross University Hospital, London, UK Aims: The National Bowel Cancer Screening Program specifies a 100% target for tattooing of suspected malignant lesions. There remains no all-inclusive guideline for colorectal tattooing. We aim to identify factors contributing to suboptimal practice. Methods: The data collected incorporated retrospective analysis of all 144 colorectal surgery patients at Whipps Cross Hospital whom underwent oncological colorectal resections for ten months from January 2008 and six months from June 2010. Results: In 2008 and 2010, 39% and 52% respectively, of our patients received pre-operative tattooing. In 2008 and 2010, 30% and 50% respectively of lesions were only documented to be distally tattooed. The mean number of days between their pre-operative endoscopy to surgery in 2010 was 69 days. In 2008 consultant gastroenterologists tattooed 70% of suspect lesions, but by 2010 this reduced to 36%. Only 40% were underwent solely distal tattooing, and 22% of ulcerating lesions were tattooed. Conclusions: Surgeons are the direct recipients of suboptimal tattooing. They are best placed to lead the colonoscopy community to ensure efficacious tattooing practices, enabling optimal uncomplicated oncological resection. The standard for practice should be a recent distal 360-degree' tattoo with one vial per 30 degrees, to all suspicious lesions, irrespective to the endoscopic morphology. 0316 IROBOT - INITIALIZING A ROBOTIC COLORECTAL SERVICE Faira Eldriana Rizal, Benjamin Stubbs, P Mathur, Colin Elton, Daren Francis Department of Coloproctology, Barnet and Chase Farm Hospital, London, UK Aims: Robotic surgery has potential advantages in the difficult pelvis, however use in coloproctology has been limited. We describe our early experience. Methods: 3 colorectal surgeons gained certification as console surgeons on the da Vinci robot and a mentoring programme was undertaken with an experienced robotic colorectal surgeon. (2 anterior resections at the mentor's hospital followed by 2 ventral mesh rectopexies performed at our trust.) Data was collected prospectively on all cases performed over 1 year. Results: 12 robotic colorectal procedures were performed (6 ventral rectopexies, 5 anterior resections and 1 ultra-low Hartmann's). No intra-operative complications occurred, with one conversion to open surgery. Mean operative times were: mesh rectopexy 270 minutes (range 205-310), anterior resection 366 minutes (304-408) and Hartmann's 355 minutes. Mean length of stays were: ventral rectopexy 2 days (range 1-3), anterior resection 7.6 days (5-10) and Hartmann's was 8 days. 1 post-operative ileus occurred with no other postoperative complications. All patients with rectal cancer had good oncological clearance on histology. Conclusions: Initiation of a robotic colorectal service is a safe and feasible option within a supervised mentoring programme. We anticipate an improvement in operating time with increased experience, however further studies into economic viability are needed.
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0324 FAMILIAL ADENOMATOUS POLYPOSIS RELATED DESMOIDS PRESENTING WITH AIR-FLUID LEVEL A CLINICAL REVIEW AND MANAGEMENT ALGORITHM Santosh Bhandari, Pravin Ranchod, Ashish Sinha, Arun Gupta, Susan Clark, Robin Phillips St Mark's Hospital, Harrow, Middlesex, UK Aim:Familial adenomatous polyposis (FAP) related desmoid tumors (DT) can present with a liquefied centre containing gas, accompanied by abdominal pain and sepsis. We present our experience of managing these desmoids grouped together as intra-abdominal desmoids (IAD) with air-fluid level. Material and methods:Retrospective review of prospectively maintained polyposis registry database was conducted at a tertiary referral centre specializing in FAP and desmoid disease. tives: Results:A total of nine patients had an IAD with air-fluid level, seven were female. Age range at diagnosis was 20-41 years. The meedd, Bangor dian time taken from primary surgery to DT development was 24 months (range 0 48 months), and the median time for further progression al of Wales, Cardiff to air-fluid level was 24 months (range 0 226 months). DT size ranged from 10cm to greater than 20cm in diameter. Two patients were successfully managed with antibiotics alone, and two patients with percutaneous drainage and antibiotics. The other five patients required surgical intervention involving either excision or drainage with or without proximal defunctioning/exclusion. Conclusions:The majority of IAD patients with an air-fluid level require surgical intervention. Antibiotics and percutaneous drainage are m: info@asit.org only successful in a limited number of patients. We present our current treatment algorithm based on this experience.
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0362 LOCAL RECURRENCE (LR) RATES AFTER OPERABLE RECTAL CANCER SURGERY Robert Nadler, Daniel Brown, Sue Hignett, Carol Makin, Goldie Khera Wirral Hospital, Liverpool, UK Aims: LR rates following curative resection have been reported to be between 2.4 - 50% with LR rates hypothesised to be higher for abdominoperonial resection (APR) vs anterior resection (AR). We analysed our LR rates over an 11 year period Methods: Between 1999 and 2010, 312 patients with operable rectal cancer (<15cm from the anal verge) were followed up to deterGoldie Khera mine local or regional recurrence. Total Mesorectal Excision (TME) principles were adhered to, together with tailored neo and adjuvant chemo-radiotherapy protocols. ASiT President Results: Age range 38 - 98 years, 60% male, follow-up for up to 11 years. Rates of APR were 23%, AR 56% and Hartmann's 8%. Bariatric Fellow, North Tyneside Total LR rates were 5%. In those developing LR, distance from the anal verge was 2-15cm (median 6cm), with AR being performed as low as 3cm. The distant recurrence rates were 18%. Conclusions: Concerns have been raised in the Association of Coloproctology of Great Britain and Ireland guidelines regarding the plane of dissection and potentially higher recurrence rates in APR vs AR. Our study demonstrates however, that with the TME technique both APR and ultra-low AR can be performed with low LR, highlighting the importance of specialist rectal surgeons in cancer surgery.
Ed Fitzgerald 0384 ASiT Conference Organiser & Past-President LAPAROSCOPIC TECHNIQUES MAY MINIMIZE THE SHORT-TERM IMPACT OF REPEATED SURGICAL RESECTION IN THE MANAGEMENT OF CROHNS DISEASESurgery Registrar, London General Christopher Whitfield, Richard Slater Rotherham NHS Foundation Trust, Rotherham, UK Introduction: Multiple surgical resections may be necessary in chronic Crohns disease management. Laparoscopic techniques offer a minimally invasive approach. The 5-year experience of a Consultant Colorectal Surgeon in a District General Hospital is described. Short-term outcomes of elective laparoscopic procedures are emphasized. Methods: Patient and operative data were extracted from a prospective database for the period November 2007 to November 2011. Jonny Wild Results: 14 elective laparoscopic procedures were performed on 13 patients (7 male, 6 female) with Crohns disease. Median age was 42.8 years (range 17.3-68.9 years). The procedures comprised: Sponsorship Co-ordinator ASiT Honorary Secretary & 11 right-hemicolectomies, 1 sigmoid-colectomy and 2 ileostomy reversals. 5 were repeat resections for recurrent disease at the ileo-colic junction. Prior ileo-colic resection had occurred in 4 patients, General Surgery 2 patients). Sheffield (6 prior resections in 1 patient, 3 in 1 patient and 2 inRegistrar, Open conversion occurred in 1 patient, who had undergone a prior resection. One anastomotic leak (1/14, 7.1%) occurred, following primary right-hemicolectomy. Median length of stay in the resection group was 6.5 days (range 211 days). No post-operative deaths occurred. Conclusion: Laparoscopic techniques may be routinely applied to the surgical management of Crohns disease; this includes patients requiring repeated resections in chronic disease, without significant additional morbidity.
0454 Robert Davies PRACTICE OF ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOLS IN ELECTIVE COLORECTAL SURGERY: A ASiT Honorary Treasurer NATIONWIDE SURVEY Jamil Ahmed1, Sajid Mehmood2, M. JavaidSurgery Registrar, West Midlands Vascular Akbar2, Harris Iqbal1, Robbie Muir1 1 Surgical Department, Ayr University Hospital, Ayr, Ayrshire and Arran, UK 2 Academic Surgical Unit, Castle Hill Hospital, Hull, UK Aims: The aim of this survey was to evaluate the implementation and compliance to ERAS protocols in elective colorectal surgery across the United Kingdom. Methods: An anonymous electronic questionnaire survey was completed by 105 colorectal surgeons, active members of the Association of Coloproctology of Great Britain and Ireland. James colorectal surgeons who completed the survey, practise ERAS pathways routinely. To ensure Results: The majority (97%n=102) of the Milburn implementation of ERAS protocols, 90% (n=95) reported having a written local ERAS pathways, 29% (n=30) reported having both an ASiT Vice-President ERAS specialist nurse and an ERAS ward, while some 23%(n=24) had services of an ERAS nurse only. A fourth (27%n=28) of the General Surgery Registrar, Inverness respondents never audited compliance to ERAS protocols. When audited, 24% (n=25) reported above 80% compliance, 26%(n=27) between 70 to 80%, and 11%(n=12) stated below 70% compliance to ERAS protocols. The most commonly encountered problems, for implementation and compliance to ERAS protocols, were lack of management support and funding, and education and training of relevant staff. Conclusions: ERAS protocols are well established practice the UK. Education, training of staff and regular audit of practice, in addition to management and funding support, would further facilitate implementation and compliance to ERAS protocols 0496 ASiT Vice-President AUDIT OF LYMPH NODE HARVEST DURING BOWEL RESECTION FOR COLORECTAL CANCER Vascular Surgery Registrar, London Kersten Morgan-Bates, James Berwin, Santosh Kumar Somasundaram, Georgios Akritidis, Olagunju Ogunbiyi Royal Free hospital NHS Trust, London, UK Aims: To perform an audit of lymph node (LN) harvest, an independent prognostic factor for 5 year survival, during colorectal resections. The National Bowel Cancer Audit in 2010 identified that the median number of LNs excised with the specimen should be15 for colonic cancer and 13 for rectal cancer. Methods: Retrospective analysis of prospectively collected data was performed of all eligible patients between January 2010 and Steve Hornby August 2011 (20 months). ASiT Director of Education Results: A total of 177 patients were diagnosed with colorectal cancer during this study period. 72 patients were excluded for a variety of reasons, but predominantlyGeneral Surgery (47). Results from 105 patients Peninsula 93 patients had colon cancer resecfor metastatic disease Registrar, South West are reported. tions. 55 (59.1%) of these patients had more than 15 LNs excised with the specimen. LNs were positive in 43 (46.2%). 12 patients underwent surgery for rectal cancer. 9 (75%) of these patients had 13 or more lymph nodes excised with the specimen. LNs were positive in 4(33.3%). Conclusions: In a majority, the LN yield following colorectal resection at our centre was above the National average for rectal and colonic cancers in this study period, butlocal ASiT Welsh Regional Representatives: With thanks to the the surgical technique needs to improve for colonic resections and a re-audit performed.
Joseph Shalhoub
Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor 0540 LARGE BOWEL OBSTRUCTION CAN BE SAFELY TREATED Fellow, University Hospital - CASE SERIES FROM A UK Mr Andrew Beamish, Clinical Research BY COLONIC STENT INSERTION of Wales, Cardiff DISTRICT GENERAL HOSPITAL Paul Blake1, Ray Delicata2, Nicholas Cross2, Graham Sturgeon2, Rachel Hargest1 1 University Hospital of Wales, Cardiff, UK With thanks to the wonderful ASiT Conference Admin team: info@asit.org 2 Nevill Hall Hospital, Abergavenny, UK Laura Andrews Kristina Gloufchev Harriet Innes
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Aim. The aim of this study is to audit our outcomes and experience of colonic stent insertion for malignant bowel obstruction. Methods. Retrospective audit of all stent insertions in a single district general hospital between August 2003 and December 2009. All patients had presented with acute bowel obstruction caused by malignant colorectal disease. Details were collected prospectively and contemporaneously onto a database. Stent insertion was a combined endoscopic and fluoroscopic procedure involving a colorectal surgeon and consultant radiologist. Results. Stenting was attempted on 62 occasions in 54 patients. The technical success rate was 86% and clinical success rate 84%. The indications for stenting were relief of acute bowel obstruction, palliation and as a bridge to surgery. There were complications in fourteen cases (22.5%) including three perforations and one perioperative mortality. There were three cases of stent migration, six cases of re-stenosis and two stents became impacted with stool. There were no incidents of acute or delayed haemorrhage in any patients. Conclusion. Our experience shows that stenting for obstructing colorectal cancer is a safe and effective method of alleviating acute and impending bowel obstruction and can be provided safely and effectively in a district general hospital.
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0560 ANTEGRADE COLONIC ENEMA IN ADULT PATIENTS: A SINGLE SURGEON SERIES Mohammed Hamdan, Andrew Gee Department of Colorectal Surgery, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK Aim: The antegrade colonic enema (ACE) procedure is a minimally invasive treatment for refractory constipation. 47-83% success rates have been reported. The aim of this study is to demonstrate the outcome of patients who underwent the ACE procedure in a district general hospital. Methods: Retrospective review of all patients who underwent the ACE procedure for refractory constipation between February 2002 and June 2011. Demographic, operative and follow up data were recorded. Results: A total of 12 female patients had the ACE procedure performed by a single colorectal surgeon. Median age was 43 (24-70) years. Median postoperative hospital stay was 6 (2-17) days. Median follow up was 36 (14-75) months. Conduit stenosis or leakage developed in 4 and 1 patients respectively requiring surgical revision.1 patient developed an incisional hernia with subsequent poor conduit function ultimately managed with an end ileostomy. 2 failed to use the conduit and are now on laxatives. Excluding the latter 3, all patients are managing their constipation without laxatives. Conclusion: The ACE procedure was successful in 75% of patients who were, thus, able to avoid more aggressive surgery. Patient education and compliance are essential to improve success rates. 0566 CHEAPER DOES NOT NECESSARILY MEAN INFERIOR Stephen Magill, Sylvia Brown, Hoey Koh, Mark Vella, Patrick Finn, Lindsey Chisholm, Andrew Renwick Royal Alexandra Hospital, Paisley, UK Aim: A recent service change at one of our sites (site 2) saw the sole utilisation of endoscopic equipment from a cheaper manufacturer. Endoscopists favoured the more expensive equipment and thought that service quality may be affected. The objective of our study is therefore to evaluate the effect of change of equipment on service quality. Methods: Data for 836 colonoscopies performed by three colorectal surgeons on both sites was prospectively collected. Results: Overall completion rates were 89.9% at site 1 (n=490) and 92.2% at site 2 (n=346) [p=0.182]. Completion rates for each consultant also showed no significant differences. The overall usage of Midazolam between sites were comparable (3.576mg vs. 3.512mg, p=0.413), however lower doses were observed for two consultants at site 2 (3.23mg vs 2.79mg, p=0.00 and 3.19mg vs 2.95mg, p=0.022). The use of analgesics showed no statistical differences between sites. Comfort score comparison showed no statistical differences overall, however comfort scoring was significantly better at site 2 for two consultants (p=0.03 and p=0.02) Conclusion: Completion rates, use of sedation and comfort scores are comparable between the sites despite the difference in equipment. Therefore we conclude the quality of service provision is not diminished by the type of equipment utilised. 0586 IS YOUR BLOOD ORDERING SCHEDULE FOR COLORECTAL RESECTIONS UP TO DATE AND COMPLIANT WITH NATIONAL GUIDELINES? AN AUDIT OF CROSS-MATCHED BLOOD UTILISATION IN ELECTIVE COLORECTAL RESECTIONS (ECR) Virginie Walker, Jane Hughes, Mandy Chadwick, Naomi MacKenzie Wrightington, Wigan & Leigh NHS Foundation Trust, Wigan, UK Aims:Assess compliancy of our blood ordering schedule against national guidelines by determining cross-matched blood usage in patients undergoing ECR. Methods:Retrospective data collection for 12 consecutive months, on ECR (benign and malignant). Patients requiring preoperative blood transfusion excluded. Data analysed;operation, pre-operative radiotherapy, preoperative and postoperative haemoglobin, units cross-matched, blood transfusions. Results:115ECR performed. 9patients excluded. 77/106(73%) patients cross-matched. 28patients required intra-operative or postoperative (within 7days of surgery) blood transfusion. 225units of blood cross-matched, but only 65/225units transfused. Crossmatch:transfusion ratio was 3.5:1 with blood utilisation rate of 28.9%. Preoperative radiotherapy, APR and Hartmanns were risk factors for blood transfusion requirement (blood utilisation rate nearing 50%). Conclusions:Our blood cross-matching schedule is outdated with 160units of blood unnecessarily cross-matched.Most of these would have been wasted. Based on British Society of Haematology guidelines (which state that blood needn't be cross-matched if usage is 50%) none of our patients required cross-matching. Adopting these guidelines could result in a cost saving of 20800 per annum (excluding laboratory costs), based on a unit of blood being 130. We agree with current ACPGBI guidelines that G&S is sufficient in uncomplicated operations but cross-matching is recommended for more extensive operations, especially rectal resections, and current hospital guidelines are under review.
0588 A PRAGMATIC APPROACH TO MR DIRECTED RECTAL SURGERY M Elmasry, J Warner, G Abbott, C McFaul, D Vimalachandran, M Johnson tives: The Countess of Chester Hospital, Chester, UK edd, Bangor AimsThis study compares the radiological and histological staging of rectal cancers within our department and thus the fundamental workings al of Wales, Cardiff of our MDT. MethodsThe pre-operative MR scans performed between April 2009 and July 2011 in patients with histologically proven carcinoma of the rectum were reviewed retrospectively. Comparison was made between the T and N stage,and the CRM involvement as reported on the MR m: info@asit.org scan with the post-operative histological staging. Results53 patients were identified. There was a 42% correlation between the MR and histological T staging. For Nodal staging there
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was a 64% correlation. Using a pragmatic approach,patients were divided into 2 groups: advanced rectal cancers ,and non-advanced rectal cancers. 18 patients were staged as having non-advanced rectal cancer. For 89% of these patients the T stage was correctly correlated. The nodal staging correlated in 83% of cases, with 100% correct prediction of CRM involvement. ConclusionPre-operative MR scans appear initially to be a poor predictive indicator of tumour stage. Interpreting their results in a pragmatic fashion shows an excellent correlation between both the T and N stage as well as CRM involvement. Therefore the MDT can confidently stage patients and accurately predict those who would benefit most from neo-adjuvant therapy.
Goldie Khera 0601 MANAGEMENT AND OUTCOME OF COLOVESICAL FISTULAS: A SEVEN YEAR REVIEW OF ALL CASES IN A SINGLE DISASiT President TRICT GENERAL HOSPITAL Bariatric Fellow, Carter, Tyneside Rami Radwan, Jaspall S Phull, Zubair Saeed, Adam North Gethin Williams Royal Gwent Hospital, Newport, UK Aim: Colovesical fistulas (CVF) are a rare, but well recognised complication of both inflammatory and neoplastic diseases. We reviewed all cases of CVF at a single institution over a seven year period. Method: A retrospective review of all patients with radiologically confirmed CVF between 2005 and 2011. The aetiology, method of diagnosis, management, and outcome of all patients were evaluated. Results: A total of 56 patients were found to have confirmed CVF. 47 cases were confirmed by CT scan alone; the remaining 9 cases Ed Fitzgerald required further contrast studies. 86% of cases were a result of diverticular disease, while the remaining 14% were secondary to loASiT Conference Organiser & Past-President cally invasive carcinoma. 52% of all diverticular cases were treated conservatively with 48% of these patients achieving resolution of their symptoms. A further 16 patients underwent resection surgery, while 7 patients were treated with defunctioning stomas. Only 50% General Surgery Registrar, London of all neoplastic fistulas underwent resection surgery, the remaining 4 patients received palliative management. Conclusions: CT scan remains the most common modality of diagnosis of CVF. The majority of these CVF are often secondary to complicated diverticular disease. Although surgery provides immediate resolution of symptoms, this study highlights the effectiveness of conservative management in such patients as well.
0625 Jonny Wild EXPECTING THE UNEXPECTED - EXTRACOLONIC FINDINGS FOUND AT CT COLON R.E Foulkes, H.M Owen, P.J Billings, HonoraryC Corr ASiT P Chandran, Secretary & Sponsorship Co-ordinator Wrexham Maelor Hospital, Wrexham, UK General Surgery Registrar, Sheffield Aim: The aim of this paper is to report our experience of extracolonic findings identified at CT colonography, in particular the high prevalence of important findings including extracolonic malignancies. Methods: Using the PACS system all CT colonograms performed for symptomatic indications between December 2008 and June 2011 were retrieved as part of our ongoing audit, extracolonic findings were then identified and analysed. They were categorized into benign, important benign findings (findings that required further investigation or management) and extracolonic malignancies. Results: 830 patients underwent CT Colon during this time period (518 females, 313 males, average age 74). Extracolonic abnormalities were found in 383 patients (46%). Of Davies Robert those patients with extracolonic findings, 9% had extracolonic malignancies, 26% had important extracolonic findings requiring either further investigation, management or referral and 65% were benign incidental findings requirASiT Honorary Treasurer ing no further follow up. Conclusion: CT Colonography has the potential to pick up malignancies andMidlands Vascular Surgery Registrar, West other life threatening lesions such as large non ruptured AAA at a preclinical stage. Whilst we acknowledge that insignificant extra-colonic abnormalities may be identified, we believe that with correct planning and management this should not increase the number of unnecessary investigations or costs. 0645 EFFECTIVE MANAGEMENT IS KEY IN PROVIDING A PRODUCTIVE DAY CASE OPERATING THEATRE C Lam, S Cleland, H Lee, B Subramanian, M Saunders James Milburn Barnet and Chase Farm Hospital Trust, London, UK Aims: The Department of Health target for all elective work to be performed on a Day Case basis is 75%. Standards include a pre-op ASiT Vice-President efficiency of 90% and an operative efficiency of 91%. By the introduction of simple cost neutral working practices we show how a unit General Surgery Registrar, Inverness can be transformed. Methods: Initial study carried out over 2 weeks in 2008 identified key areas for service improvement. Only 54% of operating lists commenced within 15mins of starting times. Theatre efficiency was 59.9%, with a high number of on-the-day cancellations. After implemented changes were introduced, including increasing the theatre sessions by 30 minutes and not cancelling patients on overrun lists, they were re-audited in 2010. Results: Theatre intra-operative efficiency increased from 59.9% in 2008 to 94.5% in 2010. Increasing the length of the theatre session by 30mins lead to a 5% increase in the case-load across our theatres. Joseph Shalhoub Conclusions: By using LEAN principles the operative efficiency of theatre utilisation can be improved. An increase of sessions by ASiT Vice-President 30mins can lead to a 5% rise in operative case load and capacity. This can be appreciated by an improved rating from 145 th to 66th out Vascular country. of all 166 Day Surgery Departments in the Surgery Registrar, London 0684 A RETROSPECTIVE CASE SERIES STUDY OF A SINGLE CENTRE'S EXPERIENCE OF SURGICAL SITE INFECTION FOLLOWING PURSE-STRING CLOSURE VERSUS LINEAR CLOSURE OF ILEOSTOMY SITES Henna Rafique Steve Hornby St Helier's hospital, Surrey, UK ASiT Director of include surgical Aims: Recognised complications of ileostomy closureEducation site infection (SSI), small bowel obstruction and anastomotic leak. Incidence of SSIs following ileostomy closure has been reported as up West Peninsula General Surgery Registrar, South to 41%, placing significant strain on healthcare resources and patient quality of life. Conventionally ileostomy wounds are closed by a linear technique. More recently purse-string closure has been tried to reduce complications. This is a study to compare the SSI rates following purse-string closure versus linear closure of ileostomy wounds. Methods: Thirty-eight patients undergoing closure of ileostomy were included. Seventeen patients underwent purse-string closure, twenty-one patients underwent linear closure. The primary end-point was a documented diagnosis of SSI either during their inpatient With thanks to the local ASiT Welsh Regional Representatives: stay, or upon discharge or thirty days post operatively. Results: Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Overall there were fewer diagnoses of SSI following purse-string closure compared with linear closure of ileostomy wounds. Three in Mr Andrew patients who underwent purse-string closure was diagnosed withHospital of Wales, Cardiff seventeen (18%) Beamish, Clinical Research Fellow, University a SSI compared with eleven in twenty-one (52%) patients who underwent linear closure. Conclusion: The results from this study suggest that purse-string closure of ileostomy wounds is favourable to linear closure in reducing the rates of SSIs. With thanks to the wonderful ASiT Conference Admin team: info@asit.org
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0691 ENHANCED RECOVERY AFTER COLORECTAL SURGERY: FACTORS AFFECTING LENGTH OF STAY Matthew Aldridge, Nicola Dowling, Emma Chater, Henry Ferguson, Steve Pandey Worcestershire Acute Hospitals NHS Trust, Worcester, UK Aim: Enhanced Recovery after Surgery (ERAS) has been shown to reduce the length of stay (LOS) after elective colorectal surgery. This programme was implemented at Worcestershire Royal Hospital in January 2011. The aim of this study was to identify factors which impact on LOS. Method: All patients undergoing elective colorectal surgery between January and December 2011 were included, with no exclusions based on factors such as age, BMI or co-morbidities. A prospectively collected ERAS database was analysed to study short term outcomes. Patients who stayed in hospital for 5 days or less were compared with those who stayed longer. Results: There were a total of 191 patients (89 females, median age 68, laparoscopic rate 52%), of which 90 (47%) were discharged within 5 days. Statistically significant factors for increased LOS were open operations (p<0.001), resections for cancer (p=0.05), ASA 2 (p=0.01), age >70 (p=0.004), planned/unplanned HDU stay >48 hours (p=0.004), and post-operative complications (p<0.001), of which the most significant was prolonged post-operative ileus (p<0.001). Conclusions: We are encouraged by our early results. Having identified factors which have a significant impact on LOS, we can now tailor our programme accordingly. Increased laparoscopic rates in the future should improve our results further.
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0693 COLONOSCOPIC BOWEL CANCER SURVEILLANCE FOLLOWING COLORECTAL RESECTION Adam Peckham-Cooper, Richard Wilkin, Max Sellers, Sian Davies, J Eccersley Burton Hospital Foundation Trust, Derbyshire, UK Aims: At a hospital in the West Midlands deanery, the protocol for follow up and surveillance after colorectal resection includes a colonoscopy at 1-year post resection, 3 years and 5 years. This audit aimed to examine the sensitivity of the protocol in detecting further cancers and explore if this had an effect on mortality. Methods: All patients undergoing colorectal resection between January 2005 - December 2006 were included using a prospective database. Data was collected retrospectively utilising the local HCISTM and GI Reporting ToolTM (Unisoft-Medical-Systems). Results: 200 Cancer resections were performed (elective and emergency) in the time period. Preliminary data analysis demonstrated an 81% survival rate at 1 year and 56% at 5 years. At completion colonoscopy 1 patient had a synchronous cancer found and 1 patient had a large hyperplastic polyp removed. 44% of patients having a colonoscopy at 1 year had polyps biopsied or removed. In this study cohort, the 5 year colonoscopic surveillance programme revealed no further colorectal cancers. Conclusions: Surveillance colonoscopy could be reduced to one completion scope at 5 years with no increase risk to patients but significant financial savings. The psychosocial benefits of regular surveillance follow-up to the patient should however not be underestimated. 0718 THE TRUE PLACE OF INTRASPHINCTERIC BOTOX IN ANAL FISSURE MANAGEMENT Sarah Braungart, Geetinder Kaur Scunthorpe General Hospital, Scunthorpe, UK Aim: Spasm of the internal sphincter muscle causes pain in anal fissures. Historically, treatment was surgical (high risk of incontinence). Alternatives are topical glyceryl trinitrate (GTN) or calcium channel blockers and Botulinum toxin injection. There is no consistency in dose, site and timing for this therapy. We performed a retrospective audit of a single surgeon's results with intrasphincteric Botulinum (Botox) to optimize anal fissure management in our institution. Methods: All patients with anal fissures who received Botox injection after failure of medical treatment from 01/01/2009 to 31/12/2011 were included. 24 patients were identified; data was collected by case note review. Results: Main symptoms were pain(87.5%), bleeding(75%), itching(17%). An extremely structured treatment approach was observed using ointments plus laxatives/ dietary modifications for 7.5 months average prior to injections. 70% of patients showed 100% symptom relief, 17% showed 90% relief, 4.3% showed 80% relief. Side effects included temporary faecal soiling(3), urge sensation(1). One patient only underwent lateral sphincterotomy showing no response to Botox injections. Conclusions: Relief of anal spasm has been associated with healing of anal fissures and can be achieved by Botox injections. This avoids dividing the anal sphincter. Our structured approach using Botox gave >80% symptom relief to 91.3% of our patients. 0734 LYMPH NODE HARVEST AS A MARKER OF QUALITY IN COLON CANCER RESECTION: A COMPARISON BETWEEN LAPAROSCOPIC AND OPEN RESECTIONS Angus Kaye3, Nicola Wright2, Nagy Rizkalla1, Emma Hamilton1, Graham Williams1, Haney Youssef3 1 New Cross Hospital, Wolverhampton, UK 2 University of Birmingham, Birmingham, UK 3 Heart of England Foundation Trust, West Midlands, UK Aim: Accurate lymph node (LN) staging is essential for planning adjuvant therapy. One concern with laparoscopic colonic resection is that complete mesocolic resection is not as thorough as for open surgery. The aim of this study was to compare LN harvests and distance to vascular pedicle (DVP) in laparoscopic versus open resections for colon cancer. Methods: Details of patients having colon cancer resection from January09-March11, were prospectively recorded. Data was analysed on primary tumour site, LN yields, positive node ratios (PNR), surgery type, DVP and pathological stage. Results: 242 patients, median age 73years (range 2797y), underwent 188 open or 54 laparoscopic (8 converted) colonic resections. Median LN harvest was 18 (range 2-43) for open vs 18 (range 6-32) for laparoscopic resection. Mean PNR was 12% for open vs 10% for laparoscopic resection. Mean DVP was 82cm (median 70cm; range 10-290) for open vs 62cm (median 55cm; range 6-140) for laparoscopic resections. There were more T4 tumours operated on in the open group than laparoscopic (44% versus 26%). Conclusion: Although greater length of mesentery was removed during open colonic resection, lymph node harvest was similar for open and laparoscopic resection suggesting that laparoscopic resection is oncologically similar to open resection.
0737 AT WHAT POINT SHOULD A LAPAROSCOPIC BOWEL RESECTION BE CONVERTED TO AN OPEN PROCEDURE? edd, Bangor Ian Gregory, Dawn Gane, Lisa Hayward, Rhys Davies, Anne Pullyblank North Bristol al of Wales, Cardiff Hospitals NHS Trust, Bristol, UK Aims: To determine whether there comes a point where the benefits of laparoscopic surgery are outweighed by increased operating time. Methods: m: info@asit.org Data was collected for three years within an enhanced recovery programme. Median day of discharge post surgery was used to assess patient outcome, and data was analysed for the six most common resections in the database.
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Results: For right hemicolectomy(n=163), high anterior resection(n=145) and sigmoid colectomy(n=37) the length of stay for laparoscopic surgery is lower than open surgery, regardless of operating time up to 6 hours. Length of stay for laparoscopic right hemicolectomy increases significantly after 6 hours suggesting open conversion may be appropriate at this stage, however n values are small in these groups. For low anterior resections(n=74) the benefit of the laparoscopic approach is less obvious after 4 hours, suggesting that conversion may be appropriate at this stage. For Hartmann's(n=57) and abdominoperineal resections(n=37), laparoscopic surgery is not associated with an earlier date of discharge. This may be due to Goldie factors such as advanced tumours, elderly patients, a perineal wound and need for stoma additional Khera care. ASiT President Conclusion: The concern that a longer operating time may offset the benefits of the laparoscopic approach is probably unwarranted for Bariatric Fellow, North Tyneside most operations.
0742 PRELIMINARY RESULTS WITH TRANSANAL HAEMORRHOIDAL DEARTERALISATION (THD) AT DISTRICT GENERAL HOSPITAL Jennie Grainger, Rebecca Saunders, Caroline Bruce, Arif Khan Mid Chesire NHS Trust, Crewe, UK Ed Fitzgerald Introduction: Advances in haemorrhoid treatment reflect our increased knowledge of their blood supply. We introduced THD at our ASiT Conference Organiser & Past-President DGH following NICE guidance in 2010. THD uses a Doppler-guided proctoscope to locate, and ligate, the terminal branches of the haemorrhoidal arteries. General Surgery Registrar, London We are presenting our preliminary results. Methods: The audit was performed retrospectively using a standardised pro-forma and patient questionnaire. All patients (83 in total) undergoing THD between March 2010 and July 2011 were included. Results: All 83 patients were completed as a day-case. The average age at surgery was 53 years with a male preponderance (58%). Preoperatively, 96% had 2nd or 3rd degree haemorrhoids. 95% had undergone previous treatments, including rubber-band ligation (86%), haemorrhoidectomy (6%) and stapled haemorrhoidectomy (2.5%). Haemorrhoidopexy was performed at time of THD in 43% of Jonny Wild patients and 4% had an additional procedure below the dentate line. 92% of patients were asymptomatic Honorary Secretary &post-operatively. Significant post-operative pain was reported in ASiT when reassessed 6-12 weeks Sponsorship Co-ordinator 4%. 3/83 (4%) reported continued rectal bleeding, with 2 patients subsequently requiring traditional' haemorrhoidectomy. General treatment Registrar, Sheffield Conclusions: THD is a suitable alternativeSurgery for 2nd- and 3rd-degree haemorrhoids. Although long-term results are not yet available, patients remained asymptomatic at follow-up with minimal symptoms post-operatively 0756 FACTORS ASSOCIATED WITH THE DEVELOPMENT OF THE UNHEALED PERINEUM FOLLOWING SURGERY Brian Ip, Najibullah Daulatzai, Mark Jones, Georgina Williams, Helen Alexander, Paul Bassett, Robin Phillips St. Mark's Academic Institute,Robert Davies London, UK Aim: To establish patient and procedural factors associated with the development of the unhealed perineum in patients underoing ASiT Honorary Treasurer proctectomy or excision of ileo-anal pouch. Method: A review of casenotes was carried out for all Registrar, West Midlands Vascular Surgery procedures performed between 1997 and 2009. All patients underwent at least 12m of follow-up. Univariable and multivariable analyses were performed in 16 parameters. For those patients who developed an unhealed perineum, a Cox regression analyses was performed to establish healing over a 12 month period. Results: 200 patients were included in this study. 6 patients had unknown wound status and were excluded. 86 (44.3%) patients had a fully healed perineum at the outset. 63 (58.3%) patients who had an unhealed perineum healed within a 12 month period. A comparison of patients with intact perineum versus those with unhealed perineum shows existing perineal sepsis was associated with lack of James Milburn healing OR 4.32 95% CI 2.16-8.62 P<0.001). In patients who had an unhealed perineum, perineal sepsis and surgical treatment were both significantly associated with time to healASiT Vice-President ing (HR 0.54 CI 0.31-0.93 P= 0.03 and HR 0.42 CI 0.21-0.84 P= 0.01). General Surgery Registrar, Inverness Conclusion: Control of perineal sepsis pre-operatively may improve healing of the perineum following surgery. 0800 AUDIT: ROUTINE TESTING OF POST OPERATIVE LIVER FUNCTION AFTER ELECTIVE COLORECTAL SURGERY: IS IT NECESSARY? Amy Ferris, Vivek Gupta, Keshav Swarnkar, Michael Rees Royal Gwent Hospital, Newport, South Wales, UK Joseph Shalhoub Aim: Liver function tests (LFTs) taken after elective surgery frequently show abnormalities, usually returning to normal without further ASiT Vice-President intervention. The aim of this study was to determine whether LFTs are routinely necessary in the post-operative phase of elective Vascular Surgery Registrar, London colorectal surgery. Method: A retrospective analysis of all patients undergoing elective colorectal surgery during a 6 month period was performed. Pathology database was used to check LFTs for the first 3 days post-operatively to assess any abnormalities. In those patients with abnormal results, case notes were reviewed to determine whether any change in management was indicated. Results: 95/104 (91.3%) patients had LFTs performed on day 1, which fell to 56/104 (53.8%) by day 3 post-op. 27 patients (25.9%) developed abnormal LFTs and only 5/104 (4.8%) had persistently abnormal LFTs on third post-operative day. 6/27 patients who deSteve Hornby veloped post-operative abnormal LFTs subsequently had imaging and no statistically significant difference were found between ASiT laparoscopic and open procedures. Director of Education Conclusions: Abnormal LFTs General3Surgery Registrar, South surgery Peninsula but does not normally necessitate in the first days following elective colorectal West is not unusual, further clinical intervention. We suggest LFTs should only be taken if there is a clinical indication, which would have cost saving implications. 0816 FUNCTIONAL RESULTS OF ANTEGRADE ASiT Welsh Regional Representatives: ENDOSCOPIC CAEWith thanks to the local COLONIC ENEMA COMPARING THE PERCUTANEOUS COSTOMY PROCEDURE (PEC) WITH THE STANDARD MALONE PROCEDURE (MACE) Miss John Gwatkin, Judith Ford, Raymond Surgery Registrar, Ysbyty Gwynedd, Bangor Rhiannon Harries, Rhiannon Harries, General Delicata Nevill Hall Hospital, Abergavenny, UK Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Introduction: Recent evidence has shown favourable outcomes with the use of both PEC and the MACE for the management of chronic constipation. We report our results on the use of PEC and MACE in those adult patients with chronic constipation who had failed conservative management.the wonderful ASiT Conference Admin team: info@asit.org With thanks to Method: Patient information, including diagnosis, Cleveland constipation questionnaire scores pre procedure and date and type of
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procedure performed were obtained from the case notes. Patients were contacted by telephone post procedure and asked to complete the Cleveland constipation questionnaire and were asked questions related to quality of life. Results: 14 patients underwent either PEC or MACE procedures between 2000 and 2009. 9 patients underwent MACE while the remaining patients had PEC. The mean modified Cleveland score pre/ post procedure was 16.3/ 5.6 for MACE and 15.6/ 5.0 for PEC respectively. 93% of patients expressed satisfaction following either their PEC or MACE procedure. Conclusion: Results showed improvement in functional results as well as patient satisfaction for both the PEC and MACE procedures. PEC is a less invasive procedure and has shown to have as favourable an outcome as the accepted MACE procedure, and should therefore be considered an alternative to MACE in carefully selected individuals. 0822 LYMPH NODE HARVEST FOR COLORECTAL CANCER COMPARING LAPAROSCOPIC AND OPEN SURGERY Rhiannon Harries, Ioannis Sarantitis, Kirk Bowling, Graham Whiteley Ysbyty Gwynedd, Bangor, UK Aims: Lymph node harvest is an important component of staging for colorectal cancer in order to decide on the requirement for adjuvant chemotherapy and to predict survival. The aims of our study were to investigate lymph node harvest comparing laparoscopic and open surgery for colorectal cancer resections. Methods: Data was obtained from all consecutive patients who underwent a segmental surgical resection for colorectal adenocarcinoma over a three year period. Resections were classed as either right sided, left sided or rectal. Results: Between Oct 2008 to Oct 2011, 561 patients presented with colorectal cancer, with 358 patients undergoing segmental bowel resection. 129 underwent right sided resections (77 open/ 52 laparoscopic), 100 underwent left sided resections (61 open/ 39 laparoscopic) and 127 underwent rectal resections (45 open/ 82 laparoscopic). The median lymph node harvest in right sided resections was 12 for open and 12 for laparoscopic (p=0.4236). The median lymph node harvest in left sided resections was 12 for open and 13 for laparoscopic (p=0.5886). The median lymph node harvest in rectal resections was14 for open and 12 for laparoscopic (p=0.1655). Conclusion: There was no statistically significant difference seen in lymph node harvest between open and laparoscopic surgery for colorectal cancer resections. 0829 DIAGNOSTIC YIELD AND SAFETY OF COLONOSCOPY IN OCTOGENARIANS IN A DISTRICT GENERAL HOSPITAL Kamran Khatri, Kate Perryman, Sam Enefer, Mazin Sayegh Western Sussex Hospitals NHS Trust, Worthing, UK Objectives: According to the British Society of Gastroenterology (BSG) guidelines, colonoscopy in elderly patients is less likely to be successful and is not without risks. We aimed to analyse the yield of colonoscopy, the completion rate and the complications in octogenarians. Methods: All patients who underwent colonoscopy from November 2008 to November 2011 in a District General Hospital were included. Data was extracted from a prospectively collected endoscopy database Data related to endoscopy findings, histology, completion rate and complications encountered was collected and analysed. Results: 986 patients underwent 1030 colonoscopies in the 3 year period. Average age of the cohort was 84 (81-97) years and female to male ratio was 1.23 (570:460). Three hundred and nine (30 %) were reported normal. Significant pathology was identified in 34.3 % including malignancy 7.2 % (75/1030), polyps 25.2 % (260/1030), and inflammatory bowel disease 1.9 % (20/1030). Diverticular disease was the most prevalent benign pathology encountered (45.6 %). The completion rate was 85%. There were 39 complications. Conclusion: Our results demonstrate that colonoscopy amongst Octogenarian has a high diagnostic yield and a relatively low complication rate. This procedure could be offered to octogenarian safely, depending on relative cancer risk and co-morbidity. 0837 MANAGING ACUTE DIVERTICULITIS - A CRITERION BENCH MARK IS ESSENTIAL Anil Bagul, Stephanie Jones, James Pain Poole Hospital NHS, Poole,Dorset, UK Background: Acute diverticulitis (AD) is a common diagnosis in patients admitted as an emergency. Although it may be a clinical diagnosis this can be supported by radiological investigations and occasionally endoscopy. After diagnosis patients are usually treated conservatively and intervention only occurs in those who develop complications (e.g. abscess formation.). Following the acute admission patients can be investigated either to confirm diverticular disease or to rule out other pathologies. Aim: To review the current pattern of management in a district general hospital. Methods: Patients admitted with AD over last two years were included. The cohort was assessed for demographics, symptoms, diagnostic studies, treatment, outcome and follow up. Results: A total of 275 patients had an index diagnosis of AD. The median age was 73(27-99) years, hospital stay was 5(0-89)days including critical care admissions of (8.4%). Early diagnosis was aided by Computerised tomography (38.8%), ultrasonography(15 %), Endoscopy (24.2%) . 39.6% of patients were subsequently seen in a clinic, 70% had follow up investigations. Conclusions: Our series revealed variable usage of diagnostic imaging tests which was mainly consultant driven and no standard pattern in the way in which patients were followed up. An algorithm to standardise practice would be helpful in reducing unnecessary investigations and clinic appointments.
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0844 THE CAUSES OF INTESTINAL FAILURE AND THE SURGICAL FACTORS INFLUENCING THE OUTCOME OF HOME PARENTERAL NUTRITION (HPN) PATIENTS IN WALES Narasimhaiah Srinivasaiah, Barnie Hawthorne, Rachel Hargest Specialty Trainee, London Deanery, London, UK Background: HPN is the gold-standard therapy in chronic intestinal failure (IF). We aim to review the surgical causes and correlate it with the bowel length and defunctioning stoma. Methods: Study is a retrospective review. Data were collected from the HPN database & clinical-notes. SPSS was used for statistics. Results: 50 patients have been managed on HPN since 2000. The causes for IF were Crohn's, infarction, fistulae, radiation enteritis and enteropathy in 17(34%), 9 (18%), 7 (14%), 2 (14%) & 8 (16%) respectively. Of the 50 patients, 8 have died (only 1 death was HPN tives: -related). HPN was stopped in 7 after planned restorative-surgery. There are currently 33 patients on HPN. 19(57.6%) were female, edd, Bangor with median age of 57 years. One patient is on small-intestinal transplant waiting-list. 18 patients (54.5%) had a stoma, 19 patients (57.5%) al of Wales, Cardiff had at least 50% of their colon remaining, 3 patients (9.1%) had less than 50% remaining whilst 9 patients (27.3%) had a defunctional colon. The average small-bowel length remaining was 127.8cm (SD 149.9cm). Conclusions: Surgeons need to salvage much small bowel as possible to prevent IF & the need for PN. Early stomal reversal and use of defunct m: info@asit.org ional colon might reduce the need PN.
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0879 CT IS BETTER THAN COLONOSCOPY FOR ANATOMICAL LOCALISATION OF COLONIC TUMOURS Mark Taylor, Samir Pathak, Daniel Bowden, Steve Lindley Royal United Hospital, Bath, UK Aims: Traditionally patients undergo a colonoscopy to identify a malignancy and gain histological samples. Recently with laparoscopic surgery the need for localisation is necessary, though intra-operative discrepancies may still arise. CT scanning stages the disease but may also provide accurate anatomical localisation of the colonic tumour. Our aim was to compare colonoscopy and CT in terms Goldie Khera of localisation of tumours. Methods: A retrospective review, over a one year period, of all patients with colorectal cancer, in a large district general hospital was ASiT President undertaken. Colonoscopic and radiological tumour localisation were compared with histopathological assessment Bariatric Fellow, North Tyneside Results: 103 consecutive patients were included. On histological assessment tumour localisation was as follows: 61 right sided tumours (caecum/ascending colon), 13 lesions between hepatic and splenic flexure and 29 tumours in the descending or sigmoid colon. Colonoscopy accurately identified the tumour location in 58% (60/103) of patients. CT localised the lesion accurately in 86% (89/103). This was statistically significant (p= .0.0001 using chi-squared). The mean size of tumours accurately localised by CT was 50mm. The mean size of tumours not accurately localised was 37mm (p =0.03 using t-test). Conclusions: CT is more accurate than colonoscopy for anatomical localisation of tumours. CT localisation is better for larger tuEd Fitzgerald mours.
0883 General Surgery Registrar, London SURGICAL OUTCOMES FOLLOWING BOWEL CANCER SURGERY IN THE VERY ELDERLY Arifa Siddika, George Malietzis, Nadeem Ashraf, Shahab Siddiqi, Thomas Pearson, Nigel Richardosn, AHMc Ross Broomfield Hospital, Chelmsford, UK Aim: The aim of this study was to assess surgical outcome in patients above the age of 85 who underwent curative surgery for bowel cancer. Method: This was an observational study that described surgical outcomes, in a consecutive series of patients diagnosed with bowel Jonny Wild cancer above the age of 85 between January 2008 and December 2010 at our hospital. Results: There were 96 patients with bowel cancer over this period of time. Their median age was 87 years (Range 85 - 100 years). 47 ASiT Honorary Secretary & Sponsorship Co-ordinator patients underwent curative surgery and 49 were palliated. The 30 day mortality for patients undergoing curative surgery was 12.8% General Surgery Registrar, Sheffield months and for those that were palliated was 6.86 (6 deaths). The median survival for those undergoing curative surgery was 19.29 months. In contrast, patients under the age of 85 years undergoing curative surgery had a median survival of 39.44 months. Conclusion: Very elderly patients undergoing curative elective surgery for bowel cancer, have a greater post-operative mortality and lower overall survival than younger patients. Despite this, survival in this carefully selected cohort of patients is fair, and confirms that curative bowel surgery in the very elderly can result in acceptable outcomes. 0887 Robert Davies RIGHT ILIAC FOSSA PAIN IN FEMALES UNDER THIRTY: THE ROLE OF ULTRASOUND SCANNING ASiT Honorary Treasurer Maire-Clare Killen, Ajibola Hakeem-Habeeb Blackpool Victoria Hospital, Blackpool, UK Surgery Registrar, West Midlands Vascular Aim: To evaluate the use of ultrasound (US) scanning for right iliac fossa pain in females under thirty. Method: A retrospective analysis was performed, identifying females admitted to the surgical assessment unit with acute onset right iliac fossa pain. Clinical findings, investigations conducted and clinical outcome were evaluated. Results: 50 females were included. 27 patients (54%) had abdominal US: 52% were normal, 11% were inconclusive and 37% identified right-sided gynaecological pathology. Ten patients (20%) underwent laparoscopy with 90% of this group undergoing laparoscopic appendicectomy; 30% had US pre-operatively. Laparoscopic and US findings correlated well: 100% of patients with a normal US had normal laparoscopy findings. James Milburn Of the patients that proceeded to laparoscopy without any prior imaging, three (43%) were found to have tubo-ovarian pathology ASiT Vice-President intra-operatively. Four patients (8%) underwent open appendicectomy; 75% had a pre-operative US (100% were normal or inconclusive). 74% of patients were managed conservatively; no intervention was required in the majority General Surgery Registrar, Inverness (46%). 14% were referred to gynaecology and 14% had outpatient investigation. Conclusion: The majority of women with right iliac fossa pain did not have appendicitis. Evidence from this study shows US to be a useful tool in demonstrating alternative pathology as a potential cause of symptoms. 0891 BOWEL CANCER SCREENING - HAS IT MADE AN IMPACT? Christopher McHague, Tamiq Joseph Shalhoub Babayev, Nicola Eardley, Christopher McFaul, Michael Johnson, Dale Vimalachandran Countess of Chester NHS Hospital, Chester, UK ASiT Vice-President Introduction: The National Bowel Cancer Screening Programme (BCSP) was introduced in 2006 with the aim of reducing colorectal Vascular Surgery Registrar, London cancer (CRC) mortality. Aim: To determine whether there had been a reduction in CRC emergency presentations and staging at presentation since BCSP was introduced. Secondary end-points included symptom duration and tumour site. Methods: Prospective computerised database (Chester Colorectal Database, Meditech, MediSec, PACS) comparing patients diagnosed with CRC over 1 year (April 2010-2011) with a historic cohort from 5 years earlier (April 2005-2006). Results: 2010/11 - 114 patients, 2005/6 - 133 patients. No change in proportion of emergency presentations - 21.2% in 2010/2011 Steve Hornby versus 25.6% in 2005/6 (p=0.6044). A significant reduction in stage - 45% Dukes C/D compared to 64% in historic cohort (p=0.0038). ASiT Director of Education More right sided CRCs presenting - 39.5% 2010/11 versus 33.8% 2005/6 (p=0.36). Greater proportion presented with anaemia (23.7% versus 14.3%, p=0.0586). Duration of anaemia prior to presentation South West days versus 150 days, p=0.292). General Surgery Registrar, increased (365 Peninsula Conclusion: Since BCSP introduction there has been a significant decrease in stage of CRC at presentation but no decrease in emergency presentations. There has been a shift towards more right sided tumours which may explain the trend to an increase in those presenting with anaemia. 0935 With thanks to the local ASiT Welsh Regional Representatives: LOOP ILEOSTOMY REVERSAL: 5 YEAR EXPERIENCE IN AN ENGLISH RURAL DISTRICT GENERAL HOSPITAL Miss Rhiannon Harries, General Rao Dhya Al-Leswas, Magdalena Oles, Daniel Negrea, MilindSurgery Registrar, Ysbyty Gwynedd, Bangor Pilgrim Hospital,Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Mr Boston, Lincolnshire, UK Introduction: Loop ileostomy(LI) is fashioned to protect against the substantial risk of leakage from low pelvic anastomosis. However, the revision of these LIs has a reported morbidity of 5.7-69%. Aim: To report the outcome of reversal wonderful ASiT Conference Admin team: info@asit.org With thanks to the LI in a rural district general hospital(DGH). Method: Retrospective data collection and analysis for patients who underwent reversal LI between November 2006 and October
Laura Andrews
Kristina Gloufchev
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2011. Results: Sixty-nine patients (45M,24F) with a median age of 69(23-87) and mean BMI of 26.8+/-5.3 had a reversal of defunctioning LI for: i) 38 rectal and 10 colonic cancers; ii) 9 inflammatory bowel and 4 diverticular diseases; and iii) 8 other. Anastomotic technique was hand sewn in 44(63.8%) and stapled closure in 25(36.2%). The mean periods for light diet tolerance and bowel movement were 2.9+/-1.8 and 3.5+/- 2.1days, respectively. The overall morbidity and mortality were 15(21.7%) and 2(2.9%), respectively. Six(8.7%) patients had septic complications and 9(13%) had small bowel obstruction(SBO). The mean in-patient stay was 7.9+/-7.5 days. Around 6% of the patients have been re-admitted within 90 days of the procedure with subacute SBO. Conclusions: Overall outcomes are comparable with tertiary centres. However this study again highlights the high morbidity associated with the procedure and senior presence at the time of surgery may help.
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0958 A REVIEW OF PATIENTS IN A SINGLE CENTRE WITH ILEAL POUCH- ANAL ANASTOMOSIS FOR ULCERATIVE COLITIS AND AN ASSESMENT OF THOSE PATIENTS WHO REQUIRE ON GOING MEDICAL THERAPY Natalie Allen, Eunice Garforth, Richard Heath, Paul Rooney The Royal Liverpool and Broadgreen University Teaching Hospitals, Mersey, UK Aims: Restorative proctocolectomy with ileal pouch-anal anastomosis(IPAA)is the surgical therapy of choice for patients with chronic ulcerative colitis. A proportion of patients require ongoing medical management, which this study assesses. Methods: A prospectively collected hospital database from a single centre and a review of case-notes was completed, assessing surgery prior to IPAA and post-operative complications. An assessment was made of those who were recommenced on medication. Results: 102 patients were included,(60 male:42 female, mean age 42 years Standard Deviation of+-12.01). Follow-up is ongoing and currently between 2 and 193 months. Complications included anastomotic leak(n=4), incisional hernia(n=7), pouchitis(n=36), stenosis (n=15), pre pouch stricture(n= 1), ileitis(n=2), enterocutaneous fistula(n=2), perianal fistula(n=6), pouch vaginal fistula(n=5), pouch ulceration(n=8). All patients prior to surgery had a histological diagnosis of UC, 4 patients were reclassified as Crohns. 13(12.7%) patients were recommenced on medication, including sulphasalazine, budesonide, azathioprine, 6-mercaptopurine and infliximab. All patients reclassified as Crohns were recommenced on medication and seen in a joint gastro/surgical clinic. Conclusions: Long-term anastomotic problems are common after IPPA. Most patients don't require additional medication other than antibiotics but 12.7% need continued complex medical therapy under the care of gastroenterologists and surgeons. Use of steroids is low. Diagnostic problems remain an issue. 1002 THE RELATIONSHIP BETWEEN CIRCULATORY AND TUMOUR CRP, PAKT, MAPK AND SURVIVAL IN PATIENTS UNDERGOING POTENTIALLY CURATIVE ELECTIVE RESECTION FOR COLORECTAL CANCER Arfon Powell, Scott Shepherd, Donald McMillan, Paul Horgan, Joanne Edwards University of Glasgow, Glasgow, UK Iintroduction: CRP is associated with activation of PI3K/Akt, MAPK, increased tumour cell proliferation and inhibition of apoptosis. This study examined the relationship between circulatory and tumour CRP, pAkt, MAPK and survival in patients undergoing potentially curative elective resection for colorectal cancer. Methods: Tumours from 147 patients with CRC had immunohistochemical analysis for CRP, MAPK and pAkt performed. Results: Nuclear(n) CRP correlated with advanced T stage (P=0.022) and cytoplasmic(c) CRP correlated with necrosis (P=0.028). npAkt correlated with higher LNR (P=0.027). There were no significant relationships between survival pathways. Minimum follow-up was 120 months with 41 cancer deaths. On multivariate analysis of all significant clinicopathological factors, LNR (P<0.001), Peterson Index (P<0.001), Klintrup score (P=0.017) and systemic(s) CRP (P<0.001) were independently related to cancer-specific survival. sCRP (P=0.007) was only significant in right sided tumours with cCRP (P=0.022) significant in left sided tumours. cpAkt (P=0.029) was significant in rectal tumours. Conclusion: This study did not elicit any link between the systemic inflammatory response and activation of pAkt and MAPK. These findings support the concept of colorectal tumour heterogeneity with different methods of invasion and metastasis. Understanding the mechanisms by which tumours from each genetic pathway progress and metastasis will help develop personalised treatment regimens. 1030 NEOADJUVANT CHEMO-RADIOTHERAPY AND LYMPH NODE RETRIEVAL RATES AFTER CURATIVE RESECTION FOR RECTAL CANCERS- SHOULD THE SAME STANDARDS APPLY? Philip Varghese, Zakir Mohamed, Fadlo Shaban, Talvinder Gill, Mohammed Tabaqchali, Dharmendra Garg, David Borowski, Anil Agarwal University Hospital of North Tees, Stockton-on-Tees, UK Aims: This study aimed to evaluate if there is a significant difference in the number of lymph nodes(LN) harvested following neoadjuvant chemo-radiotherapy(N-CRT) and resection vs. curative resection only. Methods: A retrospective review of a prospectively collected data of patients who underwent curative resection for rectal cancers between 2008-2011 was carried out. LN yield was compared in the two groups with respect to the tumour stage, type of surgical resection, location of tumour and response to treatment on imaging and final histology. Results: 138 patients with rectal cancer were identified; 71 N-CRT group(A) and 67 in the primary resection group(B). The mean age at treatment was 65.7 yrs(A) and 67.8yrs(B), male:female ratio of 2:1 in both groups. The groups were well matched. There were more patients with fewer than 12 LN in group-A (28 vs.22); however this was not statistically significant(p>0.05). No significant correlation between LN yield vs. tumor stage and type of resection was seen. Tumour response to N-CRT on MRI and histology showed no significant difference in LN yield in the good, partial and no response group(p>0.05). Conclusions:N-CRT for rectal cancer did not result in any significant reduction in LN yield. We recommend continuing use of AJCCTNM standard of minimum 12 for accurate nodal staging.
1088 DOES CONVERSION ALTER OUTCOME IN LAPAROSCOPIC COLORECTAL SURGERY? Nigel Rajaretnam, Gregory Nason, Brian Barry, Paul Neary Adelaide and Meath incorporating the National Children's Hospital, Tallaght, Dublin, Ireland tives: Introduction: Laparoscopic Colorectal surgery has been shown by some trials to confer a survival advantage to patients.Controversy edd, Bangor exists on the impact of converting laparoscopic cases to open in terms of increasing morbidity and impairing cancer related survival.We al of Wales, Cardiff assessed whether conversion to open surgery had long term implications. Methods: We performed a retrospective analysis of our prospective database for all patients undergoing colorectal cancer surgery from January 2005 to April 2008.Disease related and overall mortality rates were cross referenced with the National Cancer Registry of Ireland. m: info@asit.org Results: 279 patients underwent surgery for colorectal cancer during this period.80.3% were laparoscopic and 19.7% open. The con-
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version rate was 13.8% (Inter-surgeon range 11-17%).The median follow up was 50 months.The overall mortality rate was 17.9%.Patients that had undergone laparoscopic surgery for colorectal cancer had a significant difference in their overall mortality rate over those that were converted (14.5% vs 32.2%; p=0.02).For disease specific related mortality laparoscopic surgery resulted in less mortality than open for non metastatic disease (AJCC Stage I, II; 5.2% vs 17.9%; p=0.04). Conclusions: In summary,overall mortality and disease specific survival is worse after conversion.Laparoscopic colorectal cancer surgery should only be undertaken by specific surgeons in specialised MIS units with low conversion rates.
Goldie Khera 1151 SHORT TERM OUTCOMESASiT President VERSUS OPEN APPROACH IN LEFT AND RIGHT HEMICOLECTOMIES IN LAPAROSCOPIC WITHIN AN ENHANCED RECOVERY PROGRAMME Bariatric Fellow, North Tyneside Kam Wa Jessica Mok, Zia Moinuddin, Lyndon Jones Royal Blackburn Hospital, Blackburn, UK Short term outcome benefits in laparoscopic colectomies remains debatable. We compared the short-term outcomes between laparoscopic and open surgery and compared these with left and right hemicolectomies. Data was collected from enhanced recovery programme database between 2009 and 2011. 61 patients underwent left hemicolectomy (laparoscopic to open ratio, 2:3) and 102 had right hemicolectomy (laparoscopic to open ratio, 5:8). Short term and postoperative outcomes were compared. Ed Fitzgerald Hospital stay was shorter in the laparoscopic group compared to open in both left hemicolectomy (7 days compared to 9, p=<0.03) ASiT Conference 0.02). Complication rates were higher and right hemicolectomy (6 compared to 7.5 days, p <Organiser & Past-Presidentamongst patient who underwent open surgery for left hemicolectomies (complication rate of laparoscopic versus open =29.17% versus 51.35%). However there were no General Surgery Registrar, London differences in complication rates when comparing the two approaches in right hemicolectomies. Rate of ileus was higher in patients who had open left hemicolectomies, but there was no difference in rate of ileus amongst right hemicolectomy open or laparsocopic approach. Laparoscopic colorectal surgery reduces length of hospital stay in both left and right hemicolectomies. It is also associated with lower morbidity in patients undergoing left hemicolectomies but does not improve morbidity in patients undergoing right hemicolectomies. Jonny Wild 1165 OPTIMIZATION OF PERI-OPERATIVE HDU CARESecretary & COLORECTAL PATIENTS ASiT Honorary FOR ELECTIVE Sponsorship Co-ordinator Khurram Siddique, Raza Cheema, Promad Bapat, Liviu Titu General Surgery Registrar, Sheffield Wirral University Hospitals NHS Trust, Wirral, UK Objectives: To review the care of high-risk elective colorectal patients with regards to timing of discharge from the HDU & its effects on post-op complications, re-admission to HDU, length of stay (LOS) and mortality. Methods:All elective colorectal patients admitted to HDU during 2010 were included. Patients were divided into two groups with regards to their stay on HDU: Group1 < 48 hrs & Group2 >48 hrs. Data regarding demographics, post-op complications, re-admission & mortality were collected & analysed using SPSS version 14. Results:Out of the total of 40 patients, 21 Davies Robert were females with a median age of 74 (range 45-92) The number of patients in group 1 & 2 were 26 and 14 respectively. Laparoscopic procedures were performed in 31 patients. Post-op complications were higher (72.2% Vs ASiT significantly longer [8 (IQR 4-41) Vs 6.5(4-12) p<0.03)]; amongst group 1 than group 2 patients. 27.8%, p<0.04) & length of stay was Honorary Treasurer Four patients in group 1 were Vascular to HDU. No mortality was reported Midlands re-admitted Surgery Registrar, West Conclusion:Early discharge from the HDU is associated with a significant risk of complications; re-admission (15.3%) and a prolonged length of stay. Ensuring a minimum stay of 48 hrs would reduce morbidity thus optimizing HDU patient care.
1194 METABOLIC EFFECTS OF CHEMORADIOTHERAPY IN RECTAL CANCER PATIENTS Maryam Alfa-wali1, Diana Tait2, Hector Keun1, Anthony Antoniou1 1 James Milburn Imperial College, London, UK 2 Royal Marsden NHS Foundation Trust, London, UK ASiT Vice-President Aim: Neo-adjuvant chemoradiotherapy is part of the standard treatment of care for down staging rectal cancers prior to surgery. HowGeneral Surgery Registrar, Inverness ever, the exact impact of treatment response is a challenge to predict, with toxicity of treatment being an added complication. The aim of the study was to investigate the metabolic alterations of rectal cancer patients undergoing therapy using proton nuclear magnetic resonance spectroscopy (1H NMR). Methods: Twenty-four specimens were obtained from patients with rectal cancer and controls. Plasma samples were used for the 1H NMR experiments. All 1H NMR spectra were acquired using a Bruker DRX600C spectrometer (Bruker, Germany). Pattern recognition and statistical analysis were performed using MATLAB and SIMCA software. Results: Higher levels in lactate and choline metabolites were seen in, rectal cancer patients undergoing chemoradiotherapy comJoseph Shalhoub pared to controls. Statistically significant changes between the groups were also observed in low-density lipoproteins, glycoproteins ASiT Vice-President and amino acids such as valine and glutamine. Conclusion: Lipids in the formVascular Surgery Registrar, London of phospholipids for cell membrane synthesis were found to account for the distinct separation of samples based on response to chemoradiotherapy. Although in its infancy, metabolic profiling may in the future be used to monitor response to chemoradiotherapy early and hence potentially avoid toxicity effects. ENDOCRINE SURGERY
ASiT Director of Education 0196 PARATHYROIDECOMY IN A DISTRICT GENERAL HOSPITAL:South West Peninsula General Surgery Registrar, OUTCOMES AND EVOLUTION IN THE ERA OF MINIMALLY INVASIVE SURGERY Sharath Paravastu, David Chadwick Chesterfield Royal Hospital, Chesterfield, UK Aim: To determine the outcomes of bilateral neck exploration(BNE) and uptake as well as outcomes of minimally invasive parathyroidectomy(MIP) forthanks to the local in a district general hospital(DGH). Representatives: With primary hyperparathyroidism ASiT Welsh Regional Methods: Review of prospectively maintained database of a single surgeons' practice for outcomes of BNE and MIP between August Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor 1999 and December 2010. Patients were considered 'cured' when serum calcium levels remained normal for more than 6 months after surgery. Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Results: 368 patients underwent parathyroidectomy; BNE(n=314) and MIP(n=54). 92 patients underwent preoperative localisation; ultrasound(n=92) and 99TC Sestamibi(MIBI) scan(n=91). Localisation from Ultrasound and MIBI was noted in 65%(n=60) and 71% (n=65) respectively; however, concordance between theASiTwas noted in only 59%(n=54). Overall cure rate was 97%. Intention-toWith thanks to the wonderful scans Conference Admin team: info@asit.org treat analysis, based on preoperative imaging showed cure rates of 96% with BNE and 98% with MIP(p=0.53); whereas, based on Laura Andrews Kristina Gloufchev Harriet Innes
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surgical approach, cure rates were 96.5% with BNE and 96.3% with MIP(p=1.0). Conclusions: Satisfactory cure rates for parathyroidectomy could be achieved in a DGH. Preoperative localisation studies with ultrasound and MIBI have a positive concordance rate in only 60% of those considered for MIP, thereby limiting the use of MIP and reinforcing the role of BNE in this era of minimally invasive surgery. 0239 IOPANOIC ACID IS SAFE AND EFFECTIVE AS A BRIDGE TO SURGERY IN THYROTOXICOSIS Suddendra Doddi, Christopher Buckle, Yazan Masannat, Narayana Prasad, Abbi Lulsegged, Prakash Sinha Princess Royal University Hospital, Bromley, London, UK Aim: To determine the efficacy and safety of iopanoic acid (IA) in achieving euthyroidism prior to total thyroidectomy in patients with thyrotoxicosis. Methods: Between 2007 and 2010, 9 patients with thyrotoxicosis were treated with IA prior to total thyroidectomy. Data regarding indications for surgery, dose of IA and final outcomes were collected Results: The age range of the patients was 22-65 years and mean was 38 years. All were females. The indications for surgery were as follows: allergic reaction to carbimazole(6 patients), neutropenia (1), propylthiouracil induced hepatotoxicity (1) and non-compliance with antithyroid drugs(1). The mean total dose of IA was 7.7 gm; the range being 4.4 to 10.5 gm. The mean total duration was 4 days. In 8 patients IA was used alone and in one patient it was used in combination with carbimazole. All achieved biochemical euthyroidism prior to surgery. Before and after the course of IA mean free T4 was 30 pmol/L and 11.4 pmol/L respectively (range: 9.4 to 22.7 pmol/ L). There were no adverse effects to IA. There were no complications following surgery. Conclusions: Iopanoic acid is safe and effective in rapidly controlling thyrotoxicosis prior to total thyroidectomy. 0623 SESTA-MIBI SCANS, CAN THEY PREDICT INTRATHYROID PARATHYROID ADENOMA? Rachel French, R. K. Maitra, Vijay Kurup North Tees Unniversity Hospital, Stockton-on-Tees, UK Aim: To evaluate the role of sesta-mibi scans in predicting intrathyroidal parathyroid adenoma in primary hyperparathyroidism. Method: Retrospective analysis of parathyroidectomies performed in a distric general hospital during the last 6 years(2005-11). Sestamibi scans were performed pre-operatively in all patients with primary hyperparathyroidism. Where no adenoma was identified during exploration of neck, a hemithyroidectomy was performed on the side suggested by sestamibi scan. Results: 78 patients had exploration of neck, 82% female, 18% male, with a mean age 62 years. Sestamibi was positive in 60 patients and 54 had parathyroid adenoma identified on exploration. 6 patients after a failed neck exploration underwent hemithyroidectomy . Histology revealed intrathyroidal parathyroid adenoma in 5 patients(83%) . Out of 18 patients with negative scans 14 had an adenoma removed. Sesta-mibi scans had a sensitivity of 81% and positive predictive value of 98.3%. Conclusion: Sestamibi scan helped to identify 5patients with intrathyroidal parathyroid adenoma when neck exploration was negative. When no adenoma is visible on exploration a hemithyroidectomy at the side suggested by the scan is justified. 0681 MINIMALLY INVASIVE PARATHYROIDECTOMY FOR PRIMARY HYPERTHYROIDISM GUIDED BY INTRA-OPERATIVE PARATHYROID HORMONE MONITORING Alison Lyon1, OO Komolafe2, Christopher Wilson2 1 University of Sydney, Sydney, Australia 2 Western Infirmary, Glasgow, UK Aim: Intra-operative parathyroid hormone (PTH) levels can demonstrate successful removal of a parathyroid adenoma during minimally invasive parathyroidectomy. However, this technique remains controversial due to variations in blood sampling and excision criteria. In this study, we explored the success rate of our technique. Methods: A consecutive series of 92 patients with histologically confirmed primary hyperparathyroidism was analysed retrospectively. All were treated with a minimally invasive technique. Serum PTH levels were checked prior to gland removal and twenty minutes after gland removal to confirm a decrease of greater than 50%, which was considered to indicate a curative procedure. Results: The median pre-operative PTH level was 14.35ng/L (interquartile range (IQR) 10.7-20.3). The two week post operative median level was 5.4ng/L (IQR 3.4-7) and median adjusted calcium level was 2.39mmol/L (IQR 2.28-2.5). The average intraoperative PTH decrease was 75.6%. Of the 92 patients, 8 (8.7%) required multiple gland removal due to adenoma location differing to that indicated by preoperative imaging (3 were retrosternal). The biochemical cure rate within this cohort was 98%. 2 patients had no intraoperative PTH drop and persisting hypercalcaemia. They underwent further imaging and curative surgery. Conclusion: Intra-operative PTH monitoring is a useful adjunct to minimally invasive parathyroidectomy. 0721 PATIENT OUTCOME FOLLOWING LAPAROSCOPIC BILATERAL ADRENALECTOMY Carol Watson, Craig Parnaby, Patrick ODwyer Gartnavel General Hospital, Glasgow, UK Introduction: The aim was to compare outcome of patients undergoing laparoscopic bilateral adrenalectomy (LBA) with those undergoing laparoscopic unilateral adrenalectomy (LUA) for similar conditions. Method: A retrospective analysis was performed of all patients (280) undergoing adrenalectomy in a single institution by the same surgeon between 1999-2011. 25 were LBA; 16 were for adrenal hyperplasia secondary to Cushing's disease, 5 for bilateral phaeochromocytoma, 3 for metastatic disease, one for bilateral adenomas and a case where one gland was hyperplastic and the other had a phaeochromocytoma. 122 patients underwent LUA for similar conditions during the same time period. Results: The mean operative time for LBA was 220 mins (range 105 to 325) compared to 110 mins for ULA (p=0.0001). There was one conversion in the LBA group compared to none in the ULA group. There were no intraoperative complications. 2 patients (8%) developed minor post-operative complications in the LBA group compared to 10 (8%) in the ULA group. The mean hospital stay was 3 days in the LBA group (range 2 to 14) compared to 1 day in the ULA group. Conclusion: Laparoscopic bilateral adrenalectomy is safe and associated with similar post operative outcomes to unilateral laparoscopic adrenalectomy.
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edd, Bangor 0912 OUTCOME al of Wales, Cardiff AFTER THYROID SURGERY - PATIENTS' PERSPECTIVE
tives:
m:
Gagandeep Grover, Gregory Sandler, Radu Mihai Departement of Endocrine Surgery, John Radcliffe Hospital, Oxford, UK Aims: The info@asit.org quoted risk of morbidity after thyroid surgery is based on published data from large series but patients' perception remains insufficiently explored. The aim was to explore and categorise outcomes of thyroidectomy into voice change, swallowing, scar, need
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for medication and calcium supplementation, and assess these complications from a subjective patients' point of view. Options of robotic thyroid surgery was also explored with patients. Method: A standardized questionnaire was mailed to 312 patients who underwent thyroid surgery in a large university hospital over 5 years. Results: Subjective voice assessment using a visual analogue scale normal in 130(67%) patients, deteriorated in 34(18%), improved in 28(15%) patients. Voice Handicap Index scores: normal 122 patients, increased in 70(36%) patients to a median of 17 (range 11-29). As a consequence Voice-Related-Quality-of-Life outcome was excellent in 100(53%) patients, fair-to-good in 81(41%) patients and poor-to-fair in 11(6%) patients. Subjective assessment of swallowing: normal 80 patients; moderately affected 112 patients. Appearance of the scarGoldie using the Manchester score ranged from 1-16 (median 7). assessed Khera Conclusions: On direct questioning a President of patients report persistent moderate voice and swallowing problems after thyASiT large proportion roid surgery. These findings are similar to the recent international multicentre survey.

0961 IS PRE-OPERATIVE 99M-TC SESTAMIBI SCANNING PREFERABLE TO NO PRE-OPERATIVE SCANNING IN PATIENTS WITH PRIMARY HYPERPARATHYROIDISM? Chevonne Brady, David Smith University of Dundee, Dundee, UK, Aim: Parathyroidectomy is key in the management of hyperparathyroidism, yet the methods used to preoperatively localize parathyroid Ed Fitzgerald pathology are controversial. 99m-Tc sestamibi scanning is the most commonly used method, however, some argue that surgical exASiT study is to establish whether pre-operative 99M-Tc sestamibi scanning is preferable to surgical perience is sufficient. The aim of this Conference Organiser & Past-President experience alone in the identification of pathology in patients with primary hyperparathyroidism. General Surgery Registrar, London Methods: Retrospective case-note review of 258 patients with primary hyperparathyroidism (199 female; mean age 61.1 13.1 years) who underwent parathyroidectomy between 2003 and 2010 in one centre. Results: 87.2% of patients underwent pre-operative sestamibi scanning. The technique had a sensitivity of 95.8% and a Positive Predictive Value of 96%. The rate of localisation to the correct side was 81.8%. 49.3% of scans could correctly localize the abnormal gland. Where no preoperative scanning was used, the abnormal gland was identified in 97% of cases. Conclusions: Surgical experience alone can successfully identify parathyroid pathology, however, bilateral neck exploration is necesJonny planning sary. Sestamibi scanning is useful in theWild of parathyroidectomy as it reduces the need for bilateral exploration, reducing postoperative morbidity. We acknowledgeHonoraryexperience is also important in improving the accuracy of parathyroidectomy. ASiT that surgical Secretary & Sponsorship Co-ordinator ENT SURGERY
General Surgery Registrar, Sheffield
0018 PREVENTION OF POST-OPERATIVE NAUSEA AND VOMITING IN TONSILLECTOMY/ADENOTONSILLECTOMY PATIENTS WITH THE USE OF ACUPUNCTURE POINT P6 STIMULATION - AN AUDIT BASED ON RECOMMENDATIONS FROM SIGN CLINICAL GUIDELINE 117 Robert Davies Stephanie Hili, Bertram Fu, Jeremy Davis ASiT Honorary Treasurer Department of Otorhinolaryngology, Medway Maritime Hospital, Gillingham, Kent, UK Aim: To audit the prevalence of using acupuncture for Post-Operative Nausea and Vomiting (PONV) prevention in patients undergoing Vascular Surgery Registrar, West Midlands tonsillectomy/adenotonsillectomy, as recommended by SIGN clinical guideline 117: "Management of sore throat and indications for tonsillectomy - A national clinical guideline". Methods: All anaesthetic practitioners of a district general hospital (DGH) in Kent were invited to complete a questionnaire regarding this practice. Results: There were 53 participants, with a 100% response rate: 17% trainees < ST3, 13% trainees ST3-8, 21% Staff Grade, and 49% Consultants. Although 58% of participants had been practising anaesthesia for over 10 years, only 25% were aware of this guideJames Milburn line. 3 consultants (6% of the cohort) were acupuncture practitioners but only 1 participant (2% of the cohort) practiced acupuncture as per SIGN clinical guideline ASiT Vice-President 117. Conclusion: If our hospital is representative of DGH's in the UK, we thus concluded that there is a general lack of awareness about the General Surgery Registrar, Inverness possible benefits of acupuncture related to ENT procedures in anaesthetic practice. Combined with lack of training and limited resources, this is preventing a practice which might be beneficial in patients not tolerating pharmacological methods, who are at high risk of developing PONV, or likely to suffer complications related to PONV. 0026 DAY CASE SEPTOPLASTY: ENSURING QUALITY WITHIN OUR TEACHING HOSPITAL James Higginson, Sinnappa Gunasekaran, Jemy Jose Joseph Shalhoub Hull an East Yorkshire Hospitals NHS Trust, Hull, UK ASiT Vice-President Aim: To compare local day case septoplasty complication rates with standards set out by the Royal National Throat and Ear Hospital Vascular Surgery Registrar, London (RNTEH). Methods: Data was collected retrospectively from case notes for patients undergoing day case septoplasty over a 5 year period. Results: Thirty-three cases were performed during the 5 year period: 28 cases by a consultant, 4 by a registrar, 1 by a staff grade clinician. Median operating time was 40 minutes (range 20-85). Mean age was 41 years (range 21-62). 29 patients were male. Indications were predominantly nasal obstruction (30). The remainder were for snoring. 15 septoplasties were performed in conjunction with another procedure. One patient (3%) was admitted following Steve Hornby surgery due to bleeding. There were no readmissions within 30 days. ASiT Director of our trust compares favourably with the results of the RNTEH: a 3% admission Conclusions: Day case septoplasty performed within Education rate compared with 8.8%. However, it must be notedRegistrar, South West Peninsula of procedures were performed by General Surgery that within our institution a greater proportion consultant grade surgeons. Should the number of septoplasties increase, a corresponding increase in more junior grades performing the operation is to be expected. Re-audit would then be required to ensure standards were maintained. 0059 PROPHYLACTIC ANTIBIOTIC USE IN NASAL PACKING FOR Regional Representatives: AND IMPLEMENTAWith thanks to the local ASiT Welsh ACUTE EPISTAXIS ADMISSIONS: AUDIT TION OF NEW GUIDELINES Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Timothy Biggs, Anthony Gough, Kari Nightingale, Phillippa Euden, Rami Salib, Nimesh Patel Gwynedd, Bangor University of Southampton NHS Foundation Trust, Southampton, UK Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Introduction: There are no published guidelines for prophylactic antibiotic use in nasal packing for spontaneous epistaxis. This audit proposes a set of guidelines and assesses their implementation. Guidelines: No systemic prophylactic antibiotics in anterior nasalConference Admin team: info@asit.org With thanks to the wonderful ASiT packing in-situ 48 hours. Oral co-amoxiclav in; anterior packing insitu >48 hours, posterior packing, traumatic nasal packing or clinical signs of infection. Naseptin topical antibiotic use in all nasally
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packed epistaxis patients (14 days duration) following pack removal. Methods: 58 patients undergoing nasal packing for spontaneous epistaxis were studied at Southampton University Hospital. Re-audit occurred after implementation of guidelines. Telephone surveys were conducted following hospital discharge. Results: Initial audit revealed the majority of nasally packed patients were receiving systemic prophylactic antibiotics. Following new guidelines systemic antibiotic prescribing fell by 44.8% with no statistically significant increase in nasal symptoms, re-bleeding or readmission rates following hospital discharge (p values 0.212 1.0). Conclusions: Systemic prophylactic antibiotics are unnecessary in the majority of anterior nasal packed spontaneous epistaxis patients. Following these guidelines doesnt have any statistically significant detrimental effects on nasal symptoms, re-bleeding or readmission following hospital discharge. Therefore these guidelines can be followed safely in hospitals across the UK. 0069 TRAINERS AND TRAINEES-HOW SATISFIED ARE WE WITH THE ISCP PLATFORM, AN ENT PERSPECTIVE Bertram Fu, Kavit Amin, Stephanie Hill, Jeremy Davis Medway Maritime Hospital, Kent, UK Aims: Using the Intercollegiate Surgical Curriculum Project (ISCP) is compulsory for all surgical trainees. We questioned ENT trainees/trainers to assess their experience with ISCP. Method: An electronic questionnaire was distributed to the Association of Otolaryngologists in Training (AOT) members and ENT consultants in Kent, Surrey, and Sussex. Results: There were 86 respondents, of which 91% used ISCP. This included 55% trainees and 45% trainers. 87% felt the 125 trainee fee to be too high. On average during a month, 51% did 1-2 Work Based Assessments (WBAs). 53% used less than 10 minutes for completing one WBA and 41% used 10-20 minute. There were mixed responses to users feeling of usefulness and satisfaction for each type of WBAs. 47% encountered problems with ISCP usage. 58% gave an overall satisfaction in using ISCP of 5 or less out of 10. Conclusions: The overall user satisfaction was sub-optimal. Possible solutions may include the introduction of specialty-specific WBAs, with better integration with surgical logbooks and websites, and a reduction of the JCST trainee fee. We are aware that the ISCP website is constantly evolving, and that some of the suggestions made here may already be being incorporated into future system upgrades.
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0094 THE BENEFIT OF BILATERAL COCHLEAR IMPLANTS Alice Talbert1, John Culling1, Steven Backhouse2 1 Cardiff University, Department of Psychology, Cardiff, Wales, UK 2 South Wales Cochlear Implant Programme, Princess of Wales Hospital,, Bridgend, Wales, UK Current evidence indicates limited hearing advantage for bilateral over unilateral cochlear implantation. This study adapts a model of spatial release from masking for use with cochlear implantees. Data was collected to test the model's predictions that current literature significantly underestimates the benefit of a second cochlear implant. Speech reception thresholds (SRTs) were measured for speech in noise in five spatial configurations for 5 normal hearing (NH) listeners and 8 unilateral cochlear implant (UCI) users. Spatial configurations included speech and noise in front (0/0), speech in front with noise at 90 (0/+90 and 0/-90) and speech and noise at 60 (-60/+60 and +60/-60). The model correctly predicted SRTs for each group. For UCI users, the difference in SRTs between -60/+60 and +60/-60 was 18 dB. The model predicted that UCI users, but not bilateral cochlear implant (BCI) users, would experience this 18 dB asymmetry. Previous studies show a 4-5 dB benefit to speech intelligibility in noise for BCI users. This study's results indicate that the benefit of BCIs has been substantially underestimated and in fact extends up to 18 dB. These outcomes can influence optimising listening performance of cochlear implantees in day to day life, and potentially guide future implantation policies. 0101 CRITERIA FOR URGENT RIGID BRONCHOSCOPY FOR SUSPECTED FOREIGN BODY INHALATION Arunjit Takhar, Javed Uddin, Raguwinder Sahota, Andrew Moir Department of Otolaryngology, University Hospitals of Leicester NHS Trust, Leicester, UK Aim: Assess our current practice with regard to timing and clinical indicators for rigid bronchoscopy in cases of suspected foreign body inhalation. We compared our findings with current best practice in order to create a guideline. Methods: Retrospective analysis of bronchoscopies performed from 2nd July 2003 - 14th July 2010. Results: 22 cases were identified in which 55% a foreign body was identified and retrieved. The median age was 2.1 years. All clinically unstable patients were taken to theatre as an emergency and stable patients underwent bronchoscopy during the next available daytime operating slot. A foreign body was found in 75% of patients where all three of the following were present: history of choking episode, persisting symptoms and abnormal physical examination. Conclusion: In patients with a history of choking episode, ongoing respiratory symptoms and examination abnormalities an urgent bronchoscopy is mandatory. Following this criteria we would have achieved a sensitivity of 80% and reduced the number of foreign body negative bronchoscopies by 70% without omitting any foreign body positive patients. For patients who only meet some of these criteria then a period of inpatient observation is advocated. Using this information we created a guideline to determine likely need for intervention.
0105 'PERMACOL PURSE' - A UNIQUE APPLICATION OF PERMACOL IN AUGMENTATION RHINOPLASTY Edward Tudor, Ali Taghi, Romana Kuchai, Hesham Saleh Imperial College Healthcare NHS Trust, London, UK Introduction: Permacol (Tissue Science Laboratories plc) is cross-linked, porcine dermal collagen with its constituent elastin fibres. It is colonised by tissues and blood vessels. Within ENT, it can be used in rhinoplasty or for camouflaging a bony dorsum. We describe a unique method that can be configured to the defect. Methodology: On assessment of the dorsal defect we create an appropriately sized rectangular pocket of Permacol. Three sides of the pocket are closed with an absorbable suture. The pocket is filled with diced autologous septal or conchal cartilage, and sutured tives: closed, before being placed subcutaneously over the dorsal defect. edd, Bangor Results: Over 3 years, we have applied this technique in more than 10 cases with no known complications. Discussion: al of Wales, Cardiff Permacol has a number of advantages making it superior to other graft materials. This technique is a modificaton of Erol's technique using Surgicel. Autologous grafting is considered entirely satisfactory; however, it is not without risks. The limited literature available has reported only a handful of disadvantages and complications associated with the use of Permacol. We have no cases of complications m: info@asit.org pertaining specifically to its use. Our case series is limited by numbers; we hope to present a comprehensive analysis in the future.
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0155 A SAFETY ASSESSMENT OF A&E REFERRED ENT PATIENTS Ananth Vijendren, Shayan Shah Luton and Dunstable NHS Trust, Luton, UK Aim / Objective: ENT presentations are common in both primary and emergency care.In our A+E, presentations are occasionally referred directly for specialist opinion. However,a subset of patients were noted to be unstable and being referred without any primary interventions.Due to the lack of guidelines, we aimed to identify Goldie Khera a)A+E referrals being made to the ENT departmen b)Appropriateness of referral ASiT President c)Interventions done prior to referral Bariatric Fellow, North 30.9.2011 were identified.Data was collected via a proforma on grade of Methods: All ENT referrals from A+E between 1.9.2011 and Tyneside referrer,nature of presentation,time referred and seen by ENT,nature of basic intervention performed and the adequacy of A+E management. Results: All 29 referrals were appropriate,mostly from A+ E doctors. Out of 14 referrals of acutely bleeding patients (half being children),9 patients did not have adequate circulatory support when seen by ENT.The remaining 15 referrals,10 had been appropriately treated prior to referral.The mean time difference from being referred and seen by ENT was 36.08 minutes with a median of 30 minutes. Ed Fitzgerald Conclusion: Of 29 referrals,15 had satisfactory A+E interventions and 14 needed further support,primarily concerning circulation.We ASiT Conference programme on ENT emergencies and to are working closely with the A+E to organise a teachingOrganiser & Past-President create a trust guideline on referring.
ASiT Honorary Treasurer 0194 CAUTERY TO INFERIOR TURBINATES IN ALLERGIC RHINITIS: RIGHT SURGERY AT THE RIGHT TIME? Vascular Surgery Registrar, West Midlands Hiten Joshi, Suzanne Jervis, Matthew Oluwole Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK Aims: To determine whether those patients undergoing cautery to inferior turbinates (CITS) were correctly diagnosed with allergic rhinitis, with appropriate documented evidence and investigations; and to determine whether they had undergone appropriate initial management prior to surgery according to guidelines.1 Method: Data was examined retrospectively between 2006 and 2011. Clinical codes for CITS were obtained and data was extracted James patient notes. from a computerized archive system and Milburn Results: 57 patients were identified. Vice-President a mean age of 29 years. Commonest symptoms were nasal obstruction ASiT 59% were male with (94%) and rhinorrhoea (19%). 26% of patients were diagnosed with allergic rhinitis through skin prick and/or RAST testing. 87% reGeneral Surgery Registrar, Inverness ceived appropriate nasal sprays with only 19% receiving oral antihistamines when nasal steroids failed to control symptoms. Postoperatively only 8% were provided with a steroid nasal spray. 31% were followed-up at a median time of 6 weeks. 64% reported symptom improvement. Conclusion: The benefit of CITs is unproven within the literature and remains a procedure to be considered once all treatments have failed. In our unit, first and second line treatments were poorly utilised prior to surgery. Treatment algorithms should improve the medical management of the condition and reduce the numbers undergoing CITs.
0205 ASiT Vice-President THE USE OF ANTICOAGULANT AND ANTIPLATELET MEDICATION IN ADMITTED EPISTAXIS PATIENTS: IMPLEMENTATION Vascular Surgery Registrar, London OF NEW GUIDELINES Anthony Gough, Timothy Biggs, Paramita Baruah, Jason Mainwaring, Phillip Harries, Rami Salib University of Southampton Hospital NHS Foundation Trust, Southampton, UK Aim: To standardise the management of anticoagulant and antiplatelet prescribing in ENT patients admitted with epistaxis. Method: Initial audit (1st Sept and 31st Dec 2010) was conducted retrospectively studying 43 admitted epistaxis patients. Guidelines on antiplatelet and anticoagulantSteve Hornby prescribing were formulated with input from ENT and haematology consultants. Guidelines have been implemented (15th Nov 2011) and re-audit currently underway. Results: On initial audit 69% ASiT Director ofwith epistaxis were on some form of anticoagulant or antiplatelet medication. A of patients presenting Education significant number of patientsGeneral medications Registrar, South to hospital (>70%) even though the majority were non life had these Surgery stopped on admission West Peninsula threatening bleeds controlled adequately with nasal packing. Guidelines were implemented and re-audit started. So far re-audit has shown a significant reduction in unnecessary withholding of anticoagulant and antiplatelet medication with no statistically significant increase in complication rates (increased admission, DVT, PE, re-admission with bleeding following discharge). Conclusion: No guidelines currently exist within the literature on the management of antiplatelet or anticoagulant use in epistaxis patients; therefore this audit is significant localrespect. Current data from re-audit has shown favourable results and full results will be With thanks to the in that ASiT Welsh Regional Representatives: available for presentation in March 2012. 0237 Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff WHAT IS THE VALUE OF A ONE-STOP' CLINIC IN ASSESSING TWO WEEK WAIT NECK LUMP REFERRALS? Arunjit Takhar1, Michael Jones1, Ram Vaidhyanath2, Peter Conboy1, Tom Alun-Jones1 1 Department of Otolaryngology, University Hospitals of Leicester Conference Admin team: info@asit.org With thanks to the wonderful ASiT NHS Trust, Leicester, UK 2 Department of Radiology,University Hospitals of Leicester NHS Trust, Leicester, UK
0190 LITIGATION WITHIN OTOLARYNGOLOGY: AN UPDATE AND REVIEW OF CURRENT TRENDS AND RECOMMENDATIONS Ali Qureishi, George Garas Queens Medical Centre, Nottingham, UK Aims: To analyse trends in litigation claims made against otolaryngologists within the NHS in the past 8 years and identify areas to be aware of during future practice. Jonny Wild Methods: The NHS litigation authority was asked to provide data relating to all claims within otolaryngology over the past 8 years. The claims were sub-divided and their nature, location, year and amount paid were recorded. A literature review using EMBASE and MedASiT Honorary Secretary & Sponsorship Co-ordinator line was performed and comparisons made to previous publications. General Surgery Registrar, Sheffieldopen. 21,837,141.27 was paid and 34million held in Results: 585 claims were notified, 313 successful, 161 unsuccessful and 111 reserve. The majority of claims related to complications within the operating theatre (49.6%) followed by outpatients (32.1%). The commonest claim was failure/delay in diagnosis (19.7%) then failure/delay in treatment (15%) and failure to warn/obtain informed consent (6.8%). The majority of claims related to head and neck surgery (27.86%) followed by otology (25.1%). There were 33 (5.6%) never events recorded. Conclusions: Clearly all claims cannot be avoided; however simple measures can decrease this number. With an increased awareness of potential pitfalls, our practice and Davies Robert patient satisfaction can improve whilst limiting financial strains on an overburdened NHS.
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Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor
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Aim: To assess our surgeon and radiologist one-stop' clinic compared to conventional head and neck clinic in the assessment of neck lumps. The one-stop' service has provision for ultrasound examination and guided fine needle aspiration. Method: Retrospective analysis of all patients referred with a lump under the two week wait from 8 th November 2010 - 31st January 2011. Results: A total of 72 new patients were seen, 26.4% of which were assessed in our one-stop' service. The average time to diagnosis was 29.5 days in a standard head and neck clinic compared to 10.7 days in our one-stop clinic (p=0.003). The average number of outpatient appointments required to make a diagnosis was 2.0 in the standard clinic compared to 1.5 in the one-stop' service (p=0.014). The longest time to cancerous diagnosis was 107 days in our standard clinic compared to 11 days in the 'one-stop' service. Conclusion: The one-stop' model of assessing patients with neck lumps leads to significantly shortened time to diagnosis and fewer follow-up appointments providing mutual benefit to both patients and limited NHS resources. This has lead to a restructuring of our outpatient services with the objective that all neck lumps are assessed in a one-stop' clinic. 0259 INTRADEPARTMENTAL VARIABILITY IN FINE NEEDLE ASPIRATION TECHNIQUE AND CYTOLOGICAL DIAGNOSTIC ADEQUACY RATE IN THYROID AND NECK MASSES Vinay Varadarajan1, Edward Ridyard2 1 North West Higher Surgical Training Scheme, Manchester, UK 2 The University of Manchester Medical School, Manchester, UK Aims: To assess variability in fine needle aspiration (FNA) technique and diagnostic adequacy rate amongst surgeons sampling thyroid and neck masses Methods: A retrospective single-blinded analysis of all surgeons' FNA results was undertaken after consent. Sample adequacy was defined as "enough cells to establish a firm cytological diagnosis". Kolmogorov-Smirnoff testing confirmed normal distribution in the data set Results: A total data set of n=70, represented the ten most recent FNA results of the seven surgeons included. Marked variability in technique existed amongst all surgeons. The diagnostic rate ranged from 80% to 30% with a departmental average of 52.7%. Ttesting showed two surgeons achieved a significantly higher diagnostic rate (P=0.007 and P=0.045) and one surgeon had a significantly lower rate (P=0.015) compared to the departmental average. The highest diagnostic rates were achieved using the same technique. Experience of surgeon was not a causal factor and correlation coefficient testing revealed no statistical difference between needle size (P=0.348) and number of samples per patient (P=0.348). Conclusions: There may exist a marked variability in FNA technique and success rate within a unit. Cytological adequacy rates are more dependent on technique rather than experience. We encourage others to monitor their FNA adequacy rates and technique. 0276 ASSOCIATION OF AGE AND OVERALL SURVIVAL (OS) IN INDUCTION CHEMOTHERAPY (IC) TREATED PATIENTS WITH LOCALLY ADVANCED HEAD AND NECK CANCER (LAHNC) Emma Cashman, Marshall Posner, Jorchen Lorch Dana Farber Cancer Institute, Boston, USA Introduction/Aim: To determine if an association exists between age and OS in IC with docetaxel, cisplatin and 5FU (TPF) versus cisplatin and 5fluorouracil (PF) followed by CRT and/ or surgery. Methods: 501 patients from the TAX 324 study (stage III or IV HNC) were evaluated. OS was estimated by Kaplan-Meier method in TPF and PF arms. In patients >55 yrs in the TPF arm, this difference was significant (p=0.04) while it was not for those < 55 (p=0.18). Conclusion: The higher rate of HPV OPC in younger patients in our series and the improved survival in both arms for this population may account for the fact that the difference did not attain significance in the younger population. Our finding that age had a positive influence on outcomes is new and previously unreported. Larger, prospective studies should observe for similar age-related differences in chemotherapy response. 0277 P 16 AND ITS ROLE IN HPV-POSITIVE KOLIOCYTIC DYSPALSIA (KD) OF THE ANTERIOR ORAL CAVITY: A CASE SERIES Emma Cashman, Sook Bin-Woo Brigham and Women's Hospital, Boston, USA Background: Over the last few years, studies demonstrate a group of oropharyngeal carcinomas that are strongly associated with high risk human papillomavirus (HPV), especially HPV-16 that is almost always p16 positive, is unassociated with cigarette smoking and that has a better prognosis, and that has a better prognosis than conventional HPV-negative cancers. Anterior oral cavity cancers are infrequently associated with high risk HPV subtypes and oral dysplasias even less so. Methods: Detection of p16 was preformed using Immunohistochemistry. A tonsillar tumor specimen with intense p 16 expression used as a positive control. For negative control primary antibody was omitted. P 16 immunostaining was considered positive if > 60% of cells were affected. Nuclear & cytoplasmic staining evaluated separately. In Situ Hybridization (ISH) to detect HPV DNA. Results: We report 10 cases of oral dysplasia clinically presenting as oral leukoplakia that present primarily on the ventral/lateral tongue and floor of mouth (80%) that occur mostly in adult men (80%) and that are positive for high risk HPV subtypes and for p16. The histology is characterized by full thickness involvement by cells in varying degrees of karyoarrhexis and apoptosis with surrounding mild to moderate dysplasia.
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0293 ENT EMERGENCY CLINIC ACTIVITY Jagdeep Virk, Behrad Elmiyeh, Arvind Singh Northwick Park Hospital, London, UK Aims: to assess activity of emergency clinics, institute changes and re-audit to gauge improvement in service provision Methods: After an initial audit, having identified the issues, we supplied guidelines for accepting, documenting and booking referrals for ENT junior doctors including recommendations to reduce follow ups safely, redirect inappropriate referrals to main outpatients and management protocols for common conditions. These changes were implemented by distribution of guidelines and educating GPs and A&E staff. tives: Results: Re-audit v 1st audit: Clinic activity 7.2 v 9.8; Follow ups 45 v 158; Direct outpatient bookings 15 v 59; Number of re-referrals edd, Bangor by GP 15 v 1; A&E and GP still main referrers (95%); referrals typically otitis externa, foreign bodies, epistaxis, nasal trauma (but less inappropriate referrals in re-audit: 21 v 89). al of Wales, Cardiff Conclusions: We can work together to improve patient care and save money (by reducing unnecessary follow ups) as well as generate income (by gaining re-referrals and GP referrals to main outpatients), reflecting the importance of interacting and working with our colleagues m: info@asit.org in management rather than remaining a separate, clinical arm of the NHS to achieve the best possible care. Clinical governance has an integral role to play in maintaining and driving forward the standard of care.
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0310 A FIVE YEAR EXPERIENCE OF STAPES SURGERY IN A DISTRICT GENERAL HOSPITAL Hannah Lancer, Azrina Zaman, Smeeta Wong, Chee-Yean Eng, Jack Lancer Rotherham NHS Foundation Trust, South Yorkshire, UK Aim: To assess the outcome of stapes surgery, and hearing improvement, and the effects of that surgery on tinnitus and taste sensation, and to assess the complication rate. Method: A retrospective study of 137 consecutive stapes operations performed by a single surgeon, predominantly carried out under Goldie Khera local anaesthesia, using the Fisch teflon-platinum prosthesis, from January 2005- December 2010. Results: 137 operations on 109 patients were analysed and included incudo-stapedotomy in 111 cases, and malleo-stapedotomy in 15 ASiT President cases. The average pre-operative air-bone gap was 31.5db HL, reducing to 13.8 db HL at one year post-operatively. Subjective hearing improvement was 94% atBariatric Fellow, North Tyneside one month (83% at one year). 21% of patients reported taste disturbance at one month. Pre-operative tinnitus was present in 50% of patients, and reduced significantly post-operatively. There were no significant complications. Conclusion: Our study has shown a statistically significant reduction in the air-bone gap, and an improvement in hearing of all patients who had stapedotomy carried out for otosclerosis. The outcome of stapes surgery for ossicular erosion or fixation secondary to chronic otitis media, and for congenital abnormalities, including osteogenesis imperfecta, tends to be rather less successful when compared to otosclerosis.
Ed Fitzgerald 0315 ASiT Conference Organiser & Past-President HOW ACCURATE IS CLINICAL SUSPICION OF ASYMMETRICAL TONSILS FOR THE DIAGNOSIS OF CANCER? A 10 YEAR COMPLETED AUDIT OF CLINICAL ASYMMETRICAL TONSILS VS. HISTOLOGY General Surgery Registrar, London Omar Mulla, Tooba Mazhar, Frank Agada, Andrew Coatesworth York Teaching Hospital, York, UK Aim: To determine sensitivity of clinical suspicion of tonsillar carcinoma based on asymmetry of tonsils. Method: A retrospective review of 147 clinical notes and pathological results was performed for patients, who presented with clinical asymmetrical tonsils from June 2001-June 2006 in York Teaching Hospital. The data was analysed, presented and best practice principles were implemented. A second audit cycle from July 2006 - July 2011 Jonny Wild was carried out, analysing a further 293 notes. Results: A total of 440 tonsillectomiesHonorary Secretary & Sponsorship Co-ordinator ASiT were performed for unilateral enlargement from 2001 to 2011. The number of histologically proven tumours increased marginally from 15.65% to 16.1% between the first and second cycles. The General Surgery Registrar, Sheffield majority were SCC. The correlation of clinical suspicion of malignancy with asymmetrical tonsils increases with age - 87.87% of all tumours werein those older than 50 MRI has a sensitivity of 88.23% and specificity of 38.46% in the detection of cancer in patients with unilateral tonsillar enlargement. Conclusion: The proven tumour rate marginally increased between the first and second audit. With such a high MRI sensitivity we feel all patients should receive a pre-operative MRI. We propose the York Clinical Criteria for Tonsillectomy in Unilateral tonsils (YCCT)to improve clinical diagnostic sensitivity. Robert Davies
0334 ASiT Honorary Treasurer THE IMPACT OF THYROPLASTY ON POST-OPERATIVE SYMPTOMATOLOGY AND PATIENT SATISFACTION C. Lucy Dalton, Elizabeth Illing, Sucha Hampal Vascular Surgery Registrar, West Midlands Warrington & Halton Hospitals NHS Foundation Trust, Warrington, UK Aim: This study's aim was to review the impact of thyroplasty on symptoms related to voice quality and to assess patient satisfaction with post-operative results. Method: All patients who underwent thyroplasty in our trust between August 2004 and July 2011 were included. Case-notes were reviewed retrospectively to identify pre-and post-operative voice quality. Additionally, a post-operative telephone questionnaire was conducted to assess patient satisfaction. James Milburn Results: 28 patients were identified, but six excluded due to unavailable case-notes. 21 cases had a Montgomery implant, one a cartilage patch graft. All patients originally presented with hoarseness. This improved post-operatively in 82%. Of patients with difficulties ASiT Vice-President speaking for longer periods prior to surgery 57% noticed a post-operative improvement. General Surgery Registrar, Inverness 10 patients completed the telephone questionnaire (five patients had deceased, seven were not contactable). 60% felt their voice had much improved, 20% noted improved swallowing, 40% reported improved talking for long periods, and 50% showed improved ability to speak on the telephone. In 60% of cases, friends and family were reported to describe the patient's ability to communicate as much improved. Conclusions: In our study, thyroplasty as a method for vocal cord medialisation led to improved voice quality post-operatively and to good patient satisfaction. 0363 ASiT Vice-President INSERTION OF A SECOND NASAL PACK AS A PROGNOSTIC INDICATOR OF EMERGENCY THEATRE REQUIREMENT IN Vascular Surgery Registrar, London EPISTAXIS PATIENTS Edward Ridyard1, Vinay Varadarajan2, Indu Mitra3 1 University of Manchester, Manchester, UK 2 North West Higher Surgical Training Scheme, North West, UK 3 Manchester Royal Infirmary, Manchester, UK Aim: To quantify the significance of second nasal pack insertion in epistaxis patients, as a measure of requirement for theatre. Steve Hornby Method: A one year retrospective analysis of 100 patient notes was undertaken. After application of exclusion criteria (patients treated ASiT Director of Education as outpatients, inappropriate documentation and patients transferred from peripheral hospitals) a total of n=34 patients were included. Of the many variables measured, specific credence was given to requirement of second packing and requirement for definitive manGeneral Surgery Registrar, South West Peninsula agement in theatre. Results: Of all patients, 88.5% required packing. A further 25% (7/28) of this group had a second pack for cessation of recalcitrant haemorrhage. Of the second pack group, 85.7% (6/7) ultimately required definitive management in theatre. One sample t-test showed a statistically significant correlation between patients with a second nasal pack and requirement for theatre (p<0.001). Conclusions: Indications for surgical management for epistaxis varyRegional to hospital. The results of this study show that inserWith thanks to the local ASiT Welsh from hospital Representatives: tion of a second pack is a very good indicator of requirement for definitive management in theatre. 0365 Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff MANAGEMENT OF LARYNGEAL CANCERS: GRAMPIAN EXPERIENCE Therese Karlsson3, Muhammad Shakeel1, Peter Steele1, Kim Wong Ah-See1, Akhtar Hussain1, David Hurman2 1 Department of otolaryngology-head and neck surgery, AberdeenConference Admin team: info@asit.org With thanks to the wonderful ASiT Royal Infirmary, Aberdeen, UK, 2 Department of Oncology, Aberdeen Royal Infirmary, Aberdeen, UK,
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University of Aberdeen, Aberdeen, UK Aims: To determine the efficacy of our management protocol for laryngeal cancer and compare it to the published literature. Method: Retrospective study of prospectively maintained departmental oncology database over 10 years (1998-2008). Data collected include demographics, clinical presentation, investigations, management, surveillance, loco-regional control and disease free survival. Results: A total of 225 patients were identified, 183 were male (82%) and 42 female (18%). The average age was 67 years. There were 81 (36%) patients with Stage I disease, 54 (24%) with Stage II, 30 (13%) with Stage III and 60 (27%) with Stage IV disease. Out of 225 patients, (130)96% of Stage I and II carcinomas were treated with radiotherapy (55Gy in 20 fractions). Patients with stage III and IV carcinomas received combined treatment. Overall three-year survival for Stage I, II, III and IV were 91%, 65%, 63% and 45% respectively. Corresponding recurrence rates were 3%, 17%, 17% and 7%; 13 patients required a salvage total laryngectomy due to recurrent disease. Conclusion: Vast majority of our laryngeal cancer population is male (82%) and smokers. Primary radiotherapy provides comparable loco-regional control and survival for early stage disease (I & II). Advanced stage disease is also equally well controlled with multimodal treatment.
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0366 RATES OF RHINOPLASTY PERFORMED WITHIN THE NHS IN ENGLAND AND WALES: A 10-YEAR RETROSPECTIVE ANALYSIS Luke Stroman, Robert McLeod, David Owens, Steven Backhouse University of Cardiff, Wales, UK Aim: To determine whether financial restraint and national health cutbacks have affected the number of rhinoplasty operations done within the NHS both in England and in Wales, looking at varying demographics. Method: Retrospective study of the incidence of rhinoplasty in Wales and England from 1999 to 2009 using OPCS4 codes E025 and E026, using the electronic health databases of England (HesOnline) and Wales (PEDW). Extracted data were explored for total numbers, and variation with respect to age and gender for both nations. Results: 20222 and 1376 rhinoplasties were undertaken over the 10-year study period in England and Wales respectively. A statistical gender bias was seen in uptake of rhinoplasty with women more likely to undergo the surgery in both national cohorts (Wales, p<0.001 and England, p<0.001). Linear regression analysis suggests a statistical drop in numbers undergoing rhinoplasty in England (p<0.001) but not in Wales (p>0.05). Conclusion: Rhinoplasty is a common operation in both England and Wales. The current economic constraint combined with differences in funding and corporate ethos between the two sister NHS organisations has led to a statistical reduction in numbers undergoing rhinoplasty in England but not in Wales. 0427 PATIENTS' PREFERENCES FOR HOW PRE-OPERATIVE PATIENT INFORMATION SHOULD BE DELIVERED Jonathan Bird, Venkat Reddy, Warren Bennett, Stuart Burrows Royal Devon and Exeter Hospital, Exeter, Devon, UK Aim: To establish patients' preferences for preoperative patient information and their thoughts on the role of the internet. Method: Adult patients undergoing elective ENT surgery were invited to take part in this survey day of surgery. Participants completed a questionnaire recording patient demographics, operation type, quality of the information leaflet they had received, access to the internet and whether they would be satisfied accessing pre-operative information online. Results: Respondents consisted of 52 males and 48 females. 16% were satisfied to receive the information online only, 24% wanted a hard copy only and 60% wanted both. Younger patients are more likely to want online information in stark contrast to elderly patients who preferred a hard copy. Patients aged 50-80 years would be most satisfied with paper and internet information as they were able to pass on the web link to friends and family who wanted to know more. 37% of people were using the internet to further research information on their condition/operation. However, these people wanted information on reliable online sources to use. Conclusions: ENT surgeons should be alert to the appetite for online information and identify links that are reliable to share with patients. 0510 ENHANCING COMMUNICATION BETWEEN DOCTORS USING DIGITAL PHOTOGRAPHY. A PILOT STUDY AND SYSTEMATIC REVIEW Hemanshoo Thakkar, Vikram Dhar, Tony Jacob Lewisham Hospital NHS Trust, London, UK Aim: The European Working Time Directive has resulted in the practice of non-resident on-calls for senior surgeons across most specialties. Consequently majority of communication in the out-of-hours setting takes place over the telephone placing a greater emphasis on verbal communication. We hypothesised this could be improved with the use of digital images. Method: A pilot study involving a junior doctor and senior ENT surgeons. Several clinical scenarios were discussed over the telephone complemented by an image. The junior doctor was blinded to this. A questionnaire was completed which assessed the confidence of the surgeon in the diagnosis and management of the patient. A literature search was conducted using PubMED and the Cochrane Library. Keywords used: mobile phone, photography, communication and medico-legal. Results & Conclusions: In all the discussed cases, the use of images either maintained or enhanced the degree of the surgeons confidence. The use of mobile-phone photography as a means of communication is widespread, however, its medico-legal implications are often not considered. Our pilot study shows that such means of communication can enhance patient care. We feel that a secure means of data transfer safeguarded by law should be explored as a means of implementing this into routine practice.
0533 THE ENT EMERGENCY CLINIC AT THE ROYAL NATIONAL THROAT, NOSE AND EAR HOSPITAL, LONDON: COMPLETED AUDIT CYCLE Ashwin Algudkar, Gemma Pilgrim Royal National Throat, Nose and Ear Hospital, London, UK Aims: Identify the type and number of patients seen in the ENT emergency clinic at the Royal National Throat, Nose and Ear Hospital, tives: implement changes to improve the appropriateness of consultations and management and then close the audit. Also set up GP correedd, Bangor spondence. Method: al of Wales, Cardiff First cycle data was collected retrospectively over 2 weeks. Information was captured on patient volume, referral source, consultation nature and patient destination. Changes implemented included ensuring the management and follow-up of otitis externa patients met the American Academy of Otolaryngology-Head and Neck Surgery Foundation guidelines. Data for the second cycle was then collected m: info@asit.org retrospectively over 2 weeks after staff education. A GP letter was issued for every patient seen. Results: First cycle: 261 patients. Follow-ups: 28%. Reviewed patients: 23% booked for emergency clinic follow-up, 17% booked for
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main clinic follow-up. Discharge rate: 43%. Second cycle: 158 patients. Follow-ups: 9%. Reviewed patients: 9% booked for emergency clinic follow-up, 3% booked for main clinic follow-up. Discharge rate: 72%. Conclusions: Managing the common condition otitis externa according to international guidelines has improved the workload and follow-up rate in the RNTNE emergency clinic. Improving staff numbers has also helped. By setting up correspondence we have also improved communication with GPs.
Goldie Khera 0563 AN AUDIT OF THE PUNCTUALITY OF THEATRE LISTS WITHIN AN ENT DEPARTMENT ASiT President Shyamica Thennakon, Christopher Webb Bariatric Fellow, Liverpool, UK Royal Liverpool and Broadgreen University Hospital, North Tyneside Aim: Operating theatres utilise between 1-16 million per annum in each trust, with our departments patient waiting lists for elective ENT operations averaging at two months. Our audit aims to assess if our department is maximising our allocated theatre time with punctual starts (standard = 95%). Methods: A retrospective audit of 35 consecutive, elective theatre lists in a two month period (01.11.2011 31.12.2011). We compare start and end times of theatre lists as recorded by the ORMIS theatre system with the scheduled theatre time. Results: 97% of our theatre lists started late (range10-58 minutes). Of the theatre lists which started late, 74% finished late (range 19Ed Fitzgerald 126 minutes), 26% finished early (range 19-126 minutes). 3% of theatre lists started early (9 minutes) and finished late (101 minutes). ASiT inefficient use of allocated theatre Past-President Conclusion: We have highlighted an Conference Organiser & time and propose a supplementary documenting system of theatre timings. This aims to Generaland raise awareness of which arm(s) of the surgical process (the anaesthetist, theatre staff, document Surgery Registrar, London surgeon, ward staff or patient) is accountable for the delays. Information from this new system aims to facilitate awareness and further changes.
0579 CONSENT FOR ENT SURGERY - ARE WE THE ONES AT RISK? Matthew Smith, Raj Lakhani Jonny Wild Peterborough City Hospital, Peterborough, UK Aim: To audit the consent process for Honorary Secretary & Sponsorshipand BMA guidance. ASiT common ENT operations against DoH, GMC, RCS Co-ordinator Method: Consecutive patients undergoing common ENT procedures were identified. 120 consent forms and all clinic letters relating to General Surgery Registrar, Sheffield tonsillectomy, grommet insertion, septoplasty and hemithyroidectomy were analyzed Results: All patients had consent forms. Only procedure', intended benefit' and anaesthetic' sections received 100% completion. Consent was taken by SHOs (4%), Staff grades (14%), SpRs (44%) and Consultants (38%). Day-of-surgery consent occurred in 7.5% cases. The average period between consent and surgery was two months, though consent confirmation only occurred in 40%, with no correlation to period elapsed. The number of risks listed for each procedure decreased with staff seniority. Despite 100% of forms for tonsillectomy listing bleeding as a risk, possible transfusion was only indicated on 20%. Clinic letters rarely featured consent details. Conclusions: Completion of consent forms is variable. There is poor compliance with guidance from professional bodies. The medicoRobert Davies legal implications are potentially significant and key areas require attention if patient safety and autonomy are to be maintained. ParASiT consent confirmation, consent ticular focus must be made regardingHonorary Treasurer for blood transfusion in procedures with a significant transfusion rate, and in the listing of operative risks. Surgery Registrar, West Midlands Vascular 0582 CAN WE SLEEP EASY? - AN ASSESSMENT OF OUT-OF-HOURS ENT COVER Matthew Smith, Raj Lakhani Peterborough City Hospital, Peterborough, UK Aims: To assess the management of ENT emergencies by cross-specialty' SHO's covering ENT at night. To evaluate confidence and experience of cross-specialty'James Milburn SHOs. Method: An online questionnaire (33 Vice-President ASiT written and photographic true-false questions) was designed to test the management of ENT emergencies. Questions were graded essential' or desirable' knowledge. A cohort of non-ENT' SHO's covering multiple specialties, General Surgery Registrar, Inverness including ENT, at night (February-November 2011) completed the survey. Additional questions surveyed training, experience and confidence. Results: 15/18 completed questionnaires were received. The median score was 19/33 (range 15-28/33). Questions testing essential' knowledge were answered correctly more often (median score 13/18). Two thirds of SHOs managed time-critical' presentations incorrectly, delaying essential treatment. Up to 9/15 mis-managed certain life-threatening conditions. Awareness of postoperative complications was poor. Only 2/15 SHO's had prior ENT experience, 9/15 had no formal training in ENT emergencies and only 7/15 were confident performing an ENT examination. 10/15 self-rated their ENT knowledge as average and 5/15 as poor Joseph Shalhoub Conclusions: SHOs that cross-cover ENT at night frequently lack relevant training, experience, and essential knowledge required to ASiT Vice-President provide emergency cover for this surgical specialty. In the setting of limited undergraduate education, additional specialist training is Vascular Surgery Registrar, London required to ensure patient safety. 0594 CLINICAL APPLICABILITY OF THE THY3 SUB-CLASSIFICATION SYSTEM Gentle Wong1, Zaid Awad1, Roy Farrell1, Stephen Wood2, Tanya Levine1 1 Northwick Park Hospital, London, UK Hornby Steve 2 Wexham Park Hospital, London, UK ASiT Director Thy3f. To assess the Aim: To determine malignancy rates of Thy3a and of Education clinical applicability of the Thy3 sub-classification system. Method: A multi-institutional prospective audit of clinical practice, spanning West Peninsula North West London. One hundred General Surgery Registrar, South 3 cancer networks in and fifteen consecutive patients with Thy3 cytology discussed at the weekly multi-disciplinary team (MDT) meetings between 2010 and 2011 were included. Our main outcome measures were Thy3f and Thy3a malignancy rates, clinical applicability of the Thy3 subclassification system. Results: In the present series, 115 Thy3 lesions were identified comprising 83 Thy3f and 32 Thy3a. 65 Thy3f and 11 Thy3a have corresponding histology. 45% ofto the local ASiT Welshwere found to be malignant on histopathological examination. With thanks the Thy3f and 64% of Thy3a lesions Regional Representatives: Conclusions: The sub-classification has not demonstrated a convincing difference in malignancy rates to help make a translational Miss Rhiannon Harries, General Surgery Registrar, Ysbyty may have a higher malignancy potential difference in how we manage these subgroup patients clinically. We have identified Thy3a Gwynedd, Bangor than Thy3f; Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff this may impact on how we evaluate future managements of Thy3a patients. 0597 ONE ON, ONE OFF'. A MODELthe wonderful ASiTPAEDIATRIC ENT SURGERY With thanks to FOR SAFE AND EFFICIENT Conference Admin David Walker, Samuel Cartwright, Jonathon Blanshard, Paul Spraggs
Laura Andrews
Kristina Gloufchev
Harriet Innes
team: info@asit.org
am 2012
Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK Aims: To demonstrate a system for efficient theatre session management using a One on, One off' approach to achieve up to 10 cases per session, and to outline the business case to support it. Methods: Routine paediatric otolaryngology procedures are allocated for surgery on a dedicated paediatric list. The day surgery ward is transformed to Paediatrics Only' and staffed by paediatric nurses. Two paediatric trained Anaesthetists and two Operating Department Assistants (ODAs) are assigned to the list, to allow a One On, One Off' system i.e. the next patient anaesthetised by the time the previous case leaves theatre. Results: Over a two year period, the average number of cases for a single theatre session was 7.9 (range 3-10), compared to 4 on an equivalent session at a neighbouring hospital. The cost of the extra Anaesthetist and ODA was 300, however this additional activity generates extra revenue of 2000-4000, depending on case mix. There were no adverse outcomes during this time period. Conclusions: This model, easily applied to other surgical specialities, can drive down waiting lists, increase efficiency and improve revenue. The business case for supplying extra Anaesthetic staff is clear and provides fast turnaround whilst maintaining patient safety and training. 0608 DISORDERED SLEEP PHYSIOLOGY IN CHILDREN PRESENTING FOR PRIMARY CLEFT REPAIR. THE USE OF SLEEP STUDY RESULTS TO GUIDE PREOPERATIVE RESPIRATORY INTERVENTION AND PLAN THE TIMING OF SURGICAL CLEFT REPAIR Justice Reilly, Craig Russell, Neil Gibson, Tony Moores, Arup Ray, Mark Devlin, David Wynne Royal Hospital for Sick Children, Yorkhill, Glasgow, UK Aim: Cleft patients are at risk of obstructive sleep apnoea due to altered nasopharyngeal anatomy and upper airway resistance; however there are no current methods to accurately predict pre- and post-operative respiratory distress. This study investigates breathing patterns indicative of the need for respiratory intervention in patients undergoing primary repair. Method: Prospective analysis of all children presenting for primary surgery in 2010 compared pre- and post-operative sleep studies, pre-operative airway adjunct requirement and post-operative respiratory High Dependency Unit support. Results: Thirty-nine consecutive patients (25 Female: 14 Male) were studied. Increased de-saturation indexes were most common but not exclusive to patients with Pierre Robin Sequence (PRS) both pre (p=0.044) and post (p=0.043) repair. PRS was also associated with pre-operative airway adjunct requirement (p=0.009) and post-operative respiratory distress (p=0.002). Conclusions: Experience is consistent with recent RCPCH report on disordered sleep physiology, which indicates need for sleep study evaluation of craniofacial patients. Experience also suggests PRS patients should have post-operative studies to guide ongoing therapy as breathing disturbances persist beyond cleft repair. Serial sleep study results can guide timing of cleft repair by indicating safer operative windows and support informed consent by indicating patients likely to require post-operative respiratory support. 0652 ENT OPERATIONS ARE OVER-REPRESENTED IN "PLANNED PROCEDURE WITH A THRESHOLD" WAITING LISTS: AN AUDIT, WITH IMPLICATIONS FOR FUNDING Vaibhav Sharma, Katherine Whitcroft, Sunil Sharma, Anthony Robinson, Jennifer Magill West Middlesex University Hospital, London, UK Background: Several interventions not normally funded, or "Planned Procedure With a Threshold" (PPwT) are specified by the North West London Commissioning Partnership in their contracts with secondary care providers. Aims: To establish the number of ENT procedures appropriately listed, and to compare local access to these procedures with SIGN and NICE guidance. Objectives: To determine numbers of patients listed for tonsillectomy, grommets, pinnaplasty or rhinoplasty and the proportion in which exceptional funding was appropriately applied for, with reference to local and national guidelines. Methods: Prospective data collected from admission databases, theatre lists and clinic letters were analysed for four months from August 2011. Interventions to improve the department's rates of being funded were implemented and the audit cycle completed. Results: Only 4 of the 38 PPwTs are ENT procedures, but these comprised 38% (238/626) of ENT procedures. Funding was delayed in 38% (35 patients) in the first cohort. Following our interventions, however, the percentage was reduced to 14% (13). Conclusion: The funding process for "Planned Procedures with a Threshold" needs to be highlighted, in particular for ENT procedures. We must ensure our correspondence explicitly highlights where patients meet national guidelines for exceptional funding. Re-audit at three months is planned. 0760 CASE SPECIFIC VIRTUAL REALITY SIMULATION IN TEMPORAL BONE SURGERY: A FEASIBILITY STUDY Chloe Swords1, Asit Arora1, Sam Khemani2, Arvind Singh2, Nasir Bhatti3, Neil Tolley1 1 Department of Otolaryngology Head and Neck Surgery, St Mary's Hospital, Imperial College Healthcare National Health Service Trust, London, UK 2 Department of Otolaryngology, Northwick Park Hospital, London, UK 3 Department of Otolaryngology Head and Neck Surgery, John Hopkins Hospital, Baltimore, Maryland, UK Aim: Virtual reality (VR) temporal bone simulation allows the incorporation of patient specific imaging data to create a three dimensional interactive model. The objective was to evaluate feasibility and pre-clinical applications of case specific surgical rehearsal (CSSR) using a VR temporal bone simulator. Method: 16 participants (experienced and trainee group) were each allocated a cadaver temporal bone which was CT scanned and uploaded onto the VOXEL-MAN temporal bone simulator. Participants performed a series of standardised temporal bone tasks using the cadaver and VR model. CSSR was assessed using a 5 point Likert scale across 4 domains. Accuracy of VR representation was validated for 6 anatomical landmarks. Results: Temporal bone upload and VR reconstruction is feasible using a semi-automated system. Participants agreed that the CSSR improves confidence (75%), aid surgical planning (75%) and facilitates training (94%). There was good visualisation of the ossicles and cochlear which facilitates rehearsal of procedures involving the ossicular chain and cochlear implantation. A lack of depth perception and soft tissue reconstruction limit its application. Conclusion: CSSR using VR temporal bone simulation is feasible and represents a promising application for selected clinical procedures to improve operative outcome. Further clinical evaluation is warranted to assess the potential benefit.
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edd, Bangor 0799 EGFR AND al of Wales, Cardiff CYCLIN D1; THEIR ROLE IN THE RADIORESPONSIVENESS OF LARYNGEAL SQUAMOUS CELL CARCINOMA
tives:
m:
Matthew Banfield University of Liverpool, Liverpool, UK, 2Cardiff University, Cardiff, UK Introduction: info@asit.org Cell cycle modulators are important in carcinogenesis and may be of prognostic and therapeutic relevance. By predicting the sensitivity of Laryngeal squamous cell carcinoma (LSCC) to radiotherapy, treatment can become more specific to the tumour/
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patient. This study examined expression of EGFR and cyclin D1 in LSCC cell lines. Method: Seven LSCC cell lines were exposed to 2Gy of gamma irradiation from a 147Caesium source and then a clonogenic assay used to determine relative radiosensitivty. Expression of EGFR and cyclin D1 was determined by western blot analysis. Results: Individually EGFR and cyclin D1 levels were not strong predictors of radioresponsiveness. However there was a strong correlation between High EGFR and low cyclin D1 in cell lines that were more radiosensitive. Conclusion: Expression of EGFR and cyclin D1 together correlate with radiosensitivty, which has the potential to make them strong indicators of tumor cell outcome to radiation treatment. This study provides a foundation for functional investigations of EGFR and Goldie Khera cyclin D1 in determining LSCC radioresponsiveness.

ASiT President
0812 Bariatric Fellow, CHONDRAL PIERCINGS: ARE WE TREATING THEM CORRECTLY? PERICHONDRITIS OF PINNA ASSOCIATED WITHNorth Tyneside Zi Wei Liu, Perumal Chokkalingam Colchester General hospital, Colchester, UK Aim: Pinna perichondritis can arise as rare complications secondary to ear piercing. Less than 30 cases have been reported, associated with an increase in chondral piercings. We systematically examine cases of pinna perichondritis associated with piercing presenting to a district general hospital over ten years, with emphasis on causative organism, antibiotic use and cosmetic outcomes. Methods: A retrospective review of case notes and microbiology results from patients diagnosed with pinna perichondritis was underEd Fitzgerald taken. Patients with no history of associated piercings were excluded. ASiT Conference piercing was & Past-President Results: 9 cases of pinna perichondritis associated withOrganiseridentified from 2001 to 2011. 8 involved chondral piercings. The length of history ranged from General Surgery Registrar, London 2 to 28 days. Microbiology swabs grew Pseudomonas aeruginosa in 8 out of 9 cases. In all 9 cases on admission, the patient had been prescribed an antibiotic that did not have anti-pseudomonal activity. In only 44% of cases was the patient given an anti-pseudomonal antibiotic by on call ENT. On follow up, 77% of patients achieved satisfactory cosmesis. Conclusion: Pinna perichondritis associated with piercing is commonly caused by Pseudomonas. Secondary healthcare providers should ensure antibiotics with anti-pseudomonal activity are given when treating this condition with potentially long term cosmetic implications.
Jonny Wild 0820 IS THERE A LINK BETWEEN THE CHANGING INCIDENCE OF PERITONSILLAR ABSCESS AND THE RATES OF TONSILLECASiT Honorary Secretary & Sponsorship Co-ordinator TOMY IN WALES AND ENGLAND? General Surgery Registrar, Sheffield Robert Mcleod, Sam Fishpool, David Owens, Steven Backhouse University Hospital of Wales, Cardiff, UK Objective: ENT UK guidelines state that one episode of peritonsillar abscess is an indication for tonsillectomy. Over the past 10 years there has been increasing pressure to reduce numbers tonsillectomy performed in the UK. This study aims to investigate if there is an association between changing tonsillectomy rates and peritonsillar abscess incidence. Method: A retrospective study of the diagnosis of peritonsillar abscess and the number of Tonsillectomies performed in Wales and England from April 1999 to March 2009 was undertaken using two national electronic patient episode databases. Data for peritonsillar Robert Davies abscess was identified using ICD Code J36X and Tonsillectomy F341-F349. ASiT Honorary Treasurer Results: 5538(Wales) and 74566(England) episodes of peritonsillar abscess were diagnosed between 1999-2009(0.1847% and 0.1439% respectively). 33416(Wales) and Surgery Registrar, West Midlands performed over the same period(1.1142% Vascular 529324(England) tonsillectomy operations were and 1.0217%). Numbers of tonsillectomies reduced significantly within Wales but there was no change in England. Peritonsillar abscess incidence increased within both England and Wales (increase was greater in Wales). Conclusion: Peritonsillar abscess is a common condition diagnosed in approximately 0.015% of the population per year. It is unclear if changes in the numbers of tonsillectomy being performed is having a direct impact on peritonsillar abscess presentations.
0838 James Milburn CALORIC AUDIT: IMPROVING THE MANAGEMENT OF PATIENTS WITH DIZZINESS' Shaun Davey1, Paul Kirkland2ASiT Vice-President 1 Royal Sussex County Hospital, Brighton, UK General Surgery Registrar, Inverness 2 Conquest Hospital, Hastings, UK Aim: Dizziness can be an extremely distressing symptom, accounting for a considerable proportion of ENT referrals. Caloric testing is a measure of vestibular system integrity, and is therefore used as confirmatory evidence of vestibular pathology. The aim of the audit was to determine if patients were referred for this investigation and managed appropriately. Method: Departmental standards were devised and others adapted from the British Society of Audiology's guidance on vestibular function testing (2010). We included all patients that underwent caloric testing between October 2009 and October 2010. Results: The mean length from initial clinic appointment to discharge was 28.3 weeks, considerably longer compared to those not Joseph Shalhoub tested. Of the tests ordered, only 68% were performed. Post testing 42% of patients had their management altered. ASiT Vice-President Conclusion: We concluded that a significant proportion of patients were inadvertently subjected to a protracted illness whilst waiting for Vascular Surgery Registrar, London testing. Adoption of all our recommendations resulted in the following: 1) A reduction in length of illness, brought about by more timely management. 2) An improved Audiology service as these lengthy tests are no longer being performed. 3) No need to purchase costly new equipment, the money saved will be spent improving patient care in other areas. 0963 SURVIVAL RATES FOR PATIENTS WITH ANAPLASTIC THYROID CARCINOMA RECEIVING DIFFERENT TREATMENT MOSteve Hornby DALITIES. ASiT Director of Education Natalie Lowe1, Beng Yap2 1 Aintree University Hospital, Liverpool, UK, General Surgery Registrar, South West Peninsula 2 The Christie Hospital, Manchester, UK Aim: To review which treatments produce greatest survival rates for patients treated for anaplastic thyroid carcinoma. Method: The case notes of 20 anaplastic thyroid carcinoma patients referred to a cancer specialist hospital were retrospectively reviewed. Results: With thanks diagnosis was 69.5 ASiT Welsh Regional Representatives: thyroid carcinoma, 8 of The median age at to the local years (56.3-80.6 years). 19 patients died due to the anaplastic whom died specifically from asphyxiation. Treatments given at the cancer hospital was radiotherapy (10 patients), chemotherapy (3 Miss Rhiannon by radiotherapy (3 patients) or no Registrar, Ysbyty Gwynedd, Bangor patients), chemotherapy followedHarries, General Surgery treatment (4 patients). 7 patients had also had surgery in the referring institution prior to referral. Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Median survival for all cases was 59 days. Patients who had previous surgery prior to any other treatment modalities with the oncologists had a longer median survival time overall compared to those who had not had previous surgery (142 days compared to 59 days) and produced the one long term the wonderful ASiT Conference Admin team: info@asit.org With thanks to survivor. However, this median survival was not as long as chemotherapy followed by radiotherapy (with no previous surgery), which produced a median survival of 220 days.
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
Conclusion: Chemotherapy followed by radiotherapy produced the longest survival in this series, even when compared to patients who received different treatment modalities post surgical resection. 1037 A RETROSPECTIVE STUDY OF CRICOPHARYNGEAL MYOTOMY FOR NON-SPECIFIC CERVICAL DYSPHAGIA Pranav Patel, Nilantha De Zoysa, Aaron Trinidade, George Mochloulis East and North Herts NHS Trust, Dept of ENT Surgery, Stevenage, Hertfordshire, UK Aim: Cricopharyngeal myotomy (CPM) is a well reported management of dysphagia and tracheo-bronchial aspiration. We aim to analyse outcomes of CPM in patients with documented cricopharyngeal dysfunction and those with complex or equivocal diagnoses. Method: A retrospective analysis was conducted of patients undergoing CPM between 2001-2010 in a single UK centre. Patients were classified as either cricopharyngeal dysfunction (CPD) or non-specific cervical dysphagia (NSCD). Study end point was dysphagia recurrence at 12 months. Questionnaires, with validated Visual Analogue Scoring (VAS) systems were used to quantify dysphagia preoperative, post-operative, 6 months and 12 months post CPM. Data was analysed with a Wilcoxon paired t-test (p-value significance 0.05). Results: A total of 28 patients underwent CPM. Pre-operative median VAS score was 5.5, improving postoperatively to 8.0 (p<0.001). Over a 12-month period, recurrence was 22% a lower rate in CPD (12.5%) versus NSCD (60%). Overall complication rate was 15%, most commonly temporary regurgitation (7.2%), aspiration (1.8%) and perforation (1.8%). Conclusion: Our results show significant improvement in swallowing solids after CPM on patients with CPD and NSCD. There is low recurrence and complication rate in patients with radiological evidence for CPD. CPM can improve swallowing in patients with NSCD, however dysphagia recurrence remains high.
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1039 HRG CODING AND PROFITABILITY FOR COMMON ENT PROCEDURES: A TWO CYCLE AUDIT Alistair Mitchell-Innes2, Damien Gill1, Richard Harris3, Hisham Khalil1 1 Derriford Hospital, Plymouth, UK 2 City Hospital, Birmingham, UK 3 The Royal Melbourne Hospital, Melbourne, Australia Aim: To evaluate Human Resource Group (HRG) coding accuracy and profitability for the most common ENT procedures at Derriford Hospital. Methods: First cycle (2010): Retrospective analysis of 395 patient journeys in nine procedures over six months. Intervention: Coding inaccuracy was discussed with the coding department, and missing costs identified. Second cycle (2011): Using updated codes and costing, the nine procedures plus thyroidectomy for 528 patients were audited. Profit analysis comparing consultants and trainees as the main surgeon was performed. Individual stages of the patient journey were compared for inefficiency. Results: Between cycles, miscoding improved from 15% to 8%, whilst profitable procedures dropped from 8 of 9 to only 3 of 10. Microlaryngoscopy was responsible for the majority of miscoding in both cycles costing the department 24,900 alone in cycle two. Irrespective of miscoding, however, microlaryngoscopy was also significantly less profitable. Excluding all miscoded procedures the average loss for trainee cases was 71.69 versus a profit of 49.46 for consultant cases. There were no isolated processes consistently responsible for delays or added costs. Conclusions: Correct coding is vital for trust remuneration. Trainees are essential, but expensive. In the current financial climate, non -profitable departments risk cuts to staff and procedures. 1066 ULTRASOUND GUIDED INTRA-SUBMANDIBULAR GLAND INJECTION OF BOTULINUM TOXIN-A (BTX-A) FOR SIALORRHOEA IN CEREBRAL PALSY PATIENTS Vanessa Chow, Gulcan Gok, David Howlett East Sussex Healthcare NHS Trust, East Sussex, UK Aim: To investigate the clinical effectiveness of Botulinum Toxin-A(BTX-A) in the reduction of drooling in patients with cerebral palsy, using ultrasound guided intra-submandibular injections. Method: Four patients with cerebral palsy underwent ultrasound guided submandibular gland injection of BTX-A under general anaesthetic. The procedure was performed using high resolution ultrasonography to identify the superficial lobe of the submandibular gland, vascular structures and aid in the positioning of 22G needle for administration of 20-25 units of BTX-A. Each procedure was performed by the same radiologist to avoid operator variation. Drooling severity and frequency was measured at baseline and reassessed at 4 weeks, using teacher drooling scale and drooling frequency score. Results: Three patients reported a subjective improvement in severity and frequency of drooling, from severe/profuse to mild/ moderate. One patient reported no improvement in severity or frequency of drooling at baseline and 4 week evaluation. One patient reported side effects, with difficultly retaining their prosthetic globes within the orbits. This resolved once the effects of BTX-A had worn off. Conclusion: Intrasubmadibular gland injection of BTX-A is an effective treatment to reduce sialorrhoea in patients with cerebral palsy. Ultrasound guidance enhances the accuracy of injection, however does not eliminate the risk of side effects. HEPATOPANCREATOBILIARY
0130 A SELECTIVE ANTIBIOTIC PROPHYLAXIS POLICY FOR LAPAROSCOPIC CHOLECYSTECTOMY IS EFFECTIVE IN MINIMISING INFECTIVE COMPLICATIONS Peter Mekhail2, Fady Yanni1, Gareth Morris-Stiff3 1 Yorkshire and Humber Deanary, Chesterfield, UK 2 Mersey Deanary, Liverpool, UK 3 Prince Charles Hospital, Merthyr Tydfil, UK Aim: To assess the effectiveness of a selective antibiotic prophylaxis policy limited to high risk patients undergoing LC with the development of port-site infections as the primary endpoint. Methods: 100 consecutive patients undergoing LC during a 1 year period were studied prospectively. Data collected included patient tives: demographics, history of gallstone disease to determine those with risk factors for bactibilia. A single antibiotic dose was administered edd, Bangor on induction to high risk patients. Information relating to all radiologically or microbiologically-confirmed infections were documented. Results: al of Wales, Cardiff 84% were females with mean age 47.7 16.0. 19% of the LCs were performed as emergencies while 81% were elective. A risk factor for bactibilia was present in 35% of patients. A wound infection was identified in 4% of cases, 2 of which were Staphylococcus aureus (1 MRSA), 1 was a coagulase -ve Staphylococcus, and 1 wound cultured a mixed anaerobic growth. Three of the infections occurred in patients receiving prophylaxis at intervals of 7, 14 and 19 days respectively. One patient (BMI of 32) in the no prom: info@asit.org phylaxis group developed a coagulase -ve staphylococcal infection at 10 days. No other abdominal infections were identified.
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Conclusions: Restricting antibiotic prophylaxis to high risk patients has no detrimental effects in terms of increasing the rate of infections in those with no risk factors. 0134 STRICT ADHERENCE TO BSG GUIDELINES REQUIRED FORCHOLECYSTECTOMY FOLLOWING PANCREATITIS TOPREVENT HIGH READMISSION RATES A Addison, D Gomez, A De Rosa, D N Lobo, I C Cameron Goldie Queens Medical Centre, Nottingham, UK Khera Background: The current British Society of Gastro-enterology guidelines (2005) for the management of acute pancreatitis suggests ASiT President that patients with gallstone-induced mild pancreatitis should undergo cholecystectomy with operative cholangiography, unless unfit for Bariatric pancreatitis. Cholecystectomy surgery, in order to prevent recurrence ofFellow, North Tyneside should be done at the same admission or within two weeks after discharge and delayed in patients with severe acute pancreatitis until systemic disturbance have resolved. Methods: Data from Patients admitted with acute pancreatitis from January 2010 to December 2010 were collated. Results: Of the 117 patients admitted with acute pancreatitis, 51 patients had gallstone-related pancreatitis. 21 patients were known to have gallstone disease from previous admissions. Of the 30 admissions with primary gallstone presentation, 20 were placed on the cholecystectomy waiting list. Eleven (55%) patients were re-admitted, and 6 patients underwent emergency cholecystectomy. The overall waiting list time was 18 (2 - 36) weeks. Of the 21 patients with previous admission for gallstone related complications, 1 had an Ed Fitzgerald emergency cholecystectomy while 15 patients were placed on the waiting list. 5 patients (33.3%) re-presented with 3 patients then ASiT Conference Organiser & Past-President undergoing an emergency cholecystectomy. Conclusion: High re-admission rates following gallstone pancreatitisLondon of non-adherence to the BSG guidelines, especially in General Surgery Registrar, are a result female patients. 0212 SINGLE INCISION COMPARED TO STANDARD LAPAROSCOPIC CHOLECYSTECTOMY Ronak Patel, Rachel Clancy, Robin Spencer, Nicholas Penney, Rachel Cave, Alan Osborne, Christopher Wong Frenchay Hospital, Bristol, UK Jonny Wild Introduction: Single-incision laparoscopic surgery is gaining momentum in general surgery. The aim of this study was to compare outcomes for day case single-incisionHonorary cholecystectomy (SILC) with standard laparoscopic cholecystectomy (StdLC). ASiT laparoscopic Secretary & Sponsorship Co-ordinator Methods: Patients scheduled for day case laparoscopic cholecystectomy were block randomized to SILC or StdLC. Patients were prospectively scored for pain,General Surgery Registrar, and recovery on a visual analogue scale (VAS) on days one and wellbeing, satisfaction with wounds Sheffield seven post operatively. Results: 49 patients were included in the study (SILC=24; StdLC=25). There were no differences in age, sex, ASA grade and BMI. Two patients were excluded from the study, one from the SILC group and one from the StdLC group. There was no significant difference in the VAS on day one. However, on day seven the SILC group rated their cosmesis significantly higher than the StdLC group (p = 0.03). There was no difference in pain wellbeing or strength between the groups. Conclusion: SILC is feasible, safe and comparable with StdLC. SILC is associated with superior cosmesis. Robert Davies
ASiT Honorary Treasurer 0257 EMBOLISATION OF INFLOW TO ALLOW SAFER LIVER RESECTION - ISMidlands Vascular Surgery Registrar, West MORE BETTER? Abigail Vallance, Rajiv Lochan, Jeremy French, Bryon Jaques, Richard Charnley, John Rose, Steven White, Derek Manas Freeman Hospital, Newcastle Upon Tyne, UK Aim: To evaluate the feasibility of portal vein embolisation (PVE) and sequential hepatic artery embolisation (HAE) to increase the future liver remnant (FLR) prior to liver resection. Methods: All patients undergoing PVE and sequential HAE between Jan 2006-May 2011 were identified from a prospectively held database. These patients were discussed at MDT meetings to decide the necessity for FLR augmentation. James with 33 (66%) Results: 50 patients underwent right PVEMilburn progressing to resection. The median FLR of those who progressed to resection following PVE, by CT volumetry, Vice-President significantly more than those who did not, 237cc (110-280)(p=0.03). All ASiT was 384.5cc (330-490), patients with small FLR following PVE (n=6) underwent HAE (with 5 undergoing resection). HAE increased the FLR by a further General Surgery Registrar, Inverness 99.8cc (80.5-130cc). Following resection after PVE and sequential HAE 9/33 (27%) and 3/5 (60%) respectively suffered serious complications (Clavien-Dindo 3/4). There were 6 post-operative deaths, 5/33 (15%) after PVE and 1/5 (20%) following sequential HAE. Conclusion: PVE is an increasingly used technique to augment the FLR, allowing resection in a significant proportion of patients who were initially considered inoperable. Patients who do not achieve adequate hypertrophy may have HAE to increase the FLR but perhaps at the expense of increasing post-operative complications.
0298 Joseph Shalhoub EMERGING INDICATIONS FOR PERCUTANEOUS CHOLECYSTOSTOMY FOR THE MANAGEMENT OF ACUTE CHOLECYSTIASiT Vice-President TITIS - A RETROSPECTIVE REVIEW Vascular Sana Nasim, Sadaf Khan, Rehman Alvi Surgery Registrar, London The Aga Khan University Hospital, Karachi, Pakistan Objective: To review our experience and determine the outcome, safety and efficacy of the use of tube cholecystostomy in high risk patients with acute cholecystitis. Methods: All patients who underwent cholecystostomy tube placement.Retrospective review of files from January 1988 to December 2009. We recorded indication, duration of tube placement, clinical outcome, complications,bacteriology and performance of cholecysSteve Hornby tectomy. Data was analyzed using SPSS version 16. ASiT Director of Education Results: 62 patients (mean age 63 yrs) had cholecystostomy tubes placed.All had confirmed or presumed acute cholecystitis.54(95%) of them had image-guided placement of Surgery Registrar, South West expired during the hospital stay,none was proceGeneral cholecystostomy tube.Nine patients(16%) Peninsula dure-related.Around 66% of them had drain in place for >4 weeks.21 subsequently had elective cholecystectomy while 2 underwent emergency cholecystectomy.Bile was culture positive in 38 (66%) patients. Conclusion: Tube cholecystostomy with delayed laparoscopic cholecystectomy has been proposed for the management of citically ill patients with acute cholecystitis as an alternative treatment.It can be used as a temporizing measure while awaiting resolution of sepsis and optimization of co-morbidities, or as a definitive Welsh Regional Representatives: conclude that it has a With thanks to the local ASiT therapeutic option for acalculous cholecystitis. We also good potential to be used as a definitive therapy for high risk (ASAIII & IV) patients with acute calculous cholecystitis 0325 Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff DOUBLE BYPASS FOR INOPERABLE PANCREATIC MALIGNANCY AT LAPAROTOMY: POSTOPERATIVE COMPLICATIONS AND LONG-TERM OUTCOME Abigail Vallance, thanks to DerekwonderfulPrentis, Chris Snowden, Steve White, Richard Charnley, Jeremy French, Bryon With Fabio Ausania, the Manas, James ASiT Conference Admin team: info@asit.org Jaques
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
Freeman Hospital, Newcastle, UK Aim: Double bypass, although associated with high risk of postoperative complications and mortality, is an option for those with pancreatic malignancy found to be inoperable at surgery. The aim of this study was to identify pre-operatively which patients undergoing bypass are at high risk of complications/mortality and to assess their long term outcome. Method: Of the 576 patients undergoing pancreatic resection for malignancy from January 2006-July 2011 identified from a prospectively held database, 50 patients had a double bypass procedure for locally inoperable disease. Demographics, risk factors for postoperative complications and preoperative anaesthetic assessment data including P-POSSUM and Cardiopulmonary Exercise Testing (CPET) results were collected. Results: 50(33 male, 17 female) patients were included; median age 64(39-79) years. The complication rate was 50% and the inhospital mortality 4%. High P-POSSUM physiology score and low Anaerobic Threshold at CPET were significantly associated with postoperative complications (P=0.005, P=0.016 respectively). Overall long-term survival was significantly shorter in patients with postoperative complications(9 vs. 18 months) and postoperative complications were independently associated with poorer long-term survival (P=0.003, OR 3.261). Conclusions: These findings question whether a palliative bypass should be performed in patients with a high P-POSSUM physiology score or low CPET score due to the high complication rate and poor long-term outcome.
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0341 LONG TERM OUTCOMES AFTER PERCUTANEOUS CHOLECYSTOSTOMY FOR ACUTE CHOLECYSTITIS - A MULTIINSTITUTIONAL REVIEW Devender Mittapalli1, Sanjay Pandanaboyana1, Aseel Marioud2, Rishi Ram2, Afshin Alijani1 1 Upper GI & HPB Unit, Ninewells Hospital, Dundee, UK 2 HPB Unit, Auckland City Hospital, Auckland, New Zealand Aim: To analyze the long-term outcomes after Percutaneous Cholecystostomy(PC). Methods: Retrospective study of all consecutive patients who underwent PC at two university hospitals between 20002010. Results: 53 patients underwent PC. 58% were ASA III and 34% ASA IV. The median duration of symptoms was 1 day(range 135). 63%(33/53) had calculus cholecystitis, whilst 37%(20/53) had acalculous cholecystitis. 7%(4/53) had gallbladder perforation. 82% (43/53) had USS-guided drainage while 18% had CT-guided drainage. The median time to PC from admission was 3 days(range 115). The median hospital stay was 15.5 days (range 7120). 13%(7/53) patients developed complications including bile leaks(n =5), haemorrhage(n=1) and duodenal fistula(n=1). The in-hospital mortality was 18%. 34%(18/53) of patients eventually had cholecystectomy. 4/18 were done on the index admission and a majority had interval cholecystectomy(78%). 6/18(33%) had laparoscopic cholecystectomy and a majority required conversion to open(67%). 22%(13/53) patients were readmitted with recurrent cholecystitis during follow-up. 13/53(24%) had repeated PC. The median time to representation was 151 days(2510). Conclusions: Only a minority of patients undergoing PC proceed to cholecystectomy. The risk of conversion to an open procedure is high and should be emphasized during the consent. A quarter of patients present with recurrent cholecystitis requiring a repeat PC during follow-up. 0379 PROSPECTIVE AUDIT ON THE MANAGEMENT OF BILIARY PANCREATITIS Nicholas Gill1, Rhiannon Harries1, Nicola Tanner2, Paul Blake1, Alan Woodward1, Phil Stevens1 1 Royal Glamorgan Hospital, Llantrisant, UK 2 Prince Charles Hospital, Merthyr Tydfil, UK Aims: The British Society of Gastroenterology (BSG) guidelines state that definitive management of biliary pancreatitis should be achieved within a 2 week period. The aims of our audit were assess the management of patients with biliary pancreatitis. Methods: Data was obtained prospectively from all consecutive patients presenting with acute biliary pancreatitis over a nine month period at two district general hospitals within our Health Board. Results: Between September 2010 to May 2011 there were 52 admissions with acute biliary pancreatitis. 34 were females. Median age 62 years (range 18-97). Median Length of stay was 6 days (range 1-28). 3 patients died (5.7%). 7 patients underwent Endoscopic Retrograde Cholangiopancreatography (ERCP), with a median wait of 6 days (range 1-12 days). For 4 of these patients, ERCP was deemed as their definitive management due to co-morbidities. 35 patients underwent cholecystectomy, with only 13 of those having surgery within 2 weeks of diagnosis. Median wait from diagnosis to surgery was 23 days (range 2-260). We experienced an 11.1% readmission rate for those that did not undergo definitive management of their gallstones within 2 weeks. Conclusion: There is significant morbidity associated with delayed definitive management of gallstones in those patients with biliary pancreatitis. 0403 COMPLIANCE WITH BSG GUIDELINES IN BILIARY PANCREATITIS IN A LARGE TEACHING HOSPITAL Tilan Lokubalasuriya, Andrew Beamish, Imran Alam, Bilal Al-Sarireh, Tim Brown Pancreatic Unit, Morriston Hospital, Morristion, UK Aim: BSG guidelines state: 1)All patients presenting with severe biliary pancreatitis should undergo ERCP and sphincterotomy within 72hours of onset of pain; 2)Patients with biliary pancreatitis should receive definitive treatment during the same admission, or within two weeks of discharge. This study aimed to determine compliance with BSG guidance on biliary pancreatitis in a large teaching hospital. Methods: Retrospective analysis was conducted on all (19) patients admitted to the surgical unit with biliary pancreatitis over 6 months (Dec 2010-July 2011). Results: Pancreatitis was graded severe in 9 (47%) patients and mild in 10 (53%) patients. Six (32%) patients underwent ERCP, none complying with BSG guidelines. Five (26%) patients underwent definitive treatment, 4 (21%) meeting BSG guidelines. There was one mortality in our cohort. Conclusion: Compliance with BSG guidelines was extremely poor. All patients in our series waited longer than 72 hours for ERCP and 85% waited longer than two weeks for definitive treatment. Indeed, most patients (70%) waited longer than six months for laparoscopic cholecystectomy. Evidence shows that these patients are at significant risk of further episodes of acute pancreatitis, which may be life threatening. We must direct resources toward ensuring adequate access to emergency ERCP and expedited surgical treatment.
edd, Bangor 0599 THOROUGH PRE-OPERATIVE ASSESSMENT MUST BE CARRIED OUT PRIOR TO LAPAROSCOPIC CHOLECYSTECTOMY al of Wales, Cardiff
tives:
m:
Rami Radwan, Chris Brown, Omer Jalil, Ashraf Rasheed Royal Gwent Hospital, Newport, UK Aims: Up info@asit.org to 20% of patients who have undergone cholecystectomy continue to experience symptoms. Our aim was to identify the symptoms for which laparoscopic cholecystectomies (LC) were carried out and then determine the prevalence and the nature of per-
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sistent symptoms following the procedure. Method: A validated pre-operative symptoms survey was completed at the time of listing of 500 consecutive LC, followed by a follow up phone survey 12 weeks post-operatively to record the nature, severity and frequency of symptoms experienced. Results: All patients had at least 2 symptoms pre-operatively and 337 (67.4%) had 3 or more. The most common symptoms preoperatively were abdominal pain (93.8%) and nausea (65.8%). A total of 90 patients were symptomatic postoperatively. Eighty one patients (16.2%) complained of abdominal pain, while 63 (12.6%) patients also experienced associated dyspeptic symptoms. Sixty patients underwent further investigation following LC; 36 patients went on to have a secondary diagnosis made, the most common (13/36) being hiatus hernia. Goldie Khera Conclusions: A significant number of patients continue to experience symptoms following LC. A careful biliary history, focused physical ASiT President examination and a thorough pre-operative assessment must be carried out prior to LC to rule out conditions that masquerade as gallBariatric Fellow, North Tyneside bladder disease.
0615 IS ULTRASOUND ALL WE NEED? A REVIEW OF BILIARY IMAGING AT FRENCHAY HOSPITAL Prem Chana, James Warbrick-Smith, James Hewes Frenchay Hospital, Bristol, UK Aim: Modern management of symptomatic gallstones needs to be streamlined with appropriate investigations and early intervention. Ed Fitzgerald We reviewed biliary radiology for emergencies admitted with suspected gallstone disease, assessing the efficiency of our radiology ASiT Conference Organiser & Past-President service. Methods: A retrospective review was conducted of all acute surgical admissions to Frenchay in September 2011. Radiology records General Surgery Registrar, London were obtained from ICE and WebPACS for patients referred as: right upper quadrant pain, jaundice or pancreatitis. Patients without gallstones or those not needing imaging were excluded. Results: 43 admissions met the referral criteria, 36 of which were suitable for review. 34 ultrasound scans (USS) and 13 MRCP were requested. Of weekday USS requests, 93% were scanned and 85% reported within 24hours. 43% of weekend USS were performed and reported within 24hours of request. 24% of USS were deemed inadequate mainly due to poor CBD views. 44% of inpatient MRCP requests were reported within 5days with only 1 of 13 adding new information from USS. Jonny Wild Discussion: This study highlights the efficiency of our weekday USS service. MRCP introduced significant delays and added little diagnostic information. The increasing use of intra-operative imaging compensates for discrepancies in USS and may render MRCP reASiT Honorary Secretary & Sponsorship Co-ordinator dundant in the emergency management of gallstones. 0784 DO LIVER FUNCTION TESTS OR MRI FINDINGS PREDICT COAGULOPATHY IN OBSTRUCTIVE JAUNDICE? Amy Lord1, Philip Pucher2, Alfredo Tonsi1, Catherine Gallagher1, Rachael Pocock1, Guy Worley1, Paul Hurley1 1 Croydon University Hospital, London, UK 2 St Mary's Hospital, London, UK Aims: Clotting abnormalities in obstructive jaundice are well documented but it is unclear which patients are most likely to be at risk. Robert Davies This study aims to investigate possible predictive factors of coagulopathies in obstructive jaundice. ASiT Honorary Treasurer Methods: Patients undergoing Magnetic Resononace Cholangiopancreatography (MRCP) between March and August 2010 were identified retrospectively. The Vascular of serum bilirubin, alkaline West Midlands aspartate transaminase (AST) and common relationship Surgery Registrar, phosphatatse (ALP), bile duct diameter to clotting was investigated. Results: 72 patients were included. 9.7% had an INR of 1.3 or greater. The mean bilirubin was 90g/L, mean ALP was 269U/L and the mean INR was 1.17. CBD diameter ranged from to 5-22.5mm with a mean of 10mm. There was no significant correlation of any parameters to INR. Conclusion: None of the factors investigated predict the likelihood of coagulopathy in obstructive jaundice. Clotting impairment in jaundice is complex and multifactorial, making it difficult to identify patients at risk of bleeding complications. Our results fail to justify the James jaundiced patients. We suggest that all patients should have coagulation studies performed routine administration of vitamin K in all Milburn but vitamin K should be reserved for those with abnormal results. ASiT Vice-President 0823 ANALYSIS OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHIC (ERCP) MANAGEMENT OF COMMON BILE DUCT STONES IN THE LAPAROSCOPIC ERA Shi Ying Hey1, Andrew J Robson1, Kathleen Beardon1, Shen H Vun1, Peter J Driscoll1, John A Wilson2, Satheesh Yalamarthi1 1 Department of Surgery, Queen Margaret Hospital, Dunfermline, UK, 2 Department of Medicine, Queen Margaret Hospital, Dunfermline, UK Aims: Common bile duct stones (CBDS) are frequent. Current management trends are to perform laparoscopic cholecystectomy and Joseph Shalhoub therapeutic endoscopic retrograde cholangiopancreatography (ERCP) separately, necessitating co-operation of surgeons and gastroASiT Vice-President enterologists. Vascular Surgery Registrar, London Methods: Patient records were interrogated between January 2006 and April 2011. All patients who underwent ERCP were included. Those who presented with CBDS were specifically identified. Results: Of 1229 patients identified, 736 underwent ERCP for CBDS. In those, stones were directly visualised on ERCP in 539 cases with the remaining 197 showing the presence of sludge or evidence of passed stones. Of the 539 patients, 390 patients had successful stone removal on first ERCP, whereas 149 patients required repeated ERCPs and placement of CBD stents. Of these, 124 eventually had successful CBDS clearance (median of 2 ERCPs: range 1-12). However, 25/149 patients proceeded to surgical CBD exploraSteve Hornby tion following unsuccessful ERCP. Overall, endoscopic CBDS clearance was achieved in 95.4%, though 23% of these required two or ASiT Director of Education more ERCPs. Conclusions: The proportion General Surgery Registrar, South West Peninsula of patients requiring repeated ERCP remains significant. Therapeutic ERCP is gaining popularity but carries specific risks. With improving laparoscopic techniques, it may be appropriate to consider early referral for laparoscopic bile duct exploration following inability to clear the CBD following ERCP. MAXILLOFACIAL SURGERY With thanks to
CANCER- IS ROUTINE REVIEW NECESSARY Neil McCulloch, Sat Parmar, Tim Martin Queen Elizabeth thanks to the wonderful ASiT Conference Admin team: info@asit.org With Hospital Birmingham, Birmingham, UK In the UK, healthcare purchasers are undergoing a rationalisation of spending. The aim of this review was to examine the need for
Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor 0253 REVIEW Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff NECK OF RECURRENT OR SECOND PRIMARY TUMOURS IN PATIENTS PREVIOUSLY TREATED FOR HEAD AND Laura Andrews Kristina Gloufchev Harriet Innes
the local ASiT Welsh Regional Representatives:
am 2012
regular review by a specialist multi-disciplinary team with respect to head and neck cancers. Patients were identified who had developed a recurrence or second primary head and neck cancer over a five year period (20052010). Assessment was made of where these patients presented to. Case notes of thirty-eight patients were reviewed. Of these 23 were deemed to have a second oro-pharyngeal tumour. Four of these were excluded: two were followed up at another trust and two second primarys were discovered incidentally at operation. Seventeen of the nineteen patients included presented to a routine hospital appointment. One patient attended their general medical practitioner and one their dentist. The importance of regular review for head and neck cancer patients by a specialist multi-disciplinary team is emphasised. 0320 CONCURRENT BILATERAL TOTAL TEMPOROMANDIBULAR JOINT REPLACEMENT SURGERY AND CONVENTIONAL MAXILLARY OSTEOTOMY UTILISING VIRTUAL PLANNING WEB-BASED TECHNOLOGY Alexander Hills, Nabeela Ahmed, Shaun Matthews King's College Hospital, London, UK Background: We describe the case of a 31 year-old lady who presented with significant temporomandibular joint (TMJ) dysfunction following a previous vertical sub-sigmoid osteotomy in 1999. Previous surgery had resulted in both condyles being displaced from their glenoid fossae and a persistent malocculsion. Though initially managed conservatively, both condyles remained out of their fossae and she re-presented 10 years later. On presentation, she had significant progressive right TMJ dysfunction with severe pain. A Class III malocclusion was apparent with a 5mm anterior open bite and jaw deviation to the right on mouth opening. Her maximal inter-incisal opening was 32mm. Method: The case was prepared using conventional orthodontic treatment, with surgery being remotely planned by a design facility using a web-based virtual planning and design process. Definitive surgery consisted of bilateral condylectomy, coronoidectomy and placement of bespoke TMJ replacement prostheses. A simultaneous Le Fort I osteotomy was performed with 4mm maxillary advancement. Results: A Class I occlusion was achieved with full range of movement, good functional and aesthetic outcomes. Conclusion: This documents one of the first reported cases of bilateral total TMJ replacement surgery performed with a concurrent maxillary osteotomy. It demonstrates the viability of simultaneous procedures and the potential of virtual planning. 0461 THE IMPORTANCE OF CODING SURGICAL PROCEDURES - THE MAXILLOFACIAL EXPERIENCE Parneet Gill, Robert Bentley Kings College London, London, UK Aim: Coding of surgical procedures in NHS hospitals is carried out using OPCS-4 and HRG4 systems, which rely upon correct initial documentation and coding of procedures by the surgical team. The transfer of these important details can result in incorrect labelling of set procedures resulting in loss of earnings to the surgical departments. We aimed to audit the coding system at Kings Maxillofacial Department. Method: Audit of surgical case coding over a two month period at Kings College maxillofacial department. Data was collected from the maxillofacial departmental database, theatre galaxy database, admissions, EPR and coding department. Actual surgical procedures performed were compared to procedures coded in order to calculate the difference in cost. Result: Of 148 patients who underwent a total of 175 procedures, 97.8% were coded correctly. The potential loss of earning to the department from incorrectly coded procedures was calculated as 6,636 over the 2 month period, which annually amounts to 39,816. Conclusion: Accurate coding of surgical procedures is very important in order to avoid miscalculations in payments to departments. Increasing the awareness of correctly coding procedures and re-auditing data is a step forward in ensuring surgical departments are correctly paid. 0708 LE FORT 1 OSTEOTOMY - USA VS UK - WHY THE DIFFERENCE? David Gray1, Ffion Dewi1, Andrew Cronin1, John Caccamese2 1 University Hospital of Wales, Cardiff, UK 2 University of Maryland, Virginia, USA Introduction: Maxillary osteotomy is a common maxillofacial procedure for correction of facial skeletal deformities beyond the scope of orthodontics alone. This can be performed via a single piece or segmental Le Fort I osteotomy. Aim: We aim to compare the practice of 2 maxillofacial units in the UK and US in terms of preference for single piece or segmental osteotomies. We present the current literature comparing the techniques. Method: We recorded and compared the techniques used for maxillary osteotomies performed during 2010 at the University of Maryland and University Hospital of Wales. The differences in surgical preference were highlighted, and supporting literature was reviewed, looking specifically at stability, blood loss, vascularity of the osteotomised segment and combined orthodontic and surgical treatment time. Results: Fewer segmental osteotomies were performed in UHW than UMMC. According to the literature the two techniques are generally comparable. Segmentalisation may expedite overall treatment time but is associated with increased intra-operative blood loss and other minor morbidities. Conclusion: There is variation in preferred orthognathic techniques between units. A literature review did not reveal a significant advantage to either technique.
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1001 A SIX-YEAR RETROSPECTIVE REVIEW OF DISTANT FREE TISSUE FLAP RECONSTRUCTIONS IN A REGIONAL MAXILLOFACIAL UNIT Shilen Patel, Lyn Low, Deepak Komath, Sheena Patel, Bhavin Visavadia North-West London Hospitals, London, UK Aims: To determine predictive factors of success, complications and survival of donor flaps in head and neck reconstruction. Methods: A review of 116 flaps-66 radial forearm free-flaps (RFFF), 31 fibular free-flaps (FFF) and 19 anterolateral thigh (ALT) flaps tives: was performed. Patients age, American Society of Anesthesiologists (ASA) status, creatinine (Cr) and haemoglobin (Hb) levels and edd, Bangor intensive care unit (ITU) admission duration were recorded. Results: al of Wales, Cardiff Results show success rates of 94% for RFFF (n=62); 90% for FFF (n=28) and 89.5% for ALT-flaps (n=17). Patients had 4.4 days longer average admissions following FFF with shorter ITU admission (22% vs 26.5% of hospital stay). Cr and Hb fall was greatest following ALT-flaps, 41.7umol/L and 3.83g/dL respectively. Hb reduction following RFFF was 3.6g/dL and 3.2g/dL following FFF. 55% and m: info@asit.org56% of patients undergoing FFF and RFFF respectively had an ASA-II status and 67.7% of ALT-flap patients were ASA-I. Conclusion: Complication rates of RFFF and FFF were comparable; however RFFF offered 4% greater success. There were no sig-
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nificant differences between pre and post-operative Hb or Cr in patients over 65 (p=0.245). FFF and RFFF success per-unit increase in ASA were 0.4 times lower (CI: 0.20, 0.79; p=0.0088). FFF is favourable in haematologically compromised patients.
MISCELLANEOUS SURHERY 0025 FLUID AND ELECTROLYTE Goldie Khera MANAGEMENT IN ADULT SURGICAL PATIENTS IN BRONGLAIS HOSPITAL Andrew Harris, Eunice Acquay, Taha President ASiT Lazim Hywell Dda Health Board, Aberystwyth, Wales, UK Bariatric Fellow, North patients recovery and can reduce complications postoperatively. The Aim: Good quality fluid and electrolyte balance is integral toTyneside GIFTASUP (2009) guidelines set clear standards for fluid management. This project assessed fluid management in Bronglais General Hospital (Aberystwyth). The aim was to ascertain if practice reached the standard described in GIFTASUP and improve any deficiencies. Method: Data was collected on the general surgery ward. All patients on IV fluids during one week were recruited. Data was taken from input/output charts, drug charts and laboratory results. An education sheet and data results were disseminated amongst surgical and nursing teams. Data was recollected after 6 months. Ed Fitzgerald Results: 52 patients were included. Appropriate volume is given to the majority of patients (average: 2.1l). All patients received an ASiT Conference Organiser & Past-President inappropriate amount of sodium as part of a maintenance regime. However, this improved from 100% receiving >150mmol to 83% in the second round (range: 131-482mmol). Surgery Registrar, London General 12% compliance in potassium prescribing in first round improved to 58%. Conclusions: There is an inappropriate reliance on normal saline as part of maintenance regimes and inadequate amounts of potassium being prescribed. Moderate improvement was seen with simple educational interventions. 0038 DOCTORS RECOGNISED BY THE BRITISH HONOURS SYSTEM: HOW DO SURGEONS FARE? Shofiq Islam, Jennifer Cole, Christopher Taylor Jonny Wild Dept of Plastic Surgery, Birmingham Childrens Hospital, Birmingham, UK Aims: The British honours system rewards doctors for achievement and services to medicine. We aimed to establish the numbers of ASiT Honorary Secretary & Sponsorship Co-ordinator Surgeons honoured, the duration of clinical practise involved, as well as additional factors. General Surgery Registrar, Sheffield CBE, OBE, MBE) in the last decade was performed. Methods: A retrospective analysis of doctors receiving honours (Knight / Dame, Demographics of all honoured doctors, including number of year's service were collected. Data pertaining to Surgeons were compared to other hospital-based-specialties. Results: 417 doctors were identified. 243 were hospital based clinicians with a subspecialty affiliation. Of the 243, Surgeons accounted for 8% (n=34) of honoured hospital doctors. The mean number of years from registration to conference of honours for surgeons was 36.9 (SD 6.9). General surgery ranked third overall based on absolute numbers of individuals honoured. Professors constituted >50% all honoured Surgeons. The incidence rate for conference of honours: 3.0 cases per 1000. There was no statistical difference between Robert Davies the number of years service and the subsequent conference of honours between Surgeons and other secondary care specialties ASiT Honorary Treasurer (p>0.05). Conclusion: Surgeons are well represented amongst Registrar, West Midlands Vascular Surgery clinicians recognised by the honours system. Academic distinction in surgery would appear to confer an advantage. The findings may be interest to Surgeons in training. 0065 THE INNERVISION SURGICAL SMOKE REMOVAL SYSTEM James Ansell1, Neil Warren1, Paul Sibbons2, Jared Torkington3 1 Welsh Institute for Minimal Access Therapy, Cardiff, UK 2 James Milburn Northwick Park & St Marks Hospitals, Harrow, UK 3 University Hospital of Wales,ASiT Vice-President Cardiff, UK Aims: The use of energy based surgical instruments results in the production of smoke. This can obscure the operative view and has General Surgery Registrar, Inverness institution. It clears smoke by electrostatic precipitapotential health implications. The Innervision is a medical device designed at our tion. Methods: A preclinical validation study, on live porcine models was conducted to test the device. Monopolar, bipolar and ultrasonic instruments were used to generate smoke. An independent laparoscopic surgeon conducted the trial. The primary outcome measure was the maintenance of a smoke free field. Secondary endpoints included adverse events up to 28-days post surgery. Results: 6 porcine models were included. When comparing Innervision "on" versus Innervision "off", there was a significant difference in no. of times the electrosurgical tool could be used before the field was obscured by smoke. In all cases, this was in favour of the Joseph Shalhoub Innervision "on" setting (no. of cuts with clear view comparing "on:off" setting: 41:9 with monopolar, 44:6 with bipolar, and 96:4 with ASiT Vice-President ultrasonic). Post-mortem showed normal biochemistry, haematology and histology results. Vascular Surgery limited. The London Conclusions: Current systems for smoke removal areRegistrar,Innervision system is a novel approach to conventional designs. It is non-intrusive, non-drying, does not led to desufflation and works continuously without intervention by the surgeon. 0067 DO WE INSIST ON REPORTING BY CONSORT AND PRISMA? A SURVEY OF INSTRUCTIONS TO AUTHORS' IN SURGICAL JOURNALS Steve Hornby James Wigley2, Saran Shantikumar1, Waseem Hameed2, Ashok Handa1 1 ASiT John Radcliffe Hospital, Oxford, UK Director of Education 2 Wycombe General Hospital, High Wycombe, UK General Surgery Registrar, South West Peninsula Background: Guidance has been published on how best to report randomised controlled trials (Consolidated Standards of Reporting Trials - CONSORT) and systematic reviews (Preferred Reporting Items for Systematic Reviews and Meta-analysis - PRISMA). The aim of this study is to establish to what extent surgical journals formally endorse CONSORT and PRISMA in the reporting of randomised controlled trials and systematic reviews. Methods: We studied 136 surgical journals indexed in the Journal Citation Report. Representatives: With thanks to the local ASiT Welsh Regional Author guidelines were scrutinized for the following guidance: conflict of interests (COI), the Uniform Requirements for Manuscripts (URM), clinical trial registration, CONSORT and PRISMA. Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Results: Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff 29% We found the frequency of guidance endorsement as follows: COI 82%, URM 62%, trial registration 32%, CONSORT and PRISMA 10%. Journals with a higher impact were more likely to adopt trial registration (p<0.001), CONSORT (p<0.001) and PRISMA (p=0.004). Journals with editorial offices in the UK were more likely to endorse trial registration (p=0.01) and CONSORT (p<0.001). With thanks to the wonderful ASiT Conference Admin team: info@asit.org Conclusion: Standardised guidelines produced to improve publication practice have not widely been implemented by surgical journals.
Laura Andrews
Kristina Gloufchev
Harriet Innes
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This may overall contribute to a poorer quality of published research. Editors of surgical journals should uniformly endorse reporting guidance and update their instructions to authors to reflect this.
0086 ADHERENCE OF TRIALS OF OPERATIVE INTERVENTION TO THE CONSORT STATEMENT FOR NON-PHARMACOLOGICAL TREATMENTS: A COMPARATIVE STUDY Rob Gray1, Mark Sullivan1, Doug Altman2, Alex Gordon-Weeks1 1 Oxford Radcliffe NHS Hospitals Trust, Oxford, UK 2 Centre for Statistics in Medicine, Oxford, UK Introduction: The CONSORT statement for non-pharmacological treatment (CONSORT-NPT) provides a set of recommendations for the reporting of randomised trials including those assessing operative interventions. We study the adherence of operative trials published in surgical journals to the CONSORT-NPT and raise surgical awareness of the statement. Methods: Five surgical journals from a range of surgical specialities were electronically searched for randomised controlled trials of operative intervention at time periods before and after publication of the CONSORT-NPT statement. A 33-point check-list containing the CONSORT-NPT items was designed and the adherence of trials meeting the inclusion criteria determined independently by two authors. Scores were compared for trials published before and after publication of the CONSORT-NPT. Results: 84 of 191 trials initially identified in the literature search were analysed. There was a significant improvement of 4.7 points in the mean CONSORT-NPT score from 2004 to 2010 (95% CI 2.77-6.71, p<0.001). This related specifically to items present in the original CONSORT statement rather than to CONSORT-NPT specific items which remained poorly reported in 2010. Conclusion: There has been a significant improvement in the reporting of trials of operative intervention published in the surgical literature since 2004, however items specific to the CONSORT-NPT remain under reported.
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0103 TOWARDS NATIONAL SURGICAL SURVEILLANCE IN THE UK - A PILOT STUDY Riaz Agha1, Gary Abel2, Martin Roland2 1 National Institute of Health and Clinical Excellence, London, UK 2 Cambridge Institute of Public Health, Cambridge, UK Aims: The Bristol heart enquiry highlighted the lack of standards for evaluating surgical performance. In contrast, standardised metrics like maternal and infant mortality have long been used in public health surveillance. In 2009, the WHO proposed six standardised surgical metrics (SSMs) for surgical surveillance. This is the first study to collect and analyse WHO SSMs from a cohort of NHS Trusts to determine their utility in measuring surgical performance. Methods: FOI requests for WHO SSMs were made to 36 NHS Trusts in England during autumn 2010. Additional data was obtained from the NPSA, Dr Foster and the Guardian Newspaper. Analysis was performed using mixed-effect logistic regression. Results: 30/36 trusts responded (83%). Over five years, 5.4 million operations were performed with a 24.2% increase from 2005-2009. There was a statistically significant trend of some hospitals increasing in mortality ratios and some decreasing. Rising volume of operations within hospitals over five years was associated with lower mortality ratios (odds ratio for 30-day mortality 0.94, 95% CI 0.87,1.00). HSMR was not associated with surgical mortality (p=0.7). Conclusion: SSMs could provide policy makers and commissioners with valuable summary data on surgical performance, allowing for statistical process control of a complex intervention and building a picture of surgical surveillance. 0150 PATIENT SATISFACTION WITH BOTULINUM TOXIN (BOTOX) INJECTIONS FOR OVERACTIVE BLADDER AT UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE (UHNS) James Rigby, Zeiad El-Gizawy, Fidelma O'Mahony, Jason Cooper, Sam Liu, Lyndon Gommersall University Hospital of North Staffordshire, Stoke-on-Trent, UK Aims: To assess patient satisfaction with bladder botox for the treatment of OAB in departments of Gynaecology and Urology at UHNS. Methods: 60 female patients, median age 59 years (range 35-85) that had bladder botox undertaken in departments of Gynaecology (67%, n=40) and Urology (33%, n=20) between January 2008-March 2011 were identified and sent a satisfaction questionnaire. Results: 67% (n=40) of questionnaires were returned. The majority of patients (58%, n=23) had undergone one bladder botox procedure and 42% (n=17) patients had 2 procedures. 80% (n=32) were investigated with urodynamic studies and 58% (n=23) had been referred for physiotherapy prior to the bladder botox. Following bladder botox, 50% (n=20) experienced a prompt improvement within 1 week and 30% (n=11) experienced an improvement between 2 weeks and 4 months post-procedure. Symptom improvement lasted between 0-9 months for 53% (n=21) of patients. Overall, 73% (n=29) of patients found bladder botox either exceeded' or met' their expectations. 80% (n=32) of patients would have repeat bladder botox and 78% (n=31) would recommend the procedure to a friend. Conclusions: Bladder botox appears to have positive effects in treating symptoms of OAB with high rates of patient satisfaction. Management of patient expectations pre-operatively needs to be improved.
0166 PATIENT OUTCOMES IN NONAGENARIANS UNDERGOING ELECTIVE AND EMERGENCY GENERAL SURGICAL PROCEDURES: THE WEST SUFFOLK HOSPITAL EXPERIENCE Brendan Bates, Philip Bennett, Craig Vickery West Suffolk Hospital, Suffolk, UK Aims: To investigate and compare patient co-morbidities and outcomes in all nonagenarians undergoing elective (EL) and emergency (EM) general surgical procedures. Methods: Nonagenarians were identified between January 2008 and October 2011 and notes retrospectively analysed for comorbidities, ASA grade, post-operative complications, 30day and 1year mortality. Data were analysed using Minitab15. Results: 38 patients underwent general surgical procedures (19EL, 19EM). With a median age of 92[91-95]years. 73% were female. EM were older than EL (94[92-96]vs.92[90-92]years, p=0.0086). There was a trend towards significance in the % of ASA4 patients in EM vs. EL (36.8vs10.5%, p=0.056). Co-morbidities included hypertension (84.2%), atrial fibrillation (31.2%), ischaemic heart disease tives: (31.2%), heart failure (21.1%) and diabetes mellitus (18.4%). EM had more post-operative complications than EL: pneumonia edd, Bangor (47.4vs.10.5%, p=0.012), arrhythmia (26.3vs.0%, p=0.016), acute renal failure (26.3vs.0%, p=0.016), greater admission rates to ITU (21.1vs.0%, al of Wales, Cardiff p=0.034) and longer hospital stays (17[7-25]vs.4[1-7]days, p=0.0003) respectively. 30day and 1year mortality for EM were 21.1 % and 41.7% respectively. All EL patients were alive at one year. Conclusion: Nonagenarians having emergency surgical procedures had worse outcomes than those having elective procedures. Age shouldn't m: info@asit.orgbe a barrier for elective procedures as, at least at WSH, all patients were alive after one year.
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0180 THE COAGULATION SCREEN IN SURGICAL PATIENTS - A WASTE OF MONEY? Robert Spence, Colin Weir Craigavon Area Hospital, Craigavon, Northern Ireland, UK Aim: Coagulation screens in surgical patients are often routinely requested while not appropriately indicated. A coagulation screen costs 4.81, and often does not alter management. We performed a prospective audit of surgical inpatients in a district general hospiGoldie Khera tal, comparing to Trust and NICE guidelines, to establish if coagulation screen requests were appropriate and identify cost implications. ASiT President Method: All coagulation screen requests in surgical inpatients over a 2 week period were analysed and compared to Trust and NICE Bariatric Fellow, North Tyneside Guidelines. Medical notes and laboratory results were reviewed. Results: 100 coagulation screen requests over a 2-week period; 52% requests for elective, 48% for emergency admissions. Only 32% requests were indicated as per guidelines. Inappropriate screens were typically due to unnecessary pre-operative (62%), and preinterventional Radiology requests (21%). No unexpected coagulopathy was found. Over 2-week period, total cost of inappropriate screens: 327.08. Conclusions: Despite guidelines, there were a large number of unnecessary screens performed, costing 327.08 per 100 coagulation screen requests. Extrapolating over 1-year, 8504.08 would be spent on inappropriate screens. Audit cycle was repeated following Ed Fitzgerald education for junior and senior medical staff, demonstrating a marked decrease in number of requests (42) over 2-week period, with ASiT (32% to 38%). an improvement of indicated requestsConference Organiser & Past-President 0192 HAS THE IMPLEMENTATION OF THE CURRENT PRE-OPERATIVE FASTING GUIDELINES (UK GIFTASUP) BEEN SUCCESSFUL? AN AUDIT OF CURRENT PRACTICE Thomas Hall1, James Stephenson1, Cristina Pollard1, Ashley Dennison1 1 Department of Hepatobiliary and Pancreatic Surgery, Leicester, UK 2 University of Leicester, Leicester, UK Jonny Wild Introduction: In patients without disorders of gastric emptying undergoing elective surgery it is unnecessary and undesirable to restrict access to clear fluids for more than two hours prior Secretary & Sponsorship Co-ordinator ASiT Honorary to induction of anaesthesia (national UK GIFTASUP guidelines). However many patients are still made nil by mouth (NBM) from midnight. Methods: A prospective audit General Surgery undergoing a general surgical procedure requiring a general anaesthetic using a of all surgical patients Registrar, Sheffield structured questionnaire over a 20 day period was performed. Day case procedures were excluded. Results: 75 patients were followed through the perioperative period with 41 elective and 34 emergency cases. The average preoperative NBM period for clear liquids was 14 and 19 hours in the elective group and emergency group respectively. Zero patients in the elective group had clear fluids 2 hours prior to induction of anaesthesia and 2 (5%) patients in this group had clear fluids between 2 and 6 hours prior to anaesthesia. Conclusion: The results demonstrate that Davies to the guidelines is poor. With the advent of enhanced recovery programs and an Robert adherence emphasis on early enteral feeding post-operatively to maintain normal' physiology we appear to have forgotten about the preASiT guidelines is Treasurer operative period. Education about theHonorarydesperately needed. 0193 BLOOD TRANSFUSION GUIDELINES IN ELECTIVE GENERAL SURGERY: AN AUDIT OF THE USE AND MISUSE OF THE BLOOD TRANSFUSION SERVICE Thomas Hall, Clare Pattenden, Chloe Hollobone, Cristina Pollard, Ashley Dennison Department of Hepatobiliary and Pancreatic Surgery, Leicester, UK Introduction: Preoperative over-ordering of blood is common and leads to the wastage of blood bank resources. The preoperative James for common blood-ordering and transfusion practices Milburn elective general surgical procedures were evaluated in our trust to formulate a maximum surgical blood-order schedule (MSBOS) ASiT Vice-President Method: We evaluated blood-ordering practises in elective general surgical procedures in our institution over a 6-month period. CrossGeneral Surgery Registrar, Inverness match to transfusion ratios (C:T) were calculated and compared to current trust and the British Society of Haematology (BSH) guidelines. Results: 541 patients were identified during the 6-month period. There were 314 minor and 227 major surgeries carried out. 99.6% (n=226) patients who underwent major surgery and 95.5%(n=300) of the patients having minor surgery had at least a G&S preoperatively. A total of 507 units of blood were cross-matched and 238 units were used. The overall C:T ratio was therefore 2.1:1 which corresponds to a 46.9% red cell usage. C:T ratio varied between 3.75-37 depending on the type of surgery performed. Joseph Shalhoub Conclusion: Complaince with guidelines is poor and over-ordering of blood products common. Implementation of the updated recomASiT Vice-President mended MSBOS and introduction of G&S for eligible surgical procedures is safe. Savings of 8596/annum are achievable with the Vascular Surgery incorporation of updated evidence based guidelines. Registrar, London 0215 AN EVIDENCE BASED ANALYSIS OF DRAIN FIXATION METHODS IN PLASTIC SURGERY Leonie Heskin, George Filobbos, V Cahill, K Bryan, J Ward, S T OSullivan, P Regan Frenchay Hospital, North Bristol NHS Trust, Bristol, UK Steve Hornby Introduction and aims: The importance of drains in plastic surgery cannot be overemphasised. Drain fixation has to be secure in order ASiT Director to avoid the complications of drain dislodgement. of Education Our aim in this study is to objectively quantify the reliability of the popular methods used in drain fixation in Plastic Surgery. Although General Surgery Registrar, South West Peninsula there is a multitude of drain fixation methods in literature, yet there is no comparison between them and no statistical analysis of their strength. Material and methods: An Instron 8872 Tensiometer running on Bluehill software was used to test each method. All fixation methods were done by the same experienced surgeon. To represent reality, the force was applied in a cyclical pulsed load manner as opposed to With thanks force. continuous applied to the local ASiT Welsh Regional Representatives: Key results: The force applied and the numbers of cycles to cause failure of each method were similar. Miss Rhiannon Harries, General Surgery Registrar, Ysbyty tie method and double loop method. The The amount of slippage of the drain was greatest for multiple loop method and least in the Gwynedd, Bangor centurion sandal method was strengthened by steristrips or ties. Fellow, University Hospital of Wales, Cardiff Mr Andrew Beamish, Clinical Research Conclusion: We recommend the double loop method as it is reliable, quick and easy to apply. We also recommend strengthening the centurion sandal method with steristrips or ties.

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0230 AN AUDIT OF PRE-OPERATIVE STARVATION IN ELECTIVE SURGICAL PATIENTS Jonathan Fussey, Asad Parvaiz, Andrew Allan, Brian Isgar, Jaleel Mohammed New Cross Hospital, Wolverhampton, UK Aim: A Recent British consensus guideline recommends that clear, non-particulate oral fluids should not be withheld for more than two hours prior to anaesthetic induction. This audit aimed to assess the extent to which this is being achieved in elective surgical patients in a West Midlands district general hospital. Method: A prospective review of all patients undergoing elective surgery under a single consultant in one month was undertaken. Information was gathered regarding the advice they were given on starvation of food and clear fluids, and their actual starvation times. Planned and actual list orders were also recorded over a year. Results: The mean starvation time for food was 16 hours 56 minutes and for clear fluids it was 9 hours 16 minutes. Analysis of list orders revealed that only 51% of patients were done in the order planned. Conclusions: Elective surgical patients are being deprived of food and fluid for too long before anaesthetic induction. There is good evidence that excessive starvation results in post-operative fluid and electrolyte abnormalities and increased nausea and vomiting. We therefore recommend giving all patients a glucose and electrolyte-rich drink on the morning of surgery, and repeating this in those delayed until the afternoon.
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0243 THE USE OF A CHAPERONE STAMP' TO RECORD THE PRESENCE OF A CHAPERONE DURING INTIMATE EXAMINATIONS IN COLORECTAL CLINICS T Barnes, K Gokul, DY Artioukh Southport & Ormskirk Hospitals, Merseyside, UK Introduction: Following the Ayling report in 2004 the importance of chaperones during intimate examinations was highlighted both by the General Medical Council and the Department of Health. It was recommended that the presence of a chaperone should be documented to protect patients and clinicians. This study aimed to establish whether the mandatory use of a chaperone stamp' in patients' clinical notes improved documentation of chaperone presence in colorectal clinics. Methods: A retrospective comparative cohort study analysed two groups of patients who underwent digital rectal examination in outpatient colorectal clinics. These consisted of 68 consecutive patients (group 1) and 56 consecutive patients (group 2) before and after introduction of mandatory placement of a chaperone stamp' in clinical notes. The stamp required completion of the date, type of examination undertaken and names of clinician and chaperone. Results: The use of a chaperone stamp' significantly increased documentation from 20% in group 1 to 54% in group 2 (p < 0.001). 96% of clinical notes with no record of chaperone had no chaperone stamp'. Conclusion: The mandatory use of a chaperone stamp' in patients' clinical notes has proved an effective way to record and maintain documentary evidence of chaperone presence during intimate examinations. 0311 PATIENT USE OF ONLINE MEDICAL RESOURCES IN A RURAL COMMUNITY Catherine Western, James Faux The Royal Cornwall Hospital, Truro, UK Aim: Despite the wealth of online information, we surprisingly underuse internet resources to explain medical conditions/interventions to patients. However, within a rural community with a relatively elderly population, how many people have access and skills to perform an internet search? We created a questionnaire to determine internet use within our population. Method: Questionnaires were distributed in colorectal clinics over a 2/12 period to determine patient demographics and patterns of internet use. Results: 142 patients completed the questionnaire (response rate 84%). Median age was 59 and 55% were female. 42% of respondents lived in a town, 37% a village, 12% a hamlet, 6% an isolated dwelling and 3% a city. 64% used the internet. 89/90 used it at home and 38/90 also used it at work. 60% stated they would independently research medical information online and 66% would if guided to a website by a medical practitioner. Of these, 10/94 did not already use the internet and 13 would not look up information unprompted. Conclusion: This study confirms that patients are utilizing the internet to access medical information and suggests 2/3 would use this resource if encouraged. This could be utilized, particularly in the outpatient setting, where consultation time is limited. 0349 MEDICAL TALC INCREASES SEROMA FORMATION AND SUPERFICIAL WOUND INFECTION FOLLOWING ONLAY REPAIR OF MAJOR ABDOMINAL WALL HERNIAS Steve Hornby, Raj Parameswaran, Andrew Kingsnorth Derriford Hospital, Plymouth, UK Introduction: Seroma is an established complication encounter in the repair of major abdominal wall hernias. Medical talc seromadesis (MTS) has been described in literature, where sublay mesh has been placed. This study aimed to determine the effect of MTS on seroma formation after onlay repair of incisional hernia. Methods: A retrospective review of a prospective database was conducted for 2 months from June 2011, when 12 consecutive patients received MTS. Outcomes were compared with a published series from the same unit. Results: There were no differences in basic demographic and co-morbidities between the groups. The incidence of recurrent incisional herniae prior to surgery was greater in MTS group (6/12 vs. 36/116, p=0.39). The seroma rate increased from 11/116 (9.5%) to 7/13 (25.8%) [p=0.004] as did the rate of superficial wound infection 10/116 (8.6%) to 4/13 (31%) [p= 0.06] in the MTS group. Patients requiring re-operation was greater in the MTS group [2/13 (15%) vs. 1/116 (2%)]. Length of stay was the same in both groups. Conclusions: MTS appears to increase seroma formation and superficial wound infection in patients undergoing open onlay repair of major abdominal wall hernia. The striking early results have stopped the further use of talc seromadesis.
0354 COMPONENTS SEPARATION WITH ONLAY MESH: A SAFE AND EFFECTIVE REPAIR FOR COMPLEX ABDOMINAL WALL HERNIAS. EXPERIENCE WITH 50 CASES AND THE DEVELOPMENT OF A TRIPLE MESH TECHNIQUE edd, Bangor Steve Hornby, James Boorer, Neil Patel, Andrew Kingsnorth Derriford al of Wales, Cardiff Hospital, Plymout, UK Introduction: Closuring complex major abdominal hernias risks abdominal compartment syndrome. Components separation (CS) allows midline closure in most cases. This poster outlines our experience including postoperative quality of life (QoL) and the evolution of a triple m: info@asit.org mesh technique. Method: Retrospective case notes review and structured telephone interview of patients undergoing CS between October 2005 and
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May 2010 at Derriford Hospital. Results: 50 patients underwent CS; 41 underwent telephone follow-up (82%). Median follow-up was 29 months (range 3.2 - 57.6). 29 Patients were men; median age was 60 and BMI 33.8 (range 20-48.1). Wound complications affected 16(38%); the majority settling with conservative management. There was 1 recurrence of original hernia and 2 subsequent parastomal hernias. One patient developed a hernia related to the lateral release. Since developing the triple onlay technique there have been no recurrences. The series has one death related to small bowel ischaemia. 36(88%) of patients reported improved QoL; (95%) were happy to recommend the procedure to a friend. Conclusion: CS is associated Goldie Khera minimal long term morbidity and improved QoL. Triple mesh technique results in with low mortality (2%); a low recurrence rate. We recommend CS with a triple onlay mesh for repairing complex major abdominal wall defects. ASiT President
Bariatric Fellow, North Tyneside 0357 THE ROLE OF PLAIN ABDOMINAL X-RAY IN ACUTE SURGICAL SETTING: A RETROSPECTIVE ANALYSIS Luke Stroman, Mohamed Ismat Abdulmajed, Cassandra McDonald, Palanichamy Chandran Wrexham Maelor Hospital, Wrexham, UK Introduction: Although the Royal College of Radiologists (RCR) guidelines state that plain abdominal x-ray (AXR) should be undertaken in acute abdominal pain, where perforation, obstruction or renal stones is suspected it is possible that plain abdominal x-rays are carried out too frequently in acute surgical admissions. We herein review the diagnostic value of plain abdominal x-ray requested Ed Fitzgerald in acute surgical setting. ASiT Conference Organiser & Past-President Methods: We performed a retrospective radiological review of all patients admitted to Surgical Assessment Unit (SAU) at our institution for acute abdominal pain between March 2011 and June 2011. General Surgery Registrar, London Results: A total of 116 patients were admitted to SAU complaining of abdominal pain between March 2011 and June 2011. All had routine AXR for possible obstruction (n=73, 63%), renal colic (n=22, 20%) or other suspected diagnoses (n=31, 27%). Positive or suggestive diagnoses were supported by plain abdominal x-ray from total SAU admissions (n=24, 21%), possible obstruction (n=16, 22%) and possible renal colic (n=5, 22%). Conclusion: Whilst abdominal x-rays can be used to negatively exclude diagnoses, the fact that vast majority of patients had normal AXR makes the diagnostic role of routine plain abdominal x-ray in acute surgical setting questionable.
0372 ASiT Honorary Secretary & Sponsorship Co-ordinator COMPARISON OF MORTALITY RATES FOR EMERGENCY ADMISSIONS OF GENERAL SURGEONS AND BREAST SURGeneral Surgery Registrar, Sheffield GEONS Jody Parker, Lloyd Jenkinson Betsi Cadwaladr University Health Board, North Wales, UK Aim: Many trusts are facing the decision whether to exclude breast surgeons from their general on call surgical rota. This study aims to establish whether there is any difference in mortality rates in emergency surgical admissions between breast and general surgeons. Methods: Risk Adjusted Mortality Index data was collected from surgeons on the general on call rota in a North Wales Trust over a period of 31 months. Actual and predicted mortalities were compared to give excess death values for breast specialists and their genRobert Davies eral surgical colleagues. Statistical comparison was performed using the Mann Whitney U test. ASiT Honorary Treasurer Results: Excess deaths for breast, colorectal and upper gastrointestinal were 3.1, -0.4 and -1.3 respectively. The difference in excess deaths between breast and general surgeons were notRegistrar,different. Midlands Vascular Surgery significantly West Conclusion: Although further information needs to be collected, this information suggests that breast surgeons are performing as well as their general surgical colleagues in the on call rota and it may be appropriate for them to remain providing this service.
Jonny Wild
0426 A PROSPECTIVE ANALYSIS OF SLEEP DEPRIVATION IN SURGICAL PATIENTS Ross Dolan, Jae Huh, Neil Tiwari, John Camilleri-Brennan, Thomas Sproat NHS Forth Valley, Stirling, UKJames Milburn Aims: Sleep deprivation has a potentially deleterious effect on postoperative recovery. The aims of our study were to identify the facASiT Vice-President tors contributing to post-operative sleep deprivation and to determine the effect of analgesia and night sedation on sleep. General Surgery Registrar, Inverness Methods: One hundred consecutive patients attending for elective general and orthopaedic surgery were interviewed preoperatively (baseline) and postoperatively on their duration of sleep, number of awakenings during the night, factors contributing to sleep loss and the use of analgesia and night sedation. Results: Patients woke up a median of 5 times in the first postoperative night compared to a median of 3 times preoperatively (p=0.01). Pain was the predominant factor preventing sleep, affecting 39% of patients preoperatively and 49% of patients on the first postoperative day. Other factors included noise from other patients and nursing staff, and using the toilet. Analgesia was taken by 80% of patients in the first two days, this Shalhoub Joseph number gradually reducing over the postoperative period. Only 5% of patients used night sedation. ASiT Vice-President Conclusion: Apart from highlighting the need for effective pain management postoperatively, we believe that our study supports the Vascular Surgery Registrar, the impact drive towards single bed bays, where steps can be taken to minimizeLondon of environmental factors on sleep. 0441 THE USE OF PAIN SCORE OBSERVATIONS TO GUIDE ANALGESIC PRESCRIBING ON SURGICAL WARDS Guy Worley, Yin Choo, Kim Hughes, Zubbar Choudri, Andrew Bradley, Sue Hobbs Croydon University Hospital, London, UK Steve Hornby Aim: Appropriate analgesia in post-operative patients decreases post-operative complications and leads to faster discharge from hospital. We assessed how pain ASiT on observations correlated to analgesia prescribing as per our hospital guidelines. scores Director of Education Method: Data was collected from drug charts, patients and VitalPac electronic observation software in two prospective samples of General Surgery Registrar, South West Peninsula inpatients on general surgery, urology and orthopaedic wards. Results: Two audits, N=65 and N=55, both recorded discrepancy between VitalPac and verbal pain scores (mild/moderate/severe) from patients in 57% and 46%. Incorrect prescribing compared to VitalPac scores in 74% and 60%, but mean 90% of patients were satisfied with their analgesia. Mean 72% of patients pain was worse on coughing or movement. Based on Audit 1, nursing staff were educated regarding recording pain scores on movement Welsh Regional Representatives:this carried out. With thanks to the local ASiT or coughing, but in only 18% of cases in Audit 2 was Conclusion: We have displayed a poor correlation between electronic pain score observations and analgesia prescribing in surgical patients. Miss this the majority of patients are satisfied with painRegistrar,scores observations are more significant if recorded Despite Rhiannon Harries, General Surgery relief. Pain Ysbyty Gwynedd, Bangor accurately in theAndrew Beamish, Clinical ResearchaFellow, University Hospital staff to inadequate analgesia. Mr context of movement and coughing, and can be useful guideline for alerting medical of Wales, Cardiff 0488 SURGICAL HANDOVER AUDIT 2011: AN AUDIT OF HANDOVER PRACTICE Admin team: info@asit.org With thanks to the wonderful ASiT Conference IN A SURGICAL DEPARTMENT IN LONDON AGAINST THE STANDARDS SET BY THE ROYAL COLLEGE OF SURGEONS OF ENGLAND
Laura Andrews
Kristina Gloufchev
Harriet Innes
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Peter Labib, Charles Craddock, Pranav Somaiya, Gabriel Sayer Queen's Hospital, Romford, London, UK Aim: Since the European Working Time Directive was introduced, emphasis has been drawn to handover practice. The Royal College of Surgeons of England published a guideline on safe handover practice to identify key aspects required for safe and effective handover. Our aim was to assess handover practice in our surgical department against these standards. Method: Between 27th October and 13th November 2011, handovers were observed and marked against the above guidelines. Results: 31 handovers were audited. 45% of handovers had a delayed start, the most common reasons being an unprepared list or team members being late. Handover attendance was poor for nursing staff and consultants. Electronic handover was always used. Of the 283 patients on the lists, data recording was good for name, date of birth, admission date, ward, diagnosis, treatment plan and outstanding tasks. Recording was substandard for results, if review was required, clinical status and patient bed space. Conclusions: The guidelines were being achieved in many key aspects of handover (thanks largely to the electronic handover system). However, areas requiring improvement include start time, nursing attendance and recording of patient bed and clinical status. We recommend that there is a handover start bleep reminder and that nursing staff and consultants attend handover.
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0489 THE USE OF GUIDELINES TO RATIONALISE BLOOD TESTS ON EMERGENCY SURGICAL PATIENTS Peter Adam Rees, Fraser Moss, Michael Marsden Stepping Hill Hospital, Stockport, Cheshire, UK Aim: Most emergency general surgical patients have blood tests performed on admission with no published evidence on the subject. This study aimed to identify blood tests frequently performed inappropriately and tests often missed, and to create and evaluate the potential impact of guidelines. Methods: A representative group of general surgical emergency admissions over 3 months were randomly selected and retrospectively analysed. Data collected included presenting complaint, blood tests on admission, and presence of diabetes, jaundice, anticoagulation and haemodynamic instability. A novel guideline was applied and comparison made between predicted and actual blood tests performed. Results: Total of 121 cases (67 female, 54 male, median age 65; range 17-101 years). 10/121 (8%) were outside the remit of the proposed guideline. Only 28/111 (25%) adhered to proposed guideline. CRP and amylase (68/107 and 88/107, actual vs predicted) were frequently missed, while an excess of coagulation screens and group and saves were performed (42/21 and 51/36, actual vs predicted). Strict adherence to the guideline would have resulted in a saving of 2.99 per patient. Conclusion: Many unnecessary blood tests are performed while others are missed. The introduction of guidelines could lead to significant savings when applied to all patients. 0536 DAY SURGERY PERFORMANCE: USING SIMPLE, COST NEUTRAL MEASURES TO IMPROVE CLINICAL AND FINANCIAL PRODUCTIVITY H Lee, C Lam, S Cleland, B Subramanian, M Saunders Barnet & Chase Farm NHS Trust, London, UK Productive Day Surgery units can help provide efficiencies needed to modernise the NHS in a challenging financial climate. This study set out to improve DS performance in an Acute Trust after audit results highlighted inefficiencies in 2008. From 2008 - 2010, data was collected at a single DS unit. Booking efficiency (% of each list booked), theatre efficiency (% of theatre time used), patient attendances, cancellations and case volume were measured. A lead surgeon, anaesthetist, nurse and manager established a DS improvement Steering group. Novel scheduling and booking programmes were developed, and new managers recruited in a cost neutral framework. Efficient practise was cemented into the work culture through clinician engagement. Booking efficiency improved from 59.9% to 79.9%, and theatre efficiency improved from 64.6% to 78.4%. Case volume increased by 17% over the first 6 months. DNA/cancellation rate fell from 21% to 5%. Global DS unit performance increased from of 145 th out of 166 units in 2008 to 66th in 2010, and revenue generation rose by more than 281,000. Improvement of DS performance can play a central role in delivering mandated DH efficiency savings. Multidisciplinary working engineered sizeable efficiency and financial gains in a cost neutral framework. 0555 CAN THE MODE OF ANAESTHESIA INFLUENCE THE READMISSION RATE FOLLOWING ELECTIVE HERNIA REPAIR? Neena Randhawa, Rory Johnston, Timothy Rowlands Royal Derby Hospital, Derby, UK Aim: To assess if the mode of anaesthesia used for elective hernia repair influences readmission following successful discharge from day surgery. Method: Retrospective case note review of 100 consecutive patients (June 2010 December 2011) who underwent elective hernia repair performed by a single consultant. Results: Average age was 55 years (19-79), with 89 males and 11 females. 46% of patients had right and 40% underwent left inguinal hernia repair. The remaining 14% were: 5% bilateral, 4% femoral, 4% umbilical and 1% epigastric hernia repair. Of 100 patients, 87% had general anaesthetic, 9% spinal and 4% local anaesthetic. Six patients were readmitted, all had the procedure under general anaesthetic; of these, four were for pain management, one for wound infection and one for scrotal haematoma. The patient with scrotal haematoma was admitted for 2 days but the rest were successfully discharged within 24 hours. Conclusion: Inadequate analgesia post-operatively was the main factor for readmission in our study. Small sample size has provided limited information but with a recent change in the consultants practice to perform procedures under local/regional anaesthesia, further study would look to compare the factors for readmission.
0558 ARE MODIFIED EARLY WARNING SCORES RECORDED CORRECTLY IN SURGICAL PATIENTS? Aakash Pai, Kavil Patel, Gajan Idaikkadar, Roshani Patel, Mark Golder Wexham Park Hospital, Slough, Berkshire, UK Background /Aims: Modified early warning scores (MEWS) have been shown to correlate well with transfer to HDU/ITU, length of stay tives: and in-patient mortality. We aimed to establish whether MEWS were being recorded and acted upon in accordance with Trust and edd, Bangor NICE guidance. Methods: al of Wales, Cardiff Surgical in-patients (n=71) were audited over a 24 hour period for MEWS, including accuracy of calculation, frequency of recording, request for review and timing of review. The results guided re-education and implementation of changes, including the introduction of a night nurse practitioner. Subsequently, we re-audited (n=67). Results: m: info@asit.org The percentage of patients with incorrectly calculated MEWS was 22% compared with 3% after re-education (p<0.0001). The percentage of missing MEWS was initially 39% compared with 14% after re-education (p<0.0001), with the majority
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of missing scores occurring between 11PM and 8AM (53%). In 60% patients a review was not asked for following MEWS triggering, compared with 14% following re-education (p<0.05). Of those MEWS that triggered, only 40% adhered to the correct timing of review (<30 minutes) compared with 71% on re-education. Conclusions: Re-education and organisational changes improved MEWS, but the level of accuracy remained unsatisfactory. Further education and the use of hand-held digital accessories may be required.
0643 Goldie Khera ARE SERUM BILIRUBIN LEVELS USEFUL IN DISCRIMINATING BETWEEN PERFORATED AND NON PERFORATED APPENDICITIS? ASiT President Sanjay Harrison, Firoozeh Salimi, Shekar Rangaiah, Omar Nugud Bariatric Fellow, North Tyneside Friarage Hospital, Northallerton, UK Aim: To assess is serum bilirubin levels can be used to differentiate between perforated and non perforated appendicitis Methods: A retrospective study of appendicectomies (n=188) performed in two different hospitals from March 2011 to September 2011 was performed. The cases were divided according to histology as normal, inflamed and perforated. Pre operative measurements of serum bilirubin, white cell count and CRP levels were compared between the three groups using a one way analysis of variance. Results: No significant difference in the mean serum bilirubin levels between the inflamed and perforated groups was noted (p=0.1). Mean serum bilirubin levels were found to be significantly lower in the normal group when compared to the inflamed (p=0.02) Ed Fitzgerald and perforated groups (p=0.001). Mean CRP levels were significantly higher in the perforated group when compared to the normal ASiT Conference Organiser & Past-President (p<0.005) and inflamed (p<0.005) groups. White cell counts were also significantly higher (p<0.005) but there was no significant difference between the inflamedGeneral Surgery Registrar, London and perforated groups. Conclusions: While hyperbilirubinaemia is suggestive of appendicitis in conjunction with the clinical presentation, it cannot be used to differentiate between perforated and non perforated appendicitis. CRP levels are more useful in this regard. 0690 CONTINUOUS WOUND INFUSION AFTER MAJOR ABDOMINAL SURGERY - BETTER RECOVERY OUTCOMES VS EPIDURAL Thomas Martin1, Alexandra Gordon1, David Clarke2, Alexander Buchanan2, Semisi Aiono1 1 Jonny Wild Wanganui Hospital, Wanganui, New Zealand, 2 Leicester Royal Infirmary, Leicester, UK ASiT Honorary Secretary & Sponsorship Co-ordinator Aim: We aimed to examine differences in post-operative mobilization and hospital stay in patients undergoing major abdominal surGeneral Surgeryvia wound catheters (WCs) compared with epidurals. gery managed with continuous ropivocaine infusion Registrar, Sheffield Method: Retrospective review of notes of patients undergoing major abdominal surgery between 2009-2011 was undertaken. Main outcomes measured were time until mobile (able to walk to toilet) and length of hospital stay. Other outcomes measured included time to removal of urinary catheter and return of bowel function. Results: 76 patients received wound catheters and 19 patients received epidurals. Patient characteristics and surgical variables were comparable in the two groups. Median length of hospital stay was 6 days for WC patients, significantly shorter than 8 days for those given epidural anesthesia (P Robert Davies to mobilisation was shorter in the WC group compared to the epidural group (2 = 0.034). Median time days vs. 3 days, P = <0.01). Urinary catheters were removed earlier in the WC group compared to the epidural group (3.5 days vs. 5 ASiT Honorary return of bowel days, P = 0.037). There was no difference in time to Treasurer function. Conclusion: Continuous regional anesthesia via wound catheters is associated with earlier mobility and shorter hospital stay compared Vascular Surgery Registrar, West Midlands to epidural anesthesia. 0722 DISTRACTIONS, INTERFERENCES AND IRRELEVANT COMMUNICATIONS (DIICS) IN THE UROLOGICAL MULTIDISCIPLINARY TEAM Rajesh Nair1, Ben Lamb2, Jonathan Lamb2, Nick Sevdalis2, James Green1 1 James Milburn Whipps Cross University Hospitals, London, UK 2 Imperial College London, London, UK ASiT Vice-President Introduction: Multidisciplinary teams (MDT) have widely been accepted as the model for urological cancer service delivery. Although General Surgery Registrar, Inverness research has shown DIICs reduce performance during urological surgery; their effect on MDT performance is unknown. We describe the content, initiators and recipients of DIICs, and consider their impact on urological MDT meeting efficiency. Patients and Methods: A single observer collected data from 815 consecutive cases (520 local, 295 specialist) at 32 urological MDT meetings over a thirty-six week period, across three independent NHS trusts. The nature of DIICs was determined through MDT behaviour, and task related activity. In addition, timing of the MDT meeting, individual cases and DIICs were recorded. Results: Distractions initiated by MDT members accounted for 44% of all observed DIICs. The remaining were task-related (17%, mobile phone, etc.), the environment (18%, temperature, etc.), equipment (12%, teleconferencing, etc.) and coordination (9%, lateJoseph Shalhoub additions, absence, etc.). Technical difficulties accounted for 30% of distractions during video-linked discussions. DIICs resulted in ASiT Vice-President individual MDT case discussions being prolonged by an average of 120 seconds, and each meeting by 21 minutes. Conclusions: DIICs consume Vascular Surgery Registrar, London time, and their reduction could improve MDT meeting efficiency. This would allow for lengthier case discussions, increased case numbers, and shorter meetings. 0724 IS THE ASSESSMENT OF DECISION-MAKING, DISTRACTIONS AND COMMUNICATION IN MULTIDISCIPLINARY TEAM (MDT) MEETINGS FROM VIDEO RECORDINGS FEASIBLE AND RELIABLE? Steve Hornby Rajesh Nair1, Ben Lamb2, Jonathan Lamb2, Nick Sevdalis2, James Green1 1 ASiT Director Whipps Cross University Hospitals, London, UK of Education 2 Imperial College, London, London, UK Surgery Registrar, South West Peninsula General Objective: The quality of MDT working has a significant impact on patient care. We assess the feasibility and reliability of decisionmaking, distractions and communication in MDT meetings from video recordings using previously validated assessment tools. Methods: 94 cases discussed at seven MDT meetings were video recorded and analysed by two blinded registrar level surgeons. Assessment was carried out using previously validated MDT tools for the assessment of decision-making, distractions and communication quality. Inter-rater reliability was assessed using an independent T-test and Intraclass Correlation Coefficient (ICC). With thanks to the local ASiT Welsh Regional Representatives: Results: Data was successfully captured for all 94 cases across 61 domains. Case discussions lasted an average of 228-seconds. Miss Rhiannon Harries, and irrelevant communications. Information from case history, radiological Most distractions came from the environmentGeneral Surgery Registrar, Ysbyty Gwynedd, Bangor and pathological investigations were frequently presented by surgeons, physicians and oncologists. There was no difference between the observers Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff for the mean ratings of any domain, and overall correlations were good for the assessment of distractions and communication (ICC=0.957, P<0.001) and decision-making (ICC=0.904, P<0.001). Discussion: The use of videoto the wonderful ASiT Conference Admin team: info@asit.org tool. With thanks recordings is a feasible and reliable method of assessing MDT working and acts as an assessment The ability of teams to assess their own performance in MDT meetings enables promotion of good practice.
Laura Andrews
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0725 WHAT IS THE NEGATIVE APPENDICECTOMY RATE IN WOMEN HAVING DIAGNOSTIC LAPAROSCOPY? J Hall, A Kaye, S Fallis, G Barsoum, H Youssef Heart of England NHS Foundation Trust, Birmingham, UK Aims: Management of the macroscopically normal appendix at surgery remains controversial. Traditionally, during open surgery, there's a negative appendicectomy rate of approximately 30% in women. However there's increasing use of diagnostic laparoscopy. The aim of this study was to investigate current practice during diagnostic laparoscopy in young and middle-aged women to assess the negative appendicectomy rate. Methods: From January 2010 - April 2011, details of women aged 16 - 60 years attending SAU with RIF pain, were recorded on a prospectively collected database and analysed. Results: 308 female patients were admitted with RIF pain (median age 25, range 16-59 years). Of these, 80 had a laparoscopic procedure. 43/80 (54%) had macroscopically inflamed or congested appendices, all of which were removed. 35/43 (81%) were confirmed as appendicitis histologically, 2 had other appendiceal pathology, 6 were normal (14%). From the remaining patients who had macroscopically normal appendices (37/80), 12 had appendicectomy (32%), all of which were histologically normal. Conclusions: The negative appendicectomy rate in macroscopically abnormal appendices was 14%, which rose to 33% (18/55) when taking into account normal-looking appendices as well. Despite the use laparoscopy as a diagnostic aid in women with RIF pain, the negative appendicectomy rate has remained constant.
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0736 A CLINICAL AUDIT OF ENHANCED RECOVERY AFTER SURGERY (ERAS) IN SIX SURGICAL SPECIALTIES AT NOTTINGHAM UNIVERSITY HOSPITALS - ONE YEAR REVIEW Sarah Humphries, Nick Simson, James Catton, John Hammond, Charles Maxwell-Armstrong University of Nottingham, Nottingham, UK Aims: ERAS aims to improve elective surgical recovery and reduce postoperative length of stay (LOS). Our unit implemented fasttrack protocols in six surgical specialities in 2010, and a previous audit evaluated initial success to produce recommendations. This audit aims to identify interventions, improvements and hindrances one year on. Methods: From September to December 2011, pre-, peri- and post-operative data was collected prospectively. Primary outcomes were success rate (discharge on or before the intended day) and LOS. Results: Success was again highest in gynaecologic surgery at 57.4% and lowest for upper gastrointestinal surgery at 25%. The largest improvement was seen in gynaecologic oncology surgery (22.3% improvement) with a 1.1 day decreased mean LOS. Mean LOS reduced for open liver resection and oesophagectomy by 3.2 and 3.7 days respectively, but increased by 2.6 days for laparoscopic colorectal surgery. Overall colorectal success decreased to just 34.4%, with distance walked on day 2 (P=0.018), drain use (OR 0.7; P<0.001) and early IV fluid cessation (OR 1.6; P=0.022) as significant predictors of success. Similar multivariate analysis was conducted for other specialties. Conclusion: Improved success rate and LOS in three specialties suggests effective recommendations and increased experience, while the worsening colorectal results raise sustainability issues. Further ERAS amendments are required. 0738 OUTCOMES FOR SURGICAL FEMALE PATIENTS ADMITTED TO A SURGICAL ASSESSMENT UNIT WITH RIGHT ILIAC FOSSA PAIN - IS IT TIME FOR A MULTIDISCIPLINARY APPROACH? J Hall, A Kaye, S Fallis, G Barsoum, H Youssef Heart of England NHS Foundation Trust, Birmingham, UK Aims: Female patients presenting with RIF pain form a large proportion of all surgical emergencies. Some 40% are treated conservatively for non-specific abdominal pain' (NSAP). This study investigates diagnostic and treatment outcomes of women presenting with RIF and lower abdominal pain. Methods: From January 2010 - April 2011, details of women aged 16 - 60 years attending A&E and transferred to SAU with RIF or lower abdominal pain, were recorded on a prospectively collected database and analysed. Results: Of 1562 female patients referred from A&E to SAU, 544 presented with abdominal pain or GI symptoms, of which 308 were admitted with RIF/lower abdominal pain (median age 25, range 16-59 years). 87 were treated operatively (80 laparoscopic; 7 open), diagnoses: 40 appendicitis; 5 other surgical; 21 gynae and 21 NAD. 153/308 (50%) were managed conservatively, diagnoses: 112 NSAP, 11 gynae, 11 urological, 5 musculoskeletal and 14 other surgical. 63/308 (20%) were referred to O&G. 1 patient was referred to infectious diseases; 4 self-discharged. Conclusions: 28% of patients were managed surgically and 46% conservatively. 31% had gynaecological pathology compared with 19% confirmed surgical pathology and 44% non-specific pathology. This suggests an MDT approach, including general surgeons and gynaecologists, would be optimal.
0904 EMERGENCY DEPARTMENT DIAGNOSIS OF WOMEN PRESENTING WITH LOWER ABDOMINAL PAIN: APPENDICITIS OR GYNAECOLOGICAL? Annakan Navaratnam1, Joshua Balogun-Lynch2, Patrick Roberts1 1 Chelsea and Westminster Hospital, London, UK 2 Imperial College School of Medicine, London, UK Aim: To investigate the diagnosis of women of childbearing age presenting to the Emergency Department (ED) with lower abdominal pain. Method: In this retrospective study, we reviewed the medical records of all non-pregnant women aged 15 55 presenting to Chelsea and Westminster ED with lower abdominal pain between September November 2011. Details of referrals, investigations and treatments were carefully recorded. Results: Of the forty-eight women that met the inclusion criteria, ED diagnoses included acute appendicitis (n=32), ovarian cyst (n=6), pelvic inflammatory disease (n=2), endometriosis (n=2) and other (n=6). In the group of patients diagnosed with acute appendicitis, 12 (37.5%) underwent laparoscopy and only 6 (18.8%) had a confirmed diagnosis of appendicitis. Additionally in this group, 8 (25%) were later found to have a gynaecological pathology confirmed by ultrasound without laparoscopy (n=6), or at laparoscopy (n=3). tives: Conclusion: Women of childbearing age presenting to the ED with lower abdominal pain may benefit from a gynaecological review edd, Bangor before being referred to the surgeons with the diagnosis of acute appendicitis. Additionally, ultrasonography has a valuable role in confirming al of Wales, Cardiff gynaecological pathology and in some cases avoiding the need for laparoscopy. 0974
DEDICATED m: info@asit.org ACCESS TO ULTRASOUND: ESSENTIAL FOR AN EMERGENCY GENERAL SURGICAL SERVICE Leah Mathews, Declan Dunne, Martin Brett
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Warrington and Halton NHS Foundation Trust, Warrington, Cheshire, UK Aim: Establish the ultrasound requirement of an emergency general surgical service. Assess the impact of a dedicated ultrasound service. Introduction: Ultrasound (USS) is the most frequently performed radiological investigation of the acute abdomen, used in up to 31% of emergency general surgical admissions. It has been shown to lead to earlier operative intervention and discharge. Methodology: All adult emergency general surgery admissions over 30 days were included and those undergoing inpatient USS were identified. Results were used to set up a dedicated emergency general surgical ultrasound service. The study was repeated to evaluGoldie Khera ate the impact. Results: A pilot study including 375 admissions revealed 66 patients (18.1%) undergoing inpatient USS, with a mean length of stay of ASiT President 8.03 days. An emergency USS service was set up with 5 daily scans available. Bariatric Fellow, North Tyneside A 14 day follow up study including 210 admissions showed 57 (27.9%) undergoing inpatient USS. There was a significantly reduced mean LOS of 4.54 days (p<0.05) in this group. Conclusions: Dedicated inpatient USS sessions has led to earlier diagnosis and treatment of emergency general surgical admissions and thus significantly reduced length of stay.
1033 IMPROVING EFFICIENCY AND REDUCING CANCELLATIONS. AUDIT OF BOOKING AND THEATRE UTILISATION EFFICIENCY Ed Fitzgerald IN A DISTRICT GENERAL HOSPITAL DAY SURGERY UNIT 1 ASiT Conference Organiser & Past-President Stuart Cleland , Muthiah Balasubramanian2, Michael Saunders2, Ema Oteri1 1 Royal Free Hospital, Hampstead, London, UK General Surgery Registrar, London 2 Barnet General Hospital, Herts, UK Aims: To improve the efficiency of day case theatres and reduce the cancellation/DNA rates. Methods: Audit criterion were set from our trusts targets for a booking efficiency/theatre utilisation of 90%. An initial prospective audit was performed in July 2008 with two reterospective follow up audits in June 2010 and June 2011. Data collected from the central data collection department in the trust. Results: The initial audit revealed poor overall theatre utlisation with high DNA and cancellation rates. The following changes were Jonny Wild implemented. Increases in the number of permanent staff members from 30 - 70%. All patients contated one week before their operation to confirm attendance/allow for re-booking if unable to attend. Day case theatre sessions increased from 3.5 to 4 hours. ImproveASiT Honorary Secretary & Sponsorship Co-ordinator ments to the booking system to include average time per case + review of list by responsible surgeon to ensure list feasibilty. General in booking efficiency from Sheffield These changes have seen: 1. Increase Surgery Registrar, 59.9% to 94.5%. 2. Increase in theatre efficiency from 64.59% to 96.74%. 3. Decrease in DNA/Cancellations from 21% to 5%. Conclusions: Improved booking systems and a reduction in cancellations/DNA rates have successfully improved the overal efficency of the day case theatres in our trust. 1051 METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) SCREENING IN DAY SURGERY PATIENTS Robert Davies Nicholas Penney, Gokulan Phoenix, Beryl De Souza ASiT Honorary Treasurer Chelsea and Westminster Hospital NHS Trust, London, UK Introduction: Healthcare associated infections, such as MRSA, are associated with considerable morbidity and mortality; costing the Vascular Surgery Registrar, West Midlands NHS approximately 1 billion per annum. The Department of Health (DoH) has issued MRSA Screening guidelines, stipulating that the bulk of surgical admissions should be screened, including most day-cases. Aim: Screening within the Day-Surgery-Unit of our trust was assessed against our trusts universal screening policy and DoH guidelines. Compliance, clinical and cost-effectiveness were noted. Method: A retrospective analysis was carried out of all patients that underwent elective surgery in the Day-Surgery-Unit between 01/12/10 30/11/11 using hospital records. James Milburn Results: 7102 patients were treated; mean (SD) age: 52.0 (19.3), Male-Female ratio: 0.8:1. Of the 4123 (58.1%) patients screened, only 12 were MRSA positive ASiT Vice-President DoH guidelines 731/1132 patients were screened (64.6%), 3 were MRSA (0.29%). After exclusions by positive (0.41%). General Surgery Registrar, Inverness was poor. Furthermore, prevalence of MRSA in this Conclusion: Compliance with Trust Policy (58.1%) and DoH guidelines (64.6%) population group was low (0.29%), compared to the 7-8% prevalence quoted for long-stay hospital patients. Screening of day-surgery patients, priced at 4.74 per screen, appears to be neither clinically efficacious nor cost-effective. We feel a revision of local policy towards targeted screening of high-risk patients is required. 1053 ASSESSING THE IMPACT OF AN AGEING POPULATION ON COMPLICATION RATES AND IN-PATIENT LENGTH OF STAY Joseph Shalhoub Terri McVeigh, Dhafir Al-Azawi, Gerrard O'Donoghue, Michael Kerin ASiT Vice-President Galway University Hospital, Galway, Ireland Vascular Surgery Registrar, London Aims: The aim of this study was to examine the demographics of the population served by the Surgical Department in a Tertiary Referral Centre in the West of Ireland, and to examine whether increasing age had an influence on morbidity, mortality and length of stay (LOS). Methods: Data pertaining to admissions over a six-month period was collected prospectively using an ACS-NSQIP-based proforma. Data collected included age, gender, operative intervention, LOS and complications. Multivariate statistical analysis was performed using PASW software to determine those factors associated with increased risk of complications. Steve Hornby Results:2209 patients were admitted over the six-month period. The average age was 50.37years (+/-23.62), with 32.2% (n=731) ASiT Director of Education older than 65. 291 experienced a complication, 71.48% having surgery. Death occurred in 41 patients, of whom 19 (46%) had surgery. Only 9.3 % of patients younger than 65 experienced Registrar, South West Peninsula General Surgery a morbidity, compared to 25.08% of older patients. Patients that died in hospital were older than patients discharged alive (P<0.001, ANOVA). Multivariate analysis showed factors predictive of morbidity to include Emergency admission, Surgical Intervention and Age(OR 0.041). Conclusion: Increasing age is associated with increased complication rates and LOS. Those patients older than 65 represent a highrisk group and should be optimised pre-operatively if possible to reduce morbidity. 1056 Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor THE IMPLEMENTATION OF THE WHO SURGICAL SAFETY CHECKLIST IN A SIERRA LEONIAN HOSPITAL - A PROSPECTIVE AUDIT Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Nikhil Ladwa, Kumaran Ratnasingham, Somaiah Aroori, Mike Singh Better Lives Foundation (Charity), London, UK Aims: Sierra Leone is among thethe wonderfulthe world Conference Admin every health care category. We report With thanks to poorest countries in ASiT and ranks near the bottom in team: info@asit.org our experience of the introduction and application of the WHO Surgical Safety Checklist during an inguinal hernia surgical camp at a
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charity hospital in Sierra Leone. Methods: An international volunteer run surgical camp took place in October 2011. Team briefs included: electricity and water supply status, autoclave functioning, anaesthetic and surgical supplies. All patients had a SSC included with case notes for completion. Satisfaction surveys were carried out by all volunteers to assess their experience. Results: 41 operations were carried out over a 6 day period. Briefing sessions were carried out daily and SSCs were complete for each patient. One patient arrived in theatre without SSC; surgery delayed and root cause analysis was carried out. There were no reported never events. Volunteer feedback regarding execution of the SSC was excellent with praise regarding improved teamwork and dedicated time available for feedback. Conclusions: When used effectively the WHO SSC provides a structured, safe approach to minimise errors in surgery. We have illustrated it can successfully be adopted and adapted in Sierra Leone to improve the standard of care for surgical patients.
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1080 A SYSTEMATIC REVIEW AND META-ANALYSIS OF SUTURE MESH FIXATION VERSUS GLUE MESH FIXATION IN OPEN INGUINAL HERNIA REPAIR N Ladwa, MS Sajid, P Sains, MK Baig Worthing Hospital, Worthing, West Sussex, UK Objective: The objective of this study is to systematically analyse the randomised, controlled trials comparing suture mesh fixation (SMF) versus fibrin-glue mesh fixation (FMF) in open inguinal hernia repair (OIHR). Methods: Randomised, controlled trials comparing the TMF versus FMF in LIHR were analysed systematically using RevMan, and combined outcomes were expressed as risk ratio and standardised mean difference. Results: Five randomised controlled trials encompassing 679 patients were retrieved from the electronic databases. There were 315 patients in the SMF group and 364 patients in the GMF group. There was a significant heterogeneity among trials (p < 0.0001). In the fixed effects model, operating time, post-operative pain , chronic groin pain, postoperative complications and length of hospital stay were statistically comparable between two techniques of mesh fixation in OIHR. Conclusion: FMF in LIHR does not increase the risk of hernia recurrence. It is comparable to TMF in terms of operation time, postoperative pain, chronic groin pain, complications, and hospital stay. FMF is an additional method of mesh fixation in inguinal hernia repair however it provides no additional benefit to suture mesh fixation in open repair. 1082 CONSENSUS VIEWS ON IMPLEMENTATION AND MEASUREMENT OF ENHANCED RECOVERY IN ENGLAND: DELPHI STUDY A Knott1, S Pathak1, R Kennedy2, F Carter1, N Francis1 1 Yeovil District Hospital, Yeovil, UK 2 St Marks Hospital, Middlesex, UK The Enhanced Recovery Partnership Programme (ERPP) commenced a spread and adoption programme throughout England and wished to examine ways to consolidate this initiative. Exploration of anecdotal evidence on the benefits of emerging new techniques in enhanced recovery programmes (ERPs) required examination, as well as methods to sustain success. The aim of this study was to interrogate expert opinion and define areas of consensus on these issues. Experts were chosen from teams with experience of delivering a successful ERP across different surgical specialties. The Delphi technique was employed to generate consesus opinions from the expert group. During the first two rounds, an online questionnaire was completed. The final (third) round was undertaken in a face to face meeting using interactive voting. 70 experts participated. Regarding emerging techniques, the group reached consensus that there was no longer a definitive requirement for epidural pain control as laproscopic surgery increases in prevalence. Experts agreed that data should be recorded, audited and reviewed at regular enhanced recovery meetings. There was unanimous agreement on the formation of a national enhanced recovery network. A national enhanced recovery society is required to set standards, facilitate research into emerging techniques and to promote education, thus consolidating the ERPP initiative. 1136 STUDY OF THE DELAYS IN REVIEWING PLAIN RADIOGRAPHS ON THE ACUTE SURGICAL TAKE IN A DISTRICT GENERAL HOSPITAL Hannah Travers, Amy Jordan, John Thompson Royal Devon and Exeter Hospital, Exeter, UK Aim: To assess the delays occurring in the requesting, performing and documenting of radiographs and their results for acute surgical take patients. Methods: Concurrent study over 2 one week periods (October 2011 and January 2012) of all adult patients admitted on the general surgical take. Electronic audit trail of timings of radiographs was correlated with the documentation in patients records. Mann-Whitney U test was performed to analyse significance. Results: During the study 139 radiographs were performed on 94 patients: 99 requested electronically, 5 manually (no audit trail so excluded). Of these, 54 (55%) radiograph results were documented in the notes (6 with no time). The median time (hours: minutes) from request to performance of radiograph was 01:59 (Range 00:0064:57). The median time from performance to documentation was 04:12 (range 00:02-17:30). This is not significantly different (p=0.2407) to radiographs requested on surgical patients by the Emergency Department: 35 radiographs requested, 18 had the results documented. The median time from performance to documentation was 02:33 (range 00:0216:11). Conclusions: Documentation of radiograph findings is poor and there are delays at all stages. Education is required to ensure accurate documentation and to avoid unnecessary delays in diagnosis and treatment of patients. NEUROSURGERY
0159 COMPLETE RESECTION RATES FOR POSTERIOR FOSSA TUMOURS IN CHILDREN IN SOUTH WALES OVER THE LAST 11 YEARS edd, Bangor Sanjay Amarasinghe, Laith Alzweri, Shafqat Bukhari, Paul Leach University al of Wales, Cardiff Hospital of Wales, Cardiff, UK Introduction: The aim of our study was to determine our complete tumour resection rates for the three most common posterior fossa tumours, pilocytic astrocytoma, medulloblastoma and ependymoma, in children for the last decade. Methods: m: info@asit.org Details of all paediatric patients (<16 years old) with posterior fossa tumours from January 2000 to November 2011 were obtained from the paediatric neuro-oncology database at the University Hospital of Wales, Cardiff - data from these case notes and
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post-operative imaging regarding tumour resection was documented and analysed. Results: 44 patients were identified. 19 children had pilocytic astrocytomas, 17 medulloblastomas and 8 had ependymomas. The mean age at operation was 7 years 2 months. Complete resections were achieved in 13 out of 19 (68.4%) pilocytic astrocytomas, 13 of 17 medulloblastomas (76.5%) and 5 of 8 ependymoma cases (62.5%). However, the complete resection rate for the last 21 cases has been 90.5% overall. Conclusions: Over the last decade complete resection rates, in Cardiff, for pilocytic astrocytomas in children has been less than ideal, however, paradoxically the resection rates for the perceived more difficult tumours has been very good, especially medulloblastomas. Goldie Khera Encouragingly complete resection rates are improving and the reasons for this are likely to be multi-factorial.

ASiT President
0219 Bariatric Fellow, North Tyneside A SINGLE CENTRE AUDIT INTO THE OUTCOME OF TRANSSPHENOIDAL SURGERY IN THE TREATMENT OF ACROMEGALY Edward Dyson1, Nigel Mendoza2 1 Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK 2 Imperial College Healthcare NHS Foundation Trust, London, UK Aim: The mainstay of treatment for growth hormone (GH) producing pituitary tumours is surgical resection using a transsphenoidal approach. Method: This audit retrospectively examined the remission rate of acromegaly following primary transsphenoidal surgery at a single Ed Fitzgerald centre from 2004 to 2011. The same data from 1996-2003 are also presented for comparison. Remission was defined biochemically ASiT Conference to 6 months following surgery. as a GH level of less than 5 mU/L in the period 6 weeksOrganiser & Past-President Results: The overall cure rateGeneral Surgeryseries (n=41) was 63.4%. This is a considerable improvement when compared to for all patients in the Registrar, London the 1996-2003 figure of 29.4% (n=17). When looking at the cure rates in relation to tumour size, the overall cure rate for macroadenomata was 61.9% (n=21) and for microadenomata it was 69.2% (n=13). The cure rate for macroadenomata compares particularly favourably with the recent literature, with cure rates of 50% being reported in specialist centres. Conclusion: As a result of increased individual experience, the cure rate of surgical resection in acromegalic patients has improved rapidly since the adoption of a dedicated pituitary surgeon. A particular improvement in remission rate has been seen in the macroadenoma group. This practice is becoming commonplace and ought to be emulated nationwide. 0321 ASiT Honorary Secretary & Sponsorship Co-ordinator PREVENTING SURGICAL SITE INFECTION IN NEUROSURGERY: A 4 YEAR AUDIT General Surgery Lewis Thorne Sheffield Patrick J Grover, Jonathan Lamb, Matthew J Pywell, Registrar, Royal Free Hospital, London, UK Introduction: An estimated 14% of hospital infections are surgical site infections. They are associated with a greater than twofold increase in hospital stay and mortality. A NICE approved audit tool is available to improve standards in preventing infections. Methods: An audit using the Department of Health Saving Lives High Impact Tool (2007) was carried out in 2008, 2010 and 2011. All neurosurgical inpatients on the day of audit were reviewed for peri-operative compliance with standards for hair removal, temperature control, glucose control and antibiotic prophylaxis. Robert Davies Results: 18-20 patients per year met the inclusion criteria. Hair removal compliance was 100% in 2010 and 2011, improved from 50% ASiT Honorary Treasurer in 2008. Antibiotic compliance was 72% in 2011, 70% in 2010 and 60% in 2008. Glucose control was maintained in 94% of cases in 2011 compared with 85% in 2010 and 100% in 2008. Temperature was maintained above 37C in 39% of cases in 2011, 85% in 2010 Vascular Surgery Registrar, West Midlands and 10% in 2008. All results were presented locally following each audit cycle. Conclusion: Compliance has improved since the introduction of the audit cycle. However, in some instances, for example temperature control, it has fallen. Regular audit and local teaching are required to maintain standards. 0546 DRIVING ADVICE FOLLOWING NEUROSURGERY: AN AUDIT TO SEE WHETHER PATIENTS ARE GIVEN APPROPRIATE James Milburn DRIVING INFORMATION Veejay Bagga, Ammar Natalwala, Graeme Hancock, Patricia Delacy ASiT Vice-President Royal Hallamshire Hospital, Sheffield, UK General Surgery Registrar, Inverness The DVLA has national guidelines regarding the fitness to drive following surgery. We surveyed patients discharged from our unit following neurosurgical intervention to see whether they were provided with driving advice according to the DVLA guidelines. Over a 3 week period, 52 patients were discharged from our unit. Of these, 38 patients (73%) were current motor vehicle drivers (all of group 1 vehicles: motorcycles, cars). 8 patients (21%) were advised to inform the DVLA regarding their recent surgery and only 2 of these (5%) given specific driving advice regarding the driving restrictions that applied following their surgery. Driving advice is not given to the majority patients following neurosurgical intervention and we believe this is mirrored across all surgical specialities. It is our obligation to ensure that all patients are advised to inform the DVLA of their recent surgery, and at a minimum, Joseph Shalhoub all patients should be told to refer to the DVLA website to look at their driving restrictions.
Jonny Wild
Vascular Surgery Registrar, London 0695 RETROSPECTIVE ANALYSIS OF INCIDENCE, RISK & DURATION OF SEIZURES AFTER OPERATIVE AND ENDOVASCULAR TREATMENT FOR RUPTURED AND UNRUPTURED INTRACRANIAL ANEURYSMS Arnold Bok, Muthupalaniappaan Muthappan, Balakrishnan Venkataraman Auckland City Hospital, Auckland, New Zealand Aim: We intend to investigate Steve incidence and duration of seizures after operative or endovascular treatment of ruptured versus the risk, Hornby unruptured intracranial aneurysms in the New Zealand population. ASiT Director of Education Method: This is a retrospective analysis of patients treated at the above institutions between Jan 2004 to Dec 2009. Information gathered include location of aneurysm, WFNS grade, Fisher grading, timing of seizure (onset, pre-operative, post-operative and delayed), General Surgery Registrar, South West Peninsula peri-operative complication and CT findings. Results: 647 patients were treated between Jan 2004 and Dec 2009. 66 patients passed away and hence 581 patients were included in the final analysis. 488 operative clippings (416 acute and 72 elective) and 159 endovascular treatments (123 acute & 36 elective) were performed. 97 patients developed peri-operative seizure with 18 delayed onset seizures. The risk of seizure was higher in the acute clipping (22.29%) and to the local groups when compared to electiveRepresentatives: patients (0%). CT eviWith thanks coiling (10.57%) ASiT Welsh Regional clipping (8.3%) and coiling dence of infarction and/or intracerebral haematoma was strongly associated with delayed seizures (p< 0.0003). The risk of seizure Harries, General Surgery Registrar, in patients with aneurysmal subarachnoid haemorConclusion:Miss Rhiannonwas similar between different treatment modalities Ysbyty Gwynedd, Bangor rhage compared to patients with elective procedures. Patients with CT evidence of infarct or haematoma during admission was Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff strongly associated with delayed seizures.
ASiT Vice-President

am 2012
0727 INFLUENCE OF CLINICIAN GRADE ON NEUROSURGICAL REFERRAL OUTCOME Shyamica Thennakon, Andrew Alalade, Jonathan Pollock, Seb Bavetta Queens Hospital, Romford, Essex, UK Aim: Our neurosurgical unit receives approximately 300 referrals per month. We aim to assess if the grade of the referring clinician affects the referral outcome. Methods: A retrospective analysis of all (890) emergency neurosurgical referrals made in a three month period (June August 2011). Parameters assessed were grade of referring clinician versus referral outcome. Referrers included nursing staff, house officers, SHOs, registrars, GPs and Consultants. Results: Of 890 referrals, 30% were from house officers (FY1) - (13% were accepted and 60% were rejected). 33% of the referrals were made by SHO grade doctors (12% accepted, 65% rejected, 4% discussed at MDT and 3% followed up in clinic). Registrar level clinicians referred 39% of the cases (22% accepted, 61% rejected, 3% discussed at MDT and 1% followed up in clinic). 6% of referrals were from consultants (30% accepted, 47% rejected, 8% discussed at MDT and 3% followed up in clinic) One of these referrals was made by a nurse and this was rejected. Conclusion: Our results show that a neurosurgical referral would likely get accepted if done by a senior grade clinician. This is probably due to several factors e.g. referring more urgent cases or because of more clinical experience. 0771 MANAGEMENT OF CEREBRAL ARTERIOVENOUS MALFORMATION (AVM): A QUALITY-BASED HOLISTIC APPROACH Adam Grose University Hospital Southampton, Southampton, UK Aim: Unruptured AVMs have huge ability for acute insult to cerebral circulation. The decision for invasive treatment is based on the potential to successfully reduce the risk. This study examines subjective quality of life and patient perspectives throughout management with an aim to improve the model for health-care delivery. Method: A cohort of recently-diagnosed patients with unruptured AVMs (n=33) were identified and consented for interview. A structured questionnaire was engineered to assess raw, subjective psychology. Patients were evaluated three times throughout management across all treatment modalities (conservative, endovascular, removal). Results: Analysis exhibited qualitative data describing patient experiences. Diagnosis produced negative impact in 100%. A spectrum of severity was experienced. The best response being I want to get rid of this and the worst; I feel like life is over. Patients described wide-ranging emotions, but common significant themes were; fear of spontaneous death (84%), anxiety of operation (60%), long-term disability (42%) and the risk of re-bleed (30%). Conclusions: Surgical management of AVMs is rightly based on angiomorphology and potential for cure. The study demonstrates that addition of education and psychological support provides an added opportunity to greatly improve patient experience and the quality of healthcare. 0773 DO OPERATIVE NOTES FROM THE NATIONAL HOSPITAL FOR NEUROLOGY AND NEUROSURGERY, QUEEN SQUARE, FOLLOW GOOD SURGICAL PRACTICE GUIDELINES? Negin Damali Amiri, Victoria Anne Nowak, Huma Sethi National Hospital for Neurology and Neurosurgery, London, UK Aim: Good Surgical Practice (Royal College of Surgeons of England, 2008) stipulates what information operative notes should contain. We recorded how closely we are following these guidelines at Queen Square and also assessed legibility. Method: We identified 52 neurosurgical patients who had operations on 6 consecutive days in November 2011. We reviewed operative notes against RCS guidelines and recorded how many words could not be read. Results: 22 aspects of the operative notes were audited. 73% of the operative notes met 70% of RCS guidelines. Certain areas however were not generally recorded e.g. time of operation' (never), 'grade of the operating assistant' (7.7%) and 'serial numbers of prosthesis or other implanted material' (25%). This is probably because the operative note template does not have places to record these details. 30% of operations had > 5 words which were not eligible; capital letters were observed to be easier to follow. Conclusions: We have identified some areas in the operative note proforma which we hope to change with the help of our Clinical Governance team. We anticipate that this, in conjunction with presenting our results locally, will improve how closely operative notes match RCS standards at Queen Square when we re-audit.
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edd, Bangor IS IT BETTER TO HAVE AN ANEURYSMAL SUB-ARACHNOID HAEMORRHAGE ON A WEEKDAY? Parag Sayal, Aimee Lawson, Chittoor Rajaraman, Paul Maliakal al of Wales, Cardiff
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0881 MEDICAL STUDENTS' AND JUNIOR DOCTORS' PERCEPTIONS OF NEUROSURGERY AS A CAREER Joseph Frantzias1, Shami Acharya2, Yasir Chowdhury2, Aaron Lawson-McLean1 1 University of Edinburgh, Edinburgh, UK 2 Bart's and the London School of Medicine, London, UK Inroduction: There has been a falling trend in the number of applicants for Neurosurgery in recent years, while the number of female applicants remains low relative to the proportion of female medical students. Aim: We tried to identify perceptions about neurosurgery, and assess factors that affect career choice. We hypothesised that a oneday careers event is a good intervention to increase the interest in the specialty. Methods: In collaboration with the Society of British Neurological Surgeons, we organised a neurosurgery Careers Day for medical students and junior doctors. We asked all participants to fill in the same questionnaire both before and after the event. Results were compared using a paired, two-tailed t-test. Results: 75% of participants identified poor work-life balance as the main disadvantage of neurosurgery, and 69% of these were female. 84% agreed/strongly agreed that they have not had enough exposure to the specialty. Significantly less attendants perceived neurosurgery as a male-dominated specialty (p<0.001), and significantly more were interested in pursuing it as a specialty (p<0.001) after the event. Conclusions: Little exposure and misconceptions about the specialty are the main reasons for discouraging potential applicants, particularly female, from pursuing a career in neurosurgery. Such careers events have significantly increased interest in Neurosurgery. 0959
m:
Department of Neurosurgery, Hull Royal Infirmary, Hull & East Yorkshire NHS Trust, Hull,Yorkshire & Humber, UK Introduction: The most treatable cause of poor outcome after Aneurysmal Sub-arachnoid haemorrhage (ASAH) is re-haemorrhage which has info@asit.org associated mortality of 50-70% with maximal frequency of 4% on day 1. Since the ISAT Trial there has been a paradigm shift in management with endovascular coiling becoming the preferred treatment over
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surgical clipping. There is limited availability of coiling facilities on weekends. Aims & Methods: Our aim was to analyse the management of patients admitted with ASAH and identify if treatment was delayed due to lack of service provision. We compiled a database of all ASAH patients admitted at the Hull Royal Infirmary Neurosurgical unit over a 2 year period. Results: 51 patients were admitted over weekends & 70 over weekdays with ASAH. Over weekends 39.5% underwent definitive treatment within 24 hrs and 67.5% within 48 hrs, whereas on weekdays it was 60 & 90% respectively. 3 patients (6.2%) re-bled over weekends prior to treatment. Goldie Khera Conclusions: We have identified delays in the management of SAH patients admitted over weekends. During weekdays, vast majority get treated the next day after ASiT President admission. These delays clearly have potential implications on outcome. As a result, we have proposed a supra-regional model for treatment over weekends.

1043 OVERCOMING THE PITFALLS OF DOCUMENTING TELEPHONIC ON-CALL REFERRALS RECEIVED BY NEUROSURGICAL REGISTRARS Parag Sayal, Ali Shah, Aimee Lawson, Chittoor Rajaraman Department of Neurosurgery, Hull Royal Infirmary, Hull & East Yorkshire NHS Trust, Hull,, UK Introduction: Acute Neurosurgical referrals are made telephonically to the on-call registrar with the majority being from distant hospiEd Fitzgerald tals. In most instances decisions are made on the basis of clinical information obtained and electronically linked scans, without first ASiT Conference Organiser & Past-President hand opportunity to review patients. The referral book, in which the information received and advice given is recorded, is therefore an important document for futureGeneralcase of follow-ups and medico-legal issues. perusal in Surgery Registrar, London Aim: Our aim was to assess the adequacy and documentation of information obtained and entered in the various sections of each referral & to come up with a scoring system to grade each entry Methods: Anonymised data collection for 150 consecutive referrals, collected by 2 different authors to eliminate bias and to reflect all the departmental registrars. Results: Patient demographics & history was recorded adequately in 100% of the cases but referring team details, neurological and systemic status were recorded in 80%, 94% & 59% of the cases. Jonny Wild Conclusions: We have identified significant pitfalls in the system and instituted changes, including Consultant counter-signature. We describe a scoring system to ASiT the relative weighting of each & Sponsorship Co-ordinator referral. An online datareflect Honorary Secretary parameter and overall adequacy of each base is also being developed. 1115 MANAGEMENT OF CEREBROSPINAL FLUID DIVERSION DEVICE-ASSOCIATED INFECTIONS IN ADULTS: A RETROSPECTIVE EVALUATION OF THE ROLE OF INTRAVENTRICULAR ANTIMICROBIAL THERAPY Mark Wilkie1, Mary Hanson2, Paul Brennan1 1 Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK 2 Department of Microbiology, Robert UK Edinburgh, Davies Aims: Management of infected cerebrospinal fluid (CSF) diversion devices is contentious and evidence limited, particularly concerning ASiT We evaluated our current practice, comparing outcomes from intraventricular versus systemic the use of intraventricular antibiotics.Honorary Treasurer antimicrobials. Vascular Surgery Registrar, West Midlands Methods: We retrospectively identified all adult patients over a five-year period with at least two consecutive infected CSF samples who were treated for CSF diversion device-associated infection. Hospital records were reviewed for clinical and laboratory parameters, microbiology, surgical and antimicrobial management, and treatment outcomes. Results: Forty-eight patients were identified 25 received intraventricular antibiotics (group A) and 23 systemic antibiotics alone (group B). Clinical features and causative organisms (predominantly coagulase-negative Staphylococci and Staphylococcus aureus) were similar between groups. Infected devices were generally revised in both groups (A=92%, B=91%). Admission CSF leucocyte James Milburn counts differed slightly between groups (A>B, p=0.067) but no laboratory parameters did so significantly. Mean times to CSF sterilisation and normalisation of CSFASiT Vice-President shorter for group A (p<0.005), as was duration of hospital stay (p<0.002). microscopy were significantly Conclusions: In the absence of significant laboratory correlates, clinical experience must influence decisions about antibiotic adminiGeneral Surgery Registrar,microbiological recovery and may therefore have a role for all cases Inverness stration. However, intraventricular antibiotics enhance clinical and of CSF diversion device-related infections. ORTHOPAEDICS 0014 Joseph Shalhoub OUTCOME OF RESULTS OF BASAL OSTEOTOMY USING THE CRESCENTRIC OSTEOTOMY FIXED WITH STAPLES TO OPEN ASiT Vice-President WEDGE OSTEOTOMY FIXED WITH B-BOP LOW PROFILE PLATE Vascular Surgery Registrar, London S.M Waqar Saadat1, Gaurav Rathore2, Sandeep Munshi2, Nadeem Baqai2 1 Princess of Wales Hospital, Bridgend, UK 2 Furness General Hospital, Barrow-in-Furness, UK Background: Basal osteotomy offers an optimal surgical solution for hallux valgus especially where primum varus is significant. We studied the results of crescentric osteotomy fixed with staples to open wedge osteotomy fixed with B-Bop low profile plate. Method: The case-notes andSteve Hornby radiographs of the patients assessed for the AOFAS forefoot scores, complications and radiological changes using the Hallux Valgus (HV) angle, Intermetatarsal (IM) angle and Metatarsal Length (ML). ASiT Director in their outcomes Results: All patients had significant improvementsof Education with respect to AOFAS scores and the radiological parameters (p>0.05) in both groups. General Surgery Registrar, South West Peninsula There was no significant difference in either group with respect to their postoperative HV angle, IM angles and AOFAS score. The first metatarsal shortening was noted with crescentric osteotomy.One patient developed metatarsalgia in crescentric osteotomy while one delayed union and one recurrence of deformity was reported in open wedge osteotomy. Discussion: B-BOP is a technically easier, reproducible and allowing early mobility according to literature but at a higher cost. Our experience has shown equally good results can ASiT Welsh Regional Representatives: With thanks to the local be achieved with crescentric osteotomy fixed with staples. The numbers in our study are not large enough to comment whether any of the complications noted were significantly and specifi in either groups. cally higher Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor 0017 SECONDARY PREVENTION OF OSTEOPOROTIC FRAGILITY FRACTURES - RESULTS FROM 5 YEARS WORTH OF AUDIT DATA With thanks to the wonderful ASiT Conference Admin team: info@asit.org Hamid Abboudi, Stella Woodward, Thomas White, Natalia Spierings, Palanisamy Ramesh
Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Laura Andrews Kristina Gloufchev Harriet Innes
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Kingston Hospital, London, UK Aim: The aim of the audit was to assess our current bone protection prescribing rates compared to NICE guidelines and thus im plement changes in order to reduce the incidence of fragility fractures in our elderly female population and thereby reduce costs of readmission as well as the morbidity and mortality associated with fragility fractures in a vulnerable patient cohort. Method: Prospective case note review of all female patients over 75 years of age who sustained a fragility fracture was undertaken. 6 audit cycles were performed from March 2007 - April 2011. Each audit cycle was over a 3-month period. Following each audit cycle various interventions were introduced in an attempt to improve prescribing rates. Results: A total of 311 discharge summaries were reviewed over the 5 year period. The mean age of patients was 84 years. Fractured neck of femur is the commonest fragility fracture in our cohort (74%). Bone protection prescribing rates increased from 16% in 2007 to 92% in 2011. Conclusions: In a multidisciplinary setting through various simple, cost effective interventions such as improved communication, bone protection posters, and junior doctor education programs we were able to improve our rates of bone protection prescribing.
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0020 RADIOGRAPHS LATE IN THE FOLLOW UP OF UNCOMPLICATED DISTAL RADIUS FRACTURES - ARE THEY WORTH IT? CLINICAL OUTCOME AND FINANCIAL IMPLICATIONS Nicholas Eastley, Zeeshan Khan Northampton General Hospital, Northampton, UK Fractures of the distal radius constitute 18% of all human fractures. Any resulting loss of wrist joint congruity can quickly lead to secondary osteoarthritis. Eventually developing callus makes manipulation of displaced fractures impractical, challenging the role of routine radiographs in asymptomatic cases at this stage. We aimed to highlight objective parameters independent of radiographs performed late in the follow up of uncomplicated distal radius fractures. Our outcome measures were visible clinical deformity, range of wrist movement and grip strength. Two groups were devised; one containing patients with no radiographs taken more than two weeks post injury (a short term group), and one containing patients with radiographs taken five or six weeks post injury (a long term group). Sixty six cases were eligible for analysis - 27 in the short term group, 39 in the long term group. No cases reported any visible clinical deformity. There were no significant differences between the grip strengths or range of movements of the short-term and long-term groups. Although complications may justify delayed imaging, results suggest 'late' radiographs have no impact on our outcome measures. We recognised the potential benefits of removing any unnecessary radiographs, and also the need to formulate an established radiological follow up regime. 0030 ENHANCING THE MECHANICAL PROPERTIES OF COLLAGEN BY PHOTO-CHEMICAL CROSS-LINKING Shafiq Shahban, Robert Brown, Umber Cheema, Laurent Bozec Tissue Repair and Engineering Centre, Royal National Orthopaedic Hospital (RNOH), Stanmore, London, UK Background: Tissue Engineering proposes a mechanism through which tendon injuries can be treated by means of inserting cellseeded scaffolds.To enhance the mechanical properties of collagen type I scaffolds we used: a) plastic compression and b) photochemical crosslinking. The scaffolds were subjected to blue light through to induce crosslinking and provoke anisotropy. This study aims to assess the mechanical properties and degree of cell viability in such a scaffold. Materials & Methods: Collagen scaffolds contained 4ml of type I collagen, 0.5ml riboflavin, 0.5ml 10x MEM and 0.5ml of cells. Each scaffold was plastically compressed and high intensity blue light was used to encourage crosslinking. Mechanical properties were assessed through tensile testing, and cell viability through using a live/dead stain. Results: The scaffolds which had photchemical-crosslinks running horizontally had a higher Force at Failure over the controls (p<0.05). A scaffold containing 2x106 HDFs, was subjected to blue light through a horizontal mask and incubated at 37C for 3 days, after which, a border of live and dead cells could be seen, signifying the non-crosslinked and crosslinked regions. Conclusion: The ability to induce anisotropy into native collagen scaffolds whilst maintaining cell viability shows immense potential for designing biomimetic structures for muscle-tendon interface. 0044 THE NEED FOR EARLY TREATMENT OF CLUBFEET IN RURAL AREAS IN SUB-SAHARAN AFRICA: A SURVEY OF CLUBFOOT MANAGEMENT IN ZAMBIA Antonella De Rosa, Alan Norrish Beit CURE International Hospital, Lusaka, Zambia In the developing world, neglected clubfoot often results in a permanent and disabling deformity with subsequent social implications. Treatment with the Ponseti method early in life can correct the deformity and produce a functional foot and ankle. Neglected clubfoot requires complex surgical treatment which is associated with a worse functional outcome. The purpose of this study was to survey the current treatment of clubfoot in Zambia - as representative of many resource poor developing countries. Data from the four organisations that manage clubfoot in Zambia was collected using clinic and operating room registries and analysed using Fisher Exact test. In the urban centres 65% (204/313 feet) of the clubfeet were suitable for treatment by the Ponseti method compared with only 23% (38/166 feet) in the rural hospitals (p<0.001), and in the urban centres only 14% (42/313 feet) of clubfeet required extensive surgery for neglected clubfeet compared with 29% (49/116 feet) in rural hospitals (p<0.015). Patients from rural areas have a higher percentage of neglected clubfeet, no longer suitable for conservative management, requiring extensive, complex and costly surgical treatment. By allowing earlier access to less invasive procedures, the burden of disability that results from neglected clubfeet may be reduced.
0048 A PROSPECTIVE RANDOMISED CONTROL TRIAL ON PATIENT RECALL AFTER INFORMED CONSENTING IN DAY CASE SURGERY. WHAT AND HOW MUCH, DO PATIENTS WANT TO KNOW? Zeeshan Khan, Adele Elizabeth Sayers, Mohammad Usman Khattak, Syed Owais Shafqat, Sabah Jasim Naima Scunthorpe General Hospital, Northern Lincolnshire, UK Introduction: Informed consent implies that the person undergoing an intervention thoroughly understands its pros and cons. W e contives: ducted a randomised control trial to evaluate patients recall of complications associated with hand surgery and the effects of age and edd, Bangor socioeconomic factors. Patients wishes on the extent and type of information were also evaluated. Methodology: Patients undergoing elective daycase hand surgery were recruited over 6 months.Patients were randomised into 2 al of Wales, Cardiff groups, one receiving verbal information and the second group both verbal and written information. On their first post op visit, a test of recall of complications was conducted. Results: 48 m: info@asit.org patients were included in group 1(verbal only) and 66 in group 2 (Verbal & written information). No statistically significant (P=0.1) difference was noted in the recall between the two groups. No effect of gender, age or socioeconomic status was noted. More
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patients preferred both written and verbal information. Preference for knowledge of rates of complications was higher if risk was 1 in 100 or more. Conclusion: Informed consenting is a contentious issue. Our results dont show any significant difference in patient recall depending on the type of consenting method.Nevertheless, we still propose that patients should receive as much information as possible before undergoing any intervention.
0050 Goldie Khera OUTCOME OF SECONDARY PATELLAR RESURFACING Mouhamed El Sayad, Gaffar Dudhniwala, Andrew Davies ASiT President Morriston hospital, Swansea, UK Introduction: Resurfacing the Bariatric Fellow, primary arthroplasty remains controversial. Patients presenting with anterior knee patella at the time of North Tyneside pain following a total knee replacement are not uncommon .There is scarce literature regarding the benefits of secondary resurfacing of the patella in these patients. Objectives: Our aim was to evaluate the outcome of a cohort of secondary patellar resurfacing in patients that had received a primary knee replacement and presented later with patellofemoral symptoms. Methods: Data were collected prospectively on 16 patients that had Secondary patellar resurfacing . These patients were assessed through two different scoring systems the Oxford knee score and the American knee society score preoperatively and in the post opEd Fitzgerald erative period between 6 weeks to 3 years of follow up. ASiT Conference Organiser & PFC fixed bearing designs, 3 Nexgen Cruciate Retaining,4 Results: Of the 16 knee prostheses included in the study, 7 were Sigma Past-President LCS porocoat and 2 Scorpio Cruciate retaining designs. Mean pre-op AKSS Knee and function scores were 41.25 and 38 .Mean PreGeneral Surgery Registrar, London op Oxford knee score was 33.68 (29.83%).These improved to 74.57,63.31 and 22.12(53.91%) respectively in the post-operative period. Conclusion: Of the 16 patients operated, 12 reported significant improvement , whilst 4 felt that they had not experienced an improvement in their symptoms. On this basis we continue to offer secondary patellar resurfacing. 0060 Jonny TENDO-ACHILLES RUPTURE USING FLEXOR HALLUCIS LONGUS. A PROSPECTIVE RECONSTRUCTION OF NEGLECTED Wild REVIEW ASiT Honorary Secretary & Sponsorship Co-ordinator Thomas Yeoman, Michael Brown, Anand Pillai General Surgery Registrar, Sheffield NHS Tayside, Dundee, UK Background: Various repair techniques have been reported for neglected tendo-Achilles rupture. We aimed to prospectively investigate the impact of short flexor hallucis longus (FHL) transfer to the calcaneus for patients with this injury. Methods: A consecutive series of patients undergoing FHL transfer for neglected tendo-Achilles rupture were reviewed. Ankle function and patient health were assessed pre and post-operatively using the American Foot and Ankle Society outcome score (AOFAS) and the SF-36 score. Results: 10 patients (6 male, Robert 50 years) with ruptures secondary to trauma were included. Mean time to surgery was 20.5 mean age Davies weeks. The average AOFAS increased from 61.4 preoperatively to 80.6 at 3 month postoperatively. The average physical component ASiT to 48.14. The average mental score of SF-36 improved from 41.84 Honorary Treasurer component score improved from 46.38 to 53.8 at 3 month postoperatively. Pain scores improved from mild to moderate preoperatively to very mild postoperatively. Vascular Surgery Registrar, West Midlands Conclusion: Our results demonstrate the benefit of FHL tendon transfer for neglected tendo-Achilles rupture. Direct transfer to the calcaneum with an interference screw allows correct tensioning and secure fixation. The procedure is reliable and has a low morbidity. This in-phase transfer restores normal ankle dynamics and power. 0076 OUTCOME MEASURES IN FLAT FOOT: ANALYSIS OF PAEDOBAROGRAPHY AND RADIOGRAPHIC TECHNIQUES James Milburn Lambros Athanatos, Mathew Nixon, Gill Holmes, Leroy James, Alf Bass Alder Hey Children's NHS FoundationVice-President ASiT Trust, Liverpool, UK Aim: To compare the paedobarographic findings of normal feet to flat feet and investigate if there are sensitive paedobarographic General Surgery Registrar, Inverness markers that can be used in diagnosing flat feet. Methods: We retrospectively collected data from eighteen patients (thirty-five feet) between 10-16 years of age. Our control group consisted of patients with normal arched feet and the study group of patients with symptomatic flat feet awaiting surgical correction.The mean and standard deviations of foot pressures measured at the hindfoot,medial/lateral/total midfoot (MMF,LMF,TMF),forefoot and the percentage of weight going through the MMF over the TMF [medial midfoot ratio (MMFR)] during the mid-stance gait phase are reported. In addition the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were estimated. Joseph Shalhoub Results: The flat feet group had significantly higher MMF,LMF,TMF and MMFR (P < 0.001 Mann-Whitney). LMF had the highest sensiASiT Vice-President tivity and NPV (94%) whereas MMF, TMF and MMFR had the highest specificity and PPV (100%). Vascular Surgery with symptomatic flexible Conclusions: Compared to our control group, patients Registrar, London flat feet had significantly higher pressures in the midfoot, in particular in the medial midfoot. Paedobarography appears to be a sensitive and specific tool in diagnosing flat feet and has the potential to make radiological examination unnecessary. 0128 TRUNNION DESIGN AND FEMORAL HEAD DIAMETER INCREASE CORROSION AT THE TAPER INTERFACE IN RETRIEVED Steve Hornby LARGE-DIAMETER METAL-ON-METAL TOTAL HIP ARTHROPLASTY Adam Hexter1, Gordon Blunn2ASiT Skinner1, Alister Hart1 , John Director of Education 1 London Implant Retrieval Centre, Imperial College London, London, UK General Surgery Registrar, South West Peninsula 2 Royal National Orthopaedic Hospital, London, UK Aim: To characterise corrosion at the taper interface in large diameter metal-on-metal total hip arthroplasty and the effect of femoral head diameter. Method: Corrosion was qualitatively assessed using a peer-reviewed grading system for 111 components from three different manufacturersWithBHR, Durom). Unexpectedly a ridged appearance was commonly observed on the female taper surfaces, which corre(ASR, thanks to the local ASiT Welsh Regional Representatives: sponded exactly with the ridges of the trunnion surface. A new grading system was created to measure this imprinting phenomenon. Results: Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor 92% of the components experienced corrosion, with at least moderate corrosion seen in 61%. The manufacturer did not influence corrosion both for head components (p=0.52)Research Fellow, University Hospital of Wales, Cardiffwas ob Mr Andrew Beamish, Clinical and trunnions (p=0.20). A strong positive correlation (r=0.776, p=0.01) served between the imprinting scores and corrosion scores. Larger head diameters showed higher corrosion (r=0.241, p=0.02). Conclusions: Corrosion affects all manufacturers and is associated with the presence of ridges on the female taper surface. It appears that the rough surface of theto the causes extensive ASiT Conference Admin team: info@asit.org corroWith thanks trunnion wonderful mechanical damage at the female taper surface and creates a hostile sive environment. Femoral head diameter correlates with corrosion, which is clinically significant considering the increasing use of
Laura Andrews
Kristina Gloufchev
Harriet Innes
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larger head sizes. Future work must now clarify the optimum trunnion design and femoral head diameter.
0129 WEAR AND CORROSION AT THE TAPER INTERFACE IN RETRIEVED ASR XL METAL-ON-METAL TOTAL HIP ARTHROPLASTY Adam Hexter1, Gordon Blunn2, Johann Henckel1, John Skinner1, Alister Hart1 1 London Implant Retrieval Centre, London, UK 2 Royal National Orthopaedic Hospital, London, UK Aim: To quantify wear at the ASR XL taper interface and determine the relationship between taper corrosion and blood metal ions. Method: Corrosion was qualitatively assessed using a peer-reviewed grading system for 52 ASR XL femoral head components. Blood metal ion levels in hips showing at least moderate corrosion was compared with those without moderate corrosion. Profilometry was performed in hips (n=12) that failed due to debris-induced synovitis in the presence of low bearing surface wear (<10m/year combined head/cup). Results: 98% of the components were corroded, with at least moderate corrosion observed in 66%. Corrosion did not influence the levels of blood cobalt (p=0.16) and chromium (p=0.12) ions. The median volumetric loss was 3.08mm 3 (range: 0.61-9.44) and the maximum wear depth ranged from 14-85m. Conclusions: Metal debris is implicated in the formation of soft-tissue reactions and we show that taper wear and corrosion is substantial. Currently there is no other culprit that could account for the higher failure rate of the ASR XL when compared to resurfacing. Greater corrosion did not equate to increased metal ion levels. Future work must determine the relative contributions of the bearing surface and taper interface to material loss and blood metal ions. 0157 ACCURACY OF DIGITAL TEMPLATING IN TOTAL HIP REPLACEMENT AND POST-OPERATIVE LEG LENGTH INEQUALITY John Kyle1, Anthony McWilliams2, Richard Grogan2 1 James Cook University Hospital, Middlesbrough, UK, 2Bradford Royal Infirmary, Bradford, UK Aims: We aimed to determine the accuracy of digital templating at predicting implant size for total hip replacement (THR) and to measure and compare pre- and post-operative leg-length inequality (LLI). Methods: The radiographs of 70 patients undergoing THR were analysed. All radiographs were templated pre-operatively using IMPAX AGFA software. Implant size data was collected from theatre records. LLI was determined using IMPAX software on the pre- and post-operative radiographs. Results: Complete templating data was available for 55 patients. In 34.7% of cases the acetabular cup size was accurately predicted by pre-operative templating, with 74.5% being within +/- 2mm. Digital templating accurately predicted the stem size in 32.7% of cases with 65.5% being within +/- 1 stem size. Complete LLI data was available for 67 patients. The mean pre-operative LLI was 5.3 mm (range -11.9mm to +30.3mm) with the mean post-operative LLI being 7.2 mm (range -19.3mm to +25.3mm). 73.1% of patients had a post-operative LLI of <10mm and 89.6% were <15mm. Conclusion: Digital templating in THR is accurate to within one cup size (2mm) in 74.5%of cases and to within one stem size in 65.5% of cases. Mean post-operative LLI is less than the generally acceptable limit of 10mm. 0160 COMPARISON OF LEVELS OF PAIN PERCEIVED WHEN USING PNEUMATIC VERSUS SILICONE RING TOURNIQUETS FOR LOCAL ANAESTHETIC PROCEDURES OF THE UPPER LIMB Oliver Smith, Richard Heasley, Gillian Eastwood, Stephen Royle Stepping Hill Hospital, Stockport, UK Aim: To compare the level of perceived pain, and therefore tolerance, of the Silicone Ring and Pneumatic tourniquets when applied to the upper arm and to evaluate whether there was a clear benefit of use of either tourniquet in local anaesthetic procedures of the upper limb. Materials and methods: 30 volunteers, 15 male and 15 female, were recruited. Pain was measured using a VAS pain scale on application and at 1, 5 and 10 minutes. Results: Volunteers experienced significantly more pain on application and at 1 and 5 minutes with the SRT. This difference in pain perceived was most marked upon application. Two volunteers could not tolerate application of the SRT. Three volunteers experienced bruising of the arm and/or forearm following use of the SRT. There was no difference in pain scores at 10 minutes. Conclusion: Due to the severe pain experienced on application of the SRT it would not be suitable for local anaesthetic procedures in the upper limb. In addition the degree of pain may reduce the patients confidence and adversely affect their experience of the procedure. The PT is more suitable for local procedures. However the SRT may have a role in procedures performed under general anaesthetic.
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0164 TRAUMA OPERATION NOTES RE-AUDIT AFTER INSTIGATION OF COMPUTER RECORDS PROGRAMME IQ UTOPIA: HOW DO COMPUTER-GENERATED OPERATION NOTES COMPLY WITH ROYAL COLLEGE OF SURGEONS OF ENGLAND'S GUIDELINES, COMPARED TO HAND-WRITTEN NOTES? Denise Yeung, Naffis Anjarwalla Wexham Park Hospital, Slough, UK Aim: Assess compliance of computer-documented (IQ Utopia) v hand-written operation notes, to Royal College of Surgeons of England (RCSE) recommendations (re-audit). Method: A cross-sectional sample of computerised operation notes were examined in Wexham Park Hospital in-patients who had Orthopaedic operations (n=40, March 2011) and compliance was noted and compared to hand-written notes (March 2010). Fourteen categories were audited: hospital number, name, date, consultant, surgeon, procedure, incision, operative diagnosis, findings, complications, tissues removed/added/altered, serial numbers, sutures, post-operative care and surgeon's signature. Results: Compliance was achieved in every category with IQ Utopia. Lowest compliance was the surgeon's signature: 80%. Compared to hand-written operation notes from 2010, compliance improved in hospital number (100%), date of operation (100%), incision tives: (97.4%), operative diagnosis (100%), findings (100%), complications (100%), details of tissue removed/added/altered (100%), sutures edd, Bangor (100%), post-operative care (100%). Two categories worsened: serial number (95.1% to 85.3%) and signature (98.1% to 80%). Conclusion: Using IQ Utopia resulted in compliance in all categories with the Operative Notes Guidelines as stated by the al of Wales, Cardiff RCSE. Compliance improved in most categories except in serial number and also signature. It is likely that the implementation of a computer programme to generate operation notes was associated with this improved compliance. 0174
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REVIEW OF SINGLE STAGE REVISION ACL RECONSTRUCTION Young-seok Cho, Peter Kempshall, Rhidian Morgan-Jones Cardiff and Vale Orthopaedic Centre, Cardiff, UK Aim: To review single stage revision ACL reconstruction Method: Between January 2002 and January 2011, 34 patients were identified as having had revision ACL reconstruction at a single stage under a single surgeon. The case notes were retrospectively reviewed and patients were contacted by telephone interview where patient reported outcome measures were recorded in the form of Tegner Activity Scale, Tegner Lysholm Knee Scoring Scale, Goldie Euroqol. Cardiff ACL Satisfaction Index and EQ5DKhera Results: 20 patients were contactable (59%), with the average follow-up of 3.8 years [range 1-10 years]. None of the revisions had ASiT President failed. The mean Tegner score was 84.4 [range 45-100], which correlated well with the EQ5D Euroqol. One patient had proceeded to Bariatric Fellow, North Tyneside TKR at 6 years but the graft was functioning at the time of surgery. Eight of the revisions used bone patella tendon bone (BPTB) as a graft material. Fixation was possible in all but one case where a femoral post and suspensory fixation was required. Tegner score was higher in revisions using hamstrings [n=8, mean 83.4] than BPTB [n=11, mean 82.6]. Conclusions: Single stage revision ACL reconstruction can yield good results, where hamstring and BPTB grafts yield similar results on functional outcome scores.
0178 Ed Fitzgerald CAN PATIENTS REMEMBER THEIR PRESENTING SYMPTOMS SIX MONTHS AFTER SURGERY? ASiT Nawaz, Rohit Gupta Rachel L O'Connell, Liza Osagie, S.Z Conference Organiser & Past-President Ashford and St Peters NHS Foundation Trust, Surrey,Registrar, London General Surgery UK Aims: The Oxford Shoulder Score (OSS) is a validated score of shoulder symptoms, little work has explored patients' recollection of pre-operative symptoms. The aim of this study was to determine how well patients recall pre-operative symptoms. Methods: Fifty patients who underwent shoulder surgery at least 6 months previously and had completed OSS pre-operatively were contacted. Patients were asked to complete the OSS questionnaire in terms of their pre-operative symptoms. Kappa coefficient was used to calculate agreement between pre and post-operative answers. Results: 41 patients completed the questionnarie, mean age was 53 years, 23 males and 19 females. omparison of pre-operative and Jonny Wild recall data on the four questions relating to pain showed poor' agreement for one and moderate' agreement for three (kappa 0.128, 0.454, 0.491, 0.502). Comparison of the eight questions relating to& Sponsorship Co-ordinator poor', four moderate', ASiT Honorary Secretary activities of daily living (ADL) showed one two fair' and one good' agreement. Pre-operative and post-operative OSS averaged 35.6 and 38 respectively (Paired t-test, p<0.001). General Surgery Registrar, original and Conclusion: There is considerable disagreement between patients'Sheffield recalled scores. Our study demonstrates the limitations of using recalled data to determine pre-operative symptoms when verifying efficacy of shoulder surgery. This illustrates the importance of pre-operative scoring when assessing post-operatively. 0184 DELAY IN DIAGNOSIS OF ACL INJURY: IS IT STILL A PROBLEM? Medhat Alaker, Nicholas Greville Farrar, Stephen Duckett Robert Davies Leighton Hospital, Crewe, UK ASiT rupture produces instability of Aim: Anterior cruciate ligament (ACL) Honorary Treasurer the knee. Many patients struggle to return to manual jobs or sporting activities. There is evidence that delay Surgery Registrar,increased incidence of meniscal tear and chondral injury. In 1996, Vascular in treatment leads to an West Midlands the average delay to diagnosis from first presentation was 21 months and the original treating doctor suspected the diagnosis in only 9.8% of cases (Bollen and Scott). Method: A retrospective case series of 50 consecutive patients who underwent ACL reconstruction were studied to determine the current delay to diagnosis and initial diagnostic accuracy. Results: The mean delay to diagnosis was 61 days. Patients first presenting to their general practitioner had a mean delay to diagnosis of 40 days, versus 90 days when initially presenting to the emergency department. At first presentation, ACL rupture was suspected in only 13% of cases. James Milburn Conclusions: Since 1996, theASiT to diagnosis has significantly improved allowing earlier treatment. This is likely to be due to indelay Vice-President creased fracture clinic capacity and shorter waiting times for orthopaedic outpatients. However, a higher degree of initial clinical suspiGeneralreferral is stillRegistrar, Inverness Surgery required. cion and a lower threshold for specialist 0238 AN INCREASING TREND OF INVESTIGATING OCCULT HIP FRACTURES WITH CT SCANS IN DISTRICT GENERAL HOSPITALS Robert Jordan, Edward Dickenson, Daniel Westacott, Kuntrapka Srinivasan Birmingham Heartlands Hospital, Birmingham, UK Joseph Shalhoub Introduction: Early diagnosis of hip fractures reduces mortality but remains a challenge in patients with occult injuries. NICE recomASiT Vice-President mend the use of MRI or, if not accessible within 24 hours, CT to establish the diagnosis in these cases. Little evidence exists into the Vascular Surgery Registrar, London role of CT and we aim to analyse the trends and benefits of its use over a five year period. Materials and method: Patients who underwent CT to diagnose an occult hip fracture were identified across two district general hospitals between 2006-2007 and 2010-2011. The corresponding plain x-rays were examined by the authors and compared against radiograph and CT reports. Any operative intervention was recorded. Results: In 2006-2007, 20 CT hips were performed and 6 (30%) hip fractures identified compared to 239 and 65 (27%) in 2010-2011. No patients underwent MRI in 2006-7 and only 3 in 2010-11. When compared to CT findings the sensitivity of radiograph interpretation Steve Hornby by the authors (53.5%) and radiologist (54.9%) were similar. ASiT increasingly reliant on CT for Conclusion: Clinicians are becoming Director of Education the diagnosis of hip fractures despite inherent and recognised weaknesses. We have demonstrated no clear patient Registrar, Souththis trendPeninsularole of CT needs to be revisited. General Surgery benefit resulting from West and feel the 0250 UNION RATES FOLLOWING PROXIMAL SCAPHOID FRACTURES; META-ANALYSES AND REVIEW OF AVAILABLE EVIDENCE Nicholas With thanks Pal Singh, local ASiT Welsh Regional Representatives: Eastley, Harvinder to the Nick Taub, Joseph Dias Department of Orthopaedic Surgery, Glenfield Hospital, Leicester, UK Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, led to a tendency towards The management of acute proximal scaphoid fractures is under reported. Worry of avascular necrosis has Bangor early surgical fixation. We Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Mr Andrew compared union of non-operatively managed proximal scaphoid fractures and non-operatively managed fractures elsewhere in the scaphoid to investigate the magnitude of nonunion. A search of electronic databases was performed for relevant articles. Assorted definitions of the scaphoid's proximal pole and union were accepted. Our search to the wonderful met eligibility criteria. ThreeAdmin team:after surgery and seven after With thanks yielded ten studies which ASiT Conference investigated union info@asit.org non-operative treatment.
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
Nine hundred and fifty two non-operatively managed acute scaphoid fractures were analysed. Of these 48 (5%) involved the proximal pole. Meta-analysis revealed a relative risk of non-union of 6.3 for proximal fractures managed conservatively compared with fractures elsewhere in the bone (95% CI 3.8-10.2 p<0.001). Comparison of operatively and non-operatively managed acute proximal fractures was attempted, but too few operative studies were available. A clear association exists between non-operatively managed acute proximal scaphoid fractures and nonunion. Literature suggests surgical management may reduce this risk. Retrograde compression screw fixation following open or percutaneous K-wire stabilisation appear safe techniques for these cases. Future work should compare union of acute proximal pole fractures managed surgically and conservatively.
0255 PAEDIATRIC KNEE INJURIES: PATIENT PATHWAY TO OPERATIVE DIAGNOSIS Michelle Baker, Damien Gill, Simon Coleridge, Christoph McAllen Derriford Hospital, Plymouth, UK Introduction and Aims: ACL ruptures and meniscal tears occur in children as well as adults, however a paediatric rapid referral pathway does not currently exist. We identified children with soft tissue knee injuries requiring operative management and examine the current patient pathway. Methods: From April 2008 to August 2010, we examined all patients less than 16 years of age with an acute knee injury requiring surgery against set standards: 1. Reparable meniscal tears should be diagnosed and treated within one month of injury. 2. Isolated ACL injuries should be diagnosed and treated within three months of injury. Results: 30 patients were evaluated with a median age of 15 years (13-16). Duration from injury to operative diagnosis was 188 days for reparable meniscal tears, and 203 days for isolated ACL rupture. Acute presentation to first clinic appointment was 25 days; first clinic appointment to MRI scan was 26 days and MRI scan to theatre 177 days. Conclusion: There is a significant time delay from initial presentation to operative diagnosis and treatment, which is largely due to theatre waiting lists commencing after MRI investigations are complete. A rapid referral pathway for paediatric knee injuries will reduce the waiting times to operative intervention. 0258 RETURN TO SPORT FOLLOWING ARTHROSCOPIC SHOULDER STABILISATION Morgan Bailey1, Angus Robertson2 1 Imperial NHS Trust, London, UK 2 Cardiff and Vale NHS Trust, Cardiff, UK Aim: Shoulder dislocation is a common injury with a number of functional implications for patients. Return to sport is considered a useful outcome measure following shoulder stabilisation surgery and is frequently the ultimate patient goal. This study explores the value of return to sport as an outcome measure and the ability of patients were able to do so. Method: The study population included all patients (n=68) undergoing primary arthroscopic shoulder stabilisation by a single surgeon (AR) over 34 month period. Patients were evaluated pre and postoperatively using the Oxford Shoulder Instability Score and a return to sport questionnaire was administered at follow up. The median follow up period was 209.5 days. Results: 85% of those responding had returned to sport, with 50% making a full return to their previous standard. The mean improvement in Oxford Score following surgery was 12.3. The improvement in Oxford Score, age and gender had an influence on return to sport. Conclusions: Return to sport is a useful outcome measure, but not in isolation. Athletes wishing to return to sport following shoulder stabilisation can expect good outcomes provided they comply with the rehabilitation protocol. Psychology plays a large role in a patients decision to return to sport. 0274 A COMPARISON OF CONSENT: PROXIMAL FEMUR FRACTURES VERSUS ELECTIVE TOTAL HIP REPLACEMENT Simon Humphry, Efstratios Gerakopoulos Gloucestershire Royal Hospital, Gloucester, UK Aims: To compare consent documentation for patients having surgery for proximal femur fractures (PFFs) versus elective patients undergoing total hip replacement (THR). Methods: Concurrent audits over a 28-day period of consent forms for adult patients (with capacity) undergoing surgery for PFFs and elective THR within the same department. Standards based on British Orthopaedic Association (BOA) endorsed Orthoconsent' website guidelines, modified following departmental consultant survey. Results: PFFs: n=24. Consenter grade: consultant=0% middle grade=8%, SHO=92% nurse=0%. Consenter operating=13%. Sticker/ stamp on consent form: 0%. Proportion of risks/complications documented: 56%. Information provided: 0%. Elective THR: n=50. Consenter grade: consultant=28% middle grade=30%, SHO=4% nurse=38%. Consenter operating=62%: Sticker/ stamp on consent form: 78%. Proportion of risks/complications documented: 76%. Information provided: 58%. Conclusions: Senior doctors and specialist nurses take consent for the majority of elective THRs, with better documentation of risks/ complications and improved provision of information. In contrast, consent for patients undergoing surgery for PFFs is mainly obtained by ward-based junior doctors. The role of stickers/stamps appears beneficial, although this audit suggests an update is needed, in accordance with the BOA endorsed guidelines. Although the study numbers are low, it demonstrates the need for further research into consenting practices and better training/support for junior doctors.
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0275 IMPROVING CONSENT IN PATIENTS UNDERGOING SURGERY FOR PROXIMAL FEMUR FRACTURES THROUGH THE INTRODUCTION OF CONSENT CARDS' FOR JUNIOR DOCTORS Simon Humphry, Efstratios Gerakopoulos Gloucestershire Royal Hospital, Gloucester, UK Aims: To audit the consent for risks/complications in patients undergoing surgery for proximal femur fractures (PFFs). To re-audit following introduction of a consent card', listing risks/complications, for use by senior house officers (SHOs). Methods: Initial audit over a 28-day period of consent forms for adult patients (with capacity) undergoing surgery for PFFs. Standards tives: based on British Orthopaedic Association endorsed Orthoconsent' website guidelines, modified following departmental consultant edd, Bangor survey. Subsequent piloting of a consent card' (easy storage in pockets / behind identity badges) for SHOs and re-audit to the same standards al of Wales, Cardiff and timescale. Results: Primary audit: n=24. Consenter grade: >SHO=8%, SHO=92%. Proportion of risks/complications documented: 56% (>SHO=SHO=56%). Re-audit following introduction of consent card': n=38. Consenter grade: >SHO=11%, SHO=89%. Proportion of risks/complications documented: 90% (>SHO=69%, SHO=92%). m: info@asit.org Conclusions: Consenting of patients undergoing surgery for PFFs is mainly undertaken by orthopaedic (or covering specialities)
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SHOs. Documented consent for risks/complications has been shown to be poor. Through provision of consent cards' to SHOs a significant improvement in consent standards has been achieved. Whilst further changes are anticipated (particularly regarding SHO inductions) it is hoped that consent cards' will improve SHO confidence in consenting, with subsequent improvement in patient information and reduction of complaints and litigation.
0280 ORTHOPAEDIC SURGEONS' PERCEPTION OF INTRAOPERATIVE BLOOD LOSS Goldie Khera Basil Budair, Taiceer Abdul-Wahab, Tim McBride, Mujeeb Ashraf University Hospital Birmingham NHS Foundation Trust, Birmingham, UK ASiT President Introduction: One of the questions on the WHO checklist to surgeons is: what is the anticipated blood loss? We feel that orthopaedic Bariatric Fellow, loss. surgeons are poor at estimating peri-operative blood North Tyneside Aim: To assess the accuracy of orthopaedic surgeons' perceptions of intra-operative blood loss, both pre and post operatively Methods: Patients undergoing hip fracture surgery from April to December 2011. Registrars were asked pre and post operatively what they expected the blood loss to be. Actual loss was calculated based on the amount of blood retrieved in both swabs and the suction Results: 55 patients undergoing hip fracture surgery were included. The mean pre op estimated value was 260ml and mean actual value was 465ml (P value= 0.01). In 44 (80%) patients blood loss was underestimated. The mean difference between pre op estimation and actual loss was 205ml i.e. almost 80% difference! Mean pre op estimate was 260ml and mean post op estimate 270ml (not Ed Fitzgerald significantly different) ASiT Conference Organiser & Past-President Conclusion Orthopaedic surgeons are poor at estimating blood loss. Answers to the WHO checklist question posed could be misleading and therefore pose a clinical risk. We propose the Registrar, London - Are you expecting excessive blood loss? Yes / No General Surgery question be changed to: 0401 THE PORTRAYAL OF BACK PAIN IN THE UK PRESS Clarissa Cheah, William James Nash, Mohamed Mussa, Arash Danesh, Andrew Harris, Shafic Said Al-Nammari Princess Alexandra Hospital, Harlow, UK Method: National newspaper articles were retrieved from LexisNexisTM Professional over 6 months (May 2009- October 2009), using Jonny Wild the terms back pain/ backpain/ back ache/ backache. Results: 284 articles were collected. 62% were from Secretary & Sponsorship 15% of articles were case reports. Back pain ASiT Honorary tabloids and 38% from broadsheets. Co-ordinator was mentioned in passing in 75% of all articles. It was the main topic in 18% and the sole topic in 7% of papers. The causes of back General Surgery treatment was more likely pain were mentioned in 11% of articles. Non-surgical Registrar, Sheffield to be mentioned. (Fishers Exact Test p=0.01). 10% of papers included a quote from an expert. Overall, 98% of articles portrayed a neutral tone, with 1% positive or negative. Articles concerning physiotherapists or new surgical techniques were significantly more likely to show a positive overall tone. (Fishers Exact Test p=0.04). Conclusion: The aetiology of back pain is poorly represented and quoted experts are frequently from non-medical personnel. New surgical treatments receive significantly less attention than new non-surgical treatments. We need to engage with the press and positively influence their reportage of back pain. Robert Davies
ASiT Honorary Treasurer 0404 SYMPTOM LENGTH, DOMINANCE ANDSurgery DO NOT AFFECT RATE OF PROGRESSION TO SURGICAL DECOMPRESVascular GENDER Registrar, West Midlands SION IN PATIENTS WITH CARPAL TUNNEL SYNDROME Nicholas Gill, Munier Hossein, Mel Jones Ysbyty Gwynedd, Bangor, UK Aims: To assess predictive factors in progression to surgical decompression following steroid injection in Carpal Tunnel Syndrome. Methods: Retrospective data analysis from patients who received steroid injections for Carpal Tunnel Syndrome over a 2 year period with a minimum 1 year follow up. James Milburn Results: 59 patients had 79 Carpal Tunnels injected over 2 years. 35 patients chose surgery following steroid injection (59%), with 24 patients not progressing to surgery (41%). In the group that underwent surgery, the mean length of symptoms was 35.3 months ASiT Vice-President (range 4-180) with 19 patients (56%) having symptoms for greater than 2 years. In the non surgical group the mean length of sympGeneral Surgery Registrar, Inverness toms was 42.9 months (range 3-180) with 14 of the sub-group (56%) suffering with symptoms for greater than 2 years (P=0.2). 59% of the dominant sided Carpal tunnels injected resulted in surgery, whereas 67% of the non dominant sided Carpal Tunnels injected progressed to surgery (P=0.15). 9 symptomatic males (26%) and 26 females (74%) underwent surgery following injection compared to 8 males (33%) and 16 females (67%) who didnt undergo surgery following injection (P=0.56). Conclusion: Length of symptoms, symptomatic dominant side and gender are poor predictors of progression to surgery following carpal steroid injection.
0408 ASiT Vice-President ORTHOPAEDICS IN THE UK PRESS Vascular Surgery 2, Andrew Harris2, Mohamed Mussa2, Shafic Said Al-Nammari1 Clarissa Cheah1, William James Nash1, Arash DaneshRegistrar, London 1 Princess Alexandra Hospital, Harlow, UK 2 Southend Hospital, Southend, UK Aim: To determine the portrayal of Orthopaedics in the United Kingdom press. Methods: National newspaper articles were retrieved from LexisNexisTM Professional over 1 year (May 2009- May 2010), using the terms Orthopaedic or Orthopedic. Steve Hornby Results: 850 articles were retrieved and 504 were relevant. Orthopaedics was mentioned in passing in 56%, the main topic in 29% ASiT Director of Education and the sole topic in 15%. Trauma (41%) was the main focus, followed by frames and paediatrics. The main anatomical focus was lower limbs (58%), upper limbs (12%) and spine (11%). Orthopaedic surgeons were quoted in 32% of articles. 20% of articles were General Surgery Registrar, South West Peninsula hospital related. The rest were orthoapedic device company related (16%), new techniques (11%) and orthopaedic surgeon (9%) related. Overall, the tone of articles was:- positive (35%); negative (28%); neutral (37%). Articles looking at orthopaedic surgeons were 50% negative, 30% positive and 20% neutral. Conclusions: Orthopaedics receives UK press attention as a main theme and in passing, concentrating on trauma and lower limbs. Majority of articles were neutral or positive, but ASiT Welsh Regional Representatives: more likely to be negaWith thanks to the local the tone of articles of orthopaedic surgeons were significantly tive than others. This profession must engage the press to improve the public image of orthopaedics. 0416 Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff ELASTIC STOCKINGS OR TUBIGRIP FOR ANKLE SPRAIN: A RANDOMISED CONTROLLED CLINICAL TRIAL Muhammad Junaid Sultan1, Adam McKeown2, Iain McLaughlin1, Charles McCollum1 1 University Hospital of South to the wonderfulUK With thanks Manchester, Manchester, ASiT Conference Admin team: info@asit.org 2 Universit of Manchester, Manchester, UK
Joseph Shalhoub
Laura Andrews
Kristina Gloufchev
Harriet Innes
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Background: Ankle sprains are generally self-limiting but significant proportion of patients with ankle sprains has persistent symptoms for months. Aims: To evaluate whether elastic stocking improve recovery following ankle sprain. Methodology: All patients within 72 hours of ankle sprain were identified in Accident & Emergency or the Fracture Clinic. Consenting patients, stratified for sex, were randomized to either: i) tubigrip or ii) class II below knee elastic stockings(ES) which were fitted immediately. The deep veins of the injured legs were imaged by duplex Doppler for deep vein thrombosis(DVT) at four weeks. Outcome was compared using the American Orthopaedic Foot and Ankle Score(AOFAS) and SF12 V2 for quality of life. Results: In the 36 randomised patients, the mean(95% CI) circumference of the injured ankle treated by ES was 23.5(23-24)cm initially and 22(22-23)cm and 22(21-22.5) cm at 4 and 8 weeks (p<0.001) compared with 24(23-25)cm initially and 24(23-25)cm and 24(2324.5)cm using tubigrip (p<0.001). By 8 weeks, the mean AOFAS and SF12v2 scores were significantly improved by ES at 99(8.1) and 119(118-121) compared with 88(11) and 192(99-107) with tubigrip (p<0.001). Of the 34 duplex images at four weeks, none had a DVT. Conclusion: Compression improves recovery following ankle sprain. 0437 MINIMALLY INVASIVE AKIN OSTEOTOMY FOR HALLUX VALGUS Samuel James, Richard Walter, Davis James Department of Trauma and Orthopaedics, Torbay Hospital, Torbay, Devon, UK Aims: Since 2009, a minimally invasive Akin osteotomy procedure has been carried out at a UK district general hospital, for the treatment of mild-to-moderate hallux valgus. The outcomes of this procedure are not well described in the international surgical literature. This case series describes radiological outcomes and complications at a median follow-up of 13 months. Methods: The notes and radiographs of all patients who underwent this procedure were analysed retrospectively. Results: Twenty six patients underwent the procedure between March 2009 and June 2011. 96% of cases were successfully performed as a daycase. All patients were followed-up in clinic. Mean pre-operative hallux valgus angle was 20.0, mean post-operative hallux valgus angle was 7.7, a statistically significant reduction (p=<0.05). Overall complication rate was 27%. 2 (7.7%) patients developed infections requiring oral antibiotics, 1 (3.8%) patient required removal of the osteotomy screw, and 4 (15.2%) patients had ongoing pain and/or stiffness at the 1st MTPJ. Conclusions: This case series demonstrates that a minimally invasive Akin procedure is effective at reducing hallux valgus angle. Overall complication rate was comparable to minimally invasive distal first metatarsal osteotomies. Randomised controlled trials are required to further compare the technique to alternative minimally invasive or open techniques. 0444 THE INTERSPINOUS DEVICE SPINOS': A CASE SERIES Sophy Rymaruk, Arif Razak, James Doyle Fairfield General Hospital, Pennine Acute Hospital Care Trust, UK Interspinous devices can be used to achieve distraction between the spinous processes to improve symptoms in spinal canal stenosis. The study was to identify radiological and clinical outcomes when using the Spinos (Privelop Spine) device in lumbar canal stenosis. Patients were identified and retrospectively analysed. Pre-operative and post-operative canal area and Oswestry Low Back Pain Disability questionnaire scores were recorded. 9 patients underwent surgery, one at two levels. Most was at L4/5 (67%). All patients underwent general anaesthesia, with a mean 4 day inpatient stay. Mean percentage increase in canal area at the level of surgery was 44%, range -3% to 158% (8% at the level above, 21% at the level below) which equated with a mean area increase of 41 mm, range 7 mm to 98 mm (14 mm at the level above, 23 mm at the level below). Patients reported an improvement of 3% in their questionnaire results. The Spinos device seems to show promising results with regards improvement in canal size, however patient outcomes are disappointing. The potential for day case surgery under local anaesthesia needs to be evaluated further, but would have significant theoretical advantage in terms of anaesthetic morbidity and cost effectiveness. 0447 LOCAL INFILTRATION ANALGESIA COULD BE SUPERIOR TO NERVE BLOCK IN TOTAL KNEE ARTHROPLASTY SURGERY A RETROSPECTIVE STUDY OF 87 CASES Abdulrahman Alsawadi, Humayon Pervez, Mark Loeffler Colchester Hospital University NHS Foundation Trust, Colchester, UK Aim: Total knee arthroplasty (TKA) is associated with significant postoperative pain. Local infiltration analgesia (LIA), a relatively new technique for postoperative TKA pain control, was introduced at our hospital in 2011, although conventional nerve block (NB) remains the method of choice. This study compares outcomes between LIA and NB in TKA patients. Method: One hundred randomly selected TKA cases from 2011 were reviewed; thirteen exclusions did not fit the two groups (Local or Block). Sample characteristics and treatment outcomes were compared. Significant differences were determined by chi-squared and ttests. Results: Both groups had similar sample characteristics and no significant differences in pain measurements, frequency of dressing, venous morphine and range of motion of the operated knee at 6-week follow-up. Length of Stay (t(85)=3.170, p=0.002) was significantly longer in the Block (M=4.65, SD=1.10) than in the Local (M=3.91, SD=1.06) group. Oral Morphine use (t(85)=2.744, p=0.007) was significantly higher in the Block (M=1.83, SD=1.57) than in the Local (M=0.98, SD=1.31) group. Complication rates were similar for both groups. Conclusions: Local group patients had significantly shorter hospital stays and used less morphine, with no increase in complications. LIA can be considered a safe approach and larger controlled randomised studies should be encouraged.
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0448 PERIOPERATIVE STRATEGIES IN THE MANAGEMENT OF PATIENTS WITH PROXIMAL FEMUR FRACTURES IN 2011: A NATIONAL SURVEY OF ORTHOPAEDIC SPECIALIST TRAINEES. Richard Forrester, Ramsay Refaie, Tim Bonner, Will Eardley James Cook University Hospital, Middlesbrough, UK Hip fractures are a frequent event, with a lack of evidence as to how these patients are globally treated peri-operatively and a need tives: exists to identify current management patterns. edd, Bangor A UK web-based survey investigated the rationale of fixation of AO 3.1.A.1 and AO 3.1.A.3 fractures, post-operative x-rays, venous, VTE prophylaxis and follow up. al of Wales, Cardiff 249 trainees responded. 98% chose a sliding hip screw for the AO 3.1.A.1 fracture. For the AO 3.1.A.3 fracture 95% chose an intramedullary device. 24% of respondents selected the option most representative of current NICE guidelines for VTE prophylaxis. 79% requested m: info@asit.org post-operative x-rays and 87% outpatient follow up. Trainees show compliance with published evidence in terms of their choice of fixation of the AO 3.1.A.1 fracture pattern. Fixation of the
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AO 3.1.A.3 fracture with an intra-medullary device is clearly common place, but the evidence to support this is currently not conclusive. Routine post-operative x-rays are not supported by the evidence and are unnecessary in terms of cost and radiation exposure. Routine outpatient follow up is an increased burden on finite resources. This work is evidence of contemporary hip fracture peri-operative care and has implications in light of the growing burden of these injuries.
0487 Goldie FEMORAL FRACTURES: COMPATIBILITY FOR FIXATION WITH A RETROGRADE INPERIPROSTHETIC SUPRACONDYLARKhera TRAMEDULLARY NAIL ASiT President Edward Lindisfarne, SM Thompson, N Bradley, M Solan Bariatric Fellow, North Tyneside Royal Surrey County Hospital, Guildford, UK Aim: The aim of this study was to review all the potential Total Knee Replacement (TKR) prostheses available, their compatibility for use with retrograde nails and to produce a Compatibility Guide for surgeons to use. Methods: Data was sought from the manufacturers and collated into a comprehensive table giving the minimal intercondylar distance by manufacturer, name of prosthesis and size. We also determined if the notch on the femoral component would be too posterior to accept a retrograde nail. Results: The details for each size and type of prosthesis have been condensed to give a range for the minimal intercondylar distance. Ed Fitzgerald An A4 Compatibility Guide of our results was constructed for easy reference. ASiT Conference Organiser particular challenge. Incidence is increasing as more patients Discussion: Periprosthetic supracondylar femoral fractures present a & Past-President undergo TKR and the patients are more Surgery Registrar, London General active and survive longer. A retrograde intramedullary nail is a commonly used treatment option. It is essential to know the compatibility of the TKR prostheses with retrograde nails and in particular the minimal intercondylar distance. Conclusion: We provide a review of the intercondylar distances of all available prostheses. This may be of practical use for the planning of operative management of periprosthetic supracondylar femoral fractures. 0491 Jonny Wild UNIPOLAR MODULAR EXETER HEMIARTHROPLASTY REDUCES LENGTH OF STAY AND ALLOWS FASTER REHABILITATION AFTER HIP FRACTURE: A RETROSPECTIVE STUDY OF 117 Sponsorship Co-ordinator ASiT Honorary Secretary & PATIENTS. EAO Lindisfarne, EJC Dawe, PM Stott General Surgery Registrar, Sheffield Royal Sussex County Hospital, Brighton, UK Introduction: This study aims to compare the early results of the Exeter Unipolar variable-offset modular device (Exeter) with the Cemented Thompson (Thompson) hemiarthroplasty. Methods: This retrospective cohort study included patients undergoing Thompson or Exeter hemiarthroplasty between November 2010 and August 2011. Choice of implant was made according to availability of equipment and surgeon preference. Groups were compared using thirteen descriptive variables to identify discrepancies in patient selection. Results were assessed using survival, complications and length of stay. Robert Davies Results: 117 patients underwent Thompsons (n=67) or Exeter (n=56) hemiarthroplasty by 24 different primary surgeons. Median follow ASiT Honorary Treasurer -up was 9 months (6-11 months). Length of stay was lower in the Exeter group (Median 5.72 (4.01-7.95) vs 6.99 (4.58-9.24) days p=0.048). Time to discharge from rehabilitation was also lower in theWest Midlands 13.6 (11.0-23.8) vs 21.7 (16.0-31.2) days, Vascular Surgery Registrar, Exeter group (Median p=0.0003). Discussion:There was faster rehabilitation in the Modular Unipolar Exeter group. This could result from more accurate restoration of anatomical offset and ease of insertion compared to mono-block designs. Conclusion: The Unipolar Exeter Hemiarthroplasty reduces length of stay and improves rehabilitation after hip fracture. We recommend its use.
James Milburn 0494 THROMBOEMBOLIC PROPHYLAXIS IN ACUTE ACHILLES TENDON RUPTURE ASiT Vice-President Shan Shan Jing, Stephen Palmer, Michael Taylor General Surgery Registrar, Inverness Broomfiled Hospital, Chelmsford, UK Aim: Current evidence for routine thromboprophylaxis in acute Achilles tendon (TA) ruptures is controversial and lacking. Rate of a venous thromboembolic event (VTE) reportedly varies between 6.3%- 34%. No national guidelines have been set specifically for this purpose. The aim of this audit is to assess the rate of VTEs and review the need for routine thromboprophylaxis for VTE at our local Orthopaedics Department with suggestions of a protocol of management. Method: Retrospective review of patient demographics, management of acute TA rupture, follow up and rate of VTEs using case notes and imaging services for patients with acute TA rupture during May 2009 to October 2011. Joseph Shalhoub Results: The rate of VTE in our case series of 76 patients was 6.6% (5/76) during the 30 months study period. 3 patients had distal ASiT Vice-President DVT and 2 patients had non-fatal pulmonary embolism all within 3 months of TA rupture diagnoses. All patients had additional associated risks for thromboembolicVascular Surgery Registrar, London events. Conclusions: In view of the evidence, low incidence of VTE does not support the use of routine chemoprophylaxis. However, anticoagulation should be considered for patients who have additional factors contributing to VTEs in the setting of acute TA ruptures.
0508 AUDIT OF HANDOVER PRACTICE IN ORTHOPAEDICS AND TRAUMA - CAN IMPROVEMENTS BE MADE? Steve Hornby Abigail Clark-Morgan, Michael Glaysher, William Knight, Melanie Orchard, Timothy Kane ASiT NHS, Salisbury District Hospital, UK Director of Education Aims: To assess the efficiency and safety Surgery Registrar, South West Peninsula General of patient handover in a level 2 trauma centre with a catchment of 650,000 patients. Method: A two week sample of handover sheets was compared to the national standards from the Royal College of Surgeons, England. These identify categories of handover information. Fifteen doctors (Foundation Year 1 to Core Surgical Trainee Year 2) collected whatever documentation for handover had been used. A template handover sheet was then created and our data presented at the multi-disciplinary departmental meeting. It was readily adopted as the working on-call list and three months later the audit cycle was completed. thanks to the local ASiT Welsh Regional Representatives: With Results: The initial audit revealed 54% of the minimum information was handed over. The re-audit showed this to be 90% and of all Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor the points within the guideline, 66% were now being handed over - an increase of 36% and 27% respectively. Conclusion:Mrclear need for improvement in handover practice has been fulfilled by the introduction of a Wales, Cardiff A Andrew Beamish, Clinical Research Fellow, University Hospital of simple, well designed template - demonstrating a safer and more complete handover practice. Shift patterns add to the challenge of handover and a system needs to be in place to accommodate this to optimise patient care.

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0522 GENERAL PRACTITIONERS REQUESTS OF KNEE RADIOGRAPHS: WEIGHT BEARING VERSUS NON WEIGHT BEARING AP VIEWS Malwattage Lara Tania Jayatilaka, Dominic C Sprott, P Hughes, Marcus Robert Cope Southport District General Hospital, Southport, UK Aim: To determine how many patients, with suspected osteoarthritis of the knee, were being referred to orthopaedic outpatient clinics from General Practitioners with non-weight bearing AP knee radiographs, to determine the number of patients subsequently having repeat weight bearing AP knee radiographs and the financial cost. Method: Prospectively over a two week period we reviewed the radiological investigations ordered prior to the consultation in orthopaedic outpatients. Results: GPs referred 36 (87.8%) the remaining 5 (12.8%) were tertiary referrals. None of the GP referrals had weight bearing AP knee radiographs prior to the consultation. Half had non-weight bearing AP knee radiographs the remainder had no radiographs taken prior to referral. Weight bearing AP knee radiographs were ordered in clinic on 23 (63.9%) of the GP referred patients, of these 9 (25%) had previous non-weight bearing AP knee radiographs thus necessitating further radiation exposure and expense. Conclusion: The additional cost for a single knee radiograph at our hospital is 30. If we extrapolate the 9 patients requiring repeat weight bearing AP knee radiographs in the study equates to 7,020 per annum. We suggest that all requests to the radiology department for knee radiographs from GPs are standardised to be weight-bearing AP.
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0541 AN AUDIT OF THE IMPACT OF PSYCHIATRIC ILLNESS OR INTOXICATION ON ORTHOPAEDIC MORBIDITY & COST B Ramasubbu, L Moran, JM Cooney, PP Grieve St James's Hospital, Dublin, Ireland Aim: To assess the impact of psychiatric illness and/or intoxication on injury severity, duration and expense of hospital stay in orthopaedic patients. Methods: Orthopaedic admissions, for July 2011, from the Emergency Department at St Jamess Hospital were reviewed. Patients were categorized into 4 groups. Group 1 (n=65). Control group - no psychiatric co-morbidities (and sober on admission). Group 2 (n=15). Patients with psychiatric co-morbidity. Group 3 (n=8). Patients in which their psychiatric co-morbidity directly caused injury. Group 4 (n=15). Patients in which intoxication (alcohol and/or drug) directly caused injury. Results: In Comparison to Group 1: (per patient basis) Group 2: 3x longer average duration of hospital stay, Twice number of theatre procedures, Twice number of scans (XR, CT and MRI). Group 3: 6x higher average duration of stay, 3x number of theatre procedures, 3.5x number of scans, 2x number of Multi-Disciplinary team components. Group 4: 3x longer average duration of stay, 1.25 number of scans, 1.5x number of MDT components. The average Injury Severity Score was highest in Group 3. Conclusions: Psychiatric illness and substance abuse were associated with substantially greater orthopaedic morbidity, duration of stay and cost. 0612 AUDIT OF DABIGATRAN ETEXILATE FOR THE PREVENTION OF VENOUS THROMBOEMBOLISM AFTER ELECTIVE HIP AND KNEE SURGERY Hannah Blanchford, Catherine Hooks, David Graham Gateshead Hospital NHS Foundation Trust, Gateshead, UK Aim: This audit assessed compliance with Gateshead Hospital NHS Foundation Trust guidelines on dabigatran for the prevention of venous thromboembolism (VTE) after elective total hip and knee replacement surgery. Method: The notes of 62 patients who underwent elective hip and knee replacement surgery in June 2010 were retrospectively reviewed for compliance with trust VTE guidelines. Following implementation of recommendations for staff training, re-audit was performed in June 2011. Results: 74% and 33% of patients received dabigatran whilst inpatients in 2010 and 2011 retrospectively. Re-audit demonstrated an improvement from 85% to 100% for patients receiving the correct post-operative dose of dabigatran. In both audits, half of patients received dabigatran within the 1-4 hour time frame after surgery. The percentage of patients not receiving any VTE prophylaxis on the day of surgery fell from 13% in 2010 to 6.6% in 2011. Conclusions: We conclude that staff training about trust guidelines has reduced errors in the prescription and administration of dabigatran. Anticoagulation omission on the day of surgery has been halved. There has been a shift towards prescribing tinzaparin for inpatient VTE prophylaxis. Further recommendations to improve practice are necessary in order to reduce delays in receiving anticoagulation post-operatively. 0628 THE INTRODUCTION OF A MULTIDISCIPLINARY HIP FRACTURE PATHWAY CAN OPTIMISE PATIENT CARE AND REDUCE MORTALITY: A PROSPECTIVE AUDIT OF 161 PATIENTS Michael Shenouda, Zacharia Silk, Sarkhell Radha, Emer Bouanem, Warwick Radford Chelsea & Westminster Hospital, London, UK Aim: A multidisciplinary hip fracture pathway was introduced in our institution to facilitate rapid preoperative medical optimisation and early surgery for patients with hip fractures. We aimed to assess its impact on patient care and outcomes. Method: Prospective data was collected on 161 patients in six months before and after implementation of the pathway, including: time to orthogeriatric assessment (TtG); time to surgery (TtS); length of hospital stay (LOS); return to original accommodation; and inpatient mortality. Significance was tested using Chi Squared and unpaired Student t-Tests. Results: With implementation of the pathway, 85% of patients received a pre-operative medical assessment (19% before, p=0.0001). There were significant reductions in average TtG (91 to 19 hours, p=0.0001), LOS (24.8 to 19.5 days, p=0.029), and mortality (14% to 4%, p=0.0336), with an increase in patients returning to their original accommodation (57% to 80%, p=0.0069). Whilst limited by theatre scheduling, there was an observed reduction in TtS (37 to 31 hours, p=0.6636). Conclusions: Rapid medical optimisation and prompt surgery can significantly improve outcomes in this challenging group of patients, often with complex comorbidities. Successful implementation of a multidisciplinary pathway can also reduce demand on services by facilitating return of patients to their pre-morbid accommodation.
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AN AUDIT OF THE USE OF THE PAVLIK HARNESS TO TREAT DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) Jennifer Aston1, Robert Hill2, Jeanne Hartley3 1 University info@asit.org of Aberdeen, Aberdeen, Scotland, UK 2 Great Ormond Street Hospital and the Portland Hospital, London, England, UK
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The Portland Hospital, London, England, UK Aim: To ascertain the length of time required for the patients hips to return to normal on ultrasound scan (USS) and to identify any correlations between the length of time taken and any patient characteristics. Method: Patient records were used to determine the characteristics and outcomes of patients treated by the same orthopaedic surgeon and physiotherapist using the Pavlik Harness. The time taken for the hips to return to normal on USS was taken to be the time for the alpha angle to return to normal for the patients age. Results: Fourteen patients were identified; four had bilateral DDH. Thirteen patients needed no further treatment and the remaining Goldie Khera patient was subsequently treated with a Hip Spica. The range of starting angles was 37-57 and treatment time was 14-82 days. On analysis it was found that there is a correlation between a shorter treatment time and a higher alpha angle at the onset of treatment ASiT President (R Linea = 0.633). Bariatric Fellow, North Tyneside Conclusions: Research into this area is recommended as it may inform appropriate USS interval times in the treatment of DDH using the Pavlik Harness.
General Surgery Registrar, Sheffield 0661 PRE-OPERATIVE ECHOCARDIOGRAPHY AND FEMORAL NECK FRACTURES. ARE WE HELPING OR HINDERING?' Lisa Burton1, Jonathan Handy2, Neil Soni2 1 Chelsea and Westminster NHS Foundation Trust., London, UK 2 Imperial College (Department of Anaesthetics, Pain Medicine and Intensive Care.), London, UK Aim: Pre-operative echocardiography of patients with femoral neck fractures is frequently requested by anaesthetists to assess for valvular and ventricular dysfunction (1.) There is a variation in practice combined with minimal evidence (1.) We performed an audit to Robert Davies assess whether pre-operative echo' delays surgery in this patient group at our institute. ASiT patients with femoral neck Method: We audited 100 consecutiveHonorary Treasurerfractures. The echocardiography and non-echocardiography cohort have had times from admission to theatre Surgery We took theseWestfrom the Accident and Emergency records and the anaesVascular compared. Registrar, times Midlands thetic charts. An operation was considered delayed if it occurred in excess of thirty six hours (2.) Results: In 100 cases 4 did not proceed to theatre. Of the remaining cases; peri-operative echocardiography was performed for 20 people. Median time to operation for the echocardiography population was 38 (18-78[14-126]) hours, compared to 23(17-41[1-132]) hours for the non-echocardiography cohort (p= 0.053, Mann Whitney Test.) Conclusion: Our data shows that locally the pre-operative requirement for an echo is associated with a trend towards delayed surgery. As a result of this audit we are looking at local service improvements.
0663 ASiT Vice-President DO PATIENTS UNDERSTAND INFORMATION LEAFLETS FOR SURGERY? General Surgery Registrar, Inverness Michael Barrett, Craig Smith, Peter Kenyon, Glyn Thomas Wirral University Teaching Hospital, Liverpool, Merseyside, UK Introduction: Patient informations leaflets (PILs) are frequently used to convey detailed information to patients regarding surgery. The Department of Health guidelines on the production of PILs suggest keeping the content simple, with a recommended maximum reading age of the literature to be suitable for an eleven year old (sixth grade student) to read and understand. This is nationally the average adult reading age. Methods: We assessed the Josephof PILs using the Flesch-Kincaid Grade Level (FKGL) and Flesch-Kincaid Reading Ease readability Shalhoub (FKRE) formulae. ASiT Vice-President Results: 26 patient information leaflets identified. 100% of articles had a FKGL greater than the maximum recommended grade Vascular Surgery Registrar, London 6. Mean FKGL grade 10.7. 84% of PIS rated 'difficult', 16% rated 'moderate' for ease of reading. Mean FKRE was 'difficult,' mean FKRE score 49.9. Discussions: Patient information leaflets are difficult to read, exceed the recommend levels of reading difficulty and are beyond the reading ability of most adults. It is therefore essential when producing patient information leaflets to take this into account, and simplify the language and analyse the complexity of the text. Following this the PILs reviewed have been revised to improve the ease of reading for patients.
0650 HIP FRACTURE MANAGEMENT AUDIT AT EPSOM AND ST HELIER NHS TRUST Harry Li Epsom and St Helier NHS Trust, London, UK Ed Fitzgerald Background: There are 30,000 new incidences of hip fractures annually in the UK with numbers projected upwards. ASiT National Hip Fracture Database & Past-President Method: Data was collected from the Conference Organiser over the period September 2009 to August 2010 for all patients admitted to St Helier Hospital General Surgery Registrar, London with fractured neck of femur. Data was audited against 3 national standards in the BOA-BGS Blue Book. Results: 436 patients: 106 men mean age 81; 330 women mean age 83. 58% were admitted to an orthopaedic ward within 4 hours vs 60% nationally. 89.5% of medically fit patients had an operation within 48 hours vs 72.8% nationally; and 78.4% received orthogeriatric input vs 42.4% nationally. 53 patients died during their admission; 31 patients (58.5%) had an ASA of grade 3 or 4. Of these, 15 patients (28%) were admitted to an orthopaedic ward within 4 hours; 31 patients (58.5%) operated on within 48 hours; and 11 patients (20.8%) did not receive any orthogeriatric input. Conclusion: St Helier Hospital is performing well nationally. However, the 53 patients who died could have received better orthopaedic/ Jonny Wild MDT management. Many were medically unfit. This recognises the importance of medical team input yet only 1 in 5 of the deceased received orthogeriatric review. ASiT Honorary Secretary & Sponsorship Co-ordinator
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ASiT Director of Education 0665 EARLY CESSATION OF PATIENT CONTROLLED ANALGESIA LEADS TO DECREASED HOSPITAL STAY IN TOTAL HIP AND General Surgery Registrar, South West Peninsula KNEE ARTHROPLASTY Peter Lorentzos Blacktown Hospital, NSW, Australia Aim: To investigate whether ceasing Patient Controlled Analgesia (PCA) day 1 post-operatively in patients receiving either Total Hip Arthroplasty (THA) or Total Knee the local ASiT Welsh decreased hospital stay. With thanks to Arthroplasty (TKA) contributed to Regional Representatives: Method: A retrospective chart review of 59 consecutive patients over a six month period undergoing either THA or TKA at two sister hospitals Miss RhiannonHospitals shared Orthopaedic surgeons, physiotherapists, Allied health, and identical discharge pawas performed. Both Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor rameters. At Hospital A PCA was ceasedClinical Research while at Hospital B PCA duration wasof Wales,by the Acute Pain Mr Andrew Beamish, day 1 post-operatively, Fellow, University Hospital determined Cardiff Team. All patients received other forms of analgesia concurrently. Results: 67 % of patients in Hospital B received PCA beyond Day 1 post-operation. Overall average hospital stay was shorter in Hospital A than Hospital B - 6 days as opposed to 4.7. Patients receiving PCA beyond Day 1 also showed an average increase in Hospital With thanks to the wonderful ASiT Conference Admin team: info@asit.org stay. Results were similar for THA and TKA. Patient groups were similar for age and gender. Laura Andrews Kristina Gloufchev Harriet Innes
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Conclusions: Restricting PCA duration to 24 hours post-operatively is shown to decrease average hospital stay in patients undergoing both THA and TKA. 0705 THE USE OF PROPHYLACTIC PERI-OPERATIVE GENTAMICIN IN ELECTIVE ARTHROPLASTY PATIENTS: IS IT SAFE? Sian Jones, Karun Veravalli, Claire Topliss Morriston Hospital, Swansea, UK Introduction: With the aim or reducing rates of Clostridium difficile infection, AMBU Health Board changed their guidelines for antimicrobial orthopaedic prophylaxis (in line with current practice nationally). This recommends single dose gentamicin in combination with flucloxacillin. Following introduction, concern was raised regarding a perceived increased incidence of acute kidney injury (AKI). Methods: Pre- and post-operative creatinine values of two patient groups were compared. Group 1 (n=230) received pre-operative cefuroxime and group 2 (n=185) received single (weight based) dose gentamicin and flucloxacillin. Data was analysed using Arcus statistical package. The stage of AKI was determined using the Acute Kidney Injury Clinical Practice Guidelines, published by the UK Renal Association. Results: There was no statistically significant difference between the pre-operative (median 76, 74.5; p>0.05) nor post-operative creatinine values (median 74, 76; p>0.05) of the two groups. The incidence of AKI did not change with the new antibiotic protocol, but there was a reduction in rates of Clostridium difficile infection (37 cases in 2009, 31 in 2010 within the orthopaedic department). Conclusion: This audit has demonstrated that single shot gentamicin in combination with flucloxacillin does not increase the risk of AKI. We can therefore safely continue its use for elective orthopaedic patients.
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0717 OPTIMAL TIMING FOR SYNDESMOTIC SCREW REMOVAL A STUDY BY RADIOLOGICAL ASSESSMENT. Vijay Rajamani, Kodali Prasad, George Zafiropoulos Prince Charles Hospital, Merthyr tydfil, UK Objective: To compare the radiological outcome of syndesmotic injuries of ankle following the syndesmotic screw removal before and after eight weeks. Methods: Between 2006 and 2009, 108 patients underwent syndesmotic screw fixation following ankle injuries. Of these 57 patients (with radiographs after the screw removal) were included in our study. Twenty eight patients (Group A) had the syndesmotic screw removed before 8 weeks. The remaining 29 patients (Group B) had the screws removed after 8 weeks. The radiographs were assessed by two observers independently for tibiofibular overlap in both the periods after surgical fixation and after screw removal. Results:The mean age of the patients was 39 in Group A and 45 in Group B (p=0.16). Forty six percent are males in Group A compared to 60% in Group A (p=0.93). Twenty eight patients (96.6%) in Group B had good tibiofibular overlap compared to 22 patients (79%) in Group A. This is statistically significant at the conventional level of 0.05, using a 2-sided test. Conclusion: Our study indicates that Group B had a better outcome compared to Group A. We conclude that based on the radiological outcome, optimal timing for syndesmotic screw removal is more than eight weeks. 0726 RADIOGRAPHIC ASSESSMENT OF THE THUMB Nicholas Penney, Gokulan Phoenix, Simon Ball, Giles Becker Chelsea and Westminster Hospital NHS Trust, London, UK Introduction: In addition to elective indications such as carpometacarpal joint osteoarthritis, a plain radiograph is commonly the initial imaging modality following acute trauma to the thumb. Adequacy is dependent upon the use of correct radiographic projections; in turn dependant on accurate information provided in the clinical request. Aim: To compare a series of anterior-posterior (AP) thumb radiographs taken in our hospital against the gold standard Roberts thumb view. Method: A retrospective analysis of 100 consecutive thumb radiographs was made by two independent assessors (NP/GP) for quality of request and adequacy of imaging. Differing opinions were arbitrated by an Orthopaedic Hand Consultant (GWB). Results: The male-to-female ratio was 1:0.6. Mean age 43 (range 18-95). Right-thumb=59, Left-thumb=41. Trauma accounted for the majority (60/100). The suspected area of pathology was specified in 64/100 requests; radiographs for the majority of these cases were inadequate (33/64, 51.6%). Conclusion: AP thumb radiographs within our Trust are inadequate, both in terms of request detail, and views obtained; this can result in misdiagnosis and resultant sub-optimal treatment. An educational programme for requesters and radiographers has been introduced, highlighting the importance of adequate request information and correct positioning. We encourage all surgeons to assess thumb radiograph adequacy locally. 0730 MUSCULOSKELETAL TUMOURS PRESENTING TO A KNEE SERVICE OVER 10 YEARS: A RETROSPECTIVE AUDIT. Samer SS Mahmoud, Michael J McNicholas Warrington Hospital, Warrington, Cheshire, UK Aim: This is a 10 year retrospective audit of musculoskeletal tumours presenting to a district general hospital knee service referred onto the Birmingham Tumour Centre (BTC). Method: Tumour service correspondence and local patients case notes were reviewed. Results: In this time 35, 409 patients were seen in this knee unit (9,565 new patients and 25,844 follow up patients). 20 patients (14 females, 6 males) with average age of 36.4 years (13-67 years) were referred from our service. Referral sources to our service were from: GP 12 (60 %), Accident and Emergency 4 (20%) and other consultants (other speciality or subspecialty) 4 (20%). All were referred onto BTC and upon further investigation 11 patients had malignant conditions and 9 were benign. 9 malignant conditions had urgent major operative intervention. Radiotherapy and chemotherapy was used in 2 patients. 5 of the benign cases required surgery while conservative treatment was used in 4 patients. Conclusion: Musculoskeletal tumours are rare. Constant vigilance is required to enable early detection & urgent referral to specialist tumour centres which has been shown repeatedly to be the best option for survival and functional outcomes. 0741 CALCULATION FOR JUNIOR DOCTORS IN TRAUMA AND ELECTIVE PATIENTS; DO WE
edd, Bangor ACCURATE LIMB DEFORMITY HAVE AN al of Wales, Cardiff ANSWER?
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Adedeji Akinyooye, Ahmed Shoaib King's College Hospital, London, UK Aim: Accurate radiological description of injuries in trauma patients is critical for optimum patient care. 4.7% of investigations commuinfo@asit.org nicated between junior Doctors and their seniors lack accurate and comprehensive detail(1). Currently, rough angulation and length
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measurements are performed on the picture archiving and communication systems(PACS). The program TraumaCad TM (Voyanthealth, USA) can assess limb deformities after fractures. TraumaCAD TM is currently used extensively for pre-operative planning. We assessed the potential for using this software in clinical settings. Method: A medical student assessed 20 radiographs with angulated fractures and 20 pre-operative radiographs of patients awaiting Total-Hip-Replacement. Neck-shaft angle, limb length discrepancy of the arthritic hip (Elective) and fracture angulation in trauma patients were measured using PACS. The calculated deformity was compared with TraumaCAD TM assessment; following a two-hour training session. Results were compared to an orthopaedic trainee trained in TraumaCad TM. Goldie Khera Results: On statistical analysis; there was no significant difference between the medical student and Trainee(p-value < 0.05). Deformities calculated using PACS and TraumaCADTM by the medical student were significantly different after positive correlation analysis. ASiT President Conclusions: The medical students' calculation of limb deformity was more accurate after a short training session in TraumaCADTM. This can be a valuable tool in Bariatric Fellow, North Tyneside improving junior Doctors' ability to communicate trauma patients' injuries.
0745 REVISION ACL RECONSTRUCTION: A PROSPECTIVE STUDY ASSESSING THE FUNCTIONAL AND OBJECTIVE OUTCOMES AND COMPARING COMPLICATION RATES WITH PRIMARY ACL RECONSTRUCTIONS Samer SS Mahmoud, Saurabh S Odak, MJ McNicholas Warrington Hospital, Warrington, Chesire, UK Ed Fitzgerald Aim: Single surgeon prospective study assessing the functional and objective outcomes after revision ACL reconstruction and comparASiT Conference Organiser & ing re-rupture rate and complication rate with his primary reconstructions. Past-President Methods: Lysholm, KOOS, IKDC scores, Surgery Registrar, London General AP laxity (at 30 knee flexion) and complications were collected prospectively on all the patients over a period of 10 years. Results: Average follow up was 21.2 months (range 12-60 months). 24 patients (21 males, 3 females) had a mean age of 31.2 years (range 17-50). 3 patients ruptured their revision (12.5 %) compared to 10 of 422 primaries (2.36%) (p<0.01). Post-operatively there was improvement in Lysholm, KOOS symptoms, KOOS ADL, KOOS QOL and IKDC scores (p<0.02). Rolimeter mean preoperative 30 value (difference between operated and contralateral knee AP laxity) was 16 mm which improved at 12 months post-operative to 1.8 mm and later increased to 5 mm by latest follow up. Jonny Wild However no significant improvement was detected in KOOS pain, KOOS sports scores (p>0.05). Complications occurred in 29.16% (7 patients) compared to 13.5% (57 patients) in the primaries. (p<0.05) Sponsorship Co-ordinator ASiT Honorary Secretary & Conclusion: Revision ACL reconstruction surgery remains a challenging problem. Improved function can be expected after revision General Surgery Registrar, Sheffield ACL surgery but there are significantly higher risks of re-rupture and complications. 0767 IMPROVING THE MANAGEMENT OF PRESSURE ULCER CARE IN FRACTURE NECK OF FEMUR PATIENTS Nicholas Raison, Wisam Alwan, Amit Abbot, Kirtsy Lawton, Radcliffe Lisk St Peter's Hospital, Chertsey, Surrey, UK Introduction: Pressure ulcers Robert Davies cause significant morbidity and mortality. Accordingly pressure area care is one of the six national standards for fracture neck of femur care (NoF) patients with emphasis on prevention and assessment at the earliest opportunity. ASiT Honorary Treasurer Method: We reviewed the management of 27 NoF patients admitted between January-February 2010 assessing them against 11 gold standard criteria. Vascular Surgery Registrar, West Midlands After the audit, the following interventions were carried out: presentation at orthopaedic clinical audit and ward managers meetings, four education sessions by Hip Fracture Nurse to all nursing staff, mobilisation algorithm agreed with physiotherapists, NoF bleep to equipment managers and a new NoF proforma highlighting pressure area inspection. A re-audit of 26 NoF patients between May-June 2010 completed the audit cycle. Results: We showed significant improvement across all the standards. Of note twice daily pressure sore assessment improved from 3.7% to 38.5% and all patients were seen within 4 days of admission James Milburn (previously 78.0%). Consequently development of new pressure sores fell from 22.0% to 4.0% and there was a reduction in the pressure sore grade 2 or ASiT Vice-President above from 7.4% to 0%. General Surgery Registrar, Inverness Conclusions: Pressure area care has improved significantly compared to the original audit and local and national benchmarks. 0786 RANGE OF MOVEMENT AS A DISCHARGE CRITERIA FOLLOWING KNEE ARTHROPLASTY ; CAN IT BE SAFELY IGNORED IN A RAPID RECOVERY PROGRAMME Nick Aresti, David Houlihan-Burne The Hillingdon Hospitals NHSJoseph Shalhoub Trust, Uxbridge, UK Aim: Length of stay following knee arthroplasty commonly reaches 7 days. A recognised discharge criterion is a range of movement ASiT Vice-President greater than 90 of flexion. We set out to determine whether a reduced length of stay with suboptimal flexion at discharge affects the overall range of movement. Vascular Surgery Registrar, London Method: We recorded the length of stay and range of movement pre-op, on day of discharge and at the first follow up clinic, of 63 knee arthroplasty patients. Results: The average length of stay was 4.4 days. The average range of movement at discharge was 4.4-79.4. Only 17.5% of patients were discharged with more than 90 of flexion. At follow up, the average range of movement was 0.6-106.1. Only 2 patients could not flex to 90, only one of which was in the original group unable to flex past 90. From the patients with an inadequate range of Steve Hornby movement at discharge, only 1.9% had an inadequate range of movement at follow up. ASiT Director of Education Conclusion: Reduced length of stay and suboptimal knee flexion at discharge does not affect the final range of movement following knee arthroplasty. With this inGeneral Surgery Registrar, South West Peninsula mind, enhanced recovery and early discharge is encouraged, providing significant savings for hospitals. 0789 BIOMECHANICAL EVALUATION OF A HYBRID BARBED-SUTURE IN THE REPAIR OF DIGITAL FLEXOR TENDONS Jonathan Evans3, Grey Giddins2, Tony Miles1 1 Centre for Orthopaedic Biomechanics,local ASiT Welsh Regional Representatives: With thanks to the Bath, UK 2 Royal United Hospital, Bath, UK 3 Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Royal Cornwall Hospital, Truro, UK Aim: The Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff tendon purpose of this study was to develop and test the utility of a hybrid barbed-suture in the core repair of digital flexor injuries. The suture construct was designed for ease and speed of application. Method: The barbed suture device was constructed by inserting 3 steel barbs into the weaved construct of a braided polyester suture. The barbed sutures were inserted intowonderful ASiT Conference Admin team: repair. Tensile testing of the With thanks to the 28 porcine lateral extensor tendons yielding a single sided core info@asit.org repair was undertaken using a tabletop load frame with the distal end of the tendon fixed in a cryo-clamp.
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Linear load testing to failure was undertaken. Maximum load, repair excursion and repair stiffness were recorded. Results: The barbed suture technique demonstrated a maximum load to failure of 40.416.4 N. The excursion of the repair at failure point was 31.411.6 mm. The stiffness of the repair derived from the linear elastic portion of the load displacement curve was 1.00.6 N/mm. Conclusions: Use of this barbed suture construct offers a fast, easily applied method of flexor tendon repair. The maximum load to failure is comparable to the commonly used non-barbed suture methods. Further testing with design modifications may limit suture excursion.
0854 POTENTIAL FOR RECYCLING OF PACKAGING WASTE GENERATED BY ORTHOPAEDIC THEATRES IN A DISTRICT GENERAL HOSPITAL Ishvinder Singh Grewal, Hussein A Kazi, Marcus R Cope Southport and Ormskirk Hospital NHS Trust, Southport, Merseyside, UK Background: Orthopaedic theatres generate a huge amount of waste product, with a significant carbon foot print. All theatre waste is currently disposed of via costly landfill and incineration. The vast majority of this waste is not, however, biohazardous and is recyclable. Many private hospitals in the US, are increasingly recycling hospital waste. In the current economic climate any potential to reduce costs should be explored. Aim: Assess potential for recycling waste generated by orthopaedic theatres and potential cost-saving associated with this. Method: A prospective assessment of all non-biohazardous paper, cardboard and plastic waste generated during one consultant's elective orthopaedic lists. Plastic was separated from paper/card and weighed at the end of each list for 3 months. Results: Mean 1.5kg card/paper; 3kg plastic. Conclusion: Extrapolated to circa 750kg card and 1.5 tonnes of plastic per annum for elective orthopaedic theatres. Local waste disposal firms have offered to recycle all this material at no cost. We currently pay our local waste disposal firm 500/tonne to dispose of this along with the biohazardous material. Therefore via the addition of 2 bins per orthopaedic theatre and simple re-education of staff waste disposal costs could be reduced by circa 1000pa, with an added environmental benefit. 0919 KNEE ARTHROSCOPY ON THE INTERNET: HOW WELL INFORMED ARE YOUR PATIENTS? Aditya Prinja, James Neffendorf Bedford Hospital, Bedford, UK Aims: This study assesses the quality of medical websites with information on knee arthroscopy. Methods: We searched the keywords "knee arthroscopy" in three search engines: Google, Yahoo and MSN/Bing. The top 50 websites were evaluated from each. Exclusion criteria were irrelevant information, repetition or inaccessibility. Readability was assessed using the Gunning-Fog Index (GFI, measure of years of schooling needed to understand content) and the Flesch Reading Ease Score (FRES, index rating - score/100). We used the LIDA tool (an online validation instrument of medical websites) to assess accessibility, usability and reliability. Results: 49 websites were analysed. The mean GFI result showed the average website was similar to reading the Wall Street Journal (mean GFI = 12.18, SD 1.90). The mean FRES was 52.18 (SD 10.5), which is below the recommended target (60-70). The mean results of the LIDA tool were accessibility 81.20%, usability 54.86% and reliability 39.67%. Conclusions: Readability and reliability of the websites was generally poor. The best resources are those belonging to medical/ academic institutions and those without financial interests. Since patients are likely to be influenced by what they read online, it is essential that we guide patients by identifying reliable sources of information. 1035 EXCESS CEMENT IN TOTAL KNEE ARTHROPLASTY: COMPARISON OF SURGEON GRADE William Nash, PW Allen, Sadia Afzal Princess Alexandra Hospital, Harlow, UK The removal of excess cement around the implant components at total knee arthroplasty (TKA) is recommended to reduce microparticulate debris. (1) However the frequency and quantity of excess cement after TKA has not previously been investigated. 210 consecutive Press Fit Condylar (PFC sigma) primary total knee arthroplasties were evaluated in a total of 10 areas of excess cement on post-operative radiographs (AP and HBL). Excess cement was further graded as A (<2mm in longest axis), B (2-5mm) or C (>5mm). Comparisons were made between operating surgeon's grade (consultant vs. ST grade) regarding frequency and amount of excess cement. There was no significant difference in the frequency of cases with excess cement when comparing surgeon grade (69% vs. 71% respectively, P=0.83). There was also no significant difference between the number of areas that had excess cement (P=0.712) or any difference between the amount of cement around the knee when comparing surgeon grade (P=0.455). Length of operation positively correlated with both the amount of excess cement (T = 0.202, P=0.0001) and with number of areas of excess cement (T=0.182, P=0.0005). The rate and quantity of excess cement appear to be independent of operating surgeon grade. They do however correlate with increased operation time.
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1036 FASCIA ILIACA COMPARTMENT BLOCK SHOULD BE TAUGHT TO MORE SURGEONS IN TRAINING TO IMPROVE PAIN CONTROL FOR PATIENTS WITH FEMORAL FRACTURES Zacharia Silk, Wei-Lin Allen Watford General Hospital, London, UK Aim: The aim of this audit was to establish the uptake of fascia iliaca compartment block (FICB) in a busy district general hospital using local guidelines as audit standards. Method: Patients with a fractured neck of femur (NOF), fractured femoral shaft or peri-prosthetic fracture were identified at a single time point. A retrospective case note review was conducted to identify those receiving FICB. Exclusions included: known coagulopathy; oral anticoagulants; sensitivity to local anaesthetic; previous vascular surgery in the affected limb; inability to identify the femoral tives: artery. edd, Bangor Results: In total, 18 patients met the inclusion criteria (17 fractured NOF / 1 proximal femoral fracture). Only 23% received FICB preoperatively. al of Wales, Cardiff All were given during weekdays, with 75% taking place during working hours. The acute pain team administered 75% of blocks and the remainder administered by the on-call anaesthetist. No surgeons performed FICB during this audit. Conclusion: FICB is a regional anaesthetic technique available to surgeons, anaesthetists and acute pain nurses. It can be conducted using simple m: info@asit.org anatomical landmarks with basic equipment and little training. The use of FICB would be increased if more surgeons were trained to perform the block. A training programme was initiated at this hospital to increase its uptake.
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1063 JUSTIFICATION FOR THE USE OF REINFUSION DRAINS IN TOTAL KNEE Mathias Nagy, Gaurav Rathore, Nigel Courtman University Hospitals of Morecambe Bay, Barrow In Furness, Cumbria, UK Aim: Autologus reinfusion drains are widely used in Total Knee Replacement (TKR) surgery. These drains avoid major problems of allogenic blood transfusion and are an excellent method for blood salvage. However, the use of these drains, which are rather costly, remains controversial. Our aim was to investigate the necessity of reinfusion drains in TKR. Goldie Khera Methods: A retrospective review was conducted of 87 patients (mean age 69 years) who underwent cemented TKR in a Distric General Hospital. Closed autologus reinfusion drain was used in all patients. Clinical and haematological findings pre- and post-op, the ASiT President operations themselves and the clinical notes were reviewed. Bariatric Fellow, North Tyneside Results: Average pre-op haemoglobin was 13.1, average collection of blood was 550 ml (20-1990 ml), average reinfusion amount was 322ml (0-1990 ml) and average post-op haemoglobin was 11.1. Four patients required additional heterologus blood transfusions. The necessity for using reinfusion drains was determined by post op haemoglobin minus the retransfused amount (converted into g/dl) of blood. Using a transfusion trigger of 8 g/dl of haemoglobin, the utilisation of a reinfusion drain was not justified in 95% of patients. Conclusion: Our results do not support the routine use of reinfusion drains in all TKR patients.
1095 Ed Fitzgerald A RETRIEVAL STUDY: HISTOMORPHOLOGICAL ANALYSIS OF FAILED HIP RESURFACING IMPLANTS ASiT Conference Organiser & Past-President Jasmine Ho, Jia Hua Institute of Biomechanical Engineering, Stanmore, London, UK General Surgery Registrar, London Aim: This study aims to explore the possible factors associated with failure of metal-on-metal resurfaced hip through histomorphological analysis of six retrieved femoral head specimens. Methods: Six un-decalcified specimens were prepared for radiography and hard-tissue histology. Cement mantle thickness and penetration were quantified and cement interface was studied for degree of bone contact. Bone vitality and areas of bone resorption activity were quantified under light microscopy. Results: Out of the six specimens, two were found to have no cement layer. Most specimens showed extensive bone changes under Jonny Wild the implant. Areas of radiolucencies were found to be filled with fibrous tissues. In such regions, there was more observable resorptive activity. Cement penetration was shown to be excessive for all cemented specimens. Percentage bone contact was higher on the ASiT Honorary Secretary & Sponsorship Co-ordinator medial side (p=0.386). Percentage occupied osteocytes increased more proximally to the implant (p=0.082). Due to the small sample General Surgeryfor the different Sheffield were not significant (p=0.779). size, the difference in percentage resorption activity Registrar, bone regions Conclusion: There were a variety of highly individualised specimens seen. It was not possible to conclude the definite reasons for failure but this study has certainly highlighted crucial points for future studies to address. 1125 FUNCTIONAL OUTCOMES FOLLOWING THE USE OF AN INEXPENSIVE MINI-EXTERNAL FIXATOR DEVICE FOR PHALANGEAL FRACTURES. Robert Davies Suzanne Thomson, Lisa Ng, David Howarth, Max Coutinho, Sahan Rannan-Eliya ASiT Honorary Treasurer Department of Burns and Plastic Surgery, Royal Victoria Infirmary, Newcastle Upon Tyne, UK Introduction: Complex phalangeal fractures are often stabilised using commercial external fixators, which are costly and require familiVascular Surgery Registrar, West Midlands arity. Here we describe our positive experience using a simple fixator constructed using readily available materials. Methods: Patients who had phalangeal external fixation by a single operator, over a five year period were identified from theatre logbooks. Data was obtained retrospectively on aetiology, fracture configuration, operative details, complications and post-operative function using Total Active Movement (TAM) scores. Results: Outcome measurements were retrieved in 26 of 38 patients identified. Injuries were sustained through altercation (n=6), crush (n=7) or fall onto hand (n=17). The majority affected the little finger (n=15) and the proximal phalanx (n=19) was most commonly fracJames Milburn tured. One fracture was open. All achieved bone union. No secondary procedures were required. Complications occurred in 9: unexpected stiffness (n = 1), unexpected swelling (n = 4) and pin-site infection (n=4). At four months the functional outcome was good (% ASiT Vice-President TAM>80%) or excellent (%TAM = 85%) in all patients with a mean TAM of 230o. General Surgery Registrar, Inverness Conclusion: This external fixator provides a reliable and cost-effective method of complex fracture fixation. The post-operative complications are acceptable and functional outcomes highly favourable when compared to other methods of phalangeal fracture fixation. 1138 TARGETED FOOT AND ANKLE INJECTION WITH ULTRASOUND GUIDANCE IN THE RADIOLOGY DEPARTMENT REDUCES THE NUMBER OF PATIENTS REQUIRING INJECTION IN THEATRE A,K Saini, D,S White, A Carne, M Solan Shalhoub Joseph Royal Surrey County Hospital, Guildford, UK ASiT Vice-President Introduction: Foot and ankle pain is common, with causes including osteoarthritis, tendonitis and fasciitis. Targeted injection with local Vascular Surgery Registrar, London anaesthetic and corticosteroid can be used for diagnostic and therapeutic purposes. This can be performed in theatre, or clinic with ultrasound guidance. Methods: Foot and ankle injections performed in theatre by a single Orthopaedic consultant from January-2007 to December-2010 were reviewed by log-book entries. Those referred for ultrasound-guided injection during this period were also recorded. These were performed by a Musculoskeletal consultant radiologist. Costs for these were calculated using clinical coding data. Results: Injections performed in theatre has reduced markedly, from 134-[2007], 118-[2008], 43-[2009] and 28-[2010]. Concurrently, Steve Hornby injections performed in the radiology department had risen from 10-[2008], 41-[2009], and 100-[2010] (p<0.001) ASiT Director of Education Cases performed in theatre cost the trust 1229, though receiving just 630 from the PCT for each; a loss of 599. Cases performed in radiology cost 206, savingGeneral Surgery projected savings of 58,164 in 2011. 393 per patient, with Registrar, South West Peninsula Discussion: Increasing numbers of injections in the radiology department, and a subsequent reduction in theatre cases has been demonstrated. Close co-operation between Orthopaedic Foot and Ankle surgeons and Musculoskeletal radiologists produces massive savings in theatre costs, time, and a more efficient patient pathway. 1202 With thanks to the local ASiT Welsh Regional Representatives: USING TOURNIQUET AND SURGICAL DRAIN IN TOTAL KNEE ARTHROPLASTY: DOES IT MAKE A DIFFERENCE? Miss Rhiannon Dharmarajan Devendra Chauhan, M Islaam, RHarries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Cumberland Infirmary, Carlisle, UK Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Aim of Study: To look for any difference in perioperative recovery and complications following use of pneumatic tourniquet and surgical drains in knee replacement surgery. Methodology: We retrospectively the wonderful ASiT Conference Admin team: info@asit.org JanuWith thanks to analysed 60 total knee arthroplasties performed by 3 different surgeons at our hospital during ary 2007 to June 2010. Patients were grouped for using tourniquet and/ drain
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Results: Surgical time: Use of tourniquets didn't improve it (123 - 133 minutes), Local Hospital pain score (1-5) at discharge: No significant difference. Blood transfusion (50%) was more if no tourniquet used. Only one proven case of superficial infection at 6 weeks which responded well to antibiotics. No deep infection was noted. The mean hospital stay in hospital was least (5.5 days) if tourniquet but no drain used. Post-operative deep vein thrombosis: No significant difference (5% in Group 1 and 3). Conclusion: Pain score at discharge was comparable in all groups Patients with tourniquet but no surgical drain had least hospital stay (mean 5.5 days) and least blood transfusion rate (5%). Decision to use pneumatic tourniquet & drain still lies with the operating surgeon. We recommend a randomised control study for further evidence. PAEDIATRIC SURGERY
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0010 RISK FACTORS ASSOCIATED WITH ADVANCED APPENDICITIS AND COMPLICATIONS AFTER CHILDHOOD APPENDECTOMY Obinna Obinwa1, Nicola Motterlini1, Michael Cassidy2, Tom Fahey1, John Flynn2 1 Royal College of Surgeons in Ireland, Dublin 2, Ireland 2 Portiuncula Hospital, Ballinasloe, Ireland Aim: To determine the risk factors associated with advanced appendicitis and complications after childhood appendectomy. Methods: A retrospective observational study was done in 435 children (< 15 y) who had surgery for a preoperative diagnosis of appendicitis during a 14-year period. Data included pre-operative symptoms and signs, time from onset of symptoms to surgery, presence of advanced appendicitis (gangrene, perforation, appendiceal abscess or mass, peritonitis), and postoperative complications within 1 year after surgery. Risk factors were analysed using logistic regression. Results: The mean time from onset of symptoms to beginning of surgery was 33 22 hours. Wound infection occured in 9/435 (2%) patients. Overall postoperative complication rate was 6%. Advanced appendicitis was significantly associated with treatment delays; age of the patient; preoperative rebound tenderness, fever, tachycardia, tachypnea, leukocytosis, and Alvarado score 5. Postoperative complications in all patients were significantly associated with preoperative fever, tachypnea, and advanced appendicitis. Conclusions: Appendicitis if untreated may progress to advanced appendicitis. Early diagnosis and urgent appendectomy are important in acute appendicitis, especially in patients with preoperative fever and tachypnea. Although other studies with similar conclusions have been done in urban settings, this study provides data supporting the care of acute appendicitis in a rural hospital setting. 0278 AUDIT OF PAEDIATRIC APPENDICECTOMIES AT A LARGE DISTRICT GENERAL HOSPITAL: 2006 - 2010 Tarek Elsayed, Mike Foster Royal Glamorgan Hospital, Llantrisant, South Glamorgan, UK Aims: To discover the number of negative paediatric appendicectomies at a large DGH between 2006-2010, compare intra-operative versus histological findings, analyse time to theatre', antibiotic prescribing, Alvarado scores, and postoperative stay. Method: Clinical, operative, and histological records of 107 children who underwent appendicectomy were analysed. A dataset was created and analysed using ExcelTM and SPSSTM. Correlation and linear regression analyses were carried out. Alvarado Scores were calculated. Results: 71 males(66%); 36 females(34%). Age range 3-16 years, (mean=11). All patients had clinical diagnoses of acute appendicitis. At operation 78%(n=83) were classified as acute appendicitis, whilst histological analysis confirmed only 61%(n=65), ie negative appendectomy rate of 39%. Conversely, 4% of appendices deemed noninflamed' at operation were later classified inflamed at hi stology. More males had positive histology (65% vs. 31%); the opposite was true for negative histology (56% vs. 44%). 18% of cases received no antibiotics. Alvarado Score correlated strongly with positive histological diagnoses, but not with complication or readmission rate. Conclusion: A large proportion of children underwent surgery which revealed, histologically, a non-inflamed appendix. Discrepancies remain between intra-operative and histological findings, with implications for those arguing for increased use of laparoscopy & proceed' techniques. Poor adherence to hospital antibiotic protocol was noted. 0389 WHEN DOES ULTRASOUND INFLUENCE MANAGEMENT IN SUSPECTED CASES OF PAEDIATRIC APPENDICITIS? A RETROSPECTIVE DUAL CENTRED STUDY BETWEEN CHRISTCHURCH PUBLIC HOSPITAL IN NEW ZEALAND AND ROYAL ABERDEEN CHILDREN'S HOSPITAL IN ABERDEEN Duncan SG Scrimgeour1, Christopher Driver1, Sebastian King1, Spencer Beasley1 1 Royal Aberdeen Children's Hospital, Aberdeen, UK, 2 Christchurch Public Hospital, Christchurch, New Zealand Ultrasound(US) is a safe imaging modality used for assessing patients with abdominal pain but its use in the management of acute appendicitis is contentious. Aim: To review the role of US in the management of suspected appendicitis in two similarly matched hospitals. Methods: Data from acute admissions, radiology and theatre were cross-referenced to review all children <16 years of age that underwent an appendicectomy an US for query appendicitis in 2009. Results: The number of US scans performed were similar between the two centres (108/442 NZ and 30/157 Aberdeen). Girls were more likely to be scanned than boys (Chi2=0.038). The visualisation rate(VR) of the appendix at US was 32% in NZ and 17% in Aberdeen with identical Positive Predictive Value(67%), Negative Predictive Value(100%) and positive appendicectomy rate(73%) in both institutions. Combined, 28%(13/46) had an appendicectomy when the appendix was not seen at US and no other pathology was detected, of which 54% were confirmed cases of appendicitis. Conclusion: We should be encouraging radiologists to look for the appendix. VR is much poorer than literature suggests. If USnegative, have a high threshold for appendicectomy. If US-positive this aids laboratory results and clinical suspicion. What is the role of a diagnostic laparoscopy?
0613 CRYING OUT FOR A DRINK?: COMPLIANCE WITH NATIONAL PRE-OPERATIVE FASTING GUIDELINES IN CHILDREN edd, Bangor Stephani Bernard, Alexander Macdonald, Jianli Samantha Goh, Niyi Ade-Ajayi King's College Hospital, London, UK al of Wales, Cardiff Aim: Appropriate pre-operative fasting in children is crucial to minimise risk of aspiration. However, over zealous fasting may adversely affect recovery as well as increasing parent and child anxiety. Children admitted for elective surgery are often initially clerked on general paediatric wards by paediatric juniors. This may result in incorrect pre-operative fasting. We set out to audit practice against nam: info@asit.org tional guidelines.
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Method: A questionnaire survey was undertaken of surgeons, paediatricians and nursing staff involved in the care of children (birth to 16yrs) from 5 surgical sub-specialties (general, neurosurgery, OMFS, orthopaedic and transplant) on both general paediatric and subspecialty specific wards. Statistical analysis for variation with p < 0.05 accepted as significant. Results: 43 individuals were surveyed (19 doctors [8 surgical, 11 paediatric], 24 nurses). 35% had full awareness of fasting guidelines and there was no statistically significant difference between staff groups. Knowledge of specific fasting times for formula and breast milk was poor compared with those for solids and clear fluids (p=0.002). Conclusions: Current awareness of paediatric pre-operative fasting guidelines is poor particularly those regarding formula and breast Goldie Khera milk and thus pertaining to younger infants. This is concerning as this group is particularly susceptible to pre-operative distress when fasted incorrectly. ASiT President
Bariatric Fellow, North Tyneside 1113 HERNIOTOMY IN CHILDREN - LONG TERM FOLLOW UP Bhavani Sidhartha Mothe, Magdi Hanafy Leighton General Hospital, Crewe, Cheshire, UK Aims: Inguinal hernia repair is the most commonly performed surgical procedure in children. Recent data suggests this operation in children carries a very low complication and recurrence rates. This study was carried out to evaluate the long term recurrence rates. Methods: Retrospective study of patient notes from 2000 - 2009(below 16yrs). Data collected via telephone interview/questionaire Ed Fitzgerald from patient & parents as appropriate. Follow up time calculated by subtracting age at operation from current age ASiT to provide required data (14 months - 14 years). 33 out of Results: 71 of 85 patients were able Conference Organiser & Past-President 71 (46.4%) were below 5 yrs, further 27/71 (38%) were above 5 years of age. Median follow up was 7 years with a minimum follow up of at least 1 year. 3 patients (4.2%) General Surgery Registrar, London developed recurrence at 1, 3 & 4 years from their initial operation. 1 child (1.2%) developed hematoma and wound infection postoperatively. Conclusions: Hernia surgery in children is associated with very low complications and long term follow up study suggests most recurrences occur within 5 years of original operation. Our study suggests recurrence is more common in above 2 year old repairs. Although this is a small study it opens a debate whether this group needs long term follow up or not.
PLASTIC SURGERY
0037 BREAKING DOWN THE HEALTH CARE LANGUAGE BARRIER: EXPERIENCE OF A REGIONAL BURN UNIT Thet Su Win, Mark Sheldon Lloyd, Mozaffor Hosain, Peter Dziewulski, Odhran Shelley St Andrew's Centre for Burns and Plastic Surgery, Chelmsford, UK Aims: The objectives of this study were to (1) assess the requirement and provision of translation service at a regional burn unit (2) to implement changes based on national guidelines to improve clinical effectiveness. Method: A prospective study was performed to assess translation requirements of 100 patients attending the burns outpatients departRobert Davies ment. A questionnaire was designed to collect data on burn distribution, mechanism, complications, native language of patient and ASiT Honorary adequacy. Changes were implemented according to the NICE guidelines, includperson accompanying patient, translation needs andTreasurer ing updating translation materials, training Surgery Registrar, West Midlands Vascular interpreters, educating referring hospitals, contacting twenty cultural centres in the region to provide burns first aid and safety in the home courses in the native community language. Follow-up study collected data on 85 additional patients following implementation of changes. Results: The number of patients whose native language is not English in the two cohorts was similar (32%vs30.5%). Translation needs decreased significantly (32%vs8%; p<0.0001) following education to the referring hospitals. Adequacy of translation improved (91.6%vs100%), and the use of ad hoc interpreters, including family members/relatives and staff, reduced. Conclusions: Targeted education can improve language service, which is an essential element of patient care in a multi-cultural sociJames Milburn ety such as Britain. 0063 General Surgery Registrar, Inverness THE TERTIARY MANAGEMENT OF PRETIBIAL LACERATIONS Marc-James Hallam, Steven Lo, Shona Smith, Tania Cubison Queen Victoria Hospital, East Grinstead, UK Aims: Pretibial lacerations remain one of the commonest yet most neglected conditions facing plastic surgey. Furthermore, these injuries afflict the most vulnerable groups of adults - the elderly and the infirm. This review aims to provide an evidence-based treatment plan, reduce unnecessary surgery and safeguard the at-risk patient. Methods: A MEDLINE searchJoseph Shalhoub was conducted using the terms (Lacerations OR Laceration) and keywords (pretibial, pre ADJ tibial) to identify high level evidence. ASiT Vice-President Results: We present an evidence-based approach of these injuries and propose a treatment algorithm that we have utilized to sucVascular Surgery Registrar, London cessfully manage 40% of pretibial lacerations conservatively. Conclusion: The evidence-based algorithm suggested for the management of these wounds is- I Linear laceration without skin loss: Manage conservatively; Level of Evidence IV. II Flap laceration viable: Steristrip and manage conservatively; level of Evidence I. III Flap laceration non-viable: Small non-viable flaps: Excise and manage conservatively; larger skin flaps: Excise and skin graft under local anaesthetic; level of Evidence II. IV Skin loss: < 1% TBSA: Manage conservatively; >1% TBSA: Skin graft under local anaesthetic; level of Evidence V. V Laceration with haematoma: Evacuate haematoma and skin graft; Level of Evidence V
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ASiT Director of Education 0100 THE QUALITY OF REPORTING IN RANDOMISED CONTROLLED TRIALSWest Peninsula General Surgery Registrar, South IN PLASTIC SURGERY Riaz Agha1, Christian Camm2, Emre Doganay3, Eric Ericson4, Muhammed Siddiqui5 1 Queen Victoria Hospital NHS Foundation Trust, East Grinstead, UK 2 University of Oxford, Oxford, UK 3 Southampton Medical School, Southampton, UK 4 University College London, London, UK With thanks to the local ASiT Welsh Regional Representatives: 5 St. Marks Hospital, London, UK Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Aims: Randomised controlled trials (RCTs) represent the gold standard in evaluating healthcare interventions. However, RCTs can yield biasedMr Andrewlack methodological rigour. The Consolidated Standards of Reporting Trials (CONSORT) statement for non results if they Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff pharmacological interventions aids reporting and consists of a 23-item checklist and flow diagram. Our aim was to assess the compliance of RCTs in Plastic Surgery with CONSORT. Methods: Medline was searchedthe wonderful to 30 June 2011 for the MESH heading "Surgery, Plastic" with limitations for With thanks to from 1 January 2009 ASiT Conference Admin team: info@asit.org English language, human studies and RCTs. Results were manually searched for relevant RCTs involving surgical techniques. The Laura Andrews Kristina Gloufchev Harriet Innes
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papers were scored against the CONSORT checklist. Secondary scoring was then performed and discrepancies resolved by consensus. Results: 57 papers involving 3,878 patients met the inclusion criteria from a manual search of 254 papers retrieved. The mean CONSORT score was 11.5 out of 23 (50%, range 5.3-21.0). Compliance was poorest with items for intervention/comparator details (7%), randomisation implementation (11%) and blinding (26%). There was no correlation between journal 2010 impact factor and CONSORT score (R=0.25). Only 61% declared conflicts of interest and 75% had ethical permission. Conclusions: The reporting quality of Plastic Surgery RCTs is poor and significant work is now needed to address this issue.
0158 CHANGES OF OXYGENATION, BLOOD FLOW AND HAEMOGLOBIN SATURATION AGAINST GRAVITY Geraldine Darmanin, Matthew Jaggard, Jagdeep Nanchahal, Abhilash Jain Charing Cross Hospital, London, UK Introduction: It is common practice to elevate the head and limbs postoperatively to reduce oedema. However, elevation may be counterproductive as it reduces the mean perfusion pressure. There are no clear data on the optimal perioperative position of the limbs. Methodology: The optimal position of limbs was investigated in 25 healthy subjects using a non-invasive micro-lightguide spectrophotometry system '02C', which indirectly measures perfusion through relative haemoglobin concentration, blood flow and oxygen saturation. Results: We found a reduction in blood flow of 37% (p=0.0001) on arm elevation as compared to heart level and an increase in blood flow of at least 35% (p=0.01) on forearm elevation of 45 degrees. Lower limb blood flow decreased by 30% (p=0.007) with elevation and by 70% on dependency (p=0.0001). Conclusions: In healthy volunteers, the position for optimal perfusion of the upper limb is with the arm placed at heart level and forearm at 45 degrees. For lower limbs the optimal position is at heart level. We are currently collecting data in patients undergoing surgery. 0188 RADIATION INDUCED SARCOMAS - THE NOTTINGHAM EXPERIENCE Isabel Teo, Tom McCulloch, Anna Raurell, Graeme Perks, Robert Ashford Nottingham City Hospital, Nottingham, UK Aims: To evaluate the incidence, patient demographics, primary tumour characteristics and treatment modalities of patients with radiation induced sarcoma (RIS) presenting to the East Midlands Sarcoma Service at Nottingham City Hospital. Methods: All consecutive patients with histologically proven RIS were entered into our database. Case notes were retrospectively analysed to identify patient demographics, oncological features and treatment outcome. Results: From 1998 to 2011, 24 patients were identified to have RIS. 17 were female, 7 male. The mean age at time of diagnosis is 67 years (range 40-85). The average latency period is 12.8 years (range 1-50). The 2 most common primary oncological diagnosis were breast carcinoma 11 (11, 45.8%) and endometrial carcinoma (3, 12.5%). The sarcoma subtypes were 9 angiosarcomas (37.5%), 7 pleomorphic sarcomas (29.1%), 3 leiomyosarcomas (12.5%), 2 myofibroblastic sarcomas (8.4%), 1 MPNST (4.2%) and 1 myxoid liposarcoma (4.2%). At the time of this study, 7 patients were deceased, 3 undergoing active treatment, 12 under surveillance, 1 palliative and 1 discharged from follow-up. Conclusions: RIS are rare and we present our 13 year experience in the management of these tumours. We plan to continue to monitor the outcome in these patients. 0189 Chemistry experiments with elemental metals - fuel for the minds, formula for disaster? Isabel Teo, Krisna Rao, Wee Lam, Robert Caulfield Sheffield Teaching Hospitals NHS Trust, Sheffield, UK Introduction: Irrigation of water is contraindicated in burns involving elemental metals as this causes an exothermic reaction. This project was taken on following a 15-year-old who came into contact with potassium at school. His injury was incorrectly managed by the teacher resulting in deepening of the burn. Aims: To identify the current practice regarding the use of elemental metals in science lessons, safety precautions and knowledge within the teaching profession. Methods : We identified a random cohort of ten schools within the catchment area of our regional burns unit, contacted the science head teacher and asked a series of questions pertaining to elemental metals. Results: All 10 schools kept these elemental metals in their labs. Only 10% were aware of the correct first aid treatment. 80% would treat a burn with elemental metals with water. None had specific first aid safety precautions or protocols in the event of such injuries. Conclusion: There is an urgent need to spread awareness of the correct management of elemental metal burns. Our unit has begun creating advice sheets and protocols for schools and commenced the process of improving the understanding of science teachers and students.
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0248 BREAST RECONSTRUCTION WITH DEEP INFERIOR EPIGASTRIC PERFORATOR FLAPS: EVOLUTION OF TECHNIQUE AND PROCEDURAL REFINEMENTS FROM AN ONGOING AUDIT OF OUTCOMES Zoe Barber, Jonathan Cubitt, Aadil Khan, Michael Tyler Stoke Mandeville Hospital, Aylesbury, UK Introduction: Approximately 45,000 women are diagnosed with breast cancer in the UK each year. More and more women are seeking reconstruction following mastectomy. This study aimed to evaluate DIEP flap reconstructions performed in our unit and, through analysis of complications, detail the evolution of our current care pathway. Materials and Methods: Retrospective analysis was performed of all DIEP flap reconstructions performed by the senior author between July 2003 and Dec 2010. Results: One hundred and fifty-nine flaps were performed on 141 patients (including 36 bilateral flaps). Average age was 49 years (28 70 years). 10% of flaps were risk-reducing for BRCA1/2. Twenty-six percent of patients suffered complications post operatively: tives: systemic complications (PE 2%); and flap-specific complications (partial flap necrosis 9%, reanastomosis 3% and fat necrosis 9%). edd, Bangor Seventy-four percent underwent further elective operations including nipple reconstruction (72%), contralateral breast reduction (36%) and scar al of Wales, Cardiff revision (21%). There were no total flap losses. Discussion: DIEP flaps are a safe, reliable option for breast reconstruction. There is a significant leaning curve, with complications, operative time and ischaemic time reducing through the series and post-operative haemoglobin increasing. We outlined evolution of our current m: info@asit.org care pathway including pre-operative imaging, peri-operative DVT prophylaxis and analgesia.
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Ed Fitzgerald 0304 ASiT Conference Organiser & Past-President INITIATING A TRANSFUSION PROTOCOL FOR FREE DIEP FLAP BREAST RECONSTRUCTION IN NORTH BRISTOL NHS TRUST General Surgery Registrar, London James Smith, James Warbrick-Smith, George Filobbos, Sherif Wilson North Bristol NHS Trust, Bristol, UK Aims. The authors aimed to identify the transfusion rate for patients having free deep inferior epigastric perforator (DIEP) flap breast reconstruction and highlight the role of pre-operative blood transfusion cross matching. Methods. A retrospective note review was performed between March 2007 and November 2011 of all patients undergoing free DIEP flap breast reconstruction post mastectomy. Patient demographics, pre-operative and post-operative haemoglobin and haemocrit, Jonny Wild operative time, blood transfusion and post-operative complications were compared. Results. A total of 174 free DIEP breast reconstructions were performed on 145 patients;Co-ordinator 29 bilateral procedures. ASiT Honorary Secretary & Sponsorship 116 unilateral and 113 patients had delayed breast reconstruction whilst 32 patients underwent mastectomy and immediate reconstruction. The overall General Surgery Registrar, Sheffield transfusion rate was 26.9%, 24 patients were transfused despite having a post-operative haemoglobin of more than 7g/dl. 44 patients had a valid group and hold and 20 of these patients had a cross-matched sample pre-operatively but did not receive a blood transfusion. Conclusions. The authors concluded that unilateral and bilateral free DIEP operations should not be cross-matched prior to surgery. This has fiscal implications for the trust and a clear protocol for staff to follow. This process might be applied to other general and plastic surgical operations.
0381 ASiT SURGERY BCC EXCISION AUDIT IN PLASTIC Honorary Treasurer Luke Lintin Vascular Surgery Registrar, West Midlands Derriford Hospital, Plymouth, UK Aims: To re-audit the incomplete excision rate of Basal Cell Carcinomas (BCCs) by a single plastic surgery department to monitor performance. Introduction: Excision margins were analysed from 115 consecutively excised BCCs between 09/09/2011 and 31/10/2011. Analysis: Of the 115 BCCs excised 6 (5.2%) were incompletely excised (where the lesions were involved at the the surgical margins). All incompletely excised lesions involved the circumferential margin and none involved the deep margin. James Milburn Discussion: Guidelines form The British Association of Dermatologists published in 2008 suggest that a 4-5mm margin will completely excise approximately 95% of ASiT An incomplete excision rate of 5.2% is comparable to studies from other British plastic surgical BCCs. Vice-President units. Data collected from a similar audit in September 2010 showed a 7.4% incomplete excision rate for BCCs in the same plastic General department'sRegistrar, Inverness consistent with no statistical difference between the Surgery performance has remained surgery department, suggesting that the two sets of data (p=0.5722). Conclusion: In order to minimise incomplete excision rates surgeons should assure that they are excising lesions with standardised 45mm circumferential margins regardless of anatomical position, wherever possible. This may require an increase in the number of local flaps or grafts performed in order to reconstruct defects. 0409 Joseph Shalhoub AN AUDIT OF ANTIBIOTIC PROPHYLAXIS IN PLASTIC SURGERY: A SINGLE-CENTRE EXPERIENCE ASiT Vice-President George Lye, Amar Ghattaura Vascular Surgery Registrar, London The Welsh Centre for Burns & Plastic Surgery, Morriston Hospital, Swansea, UK Aim: Incorrect antibiotic usage is financially expensive and may harm individuals. The SIGN Guidelines 104 stipulate best-practice in antibiotic prescriptions to prevent surgical-site infections. This audit aimed to establish the appropriateness of antibiotic prescriptions in the department. Method: A retrospective-study of acute (n=58) and elective (n=20) admissions to the plastic surgery department over a period of 1 week was performed using the SIGN 104 guidelines for antibiotic usage in surgical wounds. Steve Hornby Results: Antibiotics were prescribed in trauma (79%) and elective (55%) cases. Co-Amoxiclav was prescribed in 60% of trauma and ASiT Director of Education 45% of elective cases. 38% of trauma prescriptions and 20% of elective cases were inappropriate. Co-Amoxiclav was inappropriately prescribed in 51% of trauma and 33% elective cases. In clean-contaminated trauma cases a 2:1 inappropriate: appropriate prescripGeneral Surgery Registrar, South West Peninsula tion ratio existed. Inappropriate prescriptions for trauma cases included 19 post-op antibiotic courses for clean-contaminated wounds; 2 IV antibiotic courses for clean-contaminated wounds; and 1 contaminated case with short-course antibiotics. Inappropriate prescriptions for elective cases included 3 post-op courses of antibiotics for clean wounds; and 1 post-op course for a clean-contaminated wound. Conclusion: There is a high to the local ASiT Welsh Regional Representatives: established to prevent With thanks inappropriate antibiotic prescription rate in plastic surgery. Guidelines should be this in the future. 0466 Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff PREDICTING MULTI-FOCALITY IN NECROTISING FASCIITIS: A PARADIGM CHANGER OR PARALYSIS BY ANALYSIS? Ussamah El-khani1, Jean Nehme1, Ammar Darwish2, Nicholas Bennett1, Simon Heppell1, Godwin Scerri1 1 Queen Alexandra Hospital, Wessex Deanery, UK With thanks to the wonderful ASiT Conference Admin team: info@asit.org 2 Manchester Royal Infirmary, Manchester, UK
0281 ANTIBIOTIC PROPHYLAXIS IN ELECTIVE PLASTIC SURGERY Gemma Pilgrim, Seemab Ashraff, Jian Farhadi Guys and St Thomas' NHS Foundation Trust, London, UK Aim: To investigate our use of prophylactic antibiotics in elective minor plastic surgery and if they affected wound infection rates. Method: A postal questionnaire was sent to every patient who underwent a minor plastic surgical procedure at Guys Hospital between April and August 2010. Data was collected on patient-reported wound appearance and post-discharge antibiotic use to identify the Goldie Khera infection rate. The medical notes of the respondents were then reviewed to identify co-morbidities, operative data and antibiotic administration. ASiT President Results: 161 patients were contacted and we received 96 responses (response rate 59.6%). Data collection was completed for 89 Bariatric Fellow, North Tyneside cases. The overall infection rate was 24%. 46% patients (41/89) had no prophylactic antibiotics; 27% (11/41) developed a wound infection. 42% patients (37/89) had a full course of prophylactic antibiotics; 22% (8/37) developed a wound infection. This difference was not statistically significant. Route of administration: Patients who received intravenous antibiotics had an infection rate of 12.5% (1/8), compared to 30% (3/10) for oral antibiotics and 16% (3/19) for topical chloramphenicol ointment. Conclusion: The use of prophylactic antibiotics in elective plastic surgery does not significantly reduce postoperative wound infection rates. However, topical chloramphenicol ointment use may be beneficial and should be investigated further.
Robert Davies
Laura Andrews
Kristina Gloufchev
Harriet Innes
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Introduction: Multifocal Necrotising Fasciitis is defined as more than one non-contiguous area of necrosis. Current management guidelines of necrotising fasciitis pertain to single-focus disease, with no recognition of the implications of multi-focality. Aim: To conduct the first ever systematic review on multi-focal necrotising fasciitis. Materials and Methods: A PRISMA-guided systematic review of MEDLINE, OLD MEDLINE and Cochrane Collaboration was performed from 1966 to March 2011 using sixteen search terms. Of the papers that demonstrated multi-focality, the following data was extracted: patient demographics, inciting injury, presentation time-line, microbial agents, sites affected, objective assessment scores, treatment and outcome. Results: 33 individual cases of Multifocal Necrotising Fasciitis were included in the quantitative analysis. 52% of cases were Type II Necrotising Fasciitis. 42% had identifiable inciting injuries. 21% developed multifocal lesions non-synchronously, of which 86% were Type II. 94% of cases had incomplete objective assessment scores. One case identified inflammatory imaging findings prior to clinically detectable necrosis. Conclusions: Multifocality in Necrotising Fasciitis is likely to be associated with Type II disease. We postulate that validated objective tools will shape management pathways and identify high risk groups. We recommend adoption of regional Multifocal Necrotising Fasciitis registers and consideration of early pre-emptive imaging in select cases.
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0484 REDUCING ABDOMINAL COMPLICATIONS FROM BREAST RECONSTRUCTION USING DIEP FLAPS Rachel Tillett, Sherif Wilson Plastic & Reconstructive Surgery Department, Frenchay Hospital, Bristol, UK Introduction: Abdominal wound complications can cause significant post operative morbidity. A retrospective review of 61 patients, undergoing DIEP breast reconstruction over a 26 month period, by a single surgeon, showed delayed wound healing requiring conservative treatment in 16 (26.2%) and operative treatment in 4 (6.6%) patients. 3 patients (4.9%) developed a seroma and 4 patients (6.6%) developed an abdominal bulge (6.6%). Junior team members had been performing abdominal wounds closure. These results were compared to a large meta-analysis of 1997 patients undergoing abdominal flap breast reconstruction (Salgarello et al, 2011). Methods: A new regime of abdominal closure involving 3 layers of monocryl, with either the senior author supervising a senior trainee or performing the procedure himself, was instituted. Data was collected retrospectively on subsequent consecutive patients undergoing DIEP reconstruction. Results: In the subsequent 21 patients there were no delays in wound healing and no seromas. This reduction in complications was statistically significant (p=0.001, Fisher's exact test). Conclusion: This completed audit loop has shown a reduction in abdominal wound complications after a change in practice of wound closure. Rates of delayed healing prior to the change in practice were comparable, and are currently better than, those in the published literature. 0517 OBJECTIVE ASSESSMENT OF INITIAL EYE EXAMINATION IN PATIENTS PRESENTING WITH MID-FACE INJURIES Kumaran Shanmugarajah1, Shiraz Sabah1, Ted Welman1, Suzanne Westley2, Ruth Skinner2, Nadine Haram1, Nicholas Segaren1, Jonathan Collier1 1 Chelsea and Westminster Hospital, London, UK 2 Barts and the London, London, UK Aims: One fifth of patients with severe facial trauma suffer ophthalmic injury. We aimed to objectively evaluate the quality of the initial visual examinations in patients with mid-face injuries and to determine whether poor early examination was associated with suboptimal management. Method: Patients (n197) were retrospectively and prospectively recruited from two tertiary craniofacial centres. Initial visual examinations were scored objectively against published gold-standards. Results: 162 patients met inclusion criteria. Complete visual examination was performed in one patient (0.6%). Soft tissue injury was the most frequently assessed parameter (n123, 74.5%). Pupil position was the most poorly assessed parameter (n10, 6.1%). Visual acuity was assessed in 32 patients (19.4%). Visual complications were included peripheral field loss, reduced acuity, residual ptosis, diplopia and epiphoria. Patients who were seen by the ophthalmologist within one day had significantly (p<0.05) more comprehensive initial eye examination. Conclusion: Early visual examination in patients with mid-face injuries was poorly performed. Importantly, visual acuity is performed in a minority of cases. More comprehensive initial eye examination was associated with prompt ophthalmology assessment. We propose the development of a standardised proforma for eye examination in patients with mid-face injury to ensure expeditious management of ocular injury. 0523 PAIN ASSOCIATED WITH INTRA LESIONAL STEROID INJECTION FOR KELOID/HYPERTROPHIC SCARS Farid Saedi, Mohammed Amin Saleh, Ahmed Bhatti, Ali Juma Countess of Chester Hospital, Chester, UK Introduction: Keloid and hypertrophic scars are unfortunate consequences of any surgery that involves skin breaches. Various methods have been used for treating these scars. Intralesional steroid injection is one of the standard treatments. It involves multiple injections and commonly it is associated with pain. Aims: To assess the severity of pain during steroid injection, considering multiple variables. Material and Methods: A six months prospective trial was designed. Simple descriptive intensity scale to analyze severity of pain was used. Variables were age, gender, size, site, volume of injection and use of intra lesional local anesthetic. Results: 20 patients were included, male to female ratio 1:2, average age 25.6 yrs, 75% in head and neck region, average volume injected 0.46 mls to an average surface area of 2.2 cm 2. During injection; 85% reported mild to moderate pain, 5% sever and 10% no pain. 45% of patients had local anesthetics added to the injection. Conclusion: Intra-lesional steroid injection is associated with pain however this can be minimized by using mixture of local anaesthetic and steroid. The size and location of scars (head and neck regions) as well as number of injections given, may have direct effect on the pain experienced. 0559
edd, Bangor TRENDS IN PLASTIC SURGICAL TRAINEE PRESENTATIONS - THE FUTURE OF OUR SPECIALTY IS IN OUR HANDS. Fern Coxon al of Wales, Cardiff 1, Jacqui Callear2, Helen Douglas2, Daniel Saleh2 1
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tives:
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Northern General Hospital, Sheffield, UK Pinderfields Hospital, Wakefield, UK Introduction: info@asit.org There are perceived future adversities for plastic surgeons such as loss of work to specialities previously providing secondary referrals.
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We surveyed presentation at the largest pan-surgical trainees meeting worldwide to establish whether plastic surgery trainees (PTs) are disseminating their academic work amongst our allied surgical peers. Method: Four recent Association of Surgeons in Training (ASiT) meeting abstracts were analysed. Total number of trainees and number of abstracts published by each speciality were compared. Number of trainee presentations at corresponding British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) meetings were also surveyed. Results: Plastics ranked 6/9 in number of abstracts/trainee presented at ASiT. Over the four years surveyed PTs consistently increased academic output at ASiT from 0.3%-6.1% of all abstracts. This increase lags behind other specialities. General trainees proGoldie Khera duce significantly more abstracts (p = 0.005). The proportion of PTs attending and presenting at BAPRAS has consistently increased over the same survey period. ASiT President Conclusion: This survey indicates PTs are overall behind allied specialties on this generic platform sampled. Dissemination of work Bariatric Fellow, North Tyneside parallel to the increases seen at BAPRAS, amongst allied colleagues, is paramount to perpetuate the exposure of "what we do" to those we may rely upon for future collaboration.
0584 REVERSE ABDOMINOPLASTY- A PRACTICAL OPTION FOR ONCOLOGICAL TRUNK RECONSTRUCTION Nicholas Pantelides1, Debabrata Mondal1, Gordon Wishart2, Charles Malata1 1 Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Ed Fitzgerald Cambridge, UK 2 ASiT Conference Organiser & Past-President Faculty of Health and Social Care, Anglia Ruskin University, Cambridge, UK Aim: Following radical oncological resection, full-thickness upper central trunk defects present a significant challenge. Common opGeneral Surgery Registrar, London tions include pedicled flaps, such as pectoralis major, rectus abdominis and latissimus dorsi. In complex cases, free tissue transfer may be required, although given the prolonged operative time and possibility of total flap failure, most surgeons prefer to use other reconstructive techniques where possible. The reverse abdominoplasty is a common procedure in aesthetic surgery, used predominantly for upper trunk contouring. However, there are only two reports in the English-language literature of its use in oncological reconstruction. We therefore reviewed our experience with this technique. Jonny Wild Method: Four consecutive cases (2004-2010) were reviewed with respect to indication, operative technique and complications. Results: There were no cases of complete flap loss.Secretary & Sponsorship Co-ordinator whilst another develop ASiT Honorary One patient underwent revision for marginal flap necrosis, local recurrence requiring re-excision and flap advancement. Conclusions: Where pedicled General Surgery Registrar, adjacent abdominal tissue can be recruited into chest wall defects, flaps are unavailable or insufficient, Sheffield avoiding microsurgical free tissue transfer. The reverse abdominoplasty can be used in conjunction with other flaps or grafts, and affords an acceptable cosmetic appearance. In the event of local recurrence, the flap can be re-advanced, whilst free tissue transfer remains available. 0669 DESMOPLASTIC MALIGNANT MELANOMA: A SYSTEMATIC REVIEW Robert Davies Farid Saedi, Rowan Pritchard Jones, Hassan Shaaban ASiT Honorary Treasurer Whiston Hospital, Liverpool, UK Background: Desmoplastic melanoma (DM) is a rare melanoma variant characterised by deeply infiltrating spindle cells with abundant Vascular Surgery Registrar, West Midlands fibrous matrix. Diagnosis is difficult due to similarity to sclerosing melanocytic nevi, and non-melanocytic skin lesions such as scars, fibromas or cysts. Objectives: To review current literatures and evaluate clinical and morphological characteristics of this neoplasm. Methods: We conducted a search of Medline, OVID and EMBASE using headings Cutaneous Melanoma' and Desmoplastic'. Results: From a total of 388 identified articles (the vast majority of which were case reports), 10 were included. Patient numbers were 11-280. DM is twice as common in males (63% of lesions) and most commonly occurs in head and neck region (53%). Diagnosis of DM can be difficult due to theJamesof pigmentation, usually presents with advanced Breslow thickness (mean 2-6.5mm), and yet absence Milburn metastasises less than other melanoma variants (7.4-53%). Sentinel Lymph Node Biopsy is not commonly positive (5% from a series ASiT Vice-President of 240 patients). General Surgery Registrar, Inverness Conclusions: Effective diagnosis and management of DM demands clinicians be aware of this unusual clinical entity. It can be locally, but not systemically aggressive, as evidenced by low SLNB positivity and surgical excision remains the treatment of choice for DM. 0673 THE USE OF ABSORBABLE VERSUS NON-ABSORBABLE SUTURES IN HAND SURGERY: A SYSTEMATIC REVIEW OF THE LITERATURE Jean Nehme1, Foiz Ahmed1, Ussamah El Khani1, Emre Doghani1, Nicholas Bennett1, Ankur Pandya1 Joseph Shalhoub 1 Queen Alexandra Hospital, Portsmouth, UK ASiT Vice-President 2 Imperial College, London, UK Introduction: In this study we Vascular Surgery Registrar,compare primary clinical outcomes associated with use of absorbsystematically review the literature to London able and non-absorbable sutures in elective-hand-surgery. Methods: This systematic review was conducted in accordance to the PRISMA statement. Multiple electronic search engines were used including PubMed, Medline, Ovid, Embase and Google Scholar. Results: A total of seven comparative studies were included for analysis, all of which were randomized control trials (RCT). The total cohort of patients included from the seven trials was 414. Some patients had bilateral procedures and therefore the total cohort of Steve Hornby hands was 420. The outcome measures included post-operative pain, wound-infection and aesthetics. None of the studies showed a ASiT Director of Education statistical difference in wound-infection rates. Pain was assessed in three of the seven papers, none of which showed a statistically significant difference in a visual-analogue score of pain. Similarly, South West Peninsulastatistically significant differences in General Surgery Registrar, none of the papers reported wound-aesthetics. Conclusion: This review of the literature suggests that there is no significant difference in wound-infection rates, post-operative pain, or cosmesis between absorbable and non-absorbable sutures in hand-surgery. We suggest that the inherent clinic-time savings and reduction in anxiety and pain (associated with removal of non-absorbable sutures) favours the use of absorbable sutures in the elective-hand-surgery. Further RCTs the local ASiT Welsh Regional Representatives: With thanks to are required.
Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor 0687 READMISSIONAndrew A SINGLE PLASTIC SURGERY UNITFellow, University Hospital of Wales, Cardiff Mr AUDIT IN Beamish, Clinical Research IN LIGHT OF RECENT DEPARTMENT OF HEALTH POLICY ON NON-PAYMENT FOR EMERGENCY READMISSIONS John Martin, Adnan Tahir, Haroon Siddiqui Department of Plastic Surgery, Jame's wonderful Hospital, Conference Admin team: info@asit.org With thanks to the Cook University ASiT Middlesbrough, UK Introduction: In April 2011 a Department of Health policy came into effect stating that no tariffs would be paid for readmission of pa Laura Andrews Kristina Gloufchev Harriet Innes
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tients to hospital within 30 days of discharge. The purpose of this audit was to determine the reasons behind readmissions in our unit. Methods: We evaluated readmissions over a one-year period from October 2009 to October 2010. A total of 140 patients were identified. 50 patients were randomly selected to conduct this audit. We also compared the readmission rate in plastic surgery to other specialties in our hospital. Results: Readmission to plastic surgery made up one per cent of the total readmissions in our hospital over a one-year period. Of the patients readmitted in plastic surgery, 34/50 (68 per cent) were emergencies and 16/50 (32 per cent) were elective. 18 per cent of readmissions were planned as part of ongoing treatment, for example delayed grafting of a wound bed, but were wrongly coded as readmissions. 8 per cent of readmissions were unrelated to the original admission. Conclusions: This audit has shown that this rule is difficult to apply in surgical practice and coding entries for planned or unplanned admissions are complex and inaccurate in the NHS. 0744 RE-RUPTURE RATE FOLLOWING PRIMARY FLEXOR TENDON REPAIR OF THE HAND WITH POTENTIAL CONTRIBUTING RISK FACTORS: CASE SERIES Mazin Ibrahim, Mai Rostom, Mohamed Asim Khan, Alastair James Platt Castle hill hospital, Cottingham, UK Aim: Flexor tendon injuries of the hand are common with over 3,105 per annum in the UK. This study was aimed to investigate rerupture rate following primary flexor tendon repair at our institution and to identify potential risk factors. Method: 51 patients with 101 flexor tendons' injuries who underwent primary repair over one year period were reviewed. Data was collected on age, gender, occupation, co morbidities, injured fingers, hand dominance, smoking status, time to surgery, surgeon grade, type of repair and suture, and antibiotic use. Causes of re-rupture were examined. Results: Re-rupture rate was 10.9%. Mean age was 35.8. Primary tendon repairs with re-rupture were compared to those without rerupture. Univariate and multivariate analysis was undertaken to identify significant risk factors. Significantly higher rate was noted when the repair was performed on the dominant hand (p-value = 0.009), in zone 2 (0.001), and when a delay more than 72 hours occurred (0.01). Multivariate regression analysis identified repair in zone 2 injuries to be the most significant predictor of re-rupture. Conclusions: Re-rupture rate of 10.9% was associated with delay in surgery, repair on dominant hand, and zone 2 repairs. Careful consideration for these factors is crucial to reduce this rate.
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0803 PLASTIC SURGERY "TOURISM" COMPLICATIONS PRESENTING TO AN NHS HOSPITAL - A ONE YEAR RETROSPECTIVE STUDY Nicholas Segaren1, Kumaran Shanmugarajah1, Sheraz Markar4, Neil Segaren3, Onur Gilleard2, Kalpesh Vaghela1 1 Chelsea and Westminster Hospital, London, UK 2 Queen Victoria Hospital, East Grinstead, UK 3 Royal Derby Hospital, Derby, UK, 4Kingston General Hospital, London, UK Aim: The advent of cosmetic surgery "tourism" packages has led to an increase in the number of people from the UK flying to foreign destinations to undertake procedures by plastic surgeons that may not have any affiliation to a regulatory body. Any complications from these operations are dealt with in NHS funded units back in the United Kingdom. We wanted to investigate the potential impact that these presentations had on our department. Method: We conducted a retrospective study examining all presentations to Chelsea and Westminster Hospital for complications following plastic surgery procedures undertaken abroad. The data was collected from January 2011 to the end of December 2011. Results: There were 21 patients in total, nineteen females and two males, the mean age was 38.6. Fourteen patients presented with complications from craniofacial procedures, and six following breast augmentation procedures. One patient was admitted with an infected buttock implant. The average in-patient stay was 2.6 days. Conclusions: The popularity of cosmetic surgery abroad is increasing and therefore the complication rates will rise in the future. The recent scandal regarding the PIP breast implants has further highlighted the potential dangers of cut price cosmetic surgery abroad. 0825 AN AUDIT EXPLORING THE ADEQUACY OF CONSENT FORMS IN PATIENTS RECEIVING EMERGENCY BURNS TREATMENT Samim Ghorbanian1, Nicki Bystrzonowski2, Pundrique Sharma2 1 Lister Hospital, Stevenage, UK 2 Broomfield Hospital, Chelmsford, UK Aim: There is disparity between Consent Forms in patients receiving Emergency Burns Treatment. Our burns unit consents the majority of patients admitted to the Burns ITU for FCBT (Full Course of Burns Treatment). We aimed to assess the units consenting practice based upon two standards; those set out by the Department of Health and those taken from model Consent Forms produced by 4 Consultant Plastic Surgeons working within the Burns Department. Method: 54 patients attended the Burns ITU at Broomfield Hospital with a burns related injury between January-August 2010. These patients were retrospectively assessed. Results: 90 % of patients admitted to the Burns ITU were consented for FBCT. There was little consistency between the Intended Benefits and Complications of FCBT between patient Consent Forms and an even greater disparity when patient forms were compared to consultant forms. Conclusions: Junior surgeons often carry out consent. Incorrect documentation on consent forms may invalidate consent and place both the consultant surgeon responsible for care and the trainee at risk of medico-legal consequences. This audit demonstrates the need for vigilance and discussion with consultants as to what information should be included on consent forms.
0951 THE IMPACT OF A MULTIDISCIPLINARY HAND CENTRE ON THE HAND TRAUMA SERVICE IN A REGIONAL PLASTIC SURGERY UNIT K S Sharma, P Witt, E Karagergou, R Caulfield, R Harper Northern General Hospital, Sheffield, UK Introduction: The Sheffield hand centre was established with the aim of offering a streamlined hand trauma service employing a multives: tidisciplinary approach. The aim of this evaluation is to assess this and after the establishment of the hand centre and to evaluate edd, Bangor its impact on the quality of service provision. Method: al of Wales, Cardiff Data was collected prospectively in October 2009 and September 2011 on a random sample of 93 and 96 patients respectively. The following criteria were evaluated and compared: waiting times from referral to initial assessment, use of general emergency theatre versus dedicated plastic surgery trauma lists, grade of the most senior surgeon present in theatre and type of anaesthetic intervention. m: info@asit.org Results: Time from referral to assessment was on average 2.6 hours in 2009 and 2.27 hours in 2011. Emergency theatre usage de-
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creased by 43% in 2009 (53%) compared to 2011 ( 10%). There was a 50% increase in consultant presence in theatre. A 14% increase in regional anaesthesia in 2009 versus 2011 was noted. Conclusion: The establishment of a hand centre has resulted in lesser out of hours operating, a more consultant led service compliant with NCEPOD guidelines and increased training opportunities for juniors under direct consultant supervision.
0971 MICRO-FENESTRATED SPLIT-THICKNESS SKIN GRAFT FOR PENILE RECONSTRUCTION Goldie Khera James Wokes, Damian Green, Ahmed Ali-Khan Royal Victoria Infirmary, Newcastle, UK ASiT President Aim: Surgical management of penile cancer involves lesion excision and neo-glans reconstruction. Unsatisfactory aesthetic appearBariatric Fellow, post-operatively. Reconstruction using meshed or sheet split thickness skin grafts ance with sexual and urinary dysfunction is common North Tyneside (SSG) have been described, each with advantages and disadvantages. Our technique of micro-fenestrating exploits the advantages of both graft types. Materials and methods: Since 2010, twenty-one patients have undergone penile reconstruction with micro-fenestrated SSG. The described technique produces uniform micro-fenestrations less than 200 micrometres in length. Results: All patients successfully healed within one month of surgery. Conclusions: Micro-fenestrated skin grafts allow free drainage of fluid from the penile wound surface without compromising the final Ed Fitzgerald aesthetic appearance of the neo-glans. Hand fenestrating could create similarly small spaces but can result in uneven fenestrations ASiT Conference as it is an easily reproducible technique and can tear the graft. The reported method is superior Organiser & Past-Presidentgenerating uniform micro-fenestrations with all of the inherent benefits of both meshed and sheet grafts. General Surgery Registrar, London 0990 IMPROVING PINNAPLASTY DAY-CASE RATES: SIMPLE CHANGE, SIGNIFICANT RESULTS! Varun Chillal, Kwang Chear Lee, Ngi Wieh Yii Leicester Royal Infirmary, Leicester, UK Aims: Currently only 70.7% of pinnaplasties are performed as day-cases nationally, representing a savings opportunity of 115K per Jonny Wild year. Since July 2010, our department has listed all pinnaplasties as day-cases to improve the rate of same-day discharge. This audit evaluated the effectiveness ofASiT Honorary Secretary & Sponsorship Co-ordinator this change and factors influencing patient stay. Methodology: Data was collected retrospectively. All patients undergoing pinnaplasties from the March 2009-April 2010 were identified from theatre databases usingGeneral Surgery Registrar, and D03.3. One month was allowed after policy change before the the ORMIS procedure codes D03.1 Sheffield 2nd cycle of the audit was performed for another 12 months. Results: A total of 55 patients were audited in the 1st cycle and 49 in the 2nd cycle. There was a significant increase of 28% in the number of pinnaplasties performed as day cases post-policy change from the 1st cycle rate of 62% (p=0.001). All pinnaplasties were performed under general anaesthetic. Gender, mean age, distance from hospital, grade of operating surgeon, and anaesthetic duration had no influence on patient stay. Post-policy change, 5 patients required overnight stay for pain (n=2) and vomiting (n=3). Conclusions: We have demonstrated that a significant increase in pinnaplasties done as day-cases can be achieved by a simple Robert Davies change in policy without compromising patient care. 1103 Vascular Surgery Registrar, West Midlands WHO NEEDS A DOCTOR TO IDENTIFY A MALIGNANT MELANOMA? Catherine Bradshaw, Elisabeth Royston, Paul Stephens, Peter Budny Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK Aims: The incidence of cutaneous melanoma is increasing faster than any other cancer worldwide (Lens 2004). We hypothesize that lay people can distinguish between malignant melanoma and benign naevi with a similar accuracy to specialist doctors, highlighting the importance of self-examination for early diagnosis. James a histological Methods: Standardised photographs withMilburn diagnosis of either malignant melanoma or benign naevi were selected. Three cohorts - specialist doctors (plastic surgeons and dermatologists), non specialist doctors and lay people - were asked to identify these ASiT Vice-President photographs as benign or malignant. Participants then received a short educational leaflet on recognition of melanoma and asked to General Surgery Registrar, Inverness re-assess the same photographs. Results: There was no significant difference in the correct identification rates between specialist doctors, non-specialist doctors and lay people (mean scores of 88%, 90% and 79% respectively). Following education, across all cohorts the number of benign lesions incorrectly identified as melanoma increased (false positives). The rate of missed melanoma remained less than 3% throughout the study (false negatives). Conclusions: Innately, most people can correctly distinguish between benign and malignant lesions. This questions the current dogma for education focusing on recognition of specific features of malignant melanomas. Patient awareness and self-examination are thereJoseph Shalhoub fore important for early diagnosis.
Vascular Surgery Registrar, London 1107 ARE PLASTIC SURGEONS EXCISING TOO MANY BENIGN LESIONS? SKIN LESIONS EXCISED IN A TERTIARY REFERRAL CENTRE Kenneth Joyce, Jemima Dorairaj, Miriam Byrne, Padraic Regan, Jack Kelly, Deirdre Jones, Alan Hussey Galway University Hospital, Galway, Ireland Aim: With existing resources, the demand for management of malignant skin lesions, in addition to the expanding benign cohort is Steve Hornby unsustainable - reflected in longer waiting-lists. We audited lesions excised over a 6-month period in our Plastic Surgery service. ASiT Director reports of skin lesions excised in April-October 2010 were analysed. Additionally, a Methods: Theatre log-books and histopathological of Education proforma was completed by plastic surgery trainees to assess the surgeon's clinical impression of lesions excised in September 2011. General Surgery Registrar, South West Peninsula Results: 825 lesions were excised in 580 patients, 56% female, 44% male. Benign to malignant ratio (BMR) was 3.7:1, 608 (79%) benign lesions versus 165 (21%) malignant. Of the malignant lesions excised, basal cell carcinoma were most common (128), followed by squamous cell (32) and malignant melanoma (4). Data was available on 125 lesions excised in September 2011. 96 lesions (76.8%) were suspected benign and 29 lesions (24.4%) either high-risk or malignant lesions. GP impressions were obtained for 84 patients giving a thanks tolesion sensitivity of 56%Welsh Regional Representatives: With GP malignant the local ASiT (14/25). Plastic surgeons clinical impressions were obtained on 110 patients giving a malignant lesion sensitivity of 90.3% (28/31). The Rhiannon Harries, lesions excised is questionable, potentially warranting re-evaluation of Conclusion:Misslarge proportion of benign General Surgery Registrar, Ysbyty Gwynedd, Bangorpolicies dictating current practice.Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Mr
1128 A SINGLE CENTER 10 YEAR REVIEW AND SUB-SETASiTANALYSIS OF BECKER EXPANDER BREAST IMPLANTS With thanks to the wonderful DATA Conference Admin team: info@asit.org Katia Sindali2, Marcus Davis1, Sam Orkar1
ASiT Vice-President
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Queen Victoria Hospital, East Grinstead, W. Sussex, UK St Thomas' Hospital, London, UK Aim: To identify, review and analyse the data of Becker' breast implants inserted at the Queen Victoria Hospital, East Grinstead, over a 10 year period (1999-2009), and compare results with the published literature. Method: Patients undergoing breast implantation using Becker Expander Implants were identified from theatre records and coding. Case notes of the 368 patients (424 implants) identified were retrospectively studied, looking at patient demographics, reasons for implantation and explantation, volumes expanded, complications, type of Becker implanted used and time in-situ. Results: Average time in-situ was 47.46 months, with the average volume expansion being 272.25ml. 2 in 5 implants were exchanged for fixed volume implants, a finding consistent with all reasons for use of Becker breast expanders. Complication rates were statistically higher in the Cancer reconstruction group (15.7%) (p=0.05). There was no statistical difference between whether or not an anatomical (Becker 35) or Round (Becker 25 & 5o) was used. Conclusions: Becker breast implants are a cost effective and reliable method of breast reconstruction in a variety of indications. However, a large number of these implants are explanted and exchanged for fixed volume implants having suffered no complication to warrant explantation.
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1148 PREDICTING RECURRENCE IN PATIENTS UNDERGOING SENTINEL LYMPH NODE BIOPSY FOR MELANOMA Kenneth Joyce, Fiachra Martin, Niall McInerney, Deirdre Jones, Michael Kerin, Jack Kelly, Alan Hussey, Padraic Regan Galway University Hospital, Galway, Ireland Aims: The aim of this study was to audit all melanoma patients who underwent SLNBx in Galway University Hospital between 20052010. Methods: Binary Logisitic regression analysis was performed using SPSSv18 on recognised predictive parameters of tumour aggression with relation to sentinel node postivity and recurrence rates. 186 melanoma patients underwent SLNBx between 2005-2010. Patients were assessed through retrospective analysis of histopathology reports, chart and radiology review. Results: 186 patients underwent SLNBx, 115 female (63%) and 69 male (37%). Superficial spreading melanoma was the most common subtype (46%) followed by nodular melanoma (25.5%). 169 patients had a negative sentinel node, 15 patients a positive node and in 2 patients a sentinel node could not be identified. SLNBx positive patients had an average Breslow thickness of 3.9mm compared with 2.1mm in SLNBx negative patients. Breslow depth and ulceration of the primary tumour were identified as the strongest predictors of sentinel node positivity. The strongest predictor of local recurrence was melanoma subtype with nodular melanoma associated with 62.5% of all local recurrences. Discussion: SLNB is central to staging of malignant melanoma. This study highlights factors that predict those who are at high risk of recurrence in the presence of a negative SLNB. 1158 THE VERY LONG POSTERIOR TIBIAL ARTERY (VLPTA) FLAP: CONCLUSIONS FROM CASE SERIES AND LITERATURE REVIEW Leela Sayed, Noemi Kelemen, Stephen Williams, Graham Offer Leicester Royal Infirmary, Leicester, UK Aims: Case series and literature review outlining the advantages and complications of using a pedicled very long posterior tibial artery (VLPTA) flap in patients with lower limb injuries and/or infection. Methods: We report three patients who underwent below-knee amputation and reconstruction using the VLPTA flap. Approximately 10cm of tibia was preserved. Intact intrinsic foot muscles and sole of the foot were harvested with subsequent proximal dissection of the posterior tibial neurovascular pedicle. The heel pad was secured over the anterior aspect of the tibia. An Ovid Medline search was also performed. Results: All patients have a viable flap and ambulate with below-knee prosthesis. A number of cases report sensation over the stump and have good range of movement at the knee joint. Five cases were complicated with minor flap infections but all were successfully treated with antibiotics and excision. Conclusions: The benefits of the VLPTA flap are numerous. Firstly, the glabrous skin of the sole is specifically designed for weightbearing and resisting shearing forces incurred upon ambulation. The pedicled flap addresses complications associated with anastomosis of free flaps and also provides sensation to the stump. Furthermore, the flap can provide sufficient coverage to enable conservation of length. 1169 BITES: A SURGICAL EMERGENCY? Fergal Marlborough, Patrick Addison, Emma Murray St John's Hospital, Livingston, UK Background/Introduction: Current protocol assumes bite injuries are infected at presentation and should be treated with emergency debridement. In busy units many fail to reach theatre within 24 hours of injury. Aims/Objectives: To compare outcomes in patients that did not reach theatre within 24 hours with those who did, and therefore determine if bites could be managed non-urgently. Method: We audited patients admitted to the plastics unit with bites over 12 months, looking at time to theatre, number of operations, and antibiotic therapy. Results: Of 56 patients, 6 avoided theatre, as wounds improved with antibiotics. 23 reached theatre within 24 hours (early), 15 between 24-48 hours (delayed) and 12 went 48 hours post bite (late). Mean number of operations for the early group was 1.13 versus 1.20 for the delayed group, which was insignificant. "Bad outcomes", defined as persistent infection after initial debridement, occurred in 4/23 patients in the early, 0/15 in the delayed and 4/12 in the late group. Discussion: In systemically well patients without structural damage antibiotics may allow surgery to be delayed. Clinical improvement with antibiotics may negate the necessity for surgery. In late presenters, who have clinical evidence of infection urgent surgical washout should be considered.
1196 ULTRASOUND SCANNING IN THE ASSESSMENT OF POST OPERATIVE FLEXOR TENDON REPAIRS edd, Bangor Fergal Marlborough, Jim Armstrong, Marcus Bisson Hutt Hostpial, Wellington, New Zealand al of Wales, Cardiff Introduction: Ultrasound diagnosis of flexor tendon rupture post repair is an area that has not been researched widely. A cheap imaging modality, ultrasound could assist with follow up. Objectives: m: info@asit.org To discover if ultrasound was useful in follow-up of flexor tendon repairs, specifically diagnosis of post-operative tendon rupture.
tives:
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Method: Over four weeks, patients having undergone flexor tendon repair were imaged. 2 operators, FM (junior doctor) and JA (plastic surgeon) visualised the scans. Data was recorded on injury method, range of movement (ROM), volar-dorsal tendon thickness at repair site and at the corresponding undamaged tendon at the on the contralateral hand. Results: 16 patients were involved, with 19 repaired tendons scanned. Mean thickness was 4.2mm in repaired tendons versus 3.6mm in healthy counterparts. This was insignificant. In 2 patients with less ROM than expected at their stage post-repair, ultrasound confirmed sliding motion of the tendon, aiding to exclude rupture. Discussion: Ultrasound may have a role in assessing tendon repairs, particularly in patients who neither have clinical evidence of total tendon division nor full rangeGoldie Khera of flexion. As a real-time modality it could be used in outpatient settings. Limitations include operator dependency and wound pain from pressure applied by ultrasound probes. ASiT President

SURGICAL TRAINING AND EDUCATION 0041 MENTOR-MENTEE RELATIONSHIPS IN THE CHANGING WORLD OF MEDICAL AND SURGICAL TRAINING: DO MENTORS STILL KNOW WHO IS WHO? Shofiq Islam, Jennifer Cole, Alexandra Lee, Christopher Taylor, Brian Isgar Ed Fitzgerald Dept of General Surgery, The Royal Wolverhampton Hospital, Wolverhampton, West Midlands, UK Aim: To determine the views ASiT Conference Organiser & Past-President training amongst a group of hospital and understanding of new titles used to describe junior doctors in consultants; following the implementation Surgery Registrar, London UK. General of Modernising Medical Careers in the Methods: A questionaire survey of 75 consultants working in a district general hospital in the West Midlands UK, eliciting information about views and knowledge of current nomenclature. Consultants were asked to match equivalent positions with those based on the traditional system. Results: Our survey revealed some lack of understanding of the new nomenclature. Replies were received from 52 consultants. Only 56%(n=29) of consultants felt they fully understood the terms. The most common title correctly matched was FY1 with House Officer (100%, n=52). 88%(n=46) matched ST3 with Junior Registrar, similarly 82%(n=43) matched ST7 with Senior Registrar. Only 50% Jonny Wild (n=26) correctly matched Specialty Doctor' with Staff Grade/Associate Specialist. Under half surveyed correctly matched ST1 and GPVTS with the correct equivalent. Only one stellar individual recorded Sponsorship Co-ordinatorno statistically significant ASiT Honorary Secretary & a perfect matching score. There was difference between consultant surgeons and physicians. We did not find a statistically significant difference in the number of correctly General Surgery experience. matched responses with respondents' age, gender or Registrar, Sheffield Conclusion: The result of our survey suggested potential disruption to the mentor and mentee relationship. 0054 THE GRADUATING MEDICAL COHORT: FUTURE SURGEONS DEMONSTRATE A DIFFERENT SET OF CAREER INFLUENCES Daniel Stevens1, John Mason1, John Jackson1, Rebecca Woolf1, Justice Kynoch2, Emily Hotton3 1 Cardiff University, Cardiff, UK Robert Davies 2 Glasgow University, Glasgow, UK 3 ASiT Honorary Treasurer University of Bristol, Bristol, UK Aim: To identify influencing factors for graduating doctors considering a career in surgery. Vascular Surgery Registrar, West Midlands Methods: A pre-existing questionnaire was distributed using SurveyMonkey to all graduating doctors at Cardiff, Bristol and Glasgow Schools of Medicine. Respondents provided demographic information, their ideal career choice and the specialty that realistically they saw themselves working in. Following this, respondents rated 19 career influences using a 5-point Likert scale. Data were analysed using independent t-tests. Results: 232/734(32%) responded. 42 ideally wanted a surgical career compared with 190 who didn't. Those who wanted a surgical career were less influenced by patient relationships (p<0.001), working hours(p<0.001), stress(p=0.007), lifestyle(p=0.001) and trainJames Milburn ing length(p=0.03) when compared to those not wanting a surgical career. They were more influenced by financial potential(p=0.015) and prestige from the public(p=0.01). Only 25(59%) of those who wanted a surgical career felt they would realistically achieve it. ASiT Vice-President Those who were not confident of achieving this goal were significantly more influenced by job security(p=0.014), lifestyle(p=0.025), General Surgery Registrar, Inverness competitiveness(p=0.003), and their financial situation(p=0.03). Conclusions: There are clear differences in influencing factors between potential surgeons and the rest of the graduating medical cohort. Those confident of achieving a surgical career demonstrate a set of influences that differ from those who are not. 0083 BRIDGING THE SIMULATION GAP HOW ARE LAPAROSCOPIC SURGICAL SIMULATORS CURRENTLY PERCEIVED BY TRAINED SURGEONS AND Joseph Shalhoub SURGEONS IN TRAINING? Paul Brennan, Roland Partridge ASiT Vice-President University of Edinburgh, Edinburgh, UK Vascular Surgery Registrar, London Background: Laparoscopic Simulators (LS) may compensate falling operative training time and improve patient safety. For trained surgeons, LS have potential value as warm-up tools prior to surgery, and for developing new skills. Method: We surveyed members and fellows of the RCS of Edinburgh online about access to, use of, and expectations for, LS. Results: 849 people responded (52% Consultants) - 53% general surgery, 8% urology, 8% paediatric surgery. 94% felt LS were important in training. 88% would use LS in their own time, rather than simply at work. 60% responded that LS should be used for assessment of surgical skills. 25% saw a role in selection to training programmes or professional examinations. However, 53% had no acSteve Hornby cess to LS equipment. 14% who did have access never used it, and 62% of those who had used a simulator this year had received no ASiT Director of Education instruction. The commonest limit to use of LS, (other than no simulator), was lack of time dedicated to simulation training. Conclusion: There is a desireGeneral Surgery Registrar, South West Peninsula practice. To realise this, simulators amongst those surveyed to better utilise LS in surgical training and must be more accessible, with dedicated time to train. Quality instruction is needed to guide best practice. 0108 HOW COMPETENT ARE SCOTTISH SURGICAL TRAINEES IN CENTRAL VENOUS CATHETER INSERTION? Eugene Tang, Marion Mackinnon, Stephen McNally With thanks to the local ASiT Welsh Regional Representatives: Royal Infirmary of Edinburgh, Edinburgh, UK Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, of the core Aim: Central venous catheter (CVC) insertion is a key skill required by trainees in acute specialties and oneBangor competencies of ISCP. Mr Andrew in training/reduced working hours may Fellow, UniversityThis study determines the Cardiff in CVC Recent changes Beamish, Clinical Research have impaired training. Hospital of Wales, changes experience in Scottish surgical registrars compared to other acute specialty registrars between 2006 and 2011. Methods: An online questionnaire was designed using web-based software. Invitations were sent to registrars (SpRs/ST3+) in General Surgery, With thanks to the wonderful ASiT Conference Admin team: info@asit.org Anaesthetics and Medicine throughout Scotland in 2006 and 2011. Results: 233 registrars replied in 2011 and 175 from 2006. 97.9% of current trainees could insert CVCs. Only 26.4% of surgeons had
Laura Andrews
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inserted over 50 lines with anaesthetists (71.8%) placing the greatest number (p<0.0001) (physicians 45.2%) and a reduction of total numbers over the 5 year period. Anaesthetists also inserted more CVCs per annum. In 2011 more trainees in each specialty used ultrasound guidance, most using it in real-time (p<0.0001). Conclusions: Fewer 2011 trainees had inserted over 50 CVCs, a number associated with reduced complications. Low annual and total numbers of CVC insertion by non-anaesthetists may expose patients to greater risks, despite the use of ultrasound guidance. If CVC insertion is to remain a key skill in surgical training, changes in training structure are required.
0109 EARLY GOAL DIRECTED THERAPY: WHO SHOULD PROVIDE IT? Eugene Tang, Marion Mackinnon, Stephen McNally Royal Infirmary of Edinburgh, Edinburgh, UK Aim: Early Goal Directed Therapy (EGDT) is a key component in managing sepsis and a cornerstone of the Surviving Sepsis Campaign (SSC). Previously we demonstrated that non-anaesthetic registrars lack the knowledge/skills to provide EGDT. This five year follow-up determines whether current trainees have had greater training in this area. Methods: A questionnaire was designed for online access. Invitations were sent to registrars (SpRs/ST3+) in Anaesthetics, General Surgery and Medicine throughout Scotland in 2006 and 2011. Results: In 2011, 233 registrars replied with 175 responses in 2006. There had been an increase in the awareness of EGDT over the 5 year period (physicians 51.3% vs. 87.5%, surgeons 70.2% vs. 88.5%). 62% of surgeons and 59% of physicians possessed the minimum skill set to commence EGDT. However, the number of non-anaesthetists able to provide EGDT remains low (physicians 32%, surgeons 9%). This contrasts with anaesthetists where 76% could provide EGDT. Conclusions: There is now a greater awareness of EGDT/SSC in non-anaesthetic trainees. Although over half of non-anaesthetists possessed skills to initiate EGDT, few are able to provide EGDT in its entirety. As non-anaesthetists lack the full complement of skills/ knowledge to implement EGDT, these patients require referral to anaesthetic colleagues for optimal management. 0186 INDEXED PUBLICATION PRACTICES OF CONSULTANT PLASTIC SURGEONS IN THE UK Nigel Mabvuure1, Michelle Griffin2, Sandip Hindocha3 1 Brighton and Sussex Medical School, Brighton, UK 2 Manchester Interdisciplinary Biocentre, University of Manchester, Manchester, UK 3 Whiston Hospital, Liverpool, UK Aim: To characterise the publication practices of consultant surgeons, who are full members of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), over a 2-year period. Method: Surgeons were identified from www.bapras.org.uk/page.asp?id=34; gender and highest academic degrees were recorded. PubMed was searched for each surgeon between 2009/11/29 and 2011/11/28 e.g. Joe Alfred Burns FRCS(Plast)'s search would be:"Burns,Joe+A OR Burns+Joe+A", "Burns,JA AND Burns+JA" and "Burns,J AND Burns+J" or "Burns" if no results returned. The article type, whether clinical or scientific and the surgeon's author rank were recorded. All searches were repeated on 3 occasions. Results: Out of 741 articles, 46.4% were research and outcome analysis articles; 26.2% case reports/series; 19.6% letters/comment/ technique articles; 6.9% reviews; 0.7% audits and 0.3% editorials. The ratio of clinical to science studies was 15:1. Consultant surgeons were first author on 6.2% of publications and last author on 62.2%. Males and females published equally(P=0.859).Surgeons with higher academic degrees had a higher number of indexed peer-reviewed publications(P=0.001). Conclusions: Outcome analyses, case reviews and letters on technique or commentaries remain popular methods of communicating and disseminating knowledge. There appears to be a greater requirement for basic science research within plastic surgery in the UK. In addition more published audits may provide improved healthcare economics and standards in practice. 0234 A SYSTEMATIC REVIEW OF MOTION ANALYSIS AS A VALID TOOL FOR LAPAROSCOPIC SKILL ASSESSMENT IN GENERAL SURGERY John Mason, James Ansell, Neil Warren, Jared Torkington Welsh Institute of Minimal Access Therapy (WIMAT), Cardiff, UK Aims: To provide an overview of the different motion analysis technologies available for the assessment of laparoscopic skill, and to assess the evidence for their validity. Methods: A systematic review was performed using Embase, MEDLINE and PubMed for studies investigating motion analysis as a valid tool for laparoscopic skills assessment. Studies were assessed according to a modified form of the Oxford Centre for Evidence Based Medicine levels of evidence and recommendation. Results: Thirteen studies were included. Twelve (92.3%) evaluated construct validity, which was demonstrated for various endpoints across a range of laparoscopic tasks for the Advanced Dundee Endoscopic Psychomotor Tester (ADEPT), the Hiroshima University Endoscopic Surgical Assessment Device (HUESAD), the Imperial College Surgical Assessment Device (ICSAD), the ProMIS Augmented Reality Simulator and the Robotic and Video Motion Analysis Software (ROVIMAS). Face validity was reported by 1 study each for ADEPT and ICSAD. Concurrent validity was reported by 1 study each for ADEPT, ICSAD and ProMIS. There were no studies investigating predictive validity. Conclusions: This study confirms the construct validity of motion analysis in laparoscopic skills assessment. The most useful metrics appear to be time, path length and number of hand movements. Future work should concentrate on predictive validity.
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0241 COMPARING THE ATTITUDES TOWARD AND KNOWLEDGE OFINCIDENT REPORTING BETWEEN JUNIOR DOCTORS AND NURSES IN A DISTRICT GENERAL HOSPITAL Jessamy Bagenal1, Kapil Sahnan1, Saran Shantikumar2 1 Severn Surgical Deanery, Bristol, UK 2 Bristol Heart Institute, Bristsol, UK Aim: Open reporting improves a system's ability to deal with risky processes. We compared the attitudes and knowledge of incident reporting between junior doctors and nurses in a district general hospital. tives: Methods: A questionnaire examined healthcare workers' attitudes towards reporting and errors. It also assessed knowledge of incident edd, Bangor reporting and attitudes towards training in patient safety. Nurses (band 5-7, n=50) and junior doctors (FY1-CT2, n=50) completed the survey online and anonymously. al of Wales, Cardiff Results: Whilst similar proportions of each group knew a safety organisation (70% nurses vs. 58% doctors, p=0.21), significantly more nurses had filled out an incident report (96% nurses vs. 52% doctors, p<0.001). Doctors felt they did not have sufficient training in patient safety m: info@asit.org (66% doctors vs. 24% nurses, p<0.001) and fewer felt confident with patient safety issues (38% vs. 72%, p<0.001) The majority of respondents agreed that incident reporting was beneficial (69%, p=0.001) although a large proportion also felt they would
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be blamed for errors (61%, p=0.03). Conclusions: Junior doctors need more training in patient safety issues and reporting. Nurses generally have a more positive and confident view towards patient safety issues. Healthcare institutions should focus on training their staff in patient safety and fostering a blame-free culture.
0301 IMPROVING THE QUALITY OF OPERATION NOTES IN AN ORTHOPAEDIC ONCOLOGY DEPARTMENT THROUGH EDUCAGoldie Khera TION AND IMPLEMENTATION OF A MNEMONIC DEVICE Robert Grimer, Natasha Bauer, Anna President ASiT Wilson University of Birmingham, Birmingham, UK Aim: To ascertain the quality Bariatric Fellow,patients undergoing a surgical procedure in the department of Orthopaedic Oncolof operation notes of North Tyneside ogy. Method: A retrospective audit involving 100 operation notes, competed by 6 consultants and 12 trainees, of patients undergoing elective procedures from January 2011 to December 2011. The quality of documentation was determined by the adherence to the guidelines published by the Royal College of Surgeons of England (Good Surgical Practice, 2008). Our findings were presented, highlighting areas requiring improvement. In addition to educating surgeons, we implemented a mnemonic device and have conducted a reaudit. Ed Fitzgerald Results: A quarter (25%) of all operation notes were considered illegible with instructions about DVT and antibiotic prophylaxis missing ASiT Conference Organiser & Past-President in 67% and 37%. The indication and post-operative management was absent in 13% and 3% of notes, respectively. The re-audit showed a significant improvement in several areas of Registrar, London General Surgery documentation. Conclusions: Clear and accurate documentation can inherently improve the subsequent quality and effectiveness of patient care. One way of doing so is by introducing a mnemonic device to ensure that important information is not routinely missed out. 0305 SUTURE AUDIT AN OBSERVATION STUDY James Smith, Richard Bromilow, Anusha Edwards Jonny Wild North Bristol NHS Trust, Bristol, UK Aims: The authors aimed to highlight an important aspect of surgical safety that appeared deficient in the local trust. ASiT Honorary Secretary & Sponsorship Co-ordinator Methods: An observational study of sutures used in surgery was performed in November to December 2010 in a single centre. An Generalsuture, was Registrar, the suture documented on the operation note. The operating and observation of the requested and used Surgery compared to Sheffield documenting surgeon was blinded to this study. The initial results were presented at the local trust audit meeting, posters placed in theatre, and published in the RCS Annals. A re-audit was performed in June to July 2011. Results: In the initial study 48 cases were observed; 28 cases of deep closure (21.4% accuracy), 16 vascular anastomosis (31.2%), 45 cases of skin closure (26.6%), and overall accuracy of 28%. In the re-audit 45 cases were observed; 37 cases of deep closure (83.7%), 45 cases of skin closure (60%). Accuracy in documentation improved from 71.4% to 28%. Conclusions: The study highlighted an important aspect of surgical safety that is often forgotten. The Royal College of Surgeons Good Robert Davies Surgical Practice 2008 state that the surgeon should give details of closure techniques, and this should include the type and brand of ASiT Honorary Treasurer suture. 0312 IMPACT OF INTRODUCING THE PRODUCTIVE OPERATING THEATRE PROGRAMME ON TEAMWORK CLIMATE Jagdeep Virk1, Sonal Tripathi1, Zaid Awad2, Rebecca Haywood2 1 Charing Cross Hospital, London, UK 2 Whipps Cross Hospital, London, UK Aims: The Productive Operating Theatre (TPOT) programme was introduced to our unit (ENT department, Whipps Cross Hospital, James Milburn London) to improve the safety of care, team performance and staff wellbeing. The objective was to investigate the impact of introducing TPOT on teamwork climate. ASiT Vice-President Methods: A prospective, five option survey of theatre staff using the 14 item teamwork survey from the University of Texas was General Surgery Registrar, Inverness done before (55) after (44) introducing TPOT. The results were analysed using mean scores and factor analysis. Results: While there were only minor changes to staff perception of teamwork climate as a whole (Mann-Whitney U p=0.3466), the individual question scores were higher (Wilcoxon p=0.0176) in the second group. We also found a noticeably better perception of the reliability of handover after TPOT was introduced (p=0.0455). Conclusions: TPOT improves certain aspects of teamwork climate especially handover of information. It requires regular monitoring with staff involvement to achieve its highest potential. 0323 ASiT Vice-President TRAINEE PERFORMANCE IN SIMULATED VASCULAR PROCEDURES IS PREDICTED BY NUMBER OF PROCEDURES PREVIVascular Surgery Registrar, London OUS PERFORMED, NOT PREVIOUSLY OBSERVED: AN UN-BLINDED OBSERVATIONAL STUDY Lucy Green2, Ian Chetter1 1 Hull York Medical School, Hull, UK 2 Hull Univeristy, Hull, UK Aim: The aim of this study was to determine if performance, using Procedure Based Assessment (PBA) during simulation training, is predicted by number of procedures performed or observed. Steve Hornby Methods: Trainees on 3 different vascular skills courses were assessed using the appropriate index specific PBA competency check ASiT Director of Education list, PBA level score and OSATS (Objective Structured Assessment of Technical Skills) tool. Self reported measures of procedures previously observed and previously performed were recorded prior South West Results were analysed using Spearman's Rho for General Surgery Registrar, to assessment. Peninsula non- parametric data. Results: There were 117 assessments in 46 trainees who were assessed performing simulated above and below knee amputation, carotid endarterectomy, sapheno-femoral junction dissection and aortic anastomosis. The PBA level score and OSATS scores demonstrated a significant correlation for numbers of procedures performed, not number of procedures observed. (r= .466p <0.0001 and r=.418 p=0.001 respectively).to the local ASiT Welsh Regional Representatives: With thanks Conclusion: This study highlights that trainee's benefit most from performing procedures rather than observing or assisting. Traditional Miss Rhiannon to change General Surgery Registrar, Ysbyty Gwynedd, Bangor surgical training paradigms need Harries, in favour of a focused skills based curriculum that will take advantage of the fact that trainees learn through doing rather than watching. Simulation training will provide Universityadjunct to this in Wales, Cardiff Mr Andrew Beamish, Clinical Research Fellow, an important Hospital of the future. 0332 CONSULTANT SURGEONSto the MOTIVATES THEM TO TRAIN YOU? With thanks WHAT wonderful ASiT Conference Muzzafer Chaudery, Lis Freeman
Joseph Shalhoub
Laura Andrews
Kristina Gloufchev
Harriet Innes
Admin team: info@asit.org

am 2012
Imperial College, London, UK Introduction: Many surgeons have taken a number of well-defined steps in their development to becoming good trainers. These steps should be highlighted so that others can flourish as trainers themselves. The aim of this study was to explore what motivates Consultant Trainers (CTs) to pursue self-development and train others? Methods: Semi-structured interviews were undertaken with three General Surgery CTs and three trainees. A grounded theory approach was used for transcript analysis from which emerging themes and categories were identified. Results: CTs identified numerous external motivators which included: providing training because it was the ethos of surgery, valuing senior trainees on their team and cherishing receiving positive feedback. Internal motivators were: feeling altruistic towards trainees, seeing trainees progress, enjoyment of training others and becoming an adaptive expert. Negative influences upon training identified included the balance between service commitments and fulfilling training requirements. All participants stated that they did not find the current CT development courses to be useful. Conclusions: We recommend that the findings from this study are incorporated into a comprehensive CT development programme. Follow up of trainer performance will establish the effectiveness of such courses and play a key part in the CT revalidation process.
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0360 SURGICAL APTITUDE - LEARNING CURVE OF BASIC SKILL ACQUISITION ON THE SEP ROBOT Mohsan Malik1, Ali Bahsoun1, Shamim Khan2, Prokar Dasgupta2, Kamran Ahmad2 1 Kings College London, London, UK 2 Guys and St Thomas' Trust, London, UK Aim: To identify the learning curve of skill acquisition on the SEP Robot, a validated virtual reality simulator, for the design of a training program for robotic surgery. Materials and method: Participants without virtual reality experience were recruited from the medical school. The two tasks performed were the application of clips onto the cystic duct and artery and performing a surgeons knot. We assessed task time for both tasks, clip error for the clipping task and maximum stretch on the thread for the suturing task. Participants were asked to alternate between the tasks till they felt fatigued. Results: 24 participants were recruited for this study. The performance of the participants reached a steady mean by their 3 rd repetition. On the tenth repetition, of both tasks, participant scores became progressively worse due to fatigue and this skewed the curve means. As participants left the study, mean scores improved beyond the level of the initial plateau meaning that people who score better also tend to last longer. Conclusion: Our observation of participants noted two groups; one, that fatigued earlier, and those who were more resistant. This supports the use of simulators for measuring surgical aptitude. 0367 SATISFACTION RATING OF CORE AND HIGHER SURGICAL TRAINING IN WALES Andrew J Beamish, John Emelifeonwu, Geoffrey Clark, Susan Hill, Wyn G Lewis University of Wales Hospital, Cardiff, UK Aims: Surgical training in Wales has recently received negative press. PMETB survey completion is obligatory, but interpretation of these results has been selective and negative findings highlighted. The aim of this study, therefore, was to determine trainee perspectives on the ability of Welsh surgical training programmes to meet trainees expectations. Methods: All surgical trainees in Wales were invited to complete a satisfaction survey comprising five key questions regarding overall satisfaction; choice of deanery; vacant posts; missed training opportunities; publication. Results: Thirty-six responses were received including 22/56 (39%) Higher Surgical Trainees (HSTs) and 14/146 (9.6%) Core Surgical Trainees (CSTs). Most trainees were satisfied (HST vs. CST=86% vs. 64%) and would choose Wales again (86% vs. 71%). Thirty-five percent of respondents had vacant posts on their rota and 53% reported having missed training opportunities in order to fulfill service demands. Seventy-three percent of HSTs reported having published in a peer review journal in the past twelve months, compared with 50% of CSTs. Discussion: The results of this brief study are encouraging and highlight some positive feedback from surgical trainees. The Welsh surgical community can build upon such findings, which reflect positively on the Welsh Deanery and may help recruitment. 0382 ABSCESS SURGERY - CAN A PATHWAY ACTUALLY SAVE TIME AND MONEY? Salmaan Khan, Vimal Hariharan North Middlesex Hospital, London, UK Aims: To assess the implementation of a locally developed abscess fast track pathway and highlight its financial implications. Methods: The study period was August 2nd 2011 to November 16th 2011. Patients were divided into two groups according to whether they followed the abscess fast track pathway or the original emergency list as admitted inpatients. Data was collected using hospital database systems and was cross referenced with the hospital coding department. Results: 40 patients underwent incision and drainage of an abscess during the study period. 30 were done as inpatients on the emergency list and 10 were sent home and brought back to hospital as per the fast track pathway. There were a total of 20 days of unnecessary overnight bed occupancies - all of which occurred with inpatients on the emergency list. The average cost of overnight stay on a surgical ward was 238. A total of 20 overnight stays in a 10 week period cost 4742. This number gives a projection of approximately 25000 that could be saved annually by implementation of the abscess pathway. Conclusions: The presence of an abscess fast track pathway is an efficient and cost-effective method of minimizing unnecessary bed occupancy and hence minimizing costs.
0425 PROVIDING HUMANITARIAN HERNIA SURGERY AS A REGISTRAR IN MONGOLIA WITH OPERATION HERNIA Frank McDermott, Tsetke Bat-Ulzii-Davidson, Andrew Kingsnorth Operation Hernia, Plymouth, UK Introduction: Operation Hernia (OH) is a charity formed in 2005 to provide hernia surgery & training to surgeons in the developing world. The organisation started working in Ghana and now operates in Ivory Coast, Nigeria, Ecuador and Mongolia (total: > 4000 hertives: nia operations). edd, Bangor Mongolian Mission: Mongolia is a country 6 times the size of the UK with 1/20th of the population. The country gained its independence 20 years al of Wales, Cardiff ago following the dissolution of the Soviet Union leaving a gap in surgical training. The 2-week mission in September 2011 comprised 3 Consultants and 2 surgical trainees. OH uses sterilized mosquito nets for mesh hernia repairs. Results: 122 operations Mean age: 27 (range 0.2 - 88); 32 mesh inguinal hernia repairs; 19 incisional hernias; 52 paediatric herniotomies;19 others; 1 peri-operative complication: scrotal haematoma m: info@asit.org Conclusion: Charities like OH provide modern hernia surgery and, more importantly, surgical training to underserved countries like
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Mongolia. The use of mosquito nets as a replacement for expensive alternatives provides a cheap and relatively simple technique to repair common hernias. It also allows surgical trainees to be involved in humanitarian work that benefits both the developing world and our own training and development.
0431 MAINTAINING STANDARDS OF TRAINING WITHIN THE CONSTRAINTS OF EWTD Thomas Hanna Goldie Khera Derriford Hospital, Plymouth, UK Aims: The European WorkingASiT President is widely perceived by surgeons as a threat to training. Maintaining standards of Time Directive (EWTD) training requires new ways of working to overcome organisational constraints of EWTD. We aimed to develop and validate a questionBariatric Fellow, North Tyneside naire to identify specific barriers which exist locally. Method: An existing questionnaire in the literature was identified and adapted with permission to apply to Consultants, Trainees and NHS managers. The electronic questionnaire was e-mailed to all groups at 3 trusts in the South West. Responses were analysed using Student's t-test and one-way ANOVA. Ethical approval was granted by NRES. Results: 216 questionnaires were completed, 108 (50%) trainees, 93 (43%) consultants and 15 (7%) managers. The three questionnaires were validated, consistent and reliable with high Cronbach's alpha values between 0.84 and 0.9. The use of locums to fill rota gaps, service delivery pressures, and management perception of Consultants not willing to change working practice were identified as Ed Fitzgerald barriers. ASiT Conference administer across Past-President Conclusion: The validated questionnaire was simple to Organiser & a deanery. Triangulation of findings from the three questionnaires identified important barriers to training specific Registrar, London can be used by other Trusts to improve training. General Surgery to the deanery. This tool 0451 CONSENT IS IT INFORMED? Mingzheng Aaron Goh, Timothy Batten, Sirwan Hadad Inverclyde Royal Hospital, Greenock, Glasgow, UK Aim: GMC guidelines state that effective communication is the key to enabling patients to make informed decisions. We wanted to Jonny Wild investigate if patient consent was truly informed. Method: Patients undergoing ASiT Honorary Secretary & Sponsorship Co-ordinator surgery were given a questionnaire post-operatively during a one week period. We asked if they received adequate information about their condition, the operation, and the risks and complications involved. The interim results were presented during the surgical General Surgery Registrar, Sheffield departmental meeting. 3 months after this intervention, the audit was repeated. Results: 23 patients were recruited in the first cycle and 25 in the second cycle. Issues identified after the first cycle included patients being unclear of their illness (2/23, 8.7%), unsatisfactory explanation of risks and potential complications (6/23, 26%) and that patients were not reading the information sheet provided (5/23, 22%). The second cycle showed a significant improvement: all patients understood their illness, risks and complications were not clearly explained in only 1/25 (4%) patients, and only 1/25 (4%) patients did not read the information sheet. Conclusions: Most patients were clear about their disease. This audit shows a trend toward significant improvement in the retention of Robert Davies information by patients due to better communication after the intervention, allowing informed consent to be given. 0465 Vascular Surgery Registrar, West Midlands SURGICAL SIMULATION IN ANATOMY EDUCATION: AN UNTAPPED RESOURCE? Ussamah El-khani, Asit Arora, Jean Nehme, Arvind Singh, Shamim Toma, Ceri Davies Imperial College, London, UK Aim: Postgraduate surgical simulators are rarely used to teach anatomy, despite possessing many features that would favour their use in such a discipline. We present the first prospective cohort-controlled trial to evaluate the use of an ENT surgical simulator in teaching temporal bone anatomy by designing an interactive simulator-based module and a non-interactive self-directed module. James Milburn Method: Two temporal bone anatomy modules were created: one designed for use on a surgical simulator, and one as a self-directed PowerPoint tutorial. The learning content of both modules were near identical and both contained images captured from the simulaASiT Vice-President tor. 25 undergraduates were assigned to the simulator group (n=14) and PowerPoint group (n=11). Pre-and-Post module knowledge, General Surgery Registrar, Inverness confidence and satisfaction scores were measured with MCQs, VAS and Likert scales respectively. Results: The knowledge improvement in the simulator and PowerPoint groups was 34% (p<.001) and 33% (p<.001), respectively. Confidence score improvement was 32% (p<.001) and 28% (p<.001), respectively. There was no difference in satisfaction (p=.758). Conclusions: Standardising the learning content of anatomy modules across contrasting learning platforms is feasible, and represents an underutilised but useful method of assessing educational efficacy. Our interactive module is an effective anatomy educational tool. A well-developed non-interactive module can produce similar improvements in knowledge gain. 0473 ASiT Vice-President DOES COMPLETING A CORE SURGICAL TRAINING PROGRAMME LEAD TO AN ST3 JOB IN ENGLAND? Carl Reynolds, Aniket Tavare,Vascular Surgery Registrar, London Alison Carr Medical Education and Training Programme, Department of Health, London, UK Aim: To investigate the relationship between the likelihood of being appointed to an ST3 surgical specialty post and the applicants' deanery of core surgical training (CST) in England. Method: English Deanery databases were accessed to establish the number of themed surgical (CST) and ST3 posts across all surgical specialties for 2011. Steve Hornby Results: There was significant inter-deanery variation in the likelihood of obtaining an offer for a surgical ST3 post (17-65%). Core ASiT Director most likely to be successful and those from Northern Ireland least likely. trainees from the North-western deanery were the of Education Conclusions: Core surgical trainees fromSurgery Registrar, South West Peninsula General different deaneries have markedly different rates of success in obtaining ST3 post offers within England. Many factors may be responsible, including the ratio of CST:ST3 opportunities, that varies between deaneries; difference in applicants and training programmes. This information is important to inform career planning and should be considered by trainees before application to CST. 0475 With thanks to the local ASiT Welsh Regional Representatives: JUNIOR SURGEONS INTEREST IN THE WELSH BARBERS RESEARCH GROUP - WHERE THE TRAINEES OF TODAY ARE Miss WITH RESEARCHRhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor David Bosanquet1, Andrew Beamish, Clinical 5Research 3, Rhiannon Foulkes5, Guy Shingler4, Dave Chan2, Julie Cornish2 Mr Andrew Beamish2, Leigh Davies , Llion Davies Fellow, University Hospital of Wales, Cardiff 1 Department of Wound Healing, UHW, Cardiff, Wales, UK 2 Department of Upper GI Surgery, UHW, Cardiff, Wales, UK 3 Deparment of Colorectal Surgery, Royal Glamorgan Hospital, Llantrisant, Wales, UK With thanks to the wonderful ASiT Conference Admin team: info@asit.org 4 Department of Upper GI surgery, Royal Glamorgan Hospital, Llantrisant, Wales, UK
Joseph Shalhoub
Laura Andrews
Kristina Gloufchev
Harriet Innes
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Department of Colorectal Surgery, Morriston hospital, Swansea, Wales, UK Background: The Welsh Barbers Research Group (WBRG) is a research collaborative that has been set up to provide surgical trainees and trainers in Wales with a platform through which research collaborations can be undertaken. We present the basic demographic data of trainees showing an interest in collaborative research. Methods: Surgical trainees and medical students registered their interest in the WBRG at either surgical teaching or via a dedicated website. Basic demographic data regarding research experience was collected and analysed. Results: 36 trainees registered their interest (17: medical student-CT2, 19: CT/ST3-ST8). Junior trainees had significantly fewer publications (mean+/-s.d=0.9+/- 1.2) compared to senior trainees (4.2+/-3.2, p<0.001), and fewer national (0.6+/-1.2 vs. 5.9+/-5.1, p<0.001) and international presentations (0.4+/-0.8 vs. 3.6+/-3.9, p=0.002). 1 junior trainee and 12 senior trainees had, or were completing, higher post-graduate degrees. Most trainees were confident in data collection and literature reviewing, whereas the majority wanted more experience in applying for ethics, article writing and statistical analysis. Conclusion: In our convenience sample of trainees interested in research, it is clear that presentation, publications and higher degrees are still associated with more advanced trainees. The WBRG provides a means through which both junior and senior trainees can collaborate together within Wales.
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0497 WHAT IS THE RELATIONSHIP BETWEEN THE NUMBER OF THEMED CORE SURGICAL TRAINING POSTS AND THE LIKELIHOOD OF PROGRESSION INTO SURGICAL ST3 POSTS IN ENGLAND? Aniket Tavare, Carl Reynolds, Alison Carr Medical Education and Training Programme, Department of Health, London, UK Aim: To describe the relationship between number of themed core surgical training (CST) posts available in England and number of surgical ST3 opportunities. Method: English Deanery databases were accessed to establish the number of themed CST and surgical ST3 posts in 2010. Results: The ratio of themed CST and ST3 posts varies across specialties and between deaneries. The 2010 ratios are as follows: Plastic Surgery - 7:1; Paediatric Surgery - 3.7:1; General Surgery - 2.9:1; Trauma and Orthopaedics - 2.9:1; Ear, Nose, and Throat - 2.7:1; Urology - 1.4:1; Cardiothoracic Surgery - 0.45:1. It should be noted that not all themed posts provided at least 1 year of specialty-specific experience; conversely some non-themed CST posts provide 1 year. Conclusions: Since doctors completing CST generally only apply to one surgical specialty at ST3, applicants to core surgical training should be aware of the variation in the opportunities to progress for each theme in England. This information is important to inform career planning and should be considered before applying to CST. Deanery structuring of CST may vary now. 0498 WHAT TYPES OF SURGICAL POSTS LEAD TO SUCCESS AT SELECTION INTO HIGHER SPECIALTY TRAINING IN ENGLAND? Aniket Tavare, Carl Reynolds, Alison Carr Medical Education and Training Programme, Department of Health, London, UK Aim: To describe the relationship between the applicant's current post and success in being recruited into ST3 surgical specialties. Methods: English Deanery databases were accessed to establish the number of applicants for ST3 posts appointed in all surgical specialties in 2011 by current post. Current posts were characterised as either 2-year core surgical training (CST), standalone 1-year core training, fixed-term specialty training appointments/locum appointments for training (FTSTA/LAT), service posts and academic positions. Results: The success of obtaining an ST3 post for core surgical trainees (CST) varies between surgical specialties. Core surgical trainees are most successful in urology (34%) and ENT (32%) and least successful in plastic surgery (11%). Success from FTSTA /LAT posts also varies across specialty. FTSTA/LAT applicants have greater success than CST applicants in cardiothoracic (31 vs 20%) and plastic surgery (20 vs 11%) but less success in ENT (18 vs 32%). Applicants from service posts are generally less successful that those from CST or FTSTA/LAT. Conclusions: Surgery continues to be highly competitive with more appointable applicants than posts. Certain specialties appoint a higher proportion of candidates from CST, whereas others appear to preferentially appoint FTSTA/LAT applicants. Specialty specific information should be used to inform career planning. 0499 THE ACCURACY OF DEATH CERTIFICATES IN SURGICAL PATIENTS Prakash Promod, Vardhini Vijay Princess Alexandra Hospital, Harlow, Essex, UK Death certificates provide the information required to generate official mortality statistics nationally and internationally, and to determine the burden of disease in a population. However, they are often left to the junior-most member of the team to complete and little information has been published regarding its validity. Aim: To evaluate the accuracy of death reports in general surgery at a district general hospital with particular emphasis on postoperative deaths. Methods: Death records at our hospital over a 15 month period between September 2010 and December 2011 were evaluated retrospectively. 47 patients had been under the care of a general surgeon at the time of death. The cause of death obtained from the death certificate was compared with the medical records and clinical coding. Results: Excluding the cases requiring post-mortems (14 cases), the cause of death on the death certificate was inaccurate in 18.18% of cases. More alarmingly, in the patients who had surgery within 30 days prior to death (21 cases), there was no documentation of this in the death certificate in 66.67% of cases. Conclusions: Consultant input and ongoing training for juniors is vital to improving the accuracy and legitimacy of death certification in surgery.
0531 DO MY LEGS LOOK FAT IN THESE? A CLINICAL AUDIT OF THROMBOEMBOLIC DETERRENT STOCKING USE IN SURGICAL PATIENTS tives: Olivia Raglan1, Parveen Jayia1, Fiona Myint2, Meryl Davis2 edd, Bangor 1North Middlesex University NHS Trust, London, UK 2 Royal Free al of Wales, Cardiff Hospital, London, UK Aim: An estimated 25,000 people in UK die from preventable hospital-acquired venous thromboembolism (VTE) every year1. All surgical patients without contraindications2 to thromboembolic deterrent (TED) stockings should receive mechanical VTE prophylaxis (stockings) m: info@asit.org on admission3. Treatment of non-fatal symptomatic VTE and related long-term morbidities are associated with significant cost to NHS1. Are patients wearing size-appropriate TED stockings and does understanding of VTE risks and complications influence
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Bariatric Fellow, North Tyneside 0554 WM SURVEY: OUT-OF-HOURS UROLOGY COVER BY GENERAL SURGEONS Amerdip Birring, Abdus Samee New Cross Hospital, Wolverhampton, UK Introduction&objectives: In many hospitals, urological staffing is inadequate to provide 24-hour middle-grade cover. As such, out-ofhours urology cover often falls upon general surgical trainees (STs). In this study we wanted to assess (i) the proportion of STs providing emergency urology cover, (ii) their prior urological training, and (iii) how confident STs are in handling urological emergencies. Ed Fitzgerald Method&Subjects: All STs, ST3 and above, in the West Midlands Deanery were sent an anonymous on-line questionnaire. ASiT Conference Organiser these have received formal training in urology. Many STs are Results: Two-thirds of STs provide out-of-hours urology cover, 60% of& Past-President confident in independently managing: testicular torsion (97%), suprapubic catheterisation (88%), and paraphimosis (84%). Fewer can General Surgery Registrar, London manage Fourniers gangrene (50%) and priapism (9.4%). Most STs (89%) want the management of these emergencies to form part of their training curriculum. Conclusion: A high-proportion of STs provide emergency urology cover. However, many of these trainees have not received any formal training in urology, and prior urological exposure does not appear to be a prerequisite for providing out-of-hours urology cover. Many STs are confident in managing the more common urological emergencies. However, we suggest core surgical training should include at least one urology placement.
0564 ASiT Honorary Secretary & Sponsorship Co-ordinator PERCEIVED RELEVANCE OF MODERN GAMING SOFTWARE TO CAREER CHOICE, SELECTION AND PROGRESSION BY UK General Surgery Registrar, Sheffield MEDICAL STUDENTS Keaton Jones, Jonathan Lund University of Nottingham, Nottingham, UK Aim: Competency in simulation techniques will soon be a necessary requirement for surgical trainees. We aim to investigate students exposure to games consoles and attitudes towards incorporating gaming ability into training selection. Method: A questionnaire was distributed to medical students. Opinion questions used a 7 point Likert style rating scale. Results: 123 students responded (62% response rate, 60% female). 36 students (29%) were surgically oriented (61% female). 74% of Robert Davies males were familiar with games consoles compared with 30% of females. Males preferred first person shooter games (59%), with ASiT Honorary Treasurer females preferring puzzle games (57%). 58% of surgically oriented students think games consoles should be incorporated into surgical education, compared with 19% of others (P<0.0001). 61% of surgically oriented students think that gaming experience is relevant to a Vascular Surgery Registrar, West Midlands surgical career compared with 26% of others (P<0.0001). Conclusion: The majority of male students have experience with games consoles and prefer games with a strong visuo-spatial aspect which may have greater similarity to surgical simulators. Students feel that skills gained in gaming are relevant to a surgical career and could be used in selection. If simulation is used care should be taken to avoid bias by gender as a result of previous gaming experience.
correct wear of stockings? Method: 60 surgical in-patients were identified (pre/post-operative, general surgery, elective/emergency cases) and leg sizes measured as per manufacturer guidelines. Consent obtained for clinical photographs and a survey to assess patient understanding of VTE distributed. We then produced a patient information leaflet to facilitate understanding of DVT/VTE. Results: 35/60 surgical patients were wearing TED stockings: 14% (5/35) had leg size measured as per guidelines by nursing staff, 11% (4/35) wearing both correct size and wearing stocking correctly, 54% (19/35) knew about DVT/VTE prior to admission. 34% (12/35) of participants received a VTE tutorial. Total number post VTE-tutorial and wearing TEDs correctly was 92% (12/13). Goldie Khera Conclusions: Patients have poor understanding of terms DVT/VTE, and their implications. Those that understand risks and complications of DVT/VTE are much more likely to wear stockings correctly. ASiT President
Jonny Wild
James Milburn 0565 THE USE OF SOCIAL NETWORKS IN SURGICAL EDUCATION: THE SCHOOL OF SURGERY EXPERIENCE ASiT Vice-President Hashem Barakat, Ravinder Vohra, Jonathan Cowley, Michael Gough General Surgery Registrar, Inverness The Yorkshire School of Surgery, Yorkshire and Humber, UK Aims: Social media platforms, such as Facebook and Twitter have become an essential part of life. Such technology can be a powerful method to deliver information quickly to networks of people. We hypothesised that social media platforms can be used to deliver knowledge to trainees. Methods: We developed a continually up-dated website (www.schoolofsurgery.org). Peer-reviewed journal articles, seminal papers, podcasts and videos were identified and uploaded daily by our Editorial team. RSS (really simple syndication) feeds were used to transfer data from the websiteJoseph Shalhoub to live feeds available to followers on Facebook and Twitter. Demographic data was analysed. Results: The website, Facebook and Twitter sites have 10,000 monthly users and during the study period (01/06/2011-31/12/2011) the ASiT Vice-President sites were viewed over 1 million times. There was a near equal split between males and females (49% vs. 46%; 5% undefined) and 63% of users were 35yearsVascular Surgery Registrar, Londonfrequently (58.2%), followed by videos (30.4%), news, old. Peer-reviewed articles were viewed most seminal papers and podcasts. Ninety-five percent of all articles were viewed within the first 24 hours following their post. Conclusions: Social media platforms provide a novel and efficient platform for delivering knowledge to trainees and potentially may augment surgical training.
0569 Steve Hornby VIRTUAL REALITY TRAINING IN LAPAROSCOPY: A UK-WIDE SURVEY OF POSTGRADUATE SCHOOLS OF SURGERY ASiT Director of Education Daniel Sinitsky Whipps Cross University Hospital NHS Trust, London, UK General Surgery Registrar, South West Peninsula Aim: Virtual reality (VR) laparoscopic skills training has been demonstrated to improve laparoscopic psychomotor skills and performance in the operating theatre. This survey aimed to elucidate the current use of VR laparoscopic training curricula and the perceived barriers in postgraduate schools of surgery. Method: 15 postgraduate schools of surgery were emailed and asked to complete a structured online questionnaire. Results: With questionnaires were completedASiT Of these, 4 Regional Representatives: mandatory training on 6 of 15 thanks to the local (40%). Welsh schools of surgery (67%) do not incorporate VR laparoscopy simulators into their curricula. Of 4 that ranked 7 potential barriers to this, all identified financial, e.g. too expensive or Miss the most important. Physical infrastructure and insufficient staffing were also ranked highly. One lack of funding as Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor school ranked insufficient Mr Andrew Beamish, Clinical most important barrier. Open text response identified unreliableCardiff evidence to support it as the second Research Fellow, University Hospital of Wales, equipment and lack of haptics as further obstacles to incorporating VR laparoscopy training. Conclusions: Involvement of VR laparoscopy training in modern surgical curricula is variable, and not all schools of surgery believe there is evidence to support to This survey suggests that VR training is perceived Admin expensive,info@asit.orgstaff to With thanks it. the wonderful ASiT Conference to be too team: requiring dedicated manage unreliable equipment.
Laura Andrews
Kristina Gloufchev
Harriet Innes
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0576 A PILOT STUDY OF CBD USE IN PERCEIVED ERRORS AND VARIATIONS BY TRAINEE GRADE. Luke Arwynck, James Read, Hayley Allan, Stella Vig Croydon University Hospital, London, UK Aim: To facilitate education junior doctors should initiate supervised reflection on perceived errors using Case Based Discussion (CBD). We completed a pilot study to analyse perceived errors recalled by trainees and the proportion of CBDs completed. Method: A paper questionnaire distributed to surgical juniors at the trust requesting information on up to three errors and whether or not a CBD was completed. Results: 25 respondents (74% FY1s, 15% SHOs, 11% SpRs). 46 errors recalled (median of 2 incidents per respondent). CBDs were used for 28% of errors and reported useful in 100% of those errors. 92% of CBDs were done by FY1s and 8% by SHOs. Prescription errors and inadequate history or examination accounted for 46% of errors reported and failure to seek senior advice accounted for 15%. CBDs were used most commonly in relation to history or examination and failure to escalate (34% and 33% respectively). Conclusions: Trainees find CBDs useful in learning from perceived process errors. Supervised reflection facilitates turning perceived errors into a change in practice and it is disappointing that SpRs citing complex errors are underusing this resource. This specific data will allows us to structure education and quality improvement projects at our trust.
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0609 THE IMPACT OF THE EUROPEAN WORKING TIME DIRECTIVE ON DAY-CASE SURGICAL TRAINING Ahmed M El-Sharkawy, Elena Theophilidou, John W Quarmby Royal Derby Hospital, Derby, UK Aim: The implementation of the European Working Time Directive (EWTD) in 2009 was viewed by some as a positive step in improving the work-life balance. Most surgeons however, believe that it compromises surgical training. We aim to evaluate the impact of the EWTD on day-case training opportunities. Methods: Operative Room Management Information System records for the Day-Case Surgical Unit (DSU) were reviewed between December 2007-2008 and 2010-2011 at the Royal Derby Hospital. Data relating to procedures performed, lead and assistant surgeons was collected. Results: Between December 2007-2008, a total of 2201 cases were performed. Trainees attended 425 (19.3%) of cases and of these 173 (40.1%) were the lead surgeon. Between December 2010-2011, a total of 1672 surgical cases were performed. Trainees attended 434 (26%) and of these 47 (10.8%) were the lead surgeon. Conclusion: The results show that the introduction of the EWTD has had no negative impact on DSU training opportunities, with trainees consistently attending a minority of cases. However, trainees took the lead in fewer procedures after the EWTD was implemented. The reasons behind these findings are multifactorial, but emphasises that surgical training needs to evolve to ensure that surgeons receive adequate experience. 0610 DO TRAINEE SURGEONS REALLY TAKE THAT MUCH LONGER WHEN OPERATING IN DAY-CASE SURGERY? Ahmed M El-Sharkawy, Elena Theophilidou, John W Quarmby Royal Derby Hospital, Derby, UK Aim: Theatre time pressures may prevent trainees from taking the lead when operating and this can impact on their training. We aim to assess the operating time taken by trainee surgeons in the Day-Case Surgical Unit (DSU). Method: Operative Room Management Information System records for DSU were reviewed between December 2007-2008 and 20102011 at the Royal Derby Hospital. Data was collected on operating times for general surgical cases and compared between consultants, associate specialists (AS) and trainees. Results: The total number of open hernia procedures performed was 772 by consultants, 398 by AS and 97 by trainees. The mean time for all open hernia surgery in minutes was 38.8 for consultants, 34.2 for AS and 41.2 for trainees. Sub-group analysis demonstrated similar trends. Furthermore, operative time in minutes for excision of benign lesions was 18.5 for consultants, 13.5 for AS and 21.5 for trainees. Similar results were demonstrated when comparing other day-case procedures including laparoscopic cholecystectomy. Conclusions: The results show that there are little differences in operating times, particularly when trainees perform appropriately selected cases. DSU provides the perfect setting for trainees to perform appropriately selected procedures on relatively uncomplicated patients in order to develop and practice their operative skills. 0616 THE IMPORTANCE OF CONSULTANT-LED SUPERVISION AND TRAINING IN EMERGENCY COLOSTOMY FORMATION Pritesh Morar, Riaz Agha, John Meyrick-Thomas West Hertfordshire NHS Trust, Vicarage Road, Watford, Hertfordshire, UK Aim: We performed an audit systematically analysing the early incidence of problematic stomas at our district general hospital. The aim of the audit was to quantify our incidence of problematic stomas, attribute causative factors, highlight awareness and implement change. Method: The standard* showed 66% of stomas were healthy and 34% were problematic nationwide. A problematic stoma was defined by complications within 3 weeks of surgery, requiring one or more accessories. Retrospective evaluation of 41 patients notes over a six month period yielded the following data: the type of operation; elective or emergency; consultant or trainee performed; and stoma-related outcome. Results: Of the 16 end colostomies produced: 25% were healthy and 75% were problematic. Retraction compromised 75% of problematic end colostomies; problematic stomas were noted in trainee (79%) verses consultant (30%) constructions, emergency (65%) verses elective (29%) constructions, with Hartmanns procedures (50%) in the presence of diverticular disease (80%). Conclusion: In conclusion, a higher incidence of end colostomy retraction following Hartmanns procedures performed by unsupervised trainees in the emergency setting exists. Consultant supervision in such settings is vital, providing additional experience in tension-free stoma formations. *Standard from National Audit of Stoma Complications within 3 weeks of Surgery, (Cottam and Richards 2006) 0619
edd, Bangor ARE MEDICAL TRAINEES FOLLOWING BEST PRACTICE GUIDELINES WHEN PERFORMING ARTERIAL BLOOD GAS SAMPLING al of Wales, CardiffON ACUTE SURGICAL PATIENTS?MATHURI SAKTHITHASAN, MICHAEL MAGRO , AKLAK CHOUDHURY, ROBERT
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FOWLERQUEEN'S HOSPITAL. BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST, ROMFORD, UNITED KINGDOM Mathuri Sakthithasan, Michael Magro, Aklak Choudhury info@asit.org Queens Hospital, London, UK
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Aim: British Thoracic Society (BTS) guidelines for emergency oxygen use in adult patients 2008 recommend that local anaesthesia (L.A.) should be used for all arterial blood gas (ABG) specimens except in emergencies or if the patient is unconscious or anaesthetised. Our aim was to determine if our current practice is following national guidelines. Methods: Questionnaires were distributed to junior doctors. Data was collected on current ABG technique, patients' perception of pain, knowledge of the BTS guideline and what individual and organisational factors influenced guideline implementation. Results: 23(82%) believed that patients find ABGs painful. 19(70%) have had patients complain due to pain. Only 4(15%) used L.A. regularly. Of the 9(32%) who were aware of the guidelines, none used L.A. The main reasons being; responders believed two needles Goldie Khera were more painful than one(n=4), L.A. administration is as painful as arterial puncture(n=3), it is time consuming(n=2) and there is a risk of injecting L.A. intravenously(n=1). ASiT President Conclusion: In our hospital, although ABGs are known to be painful, only a small number of doctors use L.A. regularly and of those Bariatric Fellow, North Tyneside familiar with the BTS guideline none are following it. This may be detrimental to our patients, causing more pain than is acceptable.
0620 THE MULTI-DISCIPLINARY TEAM (MDT) FROM THE COORDINATORS' PROSPECTIVE. REPORT OF THE MDTCOORDINATORS' SURVEY Rozh Jalil1, Benjamin Lamb1, Nick Sevdalis1, James Green2 1 Imperial College london, London, UK Ed Fitzgerald 2 Whipps Cross University Hospital, London, UK ASiT Conference Organiser it Past-President Introduction: The MDT-Coordinators' role is relatively new, and as such& is evolving. What is apparent is that the coordinator's work is pivotal to the effectiveness and efficiency Surgery Registrar, London the views and needs of MDT-coordinators. General of an MDT. This study aimed to assess Methods: Views of MDT-coordinators were evaluated through an online survey that covered their current practice and role, MDT chairing, opinions on how to improve MDT meetings, and coordinators' educational/training needs. Results: 265 coordinators responded to the survey. 80% of the respondents reported that the MDTs are chaired by Surgeons. Whereas 68% of respondents thought that MDT chairmanship could rotate, only 24% reported that it does in their own MDTs. Majority reported having training on data management and IT skills while more than 50% reported that further training is needed in areas of Oncology, Anatomy and physiology, audit and research, peer-review, and leadership skills. Jonny central Conclusions: MDT-Coordinators' role is Wild to the care of cancer patients. The study reveals areas of training requirements that remain unmet. Improving the ASiT Honorary SecretaryMDT-coordinators can give them an opportunity to develop the reresources and training available to & Sponsorship Co-ordinator quired additional skills and contribute to improved MDT performance and ultimately cancer care. 0629 TRAINING IN DAY-CASE SURGERY - A MISSED OPPORTUNITY Elena Theophilidou, Ahmed El-Sharkawy, J W Quarmby Royal Derby Hospital, DERBY, UK Aim: Surgical training needs to evolve to ensure that surgeons receive adequate training. Dedicated training lists have been suggested; this however is costly Robert Daviesgiven the current financial climate. and therefore unlikely We aim to identify training opportunities in Day-Case Surgical Units (DSU) that may be missed therefore highlighting feasible options accessible to most trainees. ASiT Honorary Treasurer Methods: Operative Room Management Information System records for DSU were reviewed between December 2010-2011 at the Vascular Surgery Registrar, West Midlands Royal Derby Hospital. Data collected included procedures performed as well as lead and assistant surgeons. Results: There were a total of 395 general surgical operating lists. Trainees attended 161(40.8%) of these lists. A total of 1796 cases were performed; 124 (6.9%) were non-surgical procedures and therefore excluded. Trainees attended 434 (26%) of the remaining 1672 cases. Further analysis revealed that of the 434 cases attended, trainees were the lead surgeon in only 47 cases (10.8%). Conclusion: The results show that trainees assisted in a minority of DSU operations and even fewer had the opportunity of being the lead surgeon. Given the difficulties surgical trainees face due to limited training time, DSU could provide the perfect setting for surgical trainees to assist and performJames Milburn relatively uncomplicated patients. common procedures on 0648 General Surgery Registrar, Inverness SINGLE PORT / INCISION LAPAROSCOPIC SURGERY:A NATIONAL SURVEY OF AWARENESS, EXPERIENCE AND OPINIONS H. Rehman, J.E.F. Fitzgerald, I. Ahmed Aberdeen Royal Infirmary, Aberdeen, UK Aims: Single port / incision laparoscopic surgery (SPILS) is a recent innovation in minimally invasive surgery which is increasingly being used across the world. This study analyses the awareness, experience and opinions of British surgeons. Methods: Electronic, 13-item,Joseph Shalhoub self-administered, anonymous questionnaire survey distributed via national / regional surgical mailing lists and websites. Results were analysed with SPSS v17.0 for Windows (SPSS, Inc, Chicago, IL). ASiT Vice-President Results: 342 fully completed responses received: 72 (21%) Consultants and 189 (55%) higher surgical trainees. Overall 330 (96.5%) were aware of SPILS. Only Vascular Surgery Registrar, London 37% had assisted or performed SPILS procedures; more consultants than trainees (56.3 vs 32.0%, p<0.05). Operative experience was limited: 6% performed 25 procedures, and 60%performed 5. 61.4% believed SPILS takes longer, and 32.8% believed it has higher complication rates. Factors cited as limiting uptake included: lack of evidence (70%), insufficient training (78%), incorrect instrumentation (70%), increased cost (62%), and hospital policy (44.5%). A greater proportion of trainees (94.6% vs 78.9%) felt there were insufficient SPILS training opportunities (p=0.001). Conclusions: Although awareness of SPILS is high, operative experience is limited and negative perceptions regarding operating time Steve Hornby and complications remain. Future uptake relies strongly on the availability of evidence, training, instrumentation and reduced costs. 0656 General Surgery Registrar, South West Peninsula IS AN INDUCTION PROGRAMME IN ENT FOR JUNIOR TRAINEES IMPORTNANT TO ENSURE PATIENT CARE AND SAFETY? Liliana Jablenska Luton and Dunstable Hospital, Luton, UK Aim: To devise and carry out an ENT induction programme for trainees working in ENT, A&E and general surgical trainees crosscovering With thanksthe impact the teaching has had on their knowledge and competence in managing ENT patients. ENT and evaluate to the local ASiT Welsh Regional Representatives: Method: A questionnaire and MCQ paper, comprising 40 questions, was used before and following a teaching programme of lectures Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, in performing simple ENT and practical ENT workshops to assess trainee improvement in knowledge and competence and confidenceBangor procedures.Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Results: Ten F2 to CT2 grade trainees took part in the project. None of the trainees felt that they had received an adequate induction in managing ENT patients. Four of the trainees had previous ENT experience of 4 or 6 months. Two of the trainees were scored zero on the MCQ paper and the average mark was 65%. Following Conference Admin team: info@asit.org With thanks to the wonderful ASiT the teaching session the MCQ score increased to 90% and trainees reported they felt more confident in managing ENT patients and knowing when to call for senior help.
ASiT Vice-President
Laura Andrews
Kristina Gloufchev
Harriet Innes
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Conclusion: An induction teaching programme for trainees working with ENT patients ensures that patient care and safety is not compromised. This project has confirmed the need for formal induction of all junior trainees starting ENT.
0675 DEVELOPMENT OF A NOVEL SURGICAL SELECTION TEST BASED ON THE ROYAL AIR FORCE FLYING APTITUDE ASSESSMENT THAT HAS PROVEN TO POSITIVELY CORRELATE WITH LAPAROSCOPIC AND OPEN SURGICAL SIMULATION TESTS Hyunmi Carty1, Eamonn Ferguson2, Bryn Baxendale1, Patrick Clarke2, Ian Sheldrake2, Charles Maxwell-Armstrong1 1 Queens Medical Centre, Nottingham, UK 2 University of Nottingham, Nottingham, UK Aims: Identify a test based on the Royal Air Force pilot selection assessment, which can be tailored to select those candidates who possess the technical abilities necessary for successful postgraduate surgical training. Methods: Medical Students, FY, medical and surgical Core trainees have undertaken: 1. RAF Flying Aptitude Test (FAT) RAF Cranwell (identify those with Spatial & Verbal Reasoning, Attentional Capability, Work Rate & Psychomotor Ability) 2. Simulated validated laparoscopic (Lap Sim) box-trainer tests (bean move, block move, common bile duct cannulation & appendicectomy) 3. Open Basic Surgical skills (BSS) simulation tests (knot & instrument tie, suturing, skin lesion excision). Results: FAT n=230, Lap Sim n=159 (Mean age 24 (19-39). 118 male & 112 females. FAT mean 51.76% (16-96%) BSS = 21. FAT + Lap Sim tests + BSS n=13 to date. Fig1 (n=159) FAT index score (%) with Total Lap Sim time (seconds) Spearman Rho 0.302 (p=0.01). Fig2 (n=13) BSS score with FAT index (Rho = 0.888; p=0.01). Conclusions: The Flying aptitude test correlates significantly with both laparoscopic and open surgical skills simulation tests. It could be used as an adjunct to the current surgical selection process to confirm that individuals have the necessary technical skills required.
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0677 IMPACT OF TRAINEE PERFORMED RESECTIONS ON POSTOPERATIVE COMPLICATIONS, LOCAL RECURRENCE AND 5YEAR SURVIVAL FOLLOWING CURATIVE COLORECTAL SURGERY ON ELDERLY PATIENTS Kanagaraj Marimuthu1, Ashraf Raja2, Jan Gearey2, Ahsan Zaidi2 1 Macclesfield District General Hospital, Macclesfield, Cheshire, SK10 3BL, UK 2 Epsom and St Helier University Hospitals NHS Trust,, Carshalton, Surrey, SM5 1AA., UK Introduction: Age of the patients and variability in surgical technique could influence the clinical outcome following Colorectal Cancers (CRC) surgery. This study aimed to compare whether trainee-performed curative CRC resections in elderly patients were associated with adverse clinical outcome compared to consultants. Methods: Retrospective data of all CRC patients aged 75 and over, who underwent curative surgical resection over two years was collected. Based on grade of primary operating surgeon, patients were stratified into trainee performed or consultant performed groups. Outcomes of interest were surgical technique-related complications (bleeding, anastomotic leak and local abscess), local recurrence and 5-year survival. Statistical analysis was performed using SPSS 11.0. Results: Among 101 underwent curative resections, trainees and consultants performed 68%(36 right & 33 left colonic) and 32%(11 right & 21 left colonic) resections respectively. Trainees were supervised for 47% of right sided and 70% of left sided colonic resections. There was no difference observed between groups in surgical technique-related complications (P=0.16), local recurrence rate (P=0.40) and 5-year survival rate (P=0.5). Conclusion: This study demonstrated no significant difference in technical complications, local recurrence and 5-year survival rate between trainee and consultant performed CRC resection on elderly patients. 0679 LAPAROSCOPIC VS OPEN APPENDECTOMY PERFORMED BY SIMULATOR TRAINED SURGICAL TRAINEES; A FIVE YEARS OUTCOME STUDY Suhail Aslam Khan, Haseeb Anwar Khokhar, AH Nasr, Eleanor Carton Surgical Department, Our Lady of Lourdes Hospital, Drogheda, Ireland Aim: Advances in computing have led to the establishment of simulators for the acquisition of surgical skills within a wider educational framework. This study compares the outcomes of LA and OA performed by simulator trained surgical trainees. Methods: An observational analysis of (1349) patients undergoing appendectomies over 5 years (2006-10) performed by 30 surgical trainees having simulator base training as part of their core curriculum. Results: A total of (1349) pts of which 731 (54.18%) had OA, 618 (45.81%) patients had LA. Mean age for OA (21.31 2.1), LA group (26.17 0.29). Male: female was (1: 1.8) for LA, while for OA was (1.6: 1). Trend analysis showed increase in LA from (23.93% to 66.85%), while OA decreased (70.76% to 33.14%). The time to perform LA was (47 6.76 mins) and for OA (39 5.43 mins). Conversion rate reduced from (8.92 to 5.98) with an increase of (43%) in LA. Length of stay for OA was (4.24 .56) and for LA (3.77 .61). 30 days complication rate for OA was (2.3%) and (7.52%; RR 2.47; p=0.0001) for LA group. Conclusion: Simulators can provide safe, realistic learning environments and with their use one can improve the outcomes of common emergency procedures.
0686 SURGICAL TRAINEE SATISFACTION WITH THE INTERCOLLEGIATE SURGICAL CURRICULUM PROGRAMME (ISCP) REVISITED: A LARGE INDEPENDENT NATIONAL SURVEY Philip Duggleby1, Erlick Pereira2, Benjamin Dean1 1 High Wycombe General Hospital, High Wycombe, UK 2 John Radcliffe Hospital, Oxford, UK Aim: ISCP (www.iscp.ac.uk) became mandatory for British surgical trainees in 2007. We previously demonstrated widespread dissatisfaction with its 2008 version 5.1. We evaluated version 8 for improvement. Method: 359 trainees across all subspecialties and UK regions were surveyed in 2011 regarding ISCP, compared to 539 users surveyed in 2008.1 5-point scales were analysed using chi-squared tests. Results: 79% used ISCP, 38% elogbook and 5% OCAP. 201 responders (56%) evaluated ISCP v8. 59% had registered before 2008 and 31% since. Modal ratings were average' throughout, with the following percentages of responders rating poor' or worse versus tives: good' or better the domains: registration 12% vs 35%; assessments 36% vs 22%; peer assessment tool 34% vs 25%; recording meetedd, Bangor ings 34% vs 19%; helpdesk 11% vs 40%. Trainees were neutral about training impact and 44% thought ISCP was needed. Statistically significant (p<0.001) improvements were seen in satisfaction throughout domains comparing v8 to v5. al of Wales, Cardiff Conclusions: While satisfaction with ISCP has improved significantly during the last 3 years and its registration and helpdesk support are considered good, its assessment and meeting recording features remain average or worse. Increased satisfaction and ISCP's perceived m: info@asit.org necessity may reflect an increased proportion of respondents who commenced training after its introduction.
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0697 PRESCRIBING FOR SURGICAL PATIENTS COMPARED TO OVERALL PRESCRIBING SKILLS OF FOUNDATION YEAR 1 DOCTORS: A STUDY BY THE AVOIDING PRESCRIBING ERRORS (APE) COMMITTEE Sarantos Kaptanis, Amy Gatward, Ania Dean, Sonia Damle, Dhanesh Solanki, Gideon Kotey, Stella Vig Croydon University Hospital, Croydon, Surrey, UK Aim: Prescribing errors are the most common type of medical error. Foundation Year 1 doctors (FY1s) are, according to recent research (1), responsible for 37.8% of these. We aimed to assess, using a validated instrument, the probability of wrong prescribing in common surgical medicationsGoldie Khera anticoagulation) among FY1 doctors. (analgesia, antibiotics, Methods: When starting in Croydon University Hospital, FY1 doctors take a prescribing test. We analysed 195 tests (over a period of 5 ASiT President years). The 13 questions in this test were analysed to identify areas for improvement by an Avoiding Prescribing Errors (APE) committee which convenes monthly, Bariatric Fellow, North Tyneside pharmacists. led by FY1s supported by senior doctors and Results: Logistic regression showed a statistical significant difference between cohorts in prescribing of opioids (41% correct answers, p<0.001) and penicillins (73% correct answers, p<0.01) but not warfarin (89% correct answers, p=0.34). Correlation coefficients were r=0.59, r=0.30 and r=0.34 respectively. There is a significant difference between pre-2010 cohorts (when formal prescribing skills teaching was implemented in medical schools, following the EQUIP study) and later cohorts. Conclusions: There is no difference in prescribing skill in surgical medications and overall prescribing skill. Between cohorts, there is an improvement after 2010. Ed Fitzgerald Reference: 1. Dornan et al. EQUIP study. GMC 2009.
0700 General Surgery Registrar, London HOURS AND SURGICAL TRAINING: THE ELEPHANT IN THE ROOM LIVES ON Benjamin Dean, Erlick Pereira, Phil Duggleby High Wycombe General Hospital, High Wycombe, UK Aim: Our aim was to assess the current impact of working hours on surgical training and explore ways in which any problems may be addressed in the future. Method: 359 trainees across all subspecialties and UK regions were surveyed in 2011 regarding working hours. Jonny Wild Results: A majority of respondents worked in excess of the legal 48 hour limit (81.1%) with the majority of these working in the 48-60 hour (57%) and 60-70 (16.6%) hour brackets respectively. The most common reason was Co-ordinator ASiT Honorary Secretary & Sponsorship to gain sufficient training exposure (48.2%), followed by service commitments with no rota gaps (28.1%) and service commitments due to rota gaps (12.5%). The vast majority of General Surgery Registrar, Sheffield trainees were prepared to work extra hours (93.2%). The most frequent responses were 48-60 hours (39.9%) and 60-70 hours (31.1%). Conclusions: The survey results confirm that the vast majority of surgical trainees would be willing to work extra hours beyond the artificial 48 hour limit, and a large number are already working extra hours in order to obtain adequate training. Increasing hours to a happy medium of around 60 hours per week in combination with improving the regulated training content of jobs appears a workable solution to the EWTD conundrum. 0706 ASiT Honorary RESOURCE A QUANTITATIVE ANALYSIS OF YOUTUBE AS ATreasurerFOR SURGICAL EDUCATION T I Phillips1, H A Elhassan2, HVascular Surgery Registrar, West Midlands B Whittet2 1 Cardiff University, Cardiff, UK 2 Singleton Hospital, Swansea, UK Aim: To assess the availability of Youtube videos for each surgical specialty PBA. Method: A list of the PBAs for all 9 surgical subspecialties was extracted from www.iscp.ac.uk. Search terms were derived from the PBA titles for each procedure excluding potentially nebulous terms. Youtube searches were conducted using the derived terms and the number of video results was recorded. The results were recorded an analysed in Microsoft Excel. James Milburn Results: 92.6% of PBAs were available online. Specialties were ranked according to videos/procedure. The top ranked subspecialty was OMF Surgery (875.5 videos/procedure), the lowest total number and the highest number of procedures with zero videos was ASiT Vice-President Urology (35.6 videos/procedure; 8/53). The breadth of General Surgery included overlap with other specialties and may have affected General Surgery Registrar, Inverness their ranking. The T&O curriculum is completely covered (20853 videos, 100% PBAs). Conclusion: There is a wealth of surgically based educational videos on Youtube. These videos represent a new, valuable and potentially underused learning resource. Videos can aid teaching of surgical technique and we would encourage sharing of good techniques, though qualitative studies will need to be completed. The relative lack of material in otolaryngology provides an opportunity for surgeons to expand their teaching portfolio via video production. 0715 Joseph Shalhoub THE QUALITY OF BLOOD TRANSFUSION DOCUMENTATION AND CONSENT IN SURGICAL PATIENTS AT A CENTRAL LONASiT Vice-President DON TEACHING HOSPITAL. WHAT SHOULD WE BE TEACHING TO MAINTAIN GOOD TRANSFUSION PRACTICE? Vascular Surgery Registrar, London Perbinder Grewal, James Neffendorf Royal Free Hampstead NHS Trust, London, UK Introduction: Accurate record keeping is a crucial component of good medical practice and blood transfusion documentation in surgical patients is essential for patient safety. There are also concerns about the level of information and consent of the patients. This study assesses the adherence to standards and quality of medical records on blood transfusion and the level of consent obtained. Methods: We analysed the records for 108 transfusions performed at a Central London Teaching Hospital. All the patients were asked Steve Hornby whether they gave written or verbal consent prior to transfusion of packed red cells and whether they received a blood transfusion ASiT Director of Education information leaflet. Results: Of the 108 patients, pre-Hb was Surgery Registrar, South West Peninsula General documented in 65 patients (60.2%), indication in 38 (35.2%), consent in 2 (1.85%) and postHb in 48 (44.4%). Verbal consent was gained in 27% and leaflets were received by 4%. Conclusion: We have shown the quality of blood transfusion record keeping and consenting to be poor. This has major safety and legal implications, exacerbated by the EWTD and the ever increasing number of patient handovers. We propose compulsory transfusion teaching to include record keeping and consenting as an education tool for junior doctors. In addition, provision of leaflets must become routine. thanks to the local ASiT Welsh Regional Representatives: With
Robert Davies
Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor 0728 TEAM-BASED STRUCTURE WITHIN DEPARTMENT INCREASES TRAINING OPPORTUNITIES FOR JUNIOR TRAINEES Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Henrietta Poon Poon, Richard Thompson, Jill Webb Queen Elizabeth Hospital, Birmingham, UK Aims: Service provision andto theof junior surgeonsASiT Conference Admin are limited info@asit.org Time With thanks training wonderful is a difficult balance. Working hours team: by European Working Directives (EWTD). We implemented a change to the plastics surgery department senior house officer (SHO) rota to allow trainees to Laura Andrews Kristina Gloufchev Harriet Innes
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work in a consultant team-based structure; in order to maximise training opportunities and meet the learning requirements set by the Joint Committee on Surgical Training (JCST). The aim of this study is to assess if this change has improved learning opportunities for senior house officers (SHOs) in plastic surgery. Methods: Retrospective review of the weekly rota for three weeks before and after the change implementation. The number of theatre sessions and outpatient clinics attended by SHOs was recorded. Results: Four core trainees (CT), two foundation year 2 (F2) and two junior specialty doctors (JSD) were included in the study. Prior to the change; eight SHOs attended 111 theatre sessions, 27 clinic sessions and spent 61 days on ward cover duties. With the new team-based structure, SHOs attended 189 theatre sessions, 55 clinics and spent 10 days on ward cover duties. Conclusions: A consultant based team-based structure within plastics surgery optimises the balance between service provision and training opportunities for SHOs. 0749 ACADEMIC CLINICAL FELLOWSHIPS IN SURGERY - SUCCESS OR FAILURE? Kartik Logishetty, Andrew Jones, S Shanko, Zeeshan Akhtar Oxford Radcliffe Hospitals, Oxford, UK Academic Clinical Fellowships, funded by NIHR, were introduced following the Walport Report. This highlighted the need for dedicated academic training, with flexible programmes allowing for clinical and academic commitments. To our knowledge, no reports have been published regarding the academic and clinical outputs of ACFs. We aimed to establish the success of the programme based on clinical and academic outputs plus trainees opinions. An online questionnaire was sent to ACF trainees in craft specialties. 34 of 83 surgical trainees responded. 32.4% logged >300 operations in the last year, while 55.9% published 2 first author articles and 67.6% 2 abstracts. Only 32.4% have secured a grant but 72.7% anticipate they will by the end. Overall 70.6% felt their surgical skills are similar to non-academic colleagues and 82.4% recommended the ACF route. The programme provides a good balance, as demonstrated by the impressive academic and clinical outputs seen in the results.
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0754 THE ANATOMICAL KNOWLEDGE OF HEALTHCARE PROFESSIONALS REFERRING TO A HAND TRAUMA CENTRE Nicholas Segaren1, Kalpesh Vaghela1, Sheraz Markar4, Onur Gilleard2, Neil Segaren3, Kumaran Shanmugarajah1 1 Chelsea And Westminster Hospital, London, UK 2 Queen Victoria Hospital, East Grinstead, UK 3 Royal Derby Hospital, Derby, UK, 4Kingston General Hospital, London, UK Introduction: Approximately 20% of all A+E presentations are hand injuries which equates to 1.36 million attendances per year in the UK. These injuries range from simple lacerations to mangled hands. Accurate descriptions of the injuries over the telephone are essential, this relies on a basic level of anatomical knowledge of the hand and we undertook a study to assess this. Method: Every professional that referred a patient with a hand injury was asked 5 questions regarding hand anatomy. We felt that the level of questioning reflected knowledge that a final year medical student should possess and we tested this on a subset of them. We stopped when we had 50 answers from each set of referrers. Results: A+ E registrars scored a mean of 4.6 questions correct; their senior house officer counter-parts scored a mean of 3.2. Medical students scored a mean of 3.8 and emergency nurse practitioners scored a mean of 2.8. Conclusions: We found that the level of anatomical knowledge in some practitioners was worse than in some medical students. W e have formulated posters highlighting basic hand anatomical structures and have distributed them in order to ensure that our patients get the best possible treatment. 0761 DOES THE SENIORITY OF OPERATING SURGEON INFLUENCE THE LENGTH OF STAY AFTER LAPAROSCOPIC APPENDICECTOMY? A Humphreys, A L Karran, T D Reid, N D Trent, T H Boyce Royal Gwent Hospital, Newport, UK Aims:.To assess factors influencing the outcome after laparoscopic appendicectomy, with particular emphasis on the seniority of surgeon. Methods: A consecutive series of patients who underwent laparoscopic appendicectomy between April 2010 and April 2011 were studied. Data was collected retrospectively from computerised operating theatre and histopathology records. The primary outcome measure was length of hospital stay (LOHS). Results: 118 patients [median age 29 (12-81), male:female 43:75] underwent laparoscopic (n=99) or laparoscopic converted to open appendicectomy (n=18). The lead surgeon was a Core Trainee or junior SpR in 44 (37.3%) and senior SpR or consultant in 74 (62.7%). The median LOHS was 2 days (1-34). On univariate analysis the following were significantly associated with a longer hospital stay: older age (p=0.001), longer duration of procedure (p=0.001), converted to open (p=0.006), more advanced appendicitis macroscopically (p<0.0001) and histopathologically (p=0.011). Time of day of surgery (p=0.078), delayed surgery (p=0.527), gender (p=0.284) and grade of surgeon (p=0.490) were not significant. On multivariate analysis only age (HR 0.987, 95% CI 0.974-1.000, p=0.046) was independently and significantly associated with LOHS. Conclusions: There was no association between the seniority of the lead surgeon and LOHS. With adequate supervision laparoscopic appendicectomy remains an appropriate training operation for surgical trainees.
0776 A TOOL TO MEASURE SURGICAL DECISION MAKING IN ACUTE ADMISSIONS Zita Jessop, Michael Charalambous, Nebil Behar Chelsea and Westminster Hospital, London, UK Aim: Design a decision making tool to measure decisions by trainees, evaluate the degree of concordance with seniors and effect on patient outcomes. Method: A decision making tool (10 management options), based on NCEPOD grading, was introduced into surgical clerkings and completed at SHO, registrar and consultant level. Data collected on final diagnosis, delay to operation, hospital stay, complications tives: and mortality. Two doctors independently derived "ideal decisions" based on final diagnosis. edd, Bangor Results: Decision making tool was completed for 136 acute surgical admissions over two months. SHO's made less "ideal decisions" compared al of Wales, Cardiff to registrars (45% vs 56%,p=0.10,Fisher's Exact Test) and consultants (45% vs 70%,p=0.0001). SHO's made more "admit and observe/investigate" decisions compared to registrars (63% vs 55%,p=0.27) and consultants (63% vs 51%,p=0.01), who were more likely to decide to "operate/discharge". There was less time to appendicectomy (21 vs 14hrs,p=0.30) and shorter hospital stay (4 vs 3 days,p=0.31) but neither was statistically significant. m: info@asit.org Conclusions: Results show that as you progress up the grades there is narrowing of decision making, with seniors more likely to de-
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cide to operate or discharge patients. This may reflect a combination of better decision making skills, demonstrating the value of early senior review, and increased availability of results. 0791 WHY WOULD STUDENTS CHOOSE A CAREER IN SURGERY IF WE NEVER LET THEM TRY IT? A SURVEY OF PROCEDURAL EXPERIENCE IN GRADUATING MEDICAL STUDENTS Nick Baylem, Matthew White Goldie Queens Medical Centre, Nottingham, UK Khera Aim: One of the greatest draws to surgery as a career is the satisfaction achieved by completing a complex practical task successfully. ASiT President In order to attract medical students to careers in surgery, it is important to give them a taste of this. The aim of this study was to asBariatric Fellow, North Tyneside sess the number of students being allowed to perform a simple surgical task on real patients. Methods: An anonymised questionnaire was distributed to 323 graduating medical students. They were asked on how many real patients they had been allowed to suture. They were also asked to rate the major barriers to gaining more procedural experience at medical school. Results: 203 questionnaires were received; a response rate of 63%. 39.7% of students had not sutured a real patient. Only 10.8% of students had sutured more than 5 times. The most commonly quoted barriers to more procedural experience were lack of on-call time and lack of enthusiasm in supervising doctors. Ed Fitzgerald Conclusions: Allowing nearly 40% of medical students to finish medical school without performing such a simple surgical procedure will not help to enthuse them ASiTaConference Organiser & and surgical trainers need to be proactive in remedying this about career in surgery. Medical schools Past-President situation. General Surgery Registrar, London 0811 SHOULD UROLOGY BE A COMPULSORY PART OF GENERAL SURGICAL TRAINING? Steven Pengelly, Aled Jones, Michael Fabricius, Paul McInerney, Anthony Lambert Derriford Hospital, Plymouth, UK Background: We aimed to determine how much of the emergency take comprises urological patients and whether general surgeons receive appropriate training toJonnythem. manage Wild Methods: A prospectively recorded database of oneSecretary & Sponsorship was examined to determine what proportion ASiT Honorary consultant's emergency admissions Co-ordinator was for urological pathology. The ISCP website was interrogated to see what urology competencies are required during basic surgery General Surgery Registrar, Sheffield training. Trainees were questioned regarding their urology exposure. Results: 5959 patients were admitted with emergency surgical problems between June 2000 and December 2010, with 887 (15%) for urological pathology. The ISCP states that all general surgeons entering ST3 should be able to manage these patients. Seven of eight (88%) surgical trainees who had done a urology SHO job felt competent to explore a scrotum or insert a suprapubic catheter. This fell to one of four (25%) who had not worked in urology. Conclusions: Urological pathology makes up a significant part of the general surgery take. Trainees who have not had formal urology training are not achieving the Robert Davies laid down by ISCP. Urology should be a compulsory part of basic general surgirequired competencies cal training. 0815 Vascular Surgery Registrar, West Midlands LEARNING CURVE IN SINGLE-PORT APPENDICECTOMY: AN EXPERIENCE FORM A UNIVERSITY TEACHING HOSPITAL 1 3 Tarek Katbeh , Tarek Katbeh , Irfan Ahmed2, Bassam Alkari2 1 NHS Highland, Inverness, UK 2 NHS Grampian, Aberdeen, UK 3 University of Aberdeen, Aberdeen, UK Aims: To identify and measure the surgical learning curve of single-port appendicectomy comparing the performance of surgical trainJames Milburn ees with experienced consultants. Methods: Prospective data of patients who underwent single-port appendicectomy, in a university-teaching hospital, from 09.2008ASiT Vice-President 07.2011 were included. Operation time was used as a proxy to assess learning. Patients were ordered based on the date of surgery General Surgery Registrar, Inverness and divided into three groups. Mean operation time of the groups was compared using ANOVA. Results: 52 patients with a mean age (SD) of 33 (15.8) years were included. The mean overall operating time was 56.6 minutes (SD 17.5). Surgeon A (surgical trainee) performed 28 cases and surgeon B (consultant) performed 24. The mean time (SD) for surgeon A and surgeon B were 63.3 (18.5) and 48.1 (11.7) minutes respectively (p=0.001). A trend in decreasing operating time occurred in the initial phase of learning of Surgeon A but did not reach statistical significance (p=0.08). No such trend was observed for surgeon B (p=0.69). Conclusion: Single-port appendicectomy can be performed safely by experienced surgeons as well as surgical trainees with experiJoseph Shalhoub ence in open and 3-port laparoscopic appendicectomy. The learning curve for the procedure is short and does not have an impact on ASiT Vice-President patient care. 0819 REQUESTING RADIOLOGICAL INVESTIGATIONS - DO JUNIOR DOCTORS KNOW THEIR PATIENTS? Jun Cho, Dave Bosanquet, Nia Williams, D Gower, Kate GowerThomas, Michael Lewis Royal Glamorgan hospital, Pontyclun, UK Aim: To ascertain clinicians' knowledge Hornby Steve of their patients when requesting radiological investigations, as required legally by government legislation "Ionising Radiation (Medical Exposure) Regulations 2000" (IRMER 2000). ASiT requests received every Monday, excluding plain films, were collected prospectively over 8 Method: All radiological investigationDirector of Education weeks. Data included grade of requesting doctor, their specialty, type of modality requested, knowledge of their patient and appropriGeneral Surgery Registrar, South West Peninsula ateness of the investigation. There were no exclusion criteria. Statistical analysis was performed using a two tailed Fisher's exact test. Results: Of the 164 requests received, the majority (61%) was made by Foundation Programme 1 (FP1) doctors. General medical specialties accounted for the highest proportion of requests (45%). Ultrasound was the most requested imaging modality (47%), followed by Computed Tomography (42%). Almost a third (30%) of the requests were made by doctors who had not seen the patient to be investigated, predominantly by FP1local ASiT Welsh Regional Representatives: 10% of requests were With thanks to the doctors (p=0.003) and general medical specialties (p=0.001). Overall, deemed inappropriate. This study states that almost one third of radiological requests were made by junior doctors who have not Conclusion:Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor seen the patient concerned and were therefore not fulfilling IRMER 2000 criteria. This potentially exposes patients to unnecessary/inappropriate radia Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff tion and wastes valuable resources.

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0824 TITLE: BECOMING A FEMALE SURGEON: DO FEMALE SURGICAL ROLE MODELS REALLY MATTER? Hui-Ling Kerr, Jennifer Cade Cheltenham General Hospital, Gloucestershire, UK Background: Women represent over half the number of medical students in the UK, despite this, few apply to become surgeons. A lack of female surgical role models has been suggested in the past as an influencing factor. Aim: To determine which factors deterred UK female junior doctors and medical students from a surgical career and the significance of female surgical role models. Materials and Methods: An anonymous voluntary paper survey was given out to female final year medical students and Foundation doctors in 2 hospitals in autumn 2010. Results: Of 46 female final year medical students 30% planned a career in surgery compared to 12% of 50 female Foundation doctors (P<0.05). Work/life balance was the main reason cited for rejecting a surgical career. 61% of medical students and 56% of foundation doctors had encountered a female surgical role model. Of those who had not, 50% in each group felt that if they had, it may have persuaded them to consider a surgical career. Conclusion: Work/life balance is still cited by newly qualified female doctors as the main deterrent to a career in surgery. Exposure to female surgical role models may not be as an influencing factor as previously thought.
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0835 OESOPHAGO-GASTRODUODENOSCOPY YIELD IN PATIENTS WITH COELIAC DISEASE PRESENTING WITH IRON DEFICIENCY ANAEMIA: A RE-AUDIT Kate Perryman, Sam Enefer, Andrew Todd, Kamran Khatri, Mazin Sayegh Western Sussex Hospitals NHS Trust, Worthing, UK Objectives: In our previous audit it was shown that the majority of patients with iron-deficiency anaemia (IDA) suspected of having coeliac disease (CD) underwent oesophago-gastroduodenoscopy (OGD) and duodenal biopsy as a routine procedure, but only 0.2% patients had serum coeliac screening prior to OGD. The purpose of this current study was to complete the audit cycle. Methods: Data related to histology and serum coeliac screen of all patients with IDA undergoing OGD in a District General Hospital from January 1st to October 31st 2011 were evaluated. Results: A total of 732 patients with IDA were referred for OGD. There were 282 male patients with a mean age of 69.1 years. Duodenal biopsy was performed in 610 patients (83.3 %); CD was confirmed in 17 patients (2.8%). Duodenal biopsy was normal in 593 patients (97.2 %). A total of 122 patients (16.7 %) had serum coeliac screening prior to OGD; 7 cases (5.7%) were positive. Conclusion: Completing the audit cycle it was found that, although there was an improvement with more patients undergoing coeliac screen before OGD but the majority (83.3 %) of patients with suspected CD presenting with IDA continue to undergo OGD and duodenal biopsy as a routine procedure. 0860 TRAINING OPPORTUNITIES IN EMERGENCY GENERAL SURGERY Mersey Emergency Surgery Audit (MEnSA) Study Group Mersey Research Group for Surgery (MeRGS), Merseyside, UK Aim: Recent guidance from the Royal College of Surgeons suggested high-risk emergency surgical cases should be supervised by a consultant surgeon. We sought to assess impact on emergency surgical training. Method: In 8 acute trusts, all emergency general surgery operations were identified during a 30-day period in 2011. Operative details were recorded. Risk prediction was calculated using P-POSSUM (predicated mortality >10% high-risk). Data was analysed centrally. Results: 494 procedures were performed on 471 patients. Overall mortality was 5%(24 patients). A consultant was present during 164 (33.2%) of operations, being the primary operator in 116(23.5%) and supervising the trainee in 48(9.7%). Trainees performed the procedure unsupervised in 313(63.4%) cases. 65(13%) cases were deemed high-risk. A consultant was present in 46(70.1%) of these cases, supervising a trainee in 7(10.8%). 15 (23%) high-risk cases were performed solely by trainees. Conclusion: To comply with the guidance only 19(4%) of all emergency surgical cases require additional consultant input. These cases offer invaluable learning opportunities for trainees, however only 7(10.8%) of patients deemed high-risk were operated on by trainees under consultant supervision. The focus should be on consultant supervision rather than consultant-led operating to maximize experience. 0866 THE WEBSITES OF THE SPECIALTY COLLEGES: ENLIGHTENING OR EXASPERATING? Hannah Sellars, Mary O'Hanlon Defence Medical Services, Staffordshire, UK Introduction: The move towards online learning, portfolios, research and guidelines draws clinicians to the college websites. Aims: To critically evaluate the websites of eighteen medical speciality colleges in the United Kingdom and Ireland with an objective scoring system. Methods: We adapted a system for evaluating web-based information (E. Kirk, John Hopkins University) to evaluate college websites. The adapted criteria were defined as: authorship, transparency, core resources, currency, design and usability. Using objective questions to test the criteria, we produced a scoring system which was applied to each website. Results: The websites were scored and the three highest rated are as follows: in third place The Royal College of General Practitioners, in joint second were the Royal College of Physicians (London) and Royal College of Surgeons in Ireland and in first place with the highest rating, the Royal College of Surgeons of England. Conclusion: These websites are key in the way the colleges interact with both medical professionals and the public. Our subjective opinion that the websites varied in their effectiveness as a resource, correlated with variability in the scoring. We found that many of the college websites have the potential to deliver more for their users.
0884 HOW CAN WE ENHANCE UNDERGRADUATE MEDICAL TRAINING IN THE OPERATING THEATRE? A SURVEY OF STUDENT ATTITUDES AND OPINIONS edd, Bangor S.J. Chapman, A.R. Hakeem, G. Marangoni, KR Prasad St. James's al of Wales, Cardiff University Hospital, Leeds, UK Aims: Attending theatre may add substantial value to undergraduate medical education. At present, student participation is left largely to individual initiative. We assessed student attitudes towards theatre participation to see how the experience could be improved. Methods: m: info@asit.org All students from Leeds School of Medicine were invited to complete an online-based questionnaire. Responses relating to previous experiences, desired improvements, acquired benefits, impact on career aspirations and attendance were gathered. Stu-
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Bariatric Fellow, North Tyneside 0893 ANATOMY IN UNDERGRADUATE MEDICAL EDUCATION: A SURVEY OF STUDENT PERCEPTIONS. S.J. Chapman, A.R. Hakeem, G. Marangoni, K.R. Prasad St. James's University Hospital, Leeds, UK Aims: A shift away from cadaveric dissection in UK medical curricula has emerged. The impacts of this on future anatomical and surgical competences are unclear. We assessed student perceptions to different methods of Anatomy teaching. Methods: All 2nd-year students from Leeds School of Medicine were invited to complete a questionnaire. Participants rated six teachEd Fitzgerald ing methods (dissection; prosection; lectures; demonstration models; computer software packages; living anatomy & medical imaging) ASiT Conference Organiser & Past-President on a 5-point scale against pre-determined learning objectives. Categorical variables are expressed as mean+/-SD versus:[all other variables]. An unpaired t-test was performed (p<0.05 considered statistically significant). General Surgery Registrar, London Results: 170 students (68%) responded to the survey. Cadaveric dissection and prosection were preferred to instil anatomical knowledge (4.6+/-0.7 and 4.6+/-0.7 versus:[3.7+/-0.8];p<0.0001). Dissection was also preferred to: provide a 3-D appreciation of the body (4.9+/-0.5 versus:[3.6+/-1.0];p<0.0001), appreciate anatomical variation (4.7+/-0.7 versus:[3.1+/-1.1];p<0.0001) and encourage selfdirected learning (3.9+/-1.1 versus:[3.2+/-1.2];p<0.01). Lectures were preferred to provide a background for basic sciences (4.0+/-0.9 versus:[3.1+/-1.1];p<0.0001) and to relate structure to pathology (4.0+/1.0 versus:[3.3+/-1.1];p<0.01). Clinical anatomy was best appreciated through living anatomy & medical imaging (4.1+/-1.1 versus:[3.7+/-1.1];p<0.001). Jonny Wild Conclusions: Cadaveric dissection is a favourable approach for achieving important learning objectives in Anatomy. Further evaluation of teaching methods is required before further changes are made to& Sponsorship Co-ordinator ASiT Honorary Secretary undergraduate medical curricula General Surgery Registrar, Sheffield 0898 ROLE MODELS AND MENTORSHIP IN SURGERY IN THE CURRENT ERA Nuala Healy, Ronan Glynn, Peter Cantillon, Michael Kerin NUI Galway, Galway, Ireland Aim: The aim of this study was to evaluate the prevalence of role models and mentors among medical students and surgical trainees and to determine how the process of mentoring works. Method: A 35-point online questionnaire was distributed to medical students at NUI Galway and members of ASiT, including questions Robert Davies regarding mentorship and role models and questions relating to the mentorship process. ASiT Honorary Treasurer Results: A total of 163 medical students and 216 surgical trainees completed the questionnaire. 80% (n=124) of medical students did not have a mentor but 51.7% Vasculartrainees claim to having a surgical mentor. 64% (n=88) of students but only 37.6% (n=61) of (n=104) of Surgery Registrar, West Midlands trainees would like to be involved in a formal mentoring programme. Only a third of students had identified a role model in medicine, while over half had identified a negative role model. 70% (n=151) of surgical trainees had identified a role model and 77% (n=112) had identified a negative role model in surgery. Important role model and mentor traits were identified by each group. Conclusions: There is a low prevalence of role models and mentors within surgery and this study illustrates the need to promote mentorship of medical students and trainees.
dents rated their overall satisfaction on a 10-point scale. Results: 287 students(20%) responded to the survey. 88% had previous theatre experience. The median overall satisfaction was 7/10. Desired improvements included: more opportunity to assist the surgeon(75%); more structured teaching(71%); feedback on performance(54%); and better induction to the theatre environment(57%). The described benefits of attending theatre were improvements in: scrub technique(82%); knowledge of anatomy(72%), anaesthetics(67%) and surgical procedures(86%). There were heterogeneous answers regarding the role of theatre in encouraging a surgical career. The totality of students who had never attended theatre would do so if given the opportunity. Goldie Khera Conclusions: Many benefits can be derived from attending theatre but these may be offset by other factors. The experience may be of increased value to medical education President ASiT if a better structured teaching programme is developed.
James Milburn 0934 MICROSURGICAL SKILLS STATION - A PRACTICAL WARD-BASED MODEL TO IMPROVE PLASTIC SURGICAL SKILLS ASiT Vice-President Richard Chalmers General Surgery Registrar, Inverness The James Cook University Hospital, Middlesbrough, UK Introduction: Various microsurgical training techniques have been published including anastomosis training on cadavers, chicken wing arteries and live pocine or rat models. Whilst in vivo vessels to practice on are ideal, the availability, cost and practicalities of these techniques are limiting. Cheaper and more accessible training formats are required to allow trainees to gain invaluable skills outside of the operating room. Microsurgical skills station: I have designed and built 2 workstations which aim to increase the practical knowledge and physical dexterity of trainees in microsurgical techniques. The first uses a surgical glove construct to practice various end-end and end-side anasJoseph Shalhoub tomosis techniques. The second comprises completing a sewing needle "Slalom Course" through which the trainee is timed using ASiT Vice-President microsurgical instruments and a 9/0 suture under the microscope. Improved course times are taken as an improvement in practical Vascular 10 and has proven to be of great educational value to our trainees. skills. The cost of the skills station is underSurgery Registrar, London Conclusion: Surgical training is evolving. Trainees need to be at the centre of this change to influence and enhance training opportunities and experience. This simulation/workstation is a cheap, reproducible and simple way of improving surgical skills and dexterity outside of the operating room.
0950 Steve Hornby PEER TO PEER CROSS-COVER SHO TEACHING, AN UNDERUTILISED AND USEFUL EDUCATIONAL TOOL ASiT Director of Nehmat Singh1, Vinay Varadarajan2, Jonathon Liew3 Education 1 North West ENT Surgery Core Surgical Training Scheme, Manchester, UK West Peninsula General Surgery Registrar, South 2 North West ENT Surgery Higher Surgical Training Scheme, Manchester, UK 3 Department of Maxillofacial Surgery, North Manchester General Hospital, Manchester, UK Aim: To measure the effectiveness of peer to peer SHO teaching in improving the confidence and knowledge of cross-cover trainees out of hours Method: With thanks to the local ASiTcross-cover Regional Representatives: covering ENT) was unA prospective three month study following six Welsh MaxFax SHOs (dentally trained and cross dertaken. Confidence levels in dealing with a medical emergency (ECG changes in ST elevation MI) and an ENT emergency (acute Miss Rhiannon Harries, General Surgery Registrar, ENT SHO was selected to provide paediatric epiglottitis) were measured via a secure online questionnaire. A senior Ysbyty Gwynedd, Bangor teaching on the above topics, then confidence levels were reassessed. Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Results: The response rate to both online questionnaires was 100%. Before the teaching sessions, 100% did not feel confident in identifying ST elevation on ECGs and 83.3% were not confident in the initial management of acute paediatric epiglottitis. All respondents agreed that peer to peer teaching would improve the quality of patient care and service provided. After interactive teaching sesWith thanks to the wonderful ASiT Conference Admin team: info@asit.org sions, marked improvement was demonstrated with 83.3% confident in identifying ST elevation on ECGs (p-value: 0.0152) and 66.6%
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felt confident in the initial management of paediatric epiglottitis (p-value: 0.242). Conclusion: Senior SHO led departmental peer to peer teaching is a useful tool in improving confidence in out of hours cross-cover trainees.
0973 DEVELOPING AN AFFORDABLE SIMULATOR OF LAPAROSCOPIC TECHNIQUES FOR UNDERGRADUATE TRAINEES Joseph Norris, Matthew Smith Brighton and Sussex Medical School, Brighton, UK Aim: To produce an affordable and effective laparoscopic simulator for undergraduate trainees. Method: A pattern was produced to build a novel laparoscopic simulator, for under 100; using a handsaw, drill and screwdriver. This consisted of an opaque plastic crate with a plywood base, two trochars and disposable laparoscopic instruments. A laptop was used in combination with LEDs and a webcam to visualise the box interior. A more realistic laparoscope-like deluxe' version can be produced with slightly more technical ability. Results: The described set up has allowed undergraduate trainees to gain familiarity with laparoscopic techniques, beginning with simple manipulation, progressing through to more relevant procedures. Novices begin by moving easy to grasp objects (e.g. beads) between containers, then attempt more challenging manipulations, such as stacking sugar cubes, threading polo-mints onto cotton and tying suture material to ligate' fastened drinking straws. These techniques introduce the necessity of careful instrument placement and increase students' comfort and dexterity with laparoscopy. Conclusions: It is difficult for undergraduates to gain exposure in laparoscopic skills, a now common surgical technique. Here, we demonstrate an affordable alternative that has given many undergraduates important experience with laparoscopic techniques, allowing them to safely improve their manual skill and confidence. 1014 A SYSTEMATIC REVIEW INTO THE INCIDENCE AND CAUSES OF INFERIOR EPIGASTRIC ARTERY (IEA) PSEUDOANEURYSM AND THE EVOLVING TREATMENT TRENDS Alison Hunter, Oliver Gosling, Andrew Stewart Musgrove Park Hospital, Taunton, UK Aims: Review reported incidence and causes of IEA pseudoaneurysm, and evolving treatment preferences. Methods: Literature review using Medline and PubMed; search terms inferior epigastric artery, pseudoaneurysm, false aneurysm, treatment. Review of relevant cited cross-references. Results: Reported IEA pseudoaneurysm cases have increased significantly (p = 0.005) over the last thirty years. In total 25 cases of IEA pseudoaneurysm have been reported since 1973; 56% in the past ten years. Prior to 2001 abdominal retention sutures were the commonest known aetiology. Since 2001 trochar insertion has become the joint leading cause of IEA pseudoaneurysm alongside open abdominal surgery. The most frequent treatment of choice since 2001 is percutaneous coil embolisation (50% vs. 10% pre2001), replacing open surgical excision (21% vs. 70% pre-2001). Conclusions: Incidence of reported IEA pseudoaneurysms is rising. Laparoscopic trochar insertion is increasingly reported as the cause. Treatment options have evolved; percutaneous coil embolisation has replaced traditional surgical excision as the leading treatment of choice. As laparoscopic surgery continues to gain in popularity, promoting awareness of trochar-induced IEA injury and the potential complications is critical to reduce patient morbidity. 1017 AN EVALUATION OF PLASTIC SURGERY IN UK MEDICAL SCHOOLS Sridhayan Mahalingam1, Puja Kalia2, Arjuna Nagendran1 1 University College London Medical School, London, UK 2 University of Leeds, School of Medicine, Leeds, UK Background & Aim: Although plastic surgery is a postgraduate specialty, career choices are increasingly made as a medical student. Whilst medical schools are required to provide structured teaching in surgery the proportion devoted to plastic surgery remains unknown. The aim of this study was to investigate UK medical student opinions of this field. Methodology: Using a questionnaire-based format, issues addressed include: satisfaction with teaching, exposure and consequent impressions of this specialty. Results: 160 medical students were recruited from 7 medical schools nationally. Almost half of medical students have considered plastic surgery as a career choice. 60% of students have had no exposure; 80% are unsatisfied with current provisions for plastic surgery teaching. Average exposure to medical students was 1.6 hours; 91% felt this insufficient in making an informed career choice in this field. Student impressions were predominated by the financial gains. Conclusions: There is limited exposure to plastic surgery within the UK medical school curriculum. The lack of experience in such a diverse field may reflect students stereotypically associating this specialty with glamour. Greater undergraduate exposure would enable students to make an informed career choice in plastic surgery whilst providing them with a skill set pertinent for any surgical career.
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1034 ESTIMATION OF OPERATIVE MORTALITY BY CLINICIANS David Allin, Alastair Dick Charing Cross Hospital, London, UK Aim: Accurately predicting the risk of operative mortality facilitates the process of gaining informed consent and optimises perioperative planning. Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) is a tool that has been extensively used to estimate operative risk. Our aim was to compare clinicians estimations of risk with those estimated by POSSUM. Method: Clinicians were asked to complete a questionnaire presenting twelve case scenarios and asked to estimate the thirty-day operative mortality for each case. The means of the estimates for each case were compared to the POSSUM predicted mortalities. Further subgroup analysis compared junior doctors with consultants and anaesthetists with surgeons. tives: Results: Fifty clinicians at a London teaching hospital completed the questionnaire in November 2009. There were ten consultants edd, Bangor and forty junior doctors, sixteen anaesthetists and thirty-four surgeons. For nine of twelve scenarios (75%) clinicians underestimated the risk al of Wales, Cardiffas compared to POSSUM. For eight of twelve scenarios (66.7%) junior doctors estimations were closer to POSSUM than consultants. For eight of twelve scenarios (66.7%) anaesthetists estimations were closer than surgeons. Conclusion: Clinicians of all grades underestimate operative mortality compared to a validated tool. Anaesthetists may be better at predicting m: info@asit.org risk than surgeons.
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1041 SURGICAL EXPOSURE AND TRAINING IN GENERAL PRACTICE VOCATIONAL TRAINING SCHEMES. Elizabeth Ward, Helen Hawkins, Peter Coyne, Maziar Navidi The Christie Hospital, Manchester, UK Aim: To ascertain the amount of GPVTS trainees receiving any formal surgical training. Method: By accessing recruitment websites and contacting UK deaneries we established the exposure of trainees to surgical specialities. Results: Of the 1565 rotationsGoldie there were 226 (14.4%) surgical posts. The posts offered were 83 ENT, 102 Orthopaedic , 29 identified, Khera General Surgery/Urology and ASiT President specialities. 12 combined surgical Conclusions: As fewer foundation trainees are exposed to surgical specialities, postgraduate experience is decreasing. The impact of Bariatric Fellow, North Tyneside this is doctors in specialities providing basic management and surgical referrals have no formal surgical training other than as an undergraduate. In time this could have an impact on inappropriate use of emergency and outpatient resources. GP VTS have limited opportunities to expand their surgical experience yet after a short course may be responsible for performing various minor surgical procedures. There could be the opportunity to offer more surgical posts to GPVTS trainees at a time when there are difficulty filling surgical rotas as core trainee numbers are decreasing. While GP training is being considered for longer term, integration of these schemes may lead to an improvement in the training of GPs and Surgeons which will positively impact on future surgical services.
ASiT Conference Organiser & Past-President 1044 THE ROLE OF SURGICAL SKILLS TEACHING IN THE UNDERGRADUATE MEDICAL CURRICULUM General Surgery Registrar, London Amy Coates1, Mudit Matanhelia1, Benjamin Soukup2, Meghana Kulkarni1, Selina Bismohun3 1 St George's, University of London, London, UK 2 Bristol Royal Infirmary, Bristol, UK 3 Great Western Hospital, Swindon, UK Aim: Surgical skills teaching is currently a small part in the undergraduate medical curriculum. The aim of our study was to see if a half day surgical skills course for medical students could improve knowledge and surgical skills. Jonny Wild Method: A four hour surgical skills workshop for medical students was established. Three core skills were included; suturing, knot tying and laparoscopy. Students completed a questionnaire before and after the course. Questions related to knowledge and confidence in ASiT Honorary Secretary & Sponsorship Co-ordinator performing surgical skills, and their views on surgical skills teaching and training at medical school. Responses were recorded on a 5General Surgery Registrar, Sheffield point Likert scale. Results: The course was attended by one hundred and three students, from eight universities in the UK. Paired analysis of responses showed a significant improvement across each of the workshops with a mean increase of 92% (p<0.01). 79% of attendees reported they did not receive enough surgical skills teaching at medical school and wish to have a surgical skills course as part of the curriculum. Conclusion: A half-day surgical skills session is a simple and effective format for improving knowledge and confidence in surgical skills. Medical students believe the current undergraduate curriculum does not provide enough time to learn surgical skills. Robert Davies
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ASiT Honorary Treasurer 1072 THE ANALYSIS OF VIDEO RECORDINGS AS A METHOD FOR ENHANCING SELF-ASSESSMENT WITHIN SURGERY. LEARNVascular Surgery Registrar, West Midlands ING FROM APPROACHES USED BY EXPERT MUSICIANS Hannah Winter, Jacqueline Rees Imperial College, London, UK Introduction: With limitations within surgical training, methods to promote efficiency of learning are required. Self-regulation is a framework for lifelong learning which has demonstrated the ability to accelerate learning. An integral component of this is accurate selfassessment, a skill that is lacking amongst doctors. Musicians, however, rely on this, developing self-critical faculties throughout their training. As such, a review ofJames Milburn an understanding of potential approaches towards developing self-assessment musicians may provide within surgery. ASiT Vice-President Methods: Retrospective semi-structured interviews were performed with four expert cellists. Thoughts and perceptions towards the General Surgery Registrar, Inverness development of musical skill were explored and analysed to identify specific approaches to self-assessment. Results: The musicians, placing great importance on their ability to self-critique, frequently used recordings of performances to analyse specific aspects of their skill. This was often with the guidance of master teachers and in the presence of peers. This approach developed their ability to self-assess, critique and thereby refine skill. Conclusions: Several factors are involved in the development of self-assessment. However, specific resources, including the use of video recordings were highlighted by musicians as assisting in developing the ability to self-critique. Integrating this within surgical training could develop self-assessment amongst surgical trainees and thereby accelerate learning and development. Joseph Shalhoub ASiT Vice-President
1098 Vascular Surgery Registrar, London 'DANGEROUS MONTH' OF AUGUST: FACT OR FICTION? Zoe Lin, George Kerans, Debasish Debnath, Lorna Cook, Isabella Karat, Raouf Daoud, Ian Laidlaw Frimley Park Hospital, Frimley, Surrey, UK Aim: August, when new doctors start, is portrayed in the media as a dangerous month'. We aimed to assess whether joining of newly qualified doctors in August affected the unplanned readmission rate in a breast unit. Method: Retrospective study of all breast-related emergency admissions (January 2009- December 2011). Steve Hornby Results: A total of 140 breast-related emergency admissions took place, of which 8.1% (n=12) took place in months of August. . Forty ASiT Director of Education eight cases were readmissions following recent surgery. Only three readmissions (6.2%) took place in the months of August. There was no significant difference of age of patients readmitted in August (45.213.2 years), compared to other months (51.213.2 years) General Surgery Registrar, South West Peninsula [p=0.46]. Incidence of readmission was not higher in months of August (n=3; 6.2%48), compared to other breast related emergency admissions (n=9; 8.9% of 101) (Pearson Chi Square=0.31; p=0.57). There were no significant early discharges resulting in early readmissions in months of August. Conclusions: Unplanned breast-related emergency readmission rate was not higher in months of August. This is not surprising as the newly qualified doctors are expected to work following Welsh induction and under supervision. This challenges the unfair media With thanks to the local ASiT thorough Regional Representatives: portrayal of junior doctors at the beginning of their career. 1099 Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff TRAINING OPPORTUNITIES IN THE EMERGENCY OPERATING LIST Matthew Clapham, Judith Ritchie, Arin Saha, Athur Harikrishnan Doncaster Royal thanks to the South Yorkshire, UK With Infirmary, Doncaster, wonderful ASiT Conference Admin team: info@asit.org Introduction: Management of emergency general surgery admissions is essential for surgical training. Recent guidelines have recom-
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mended consultant-level input for higher risk surgical patients. This audit assessed whether these could be combined in a district hospital setting. Methods: There is an acute 'CEPOD' operating theatre at our hospital. All operations in this theatre were audited from August to September 2011. Demographics of the patients, primary surgeon, consultant involvement and details of the operations were recorded. Results: There were 229 operations, of which 55(24%) were at night. There were 193(84%) general surgical, 24(11%) vascular and 13 (5%) urological operations. The majority of cases were abscess drainage (n=46, 20%), laparotomy (n=44, 19%) and appendicectomy (n=37, 16%). An SpR was primary surgeon in 183 cases (80%). Of SpR cases, a consultant was scrubbed in 71 operations (39%). There were no differences in operating time between SpR and consultant cases. Consultants were present in 45% of cases at night and during the day. Conclusions: Consultants were involved in almost half of all acute operations, throughout an on-call period. With a dedicated acutesurgical SpR and encouragement to teach combined with senior-level input, good training opportunities and consultant-led care can both be delivered for emergency general surgical operations. 1118 THE EARLY CONSEQUENCES OF THE THE MODERNISING MEDICAL CAREER (MMC) ERA ON SURGICAL RESEARCH CONDUCTION IN WALES Amir Kambal1, Sue Hill2, Colin Ferguson3, Louis Fligelstone3, Nick Sevdalis1 1 Imperial College, London, UK 2 University Hospital of Wales, Cardiff, UK 3 Morriston Hospital, Swansea, UK Aim: The introduction of MMC has had a substantial impact on the structure of surgical training in the UK. However, its effect on academic or research surgery is yet to be assessed. Method: An online survey was conducted targeting the higher surgical trainees (HST) in Wales region in 2009. The data collected included their level of training, the number of audit, research projects and publications they produced before and after HST. Results: 30/54 HST attempted the survey, 12 Specialist Registrars (SpRs), 18 Speciality Registrars (StRs). Before HST the SpRs had a greater number of laboratory projects (p=0.002), presentations (p=0.004), writing of research projects (<0.001) and total publications (p=0.002). Conversely, the StRs had significantly more audits (p=0.02). After obtaining the HST the trend continued. Typically the amount of research projects performed (p=0.03), presented (p=0.02), written (p=0.004) and total publications (p=0.01) were larger in the SpRs group. Audit productivity between the two groups levelled out after obtaining HST. Conclusions: The results suggest that in the early period following the introduction of the MMC programme, the research experience gained before HST by SpRs equipped this group better for research productivity. Future similar surveys are required to see if this effect is permanent. 1174 ORGANISING CLEFT LIP AND PALATE SURGERY MISSION TRIPS IN CHINA - A TRAINEE'S PERSPECTIVE Charles Loh, Alex Loh, Philip Lim Royal Hallamshire Hospital, Sheffield, UK Introduction: Cleft Lip and Palate Surgery is commonly performed by Plastic Surgeons in austere conditions around the world. As a trainee, taking part and learning how to organise such a trip can prove invaluable and diversifies our training experience. Methods: A strong emphasis on the multidisciplinary aspect of Cleft Lip and Palate surgery is paramount. Under the guidance of Emeritus Professor ST Lee of the Singapore General Hospital Plastic Surgery Department, we describe the process of starting up a mission trip to Hainan, China. The involvement of health professionals including Plastic Surgeons, Anaesthetists, Orthodontists and Speech and Language Therapists are key to a successful mission trip. Results: Having participated in two consecutive years, each yearly mission trip was a success. In total, 46 patients were screened and 31 of those (ages 4 months to 27 years of age) were operated on. A total of 19 patients were referred for Speech and Language therapy. A total of 7 patients had dental procedures done. Conclusion: As a trainee, I believe that such trips provide a learning opportunity to work in an environment different from that in the UK. It also concentrates learning and broadens our exposure to Cleft Lip and Palate Surgery.
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1204 TRAINING OPPORTUNITIES FOR CORE TRAINEES IN OPEN ELECTIVE INGUINAL HERNIA REPAIR A FOUR-YEAR EXPERIENCE FROM DISTRICT GENERAL HOSPITAL Tou Pin Chang, Leszek Wolowczyk Tameside Hospital NHS Foundation Trust, Ashton-under-Lyne, UK Aim: The aim of this study is to investigate current trends in the provision of training opportunities for open elective inguinal hernia repair following the implementation of EWTD. Methods: We conducted a retrospective study on 569 consecutive open and laparoscopic inguinal hernia repairs between 2007 and 2011. We retrieved the relevant details from theatre registers and cross-checked the data retrieved with logbooks of Core Trainees where possible. Results: Overall numbers of open inguinal hernia repairs performed had decreased from 184 in 2007 to 120 in 2011 with a mean percentage decrease of 13% per year. The proportion of laparoscopic hernia repairs performed increased significantly over the last four years (18% vs 38%, Chi-square test; p<0.01). The proportion of open inguinal hernia repairs attended by Senior House Officer (SHO) grade decreased significantly between 2008 and 2011 (51% vs 24%, Chi-square test; p<0.01). In particular, there were no significant differences in the attendance of Core Trainees as compared to non-trainee grade SHOs. Conclusion: The reduction in overall case volume and increase in laparoscopic repairs further diminished training opportunities for Core Trainees in open elective inguinal hernia repair. Targeted theatre attendance might reduce missed training opportunities in the era of EWTD.
1207 SPORTS HERNIAS - OPERATION TO FULL RECOVERY IN 2 WEEK WITH NEW TECHNIQUEMR K.THIRUPPATHY, MR. P. LYON, MR S.J SNOOKS, DEPARTMENT OF SURGERY, KING GEORGE HOSPITAL, ILFORD, LONDON tives: Kumaran Thiruppathy, Paul Lyon, Steve Snooks edd, Bangor King George Hospital, Ilford, Essex, UK Introduction: Inguinal sports hernias affect 5-28% of athletes disrupting their livelihood. It is characterised by a weakness of the transal of Wales, Cardiff versalis fascia. Many methods exist to repair these hernias using open and laparoscopic techniques. We present our series using an open hernia repair technique using, with a self adhesive mesh versus open repair with a non adhesive mesh. Methods: m: info@asit.org Four hundred and sixty professional male athletes noted clinically and confirmed radiologically to have groin hernias were operated on between 2005 -2010, with 70% having bilateral repairs. 202 Patients had open hernia repair - a non-adhesive mesh, 256
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patients had open repair with a self adhesive mesh (pro-grip mesh, Covidian). Patients were seen 1 weeks post operatively by the operating surgeon and then by team medics. Results: Open technique with placement of the pro-grip mesh could be performed through a small incision 3cm VS 5cm. Athletes were able to return to team normal sporting activity at 2 weeks. Conclusion: Open technique using a pro-grip mesh has a far superior outcome as patients required a smaller incision and less tissue dissection. With this technique Athletes had a faster return to training and full sporting duties compared to conventional techniques.

Goldie Khera
TRANSPLANT SURGERY
0002 EFFICACY OF TRANSVERSUS ABDOMINIS PLANE BLOCK IN LAPAROSCOPIC LIVE DONOR NEPHRECTOMY- A SINGLE CENTRE EXPERIENCE Umsankar Mathuram Thiyagarajan, Atul Bagul, Sarah Hosgood, Rupley Pande, Inthira Jeyapalan, Michael Nicholson University Hospitals of Leicester, Leicester General Hospital,, Leicester, East Midlands, UK Aims: Post-operative wound pain is a disincentive to potential live kidney donors. The transverse abdominis plane (TAP) block is a technique where the local anaesthetic agent is given to block the afferent nerves of the abdominal wall. The aim of this study was to Ed Fitzgerald determine the effectiveness of pre-operative transverse abdominis plane blocks on post-operative pain after laparoscopic live donor ASiT Conference Organiser & Past-President nephrectomy (LLDN). Methods: A consecutive series of 50 patients receiving TAP blockLondon General Surgery Registrar, prior to LLDN were compared to a historical control group of 50 patients who had no TAP block. Results: Patients in the TAP group required significantly less post-operative morphine (22.829.2 mg) versus (57.431.7 mg); P<0.0001), oral analgesics and anti-emetics compared to the control group. Similarly TAP group discontinued their PCAS quicker than patients in the control group (1.270.59) days versus (1.880.65) days; P<0.0001). Post-operative pain scores (P < 0.0001) and sedation scores (P < 0.0001) were lower in TAP block group compared with controls. The length of hospital stay was lower in TAP than the control group (4.31.10) days versus (5.141.12) days respectively; P= < 0.0034. Conclusion: The transversus Jonny Wild abdominis plane block provides a safe and highly effective form of post-operative analgesia in patients undergoing laparoscopic donor nephrectomy. ASiT Honorary Secretary & Sponsorship Co-ordinator
General Surgery Registrar, Sheffield 0015 EARLY REMOVAL OF URETERIC STENTS AND ITS IMPACT ON REDUCING THE URINARY INFECTION IN RENAL TRANSPLANTATION- A SINGLE CENTRE EXPERIENCE Umasankar Mathuram Thiyagarajan, Prarthana Thiyagarajan, Atul Bagul, Michael Nicholson University Hospitals of Leicester, Leicester General Hospital, Leicester,England, UK Aims: Urological complications, in particular urinary tract infection (UTI) are common, debilitating and affect graft survival, increases morbidity. The study was aimed to assess early removal of ureteric stent and its impact on the incidence of UTI, major urological comRobert Davies plications (MUC), graft function and rejection episodes. ASiT Honorary Treasurer Methods: The study was carried retrospectively on 127 consecutive renal transplant recipients from 2007-2009 with 1year followup. Among 127 recipients, 48Vascular Surgery Registrar, West Midlands them removed at 4-6 weeks after transplanof them had stent removal on day 5 while remaining 79 had tation with flexible cystoscope. Results: The 127 consecutive renal transplant recipients are included in this study (live donor: n = 85 and cadaveric: n= 42). All recipients were grouped in two arms based on either early (ESR) or late US removal (LSR). The incidence of UTI at 3 months after transplant between ESR and LSR groups were 12/48 (25%) and 35/79 (44%) respectively; P=0.03. The incidence of MUC in ESR is 2/48 (4%)\ while in LSR groups is 6/79(7%); P= 1.0. Conclusions: The ESR significantly reduces the risk of UTIs in renal transplant patients with no associated increase in MUC in addiJames Milburn tion to patient avoiding a further procedure for ureteric stent removal.
0692 General Surgery Registrar, Inverness TACROLIMUS PRELOADING IN RENAL TRANSPLANTATION FROM LIVE DONORS 1 Karl Pang , Murali Somasundaram2, James Gilbert2 1 Department of General Surgery, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK 2 Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK Aim: To report the outcomes of renal transplantation from live donors (LD) in patients receiving pre-transplant Tacrolimus (TAC) loading in a single transplant unit. Methods: A retrospective analysis was performed of LD renal transplants between July 2008- 2010, Patients were preloaded with TAC Joseph Shalhoub prior to transplantation (0.05mg/kg twice daily), beginning 4 days preoperatively. TAC levels were measured preoperatively (day 0) ASiT Vice-President and target range was 8-10 ng/ml. Patient and graft outcomes were analysed using standard statistical methods. Results: In the cohort (n=81) Vascular Surgery Registrar, 10.5 (+/- 7.0). 3 patients had delayed graft function (DGF, day 0 the mean (SD) day 0 TAC level was London TAC levels of 3.9, 7 and 8.6). 20 graft biopsies were performed demonstrating; rejection (n=10), TAC toxicity (n=7), disease recurrence (n=2) and vascular occlusion (n=1). Mean (SD) day 0 TAC levels in these groups were 9.6 (+/- 4.3), 11.6 (+/- 7.2), 17.0 (+/- 16) and 11.6 respectively. Appropriate statistical comparisons were made between groups. Conclusions: Therapeutic TAC levels were achieved with a pre-operative loading regimen in the majority of patients, even those who developed rejection, DGF and TAC toxicity. Further analysis and comparison with non preloaded patients is necessary to determine Steve Hornby the efficacy of this treatment. 0863 General Surgery Registrar, South West Peninsula USE OF AORTIC ALLOGRAFT IN RETROHEPATIC INFERIOR VENA CAVA RECONSTRUCTION: A CASE SERIES Annalise Katz-Summercorn, Kourosh Saeb-Parsy, Neville Jamieson, Raaj Praseedom Department of Surgery, Cambridge University Academic Health Sciences Centre, Cambridge, UK Aims: Reconstruction or replacement of the inferior vena cava (IVC) may be necessary to treat IVC obstruction e.g. post-liver transplantation, or to enable tumour excision. Previous techniques have involved using synthetic or natural venous material. The optimal With thanks to the local ASiT Welsh Regional Representatives: choice of material is unclear. We aim to assess the feasibility of using aortic allograft for IVC reconstruction. Miss Rhiannon or cryopreserved aortic allograft were used to reconstruct the retrohepatic IVC were Methods: Cases in which fresh Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor recorded and followed Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff up retrospectively. Results: Since 2007 six patients have undergone reconstruction of the retrohepatic IVC with fresh or cryopreserved aortic allograft. The surgical procedure was successful in all cases, however one patient died 6 weeks post-operatively from a complication of chest drain insertion and one died 10 weeks post-operatively from tumour recurrence. With thanks to the wonderful ASiT Conference Admin team: info@asit.org Conclusions: To our knowledge, our group is the first to be using aortic allograft for the IVC reconstruction. Aortic allograft offers a
ASiT Vice-President
Laura Andrews
Kristina Gloufchev
Harriet Innes
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promising alternative to previous techniques: a better size match; decreased infection and thrombosis rate compared to synthetic graft; decreased stenosis and aneurysm formation compared to cryopreserved venous graft. We therefore recommend that in planned procedures, cryopreserved (or fresh ABO-matched) aortic allograft represents the optimal choice of graft material for IVC reconstruction.
0894 CAN REGISTRAR TRAINEES PERFORM VASCULAR ACCESS SURGERY EFFECTIVELY? Belinda Pearce, Basel Jaber, Lynn Davis, Mike Stephens, Adel Ilham Cardiff Transplant Unit, University Hospital Wales, Cardiff, Wales, UK In some centres, vascular access surgery is performed exclusively by transplant surgeons. With vascular training program reconfiguration, discussions concerning how vascular trainees can become skilled in fistula formation continue. Aim: To compare early patency rates for fistula surgery performed by trainees and consultants. Method: Data was collected prospectively between October 2010 and 2011 on 241 fistulas performed in a single UK centre. All access surgery is performed by transplant surgeons who supervise registrar trainees. Complete data was available for 197 fistulas and these were analysed (78 radiocephalic, 104 brachiocephalic, 15 brachiobasilic). Early patency rate was defined as palpable thrill and audible bruit at 6cm from the anastomosis at 2 weeks. We compared patency rates when the first surgeon was a trainee or consultant. Chisquared calculations were performed for statistical significance. Results: Early patency rate for surgery performed by registrars was 72% and for consultants 81%. This was not significant (p=0.224). Subanalysis according to fistula type revealed no significant difference (radiocephalic p =0.155, brachiocephalic p=0.729, brachiobasilic p=0.360). Conclusion: A mix of registrar grades achieved patency rates comparable with consultants. We conclude that vascular access surgery is effective when performed by trainees and provides useful skills transferable to other areas of surgery. 1112 STATIC COLD STORAGE VERSUS HYPOTHERMIC MACHINE PERFUSION FOR PRESERVATION OF MARGINAL RENAL ALLOGRAFTS; A REAL TIME COMPARISON USING RAPID SAMPLING MICRODIALYSIS (RSMD) Nicholas Bullock1, Samir Damji1, Karim Hamaoui1, Oluwadamilare Oladokun1, Martyn Boutelle2, Agnes Leong2, Michelle Rogers2, Sally Gowers2, George Hanna1, Ara Darzi1, Vassilios Papalois1 1 Department of Surgery and Cancer, Imperial College London, London, UK 2 Department of Bioengineering, Imperial College London, London, UK Aim: Static cold storage (SCS) and hypothermic machine perfusion (HMP) are two techniques used to reduce ischaemic injury sustained by renal allografts during the preservation period. We aimed to assess the feasibility of using our novel, clinically validated, rapid sampling microdialysis (rsMD) system in the organ preservation setting, and use it to compare the effects of each technique on tissue metabolism and ischaemia in real time. Method: 12 porcine kidneys were retrieved, subjected to 15 minutes of warm ischaemia and placed upon clinical models of SCS (n=6) or HMP (n=6) for 24 or 10 hours respectively. A microdialysis catheter was tunnelled into the renal cortex and connected to the rsMD analyser, producing lactate concentrations every 60 seconds. Results: HMP Kidneys displayed excellent perfusion parameters and the analyser reliably detected quantifiable concentrations of lactate in all experiments. Initial lactate concentrations were significantly higher in kidneys preserved using SCS. Conclusions: This is the first study confirm the feasibility of rsMD for monitoring the effects of SCS and HMP on renal metabolism and ischaemia in real time. The different cortical lactate profiles in the two groups suggest HMP is superior to SCS at attenuating injury accumulated during procurement and warm ischaemia. TRAUMA / EMERGENCY SURGERY 0008 A SYSTEMATIC REVIEW OF TREATMENT OF ACROMICLAVICULAR JOINT (ACJ) INJURIES Imran Haruna Abdulkareem Leeds University Teaching Hospital, Leeds, West Yorkshire, UK Hypothesis: There is not enough evidence in the literature to support either surgery or conservative treatment in the management of acute grade III ACJ injuries. This systematic review aims to establish an evidence base for effective treatment of grade III ACJ injuries. Eligibility Criteria: A review of all articles published on PubMed in English language in relation to the treatment of ACJ injuries was done. All systematic reviews, meta-analyses and randomised controlled trials (RCTs) were critically reviewed and analysed. Results of search: There were eleven studies which include a Meta-analysis, 3 Systematic reviews, a Literature review and 6 RCTs. Five of these studies recommended non-operative treatment as the best form of management for acute ACJ dislocations, among which only one clearly recommended non-operative treatment for acute grade III ACJ dislocation. The remaining six studies did not find any statistical significance between operative and non-operative treatment of acute ACJ dislocations (at least Rockwood grade III) in terms of functional outcomes and patient satisfaction. None of the studies reviewed recommended surgery as the best overall form of treatment for acute ACJ dislocations grade III-VI. Conclusion: There is no adequate literature to support the recommendation of operative management for acute grade III ACJ dislocations.
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0170 THE TRAUMA OF SURGICAL TRAINING. AN AUDIT OF TRAUMA EXPOSURE & THE IMPACT OF ATLS ON CORE SURGICAL TRAINEES IN THE NORTHERN DEANERY C Nesbitt, A Hayes, R Figueiredo, R Milligan, V Bhattacharya Queen Elizabeth Hospital, Gateshead, UK Introduction: Successful completion of Advanced Trauma Life Support (ATLS) is an essential person specification for entry into Speciality Training in General Surgery. Aim: To establish the trauma exposure Northern Deanery core surgical trainees (CST) experience, and the impact of completing ATLS on both experience and confidence in handling trauma scenarios. tives: Methods: A survey of all CST in the Northern Deanery, establishing their experience in the trauma skills taught during ATLS, and the edd, Bangor impact of completing ATLS on their procedural experience, and confidence in handling trauma. Results: al of Wales, Cardiff 39 questionnaires were completed reflecting 426 months of CST. Prior to ATLS 6 (15%) trainees had inserted a central line, 6 (15%) a chest drain, 4 (10%) an endotracheal tube and 4 (10%) an orthopaedic traction splint. Numbers did not increase significantly following ATLS. Confidence to perform trauma procedures unsupervised was unaffected by ATLS completion. Confidence to assess trauma patients did improve. No trainees had performed diagnostic peritoneal lavage, venous cut down, intra-osseous line insertion, m: info@asit.org surgical or needle circothyroidotomy.
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Conclusion: CST in the Northern Deanery report limited exposure to trauma. ATLS has minimal affect on trainees confidence to perform trauma related procedures. ATLS does improve their confidence to assess trauma patients 0214 IS THE INJURY SEVERITY SCORE (ISS) RELEVANT IN COMPLEX LOWER LIMB TRAUMA? George Filobbos, Faisal Salim, Umraz Khan Frenchay Hospital, North Bristol NHS Trust, Bristol, UK Goldie Khera Introduction: Injury Severity Score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. Major trauma is defined ASiT President more than 16. Our aim was to study the relationship between ISS and return of as ISS score equal or limb function after open fractures of the lower limb when treated in a specialist centre. Bariatric Fellow,patients with lower limb trauma requiring free flap coverage. We examined age, Methods: Retrospective case note analysis of 50 North Tyneside mechanism of injury, type of fracture, Gustilo classification, ISS score, hospital stay, complications and Enneking score to measure outcome. Results: The mean age of patients at time of surgery is 44.1 yrs (range 5-90). 38% of patients had road traffic accidents, 30% had a fall. 52% had Gustilo 3B fractures while 26% had closed fractures initially. We had 2 flap failures. The average ISS score is 8.3 (range: 1 to 26). Conclusion: Mean ISS for patients with severe complex lower limb trauma was 8.3. These patients would not have been referred to a Ed Fitzgerald major trauma centre based on the ISS; however, they are best treated in a specialist centre indicating that a specialist Ortho-Plastic ASiT Conference Organiser & Past-President centre is integral to a Major trauma centre. 0233 LAPAROSCOPIC APPENDICECTOMY: ARE WE DOING TOO MANY THAT ARE AVOIDABLE? Senthurun Mylvaganam1, Tom Fowler2, Misra Budhoo1 1 Heart of England NHS Trust, Birmingham, UK 2 Department of Health, London, UK Introduction: Appendicitis is the most common intra-abdominal condition requiring surgery. Non-appendiceal pathologies in the right Jonny Wild iliac fossa (RIF) can clinically mimic appendicitis raising diagnostic doubt. The use of laparoscopy in managing RIF pain has increased the negative appendicectomyCo-ordinator ASiT Honorary Secretary & Sponsorship rate. Aim: Can biochemical and radiological investigations be used to guide the decision for laparoscopy. General Surgery Registrar, Sheffield Methods: All patients undergoing emergency diagnostic laparoscopy or laparoscopic appendicectomy over 10 months at the Heart of England Foundation Trust retrospectively analysed. Data collected on white cell count (WCC), C Reactive Protein (CRP), ultrasound scan (USS) findings, laparoscopic findings and histology. Results: N =221 representing 15% of patients presenting with RIF pain. F:M ratio 3:1. Negative appendicectomy rate 27%. 70/221 patients had WCC, CRP and USS performed. Where all three investigations are normal the positive predictive value for a normal appendix is 92% (95% CI 66.7-98.6) with a specificity of 82% and sensitivity 38%. Discussion: Published literature has looked at WCC and USS findings independently to predict appendicitis however a combination of Robert Davies WCC, CRP and USS findings as a single predictor has not previously been reported. Where all three parameters are normal it strongly ASiT initial conservative management can be pursued. predicts for a normal appendix and soHonorary Treasurer 0264 DOES SYMPTOM-TO-TREATMENT TIME AFFECT SEVERITY OF APPENDICITIS? Gemma Owens, Arnab Bhowmick, Nigel Scott Lancashire Teaching Hospitals Trust, Preston, UK Aims: Delay in treatment may affect operative severity of appendicitis. We compared time to appendicectomy from symptom onset and surgical admission with appendix histology. James Milburn Methods: A retrospective case note review of emergency appendicectomies in our surgical unit over a 5-month period. Time from symptom-onset and from admission to appendicectomy was recorded in days. Histology was classified as normal, uncomplicated or ASiT Vice-President severe appendicitis (gangrenous/perforated). Results were statistically analysed using logistic regression in PASW18. General Surgery Registrar, Inverness Results: Of 83 appendicectomies, 83% had histological appendicitis. Mean patient age was 28.8 (range 5-65). Median time (days (IQR)) from admission-to-appendicectomy and symptoms-to-appendicectomy was 3 (2-4) and 2 (1-2), respectively. Of appendicectomies on the day of admission (n=34), there was significantly higher severity of appendicitis compared to those whose operation was delayed >1 day (n=49)(p<0.02). Similarly, there was a significantly higher severity in those who had an appendicectomy <2 days of symptoms onset (n=20) compared to those >2 days (n=63)(p<0.02). There was significantly more normal histology after >4 days (n=25)(p<0.02). Conclusions: Previous studies have suggested delayed appendicectomy may lead to worse outcomes. Our study shows that true Joseph Shalhoub appendicitis was dealt with rapidly and severity of appendicitis decreases with increasing time to operation.
Vascular Surgery Registrar, London 0328 AN AUDIT OF EMERGENCY CT IMAGING REPORTING IN ACUTE GENERAL SURGICAL PATIENTS Guy Martin, Khalil Hassanally, Stefano Palazzo, Neil Soneji Northwick Park & St Mark's Hospital, London, UK Aim: To audit the frequency, causative factors and impact on patient care of delayed amendments to emergency CT imaging reports in a District General Hospital Steve Hornby Methods: 731 consecutive emergency surgical admissions over an 8-week period were studied. 240 emergency CT scans were perASiT Director of Education formed and imaging reports analyzed for amendments made following initial publication. Amendments were classified into major or minor based upon the degree General Surgery Registrar, South West Peninsula of initial reporting inaccuracy and impact on patient care Results: 32.8% of patients had emergency CT imaging performed producing 240 imaging reports 19.6% (47) of CT reports were amended following publication: 53.2%) minor amendments; 22 (46.8%) major amendments. Impact of out-of-hours and weekend reporting on the frequency of amendments to CT reports: 46.8% of amendments during weekend reporting; 32% of amendments during out-of-hours reporting; 21.2% of amendments during normal hours; Delay in amendments being made to imaging reports significantly increased at weekends and out-of-hours With thanks to the local ASiT Welsh Regional Representatives: Conclusions: A significant number of imaging reports are subject to change following publication of an initial reporting of imaging at Miss Rhiannon Harries, General Surgery being made Ysbyty Gwynedd, imaging in weekends and out-of-hours increases the frequency of amendmentsRegistrar,initial mis-reporting of CT Bangor the acute surgical patient can adversely affect patient care Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff
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0338 IS THAT A RING I SEE? RADIOLOGICAL REVIEW OF ALL HAND & WRIST TRAUMA AT STAFFORD HOSPITAL IN 2010 Thomas Moores, David Morley Stafford General Hospital, Staffordshire, UK Introduction: Trauma surgeons teach that part of basic first aid in the treatment of upper limb injury that rings should be removed during the initial assessment, preventing complications of oedema secondary to trauma, because rings are a fixed diameter and act as a tourniquet for that distal digit. No national or local guidelines exist for ED clinicians that recommend ring removal as part of upper limb trauma initial assessment. Methods: A retrospective radiological review of all hand, wrist, scaphoid and finger trauma at Stafford General Hospitals between 1st January and 31st December 2010. All radiographs were reviewed noting the presence of rings and the associated injury. Results: There were a total of 5140 radiographs taken for wrist and hand trauma in 2010, with 191 rings not removed as part of the initial assessment or prior to a radiograph being taken. 70/191 radiographs with rings visible had an associated fracture, dislocation, or soft tissue injury. Discussion: The standards are not being met for basic first aid assessment and management of upper limb trauma, this may be because there is no local or national guidance, or evidence in the trauma literature upon the removal of rings as part of this assessment. 0344 EXPERIENCES OF LOWER LIMB OPEN FRACTURE MANAGEMENT AT THE ROYAL UNITED HOSPITAL, BATH William Carlino, Caroline Bartolo, Gavin Jennings Royal United Hospital, Bath, UK Aim: The aim of this audit was to review open lower limb fracture management at the Royal United Hospital and identify adherence to the British Orthopaedic Association Standards for Trauma 4 (BOAST 4). Method: We retrospectively collected data on all open lower limb fractures between September 2009 and January 2011. Results: We identified thirteen consecutive open lower limb fractures. Antibiotics were appropriately administered on admission in 15% of patients. 62% had a photograph documented. 92% had a saline soaked dressing applied, neurovascular status documented while 85% had the fracture splinted before x-ray. 60% of patients were discussed with plastics and underwent early transfer. 80% of patients had wound debridement within 24 hours. 67% had definitive treatment within seventy two hours. Conclusion: The management of open lower limb fractures was suboptimal. As with all audits the areas highlighted in which teams are underperforming may reflect poor management, poor documentation or both. Clearly there it is also a priority to ensure all new Emergency Department and Orthopaedic trainees are aware of BOAST 4 standards. The antibiotics failures reflects delayed updates in local policy, the microbiology department are aware. An open fracture pro-forma and poster campaign has been initiated. A re-audit is planned. 0378 AN AUDIT TO ASSESS THE EFFICACY OF A DEDICATED UNIT FOR THE TREATMENT OF FRACTURED NECK OF FEMURS Al-achraf Khoriati, Zahra Jaffer, Anand Patel Lister Hospital, Hertfordshire, UK Fractured necks of femurs (#NOFs) are associated with high levels of morbidity and mortality. There is a proven link between rapid intervention and increased survival. We have established a dedicated unit for the treatment of #NOFs. Aims: To prove that our dedicated centre decreases the time taken to operate and provides a consultant led, improved specialist service. Methods: The time taken to treat a patient, the grade of surgeon operating, the time of the operation and the number of breached cases (those taking >36hrs to be completed) were recorded on a number of patients with #NOF (63) both before and after the creation of our dedicated centre. Results: The time taken to treat was more than halved. Consultants performed more of the procedures. All cases were performed in normal working hours with a dedicated team. The number of breached cases was dramatically reduced. Conclusions: A dedicated #NOF unit provides a safer and more efficient service for patients
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0390 TRAUMA OPERATION NOTES: DOES A PROFORMA IMPROVE THE QUALITY OF DOCUMENTATION? Amanda King, Amy Morgan, Francis Brooks University Hospital of Wales, Cardiff, UK Aims: To design, implement and audit a trauma proforma. Methods: We retrospectively reviewed operation notes 1 month prior and 1 month after the proforma. Notes were scored according to criteria adapted from Royal College of Surgeons guidelines. These included documentation of patient demographics, date, time, consultant, name and grade of operating surgeons, anaesthetist and scrub nurse, and ASA grade. Also, the post-operative plan including requirement of antibiotics, thromboprophylaxis, check radiographs, suture removal and outpatient follow-up. Results: Fifty operation notes were reviewed before and after implementation. After implementation, documentation of patient demographics, date, time, consultant, name and grade of operating surgeons, anaesthetist and scrub nurse, and ASA grade improved by 52%. Documentation of post-operative antibiotics thromboprophylaxis, check radiographs, suture removal and outpatient follow-up improved by 24%. Average total score pre-proforma was 52% which improved to 72% with the proforma. Conclusions: Adequate information on operation notes is essential for medico-legal purposes. Also, many procedures are not performed by the team looking after the patient, emphasising the need for legible notes with clear post-operative instructions. Our results suggest that our proforma is fit for use and improves the quality of documentation. Continued use will optimise immediate, postoperative, pre-discharge and follow-up care of the patient, preventing delays in management/discharge.
0396 THE VALUE OF TIP APEX DISTANCE Ravindra Thimmaiah, Matthew Cartwright-Terry, George Ampat Southport Hospital, Southport, UK tives: Aim: The longevity of the fixation in dynamic hip screw used to treat intertrochanteric fractures of the femur is dictated by correct edd, Bangor placement of the screw. The purpose of this study was to measure the tip apex distance and compare it with the 'Gold Standard'. Method: al of Wales, Cardiff A retrospective audit was conducted in a District General Hospital. All consecutive patients operated over a six month period were included. Intra-operative and postoperative films were reviewed for DHS tip apex distance. The evidence of any failure was investigated on picture archive and communication system. Results: There were 51 patients in total (16 males, 35 females). The average age was 80.3 years. The mean tip apex distance was m: info@asit.org 35.1mm with a range from 18.3 to 72.3mm. There was only one evidence of revision. Fourteen percent were within the guideline while
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82 percent were outside the guideline. This information was not available in 2 cases. Conclusion: The standard tip apex distance is less than 25mm. Unfortunately, majority of our cases fall outside the guideline and demonstrates that care and attention is required in treating these fragile fractures. Though revision was required in only one patient, this should not make us complacent about the surgical technique.
0474 ANTI-BACTERIAL PERITONEAL LAVAGE REDUCES POST-OPERATIVE SURGICAL INFECTIONS FOLLOWING APPENDICECGoldie Khera TOMY Michael Gale1, Elizabeth Head2, Ren Lee2, Mariana Pereira2, Alan Grant2 ASiT President 1 Aberdeen Royal Infirmary, Aberdeen, UK 2 Dr Gray's Hospital, Elgin, UKBariatric Fellow, North Tyneside Aim: Debate remains regarding peritoneal lavage following appendicectomy. We examined whether those patients who underwent appendicectomy had any reduction in post-operative surgical infections with the use of peritoneal lavage (both saline & antibiotic) versus none. Method: A retrospective study of the medical records between 2005 and 2010 of patients who underwent an appendicectomy was performed. Type of lavage was recorded and then correlated to post-operative complications. Surgically significant infections were determined as those relating directly to the surgical wound, pelvic / abdominal collections and required treatment within the hospital. Ed Fitzgerald Results: 342 cases of appendicitis were identified from the case records. 122 patients had no form of lavage following appendicecASiT Conference only, 138 had & Past-President tomy, 82 patients who had lavage with saline solution Organiser antibiotic lavage solution. No allergic reactions were recorded. Post-operatively 27 patients developed surgical infections. Rates of infection within the groups were 8.2%, 11.0% and 5.8% respecGeneral Surgery Registrar, London tively. (P=0.354) Conclusion: Our results demonstrate further proof that there is a reduction in post-operative infective complications, albeit not statistically significant, when antibiotic lavage of the peritoneum is used. Whilst this is not a randomized control trial, it, along with other published data, suggests that there is a likely benefit to using antibiotic lavage. 0511 Jonny Wild PROGNOSTIC VALUE OF DIGITAL RINGS IN PATIENTS IN SURGERY Chantelle T Rizan, Abigail E Nicolson, Emily C Rose, Andrew J Beamish, Sharif Kalifa, Wyn G Lewis ASiT Honorary Secretary & Sponsorship Co-ordinator University Hospital of Wales, Cardiff, UK General Surgery faith, heritage, culture, class and lifestyle and by tradition the upper limit of normal Aims: Digital jewelry can represent an expression of Registrar, Sheffield is 3 rings. Hospital surgical intakes provide a heterogeneous population spectrum and this study aimed to determine the prognostic significance of the number and distribution of digital rings. Methods: Data were collected prospectively on 55 consecutive patients presenting acutely to a UK university teaching hospital (5 male, median age 52 years, range 16-89, IQR 30-72). Results: Forty-six of the 55 patients (84%) wore digital jewelry, 21 (38%) wearing >3 rings. These patients were older (median 59 vs. 38 years, p=0.015); more frequent A&E attenders (8 vs. 5 attendances, p=0.049); less likely to complain of abdominal pain (19 vs. Robert Davies 76%, p<0.0001) and required less analgesia (opiate therapy 38 vs. 65%, p=0.05). The absence of a ring on the right index (p=0.034) or right little (p=0.049) finger ASiT Honorary Treasurerdeprivation. Ring number and distribution were not associated with was associated with socioeconomic diagnostic accuracy, number and breadth of investigations performed, or length of hospital stay. Vascular Surgery Registrar, West Midlands Conclusion: The number and pattern of digital rings emerged as a potentially useful new clinical sign. A larger prospective study is justified to clarify this. 0549 CAN RCSENG STANDARDS FOR THE MANAGEMENT OF HIGH RISK GENERAL SURGICAL PATIENTS BE ACHIEVED IN UK HOSPITALS? James Milburn Tarig Abdelrahman, Angharad Griffiths, Lowri Davies, Sanjay Furtado, Mark Henwood West Wales General Hospital, Carmarthen, UK ASiT Vice-President Aims: An increasingly high risk patient population are undergoing emergency surgery. 2011s NCEPOD reported an unacceptably high General Surgery Registrar, Inverness mortality within this group. New RCSEng guidelines aim to formalise the emergency patients clinical pathway to ensure optimal care by the appropriate level of clinician seniority. We retrospectively audited the practice in our DGH. Methods: 100 emergency laparotomies performed over the last 18 months were audited for the following: seniority of operating/ supervising surgeon and anaesthetist; HDU/ITU admission post-operatively; Timing to CT-scan, decision to operate and operation; 48hr readmissions to ITU/HDU; Mortality prediction documentation. We retrospectively calculated P-Possum scores to define high risk (predicted mortality > 5%). 30 day mortality was documented. Results: All high risk patientsJoseph Shalhoub Consultants performed>90% of laparotomies. No patient had a mortality were managed in ITU/HDU. prediction calculated. Readmissions to ITU/HDU were low. 30 day mortality rates compared favourably with published figures. Timings ASiT Vice-President to surgery however did not meet RCSEng standards. Vascular Surgery Registrar, a high standard of care in emergency patients, however formulaConclusions: A dedicated consultant-led surgical service can provideLondon tion of clinical pathways to integrate nursing, radiological, anaesthetic and intensive care needs of the patient, can reduce delays to surgery. With active involvement of these specialties, RCS standards can be met. 0633 THE USE OF WHOLE BODY' COMPUTED TOMOGRAPHY (WBCT) IN TRAUMA AT A DISTRICT GENERAL HOSPITAL Steve Hornby Jadesola Ekpe, Eleanor Bard, Abdulhalim Al Zein The Horton General Hospital, ASiT Director of Education Banbury, UK Aim: In trauma major injuries General clinical assessment. We questioned whether there was evidence to support WBCT scans of can evade Surgery Registrar, South West Peninsula patients based on mechanism of injury as opposed to clinical criteria. Method: A retrospective assessment of all 28 patients (17 male, 11 female), registered as trauma calls from January to December 2011. Ages ranged from 2-83 (mean 35.9) and Injury Severity Score (ISS) from 0 -75 (mean 21.8). We investigated which patients had WBCT scans, how many were not scanned, mechanisms of injury, reasoning for scanning and subsequent outcomes. Results: Withof the patients had WBCT scans whilst in the Emergency Department, 87.5% revealed significant unsuspected pathol28.6% thanks to the local ASiT Welsh Regional Representatives: ogy. 27.2% of the non scanned population subsequently deteriorated on the ward and had CT scans revealing management altering There Rhiannon Harries, scanning which was at the discretion of the examining clinician and no pathology. Miss were no formal criteria forGeneral Surgery Registrar, Ysbyty Gwynedd, Bangorsignificant differences in Mr Andrewof injury or ISS Clinical Research Fellow, University Hospital of Wales, Cardiff the mechanisms Beamish, of the 2 groups. Conclusion: WBCT based on mechanism of injury may result in substantial changes in management of trauma patients when used as an adjunct to clinical examination in the initial assessment. We propose collecting further data with a view to implementing a formal protocol. With thanks to the wonderful ASiT Conference Admin team: info@asit.org
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0678 EMERGENCY MANAGEMENT AND OVERALL OUTCOME OF SURGICAL PATIENTS IN EXTREME OLD AGE Andrew Torrance, Piyush Sarmah, Koren Stickland, Charles Robertson Worcester Royal Hospital, Worcester, UK Aim: The UK population is living longer, with average life expectancy rising from 72 to 80 years since the 1970s. More nonagenarians and centenarians are being admitted with surgical emergencies, although little data exists in this group. This study aims to review the management and outcomes of emergency surgical admissions in these patients. Method: A retrospective review of a prospectively maintained database of all emergency surgical admissions over 20 months. Results: 192 patients (215 admissions, 3% of total) were identified (median age 92, range 90-105). 14 (6.5%) patients underwent emergency surgery. Median length of stay was 4 days (IQR 1-8 days). 47.9% patients were discharged to their own home. No significant difference was shown in in-hospital mortality (28.6% Vs 14.4%, p=0.239) and overall survival (Log-rank test; Chi 0.035, p=0.851) between surgical and non-surgical intervention. Survival was 50% at 1 year. Conclusion: Most patients over the age of 90 are discharged within one week to their own home, only a small proportion undergoes surgery. Surgery results in a 2-fold increase in in-hospital mortality although overall survival is comparable. We advocate admitting patients over the age of 90 under the care of a specialised geriatric medical team with surgical input if required.
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0731 MANAGEMENT OF WARFARINISED PATIENTS WITH FEMORAL NECK FRACTURES Rachael Andrews, Adam Smith, Harry Sprot Royal Gwent Hospital, Newport, UK Introduction: Femoral neck fractures occupy a significant proportion of the trauma workload. There is great emphasis on early operative management. Anticoagulation has implications for surgery and anaesthetic. The literature provided very vague directives on management of warfarinised patients. Objectives: We retrospectively compared warfarinised patients to a standard cohort of patients. Our outcome measure was the time from admission to theatre. We aim to devise a protocol for safe and expeditious pre-operative management of warfarinised patients. Methods: We statistically compared time to theatre data for warfarinised patients to the general NOF cohort November 2009 to November 2010. 799 NOF fractures were admitted under orthopaedic care; 41 of which were on warfarin. Results: In the general cohort of NOF patients the mean time to theatre was 2.9 days compared to 4.7 days for the warfarinised group. (p=<0.001). There was no consistent approach to warfarin reversal. There were no embolic events in the warfarinised patients within 3 months of surgery. Conclusion: New NICE guidance sets best practice standards at 36hours for surgery, and thus unnecessary delays must be avoided. Warfarin significantly increases time to theatre. A standardised approach to warfarin reversal is essential, and we are currently devising a protocol using multidisciplinary input. 0752 PAEDIATRIC APPENDICECTOMY: AUDIT OF PRACTICE AND OUTCOMES FINDS VARIATION IN ANTIBIOTIC USE Alexander Brown1, Eleanor Morad1, Wes Lai2 1 Royal Devon and Exeter Hospital, Devon, UK 2 Severn and Peninsula Audit and Research Collaborative for Surgeons, Plymouth, UK Aim: This retrospective audit reviewed current practice and outcomes for appendicitis in children at a district general hospital as part of a wider regional audit to identify variations and deficiencies (Severn and Peninsula Audit and Research Collaborative for Surgeons, SPARCS). Methods: All patients aged <17 years undergoing emergency appendicectomy between August 2007 and July 2011 were included. Patients were identified by clinical coding and all case-notes reviewed. Data was collected and analysed using Microsoft Excel and VassarStats (http://faculty.vassar.edu/lowry/VassarStats.html). Results: 312 patients were identified, with 275 case-notes reviewed at time of submission. Median age was 12(2-16) overall, 11(2-16) for open appendicectomy (n=210) and 15(9-16) for laparoscopic appendicectomy (n=65) (p<0.0001 using Mann-Whitney test). Negative appendicectomy rate was 14.9%. Operative and histological findings differed in 23 cases (15 false positive and 8 false negative). Uncomplicated appendicitis occurred in 137 cases with 56 (40%) prescribed postoperative antibiotics. Complicated appendicitis occurred in 99 cases, 9 of whom (9%) received no postoperative antibiotics. Septic complications occurred in 15 cases, all from the complicated appendicitis group. Conclusions: Overall findings were in line with previously published data, but antibiotic use was variable and patients would benefit from a standardised hospital policy. 0790 PROSPECTIVE COST ANALYSIS STUDY OF CASES OF RIGHT ILIAC FOSSA PAIN IN LIMERICK REGIONAL HOSPITAL Donagh Healy, Aamir Aziz, Michael Wong, Pierce Grace, John Calvin Coffey, Stewart Walsh Mid-Western Regional Hospital, Limerick, Ireland Aims: There has been no previous study on the cost of managing cases of right iliac fossa (RIF) pain. We aimed to prospectively analyse the cost of managing such a group. Methods: Admissions with RIF pain from 1st April 2011 to 4th May 2011 were identified prospectively. After discharge, patients' medical records were reviewed to ascertain the cost. Data on length of stay (LOS), number and type of radiological investigations, number and type of blood investigations, medications administered and operations performed were collected. Costs for radiological investigations, bed days, blood investigations, medication costs and operation costs were obtained from the relevant departments. Results: 94 patients with RIF pain were admitted. 62 patients underwent surgery (45 laparoscopic, 17 open, 53 appendectomies (42 histologically positive)). The average LOS was 4 days. The total cost was 595,348 (6,300 per patient). The cost related to hospital bed-days occupied was (522,060). Radiology costs were 3388. Medication costs were 3,517. Blood test costs were 1,619. Operative costs were 61,632. Histology costs were 3,074. Conclusion: Length of stay should be targeted in order to reduce costs. This study is limited by the difficulty to accurately ascertain the cost of staffing and certain other costs.
edd, Bangor 0831 DOES GREATER ACCESS TO DIAGNOSTIC LAPAROSCOPY REDUCE NEGATIVE APPENDICECTOMY? al of Wales, Cardiff
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Lucinda Tullie, Ashar Wadoodi Maidstone Hospital, Maidstone, UK Aims: Limited info@asit.org guidance exists regarding best use of diagnostic laparoscopy in general surgery. Local expertise and cost have resulted in variable implementation across the UK. We aimed to assess whether increasing opportunity to perform diagnostic laparoscopic
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surgery reduced negative appendicectomy rates in females of child-bearing years. Methods: This was a retrospective audit of women, 18-45 years, who underwent laparoscopic appendicectomy from April 2007- April 2011. Patients were identified using hospital codes for laparoscopy, appendicitis and normal appendix. Operative notes were examined for intra-operative diagnosis and compared with histological diagnosis. Seventy-five patients were audited. At operation, 29 had a normal appendix described, 38 appendicitis and 8 other pathology. Results: 46.7% of appendices removed were histologically normal. Intra-operative diagnosis correlated with pathology in 45 women (60.0%). Consultant surgeons performed 12 appendicectomies (16.0%) and registrars 67 (84.0%) with intra-operative diagnostic accuGoldie Khera racy 41.7% and 63.5% respectively.(P=0.15) Conclusions: Our data showsASiT President poor correlation between intra-operative and histological diagnoses. In our unit, incidence of negative appendicectomy exceeded rates reported in the literature for open surgery (10-30%). This suggests laparoscopy is unreliable in diagBariatric Fellow, North Tyneside that diagnostic laparoscopy be used sparingly in a climate nosing appendicitis and does not improve with experience. We suggest where economic viability is paramount.
0878 A REVIEW OF OUTCOMES FOR APPENDICECTOMY COMPARING LAPAROSCOPIC AND OPEN APPROACHES Christopher Emmett, Poonam Valand, Claire Millins, John Martin, Venkatesh Shanmugam Darlington Memorial Hospital, Darlington, County Durham, UK Ed Fitzgerald Aim: Appendicectomy may be performed either open or laparoscopically, with the latter gaining in popularity. We aim to assess the ASiT Conference population of adults and children. difference in outcome between the two approaches in a Organiser & Past-President Method: Ninety-seven patients were identified between 1st June and 31st October 2011. Complete clinical data was available for General Surgery Registrar, London ninety. Surgeons' preference and clinical judgement determined which approach was employed. Results: 90 patients were included, 50% (n=45) male and 98% (n=88) emergency. 39 were open procedures, 51 were laparoscopic (3 converted to open, 6%). 19 appendices were histologically normal (21%); proportionally more of these were removed laparoscopically (29% vs 10%, p=0.037). Post-operative stay was shorter following laparoscopic surgery (1.8 vs 2.7 days, p=0.04). In-hospital complications were marginally higher after open procedures (8% vs 2%, p=0.31) as were 30-day re-admission rates (10% vs 6%, p=0.46); not statistically significant. Patients with abnormal histology had a higher mean white cell count (WCC) (13.5 vs 11.2, p=0.07) and Jonny Wild CRP (71 vs 20, p=0.027) at presentation. Conclusions: Our study demonstrates similar complication rates for both approaches. However, length of stay is shorter after laparoASiT Honorary Secretary & Sponsorship Co-ordinator scopic surgery. More normal appendices were removed laparoscopically. WCC and CRP were identified as valuable markers in diagGeneral Surgery Registrar, Sheffield nosing acute appendicitis. 0909 IDENTIFICATION OF HIGH RISK SURGICAL PATIENTS Mersey Emergeny Surgery Audit (MEnSA) Study Group Mersey Research Group for Surgery (MeRGS), Merseyside, UK Aim: A recent publication from the Royal College of Surgeons suggested guidance on management of high-risk surgical paRobert Davies tients. However, the most appropriate way to identify these patients is unclear. We compared efficiency of P-POSSUM and ASA ASiT score to identify high-risk patients. Honorary Treasurer Method: In 8 acute trusts, all emergency surgery operations were identified during a 30-day period in 2011. Details on operation and in Vascular Surgery Registrar, West Midlands -hospital mortality within 30 days were recorded. High-risk was deemed as P-POSSUM predicted mortality 10% or ASA 3. Data was analysed centrally. Inter-observer agreement was compared with kappa statistic. Results: 430 procedures were identified. Overall mortality was 6% (24 patients). 65 cases were identified as high risk using PPOSSUM and 143 using ASA. Correlation between the two methods was fair (kappa=0.38). Of those deemed high-risk by P-POSSUM, 14 died (26.5%) leaving 10 patients not identified; sensitivity 63%, specificity 88%. All 24 who died had an ASA 3; sensitivity 100%, specificity 71%. James Milburn Conclusion: Although specificity of ASA is lower, it appropriately identified all in-hospital mortalities. ASA is easier to calculate and is available preoperatively allowing it to Vice-President ASiT be used to optimize surgical management. ASA is a robust and accessible identifier of high-risk patients.
0945 HAVING NO ASSISTANT AT HIP FRACTURE SURGERY RAISES INFECTION RATE AND MORTALITY Charlotte Lewis, Olivia Mitchell, Sherief Elsayed, Christopher Moran, Daren Forward Queens Medical Centre, Nottingham, UK Introduction: We sought to evaluate the influence of consultant supervision and presence of assistants in hip fracture surgery with respect to infection rate and mortality. Joseph Shalhoub Methods: Retrospective study of patients admitted to the Queen's Medical Centre with a fractured hip (n=9032). Comparisons were ASiT Vice-President made between infection rates and assistant availability when a consultant was present or absent, the infection rate when a single surVascular Surgery Registrar, London geon operated and mortality with or without an infection complication. Results: The overall infection rate was 2.9% (120 / 4086), with no significant difference in infection rate when surgery was performed by a consultant compared to a trainee (p=0.186). When a consultant was present, 27.4% had no assistant; when absent, 49.6% cases were operated on by a lone surgeon (p=0.001). With a lone surgeon the infection rate was significantly higher regardless of their grade compared to when there was a surgeon and an assistant (3.6% (63 / 1742) compared to 2.4% (57 / 2344), p=0.027). Conclusion: This study provides evidence that a lone surgeon in hip fracture surgery raises infection rates leading to increased mortalSteve Hornby ity. Absence of a consultant increases the chance of operating unassisted. 0952 General Surgery Registrar, South West Peninsula LOWER ABDOMINAL PAIN IN FERTILE FEMALES - A DIAGNOSTIC DILEMMA IN EMERGENCY SURGERY Andrew Torrance, John Hardman, Lewis Taylor, Alex Coupland Heart of England NHS Foundation trust - Good Hope Hospital, Birmingham, UK Introduction: Females of childbearing age presenting with lower abdominal pain remain a diagnostic dilemma. This study aims to examine With thanks to the local ASiT Welsh Regional to predict diagnosis. whether initial presenting signs, symptoms or investigations can be used Representatives: Method: A retrospective audit was performed of all female patients of childbearing age presenting with lower abdominal pain to a gen Miss Rhiannon Harries, General Surgery and examination, blood tests, urinalysis, imaging, eral surgical take over a 6 month period. Details from their historyRegistrar, Ysbyty Gwynedd, Bangor operation and diagnosis were collected. Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Mr Andrew Results: 200 patients were identified, median age 24 (IQR 19-36). 57 (28.5%) patients had non-specific abdominal pain, 51 (25.5%) gynaecological, 31 (15.5%) gastrointestinal, 29 (14.5%) appendicitis, 23 (11.5%) urological and 9 (4.5%) other diagnoses. Multivariant logistic regression identified neutrophilia as a predictor of appendicitis (p=0.011; OR=6.034[95%CI 1.511-24.088]) and recent history With thanks to the wonderful ASiT Conference Admin team: info@asit.org of gynaecological complaint (p=0.002; OR=6.303[95% CI 2.008-19.789]) and irregular menstruation (p=0.039; OR=12.430 [95%CI
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1.140-135.584]) as predictors of gynaecological pathology. Conclusion: This study has shown that in fertile females with lower abdominal pain referred to the general surgeon a high proportion have causative gynaecological conditions. Patients with a recent history of a gynaecological complaint have a significant increased likelihood of having a gynaecological cause for referral. These patients may be best initially investigated by a gynaecologist. 0962 SURGICAL REFERRALS FROM NURSING HOMES; MORE EVIDENCE FOR A GERIATRIC MEDICINE LIAISON SERVICE Daniel Burchette, Gagandeep Grover, Michael Booth, Margot Gosney Royal Berkshire NHS Foundation Trust, Berkshire, UK Aims: To assess outcomes of inpatient stay in patients referred to acute surgical unit from residential homes, comparing with noninstitutionalised patients with similar presenting complaints. Methods: 40 patients admitted from homes over six months were matched with following emergency surgical admission living independently aged >70. Data gathered via take lists and discharge summaries. Results: Dementia was more prevalent in the residential care (45 vs. 28%), who also had more co-morbidities (4.4 vs. 2.6). Presenting complaints between groups were similar, abdominal pain and haematemesis being leading causes. Larger proportion of community residents underwent surgery during admission (28 vs. 5%) whilst greater proportion of residential care died during admission (15 vs. 2.5%). Residential care patients had a slightly longer average duration of stay in this study (5.5 vs 4.2 days). Conclusions: Whilst presenting with similar complaints, residential care patients are less often surgical candidates; fewer undergo surgery and a larger proportion die during admission. This supports value of geriatric liaison, particularly discharge planning, including in those patients palliative needs, as well as medical optimisation of co-morbidities when surgery is considered. Presented to the surgical and elderly care department: a new admission pathway for this group of patients was instituted in this trust. 1045 OUTCOMES FOLLOWING EMERGENCY GENERAL SURGERY IN NONAGENARIANS Gregory Jones, Tim Sparkes, Charles Evans Buckinghamshire Healthcare NHS Trust, Stoke Mandeville, UK Aim: In 2010 NCEPOD highlighted concerns over outcomes of elderly patients undergoing emergency surgery. This study aimed to investigate outcomes in nonagenarians undergoing emergency surgery and identify predictive risk factors for mortality and the impact on care requirements. Method: All nonagenarian patients who underwent emergency general surgery operations between June 2005 and June 2010 within one NHS Trust were retrospectively reviewed. Risk factors analysed included age, sex, ASA grade, clinical parameters, preoperative blood tests (including C-reactive protein (CRP)), preoperative care dependence, operation factors and surgeon factors. Kaplan-Meier survival analysis was performed using one year mortality rates. Results: Forty six patients (30 female) underwent surgery with an inpatient mortality of 32.6% and one year mortality of 54.3%. Patients undergoing major index surgery, a CRP > 100 or who required any form of preoperative social care had significantly reduced survival (P= 0.013, P<0.001 and p=0.0024 respectively). Upon discharge 59.3 % of patient required no change in social care, 29.6% a temporary change and 11.1% a permanent change. Conclusion: Emergency surgery in the nonagenarian is feasible with little long term change in social care requirements. Predictors of mortality are CRP >100, requirement for social care preoperatively and major index surgery. 1096 LAPAROSCOPIC APPENDICECTOMY A NEGATIVE IMPACT ON EMERGENCY OPERATING? Elisabeth Royston, Catherine Bradshaw, Peter Budny, Shaun Appleton Stoke Mandeville Hospital, Aylesbury, UK Background: Acute appendicitis is commonly managed with laparoscopic appendicectomy. However, there is a perception that it takes longer than an open operation and may, therefore, impact on the efficiency of emergency operating lists. The purpose of this study was to 1) evaluate the increase in laparoscopic appendicectomies over a five year period; 2) assess whether operating times are increased and 3) identify how this effects the provision of emergency operating lists. Methods: Data was collected retrospectively for all appendicectomies performed in a single NHS trust from 2006 to 2011 and analysed over three time periods. Results: The total number of appendicectomies performed annually ranged from 336 to 399. The percentage performed laparoscopically has progressively increased from 9% in 2006 to 56% in 2011. The average time taken to perform a laparoscopic appendicectomy was eight minutes longer than for an open procedure (p<0.001). The average duration of laparoscopic appendicectomy has not changed since 2006. Conclusion: Although laparoscopic appendicectomies took consistently more time than open appendicectomies, the average difference was only eight minutes. Given the average number of appendicectomies performed per day is one, it is unlikely this increased operating time will negatively impact on the provision of emergency surgery.
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1129 IS THE USE OF LAPAROSCOPY LEADING TO A RISE IN THE NEGATIVE APPENDICECTOMY? Amy Whiteford, Carole Neff, James Mansell Hairmyres Hospital, Hairmyres, UK Aim: Studies have shown that negative appendicectomy rates are not significantly reducing and that laparoscopy is possibly lowering the threshold for intervention in patients with suspected appendicitis. Our aim was to establish the rate of negative appendicectomy in our instituion and identify related factors. Methods: A retrospective review of patients undergoing an appendicectomy over 12 months was performed. Data on the preoperative assessment, investigation, operative management and final pathology of patients were collected. Chi squared test was used to identify any factors associated with a negative appendicectomy. Results: 95 patients underwent an appendicectomy. The median age was 30yrs. 51 (54%) of patients were male. 19% of patients underwent preoperative computed tomography (CT). 29 patients underwent open appendicectomy, 65 laparaoscopic and of these 6 tives: were converted to open. Appendicitis was significantly more likely in patients undergoing open surgery compared with laparoscopic edd, Bangor surgery (93% vs. 63%, p=0.004). Women were significantly more likely to undergo laparoscopy (78% vs 50%, p=0.02). 93% of patients with al of Wales, Cardiff CT findings suggestive of appendicitis had appendicitis. Conclusions: The use of laparoscopy appears to be associated with an increased rate of negative appendicectomy. Increased use of CT may be preferable to initial laparoscopy.
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1177 THE EFFECT OF CENTRALISING THE TRAUMA SERVICE ON GENERAL SURGERY EMERGENCY OPERATIONS: CLOSING THE LOOP ON AN AUDIT OF TIME WAITING FOR SURGERY P.Z. Maguire1, C. Nicolay2, T.M.H. Gall1, R. Grossman1, A.M. Howell2, M.H. Sdergren2, P. Ziprin2 1 St Mary's Hospital, London, UK 2 Imperial College, London, UK Aims: Following the centralisation of trauma services to a single unit there were concerns that this would increase pressure on emerGoldie Khera gency general surgery provision and theatre access. Therefore, time to theatre was audited before and after centralisation against guidelines set by the Royal College ofPresident ASiT Surgeons. Methods: Data was collected from 471 patients: January-June 2009 before and January-June 2011 after the addition of the trauma Bariatric Fellow, North Tyneside unit. The waiting time from booking emergency general surgery to operation for admissions was audited using the theatre database Results: The median waiting time was 6.6 hours (0.3-61.1) for procedures before trauma centralization compared with 12.5 hours (0.0120.3) for procedures after trauma centralisation. For laparotomy, appendicectomy and incision and drainage of abscess waiting times were 3.6 hours (0.3-26.6), 5.7 hours (0.4-37.4) and 15.1 hours (0.4-61.1) respectively before centralization and 6.5 hours (2-39), 7.8 hours (0.7-58.3), and 16.7 hours (1.3-120.3) respectively following centralisation. 37% of appendicectomies breached the18-hour sepsis target following centralization compared with 17% prior to centralisation. Conclusions: Centralisation of trauma services has resulted in increased waiting times for general surgery emergencies. Following this Ed Fitzgerald audit general emergency theatre provision has been increased and protected from other service demands.
UPPER-GASTROINTESTINAL SURGERY
0036 STOPPING PPIS PRIOR TO ENDOSCOPY Claire Marie Agius1, Emma Rivers1, Paul Gallagher1, Sadiq Bawa1 1 University of Malta, Tal-Qroqq, Malta 2 Jonny UK University of Birmingham, Birmingham, Wild 3 University of Newcastle, Newcastle, UK ASiT Honorary Secretary & Sponsorship Co-ordinator 4 Ahmadu Bello University teaching Hospital, Zaria, Nigeria General Surgery Registrar, Sheffield treatment with a PPI or H2 receptor antagonist for Background: NICE recommends that patients undergoing endoscopy should cease a minimum of 2 weeks prior to endoscopy to prevent false negative tests. Aim: To determine the extent to which these NICE guidelines are being followed in our Trust. Method: This study analysed data obtained from questionnaires filled in by endoscopists at a district general hospital between October, 2010 and January, 2011. Results: 67 questionnaire's were analysed. Median patient age was 80 years (male 48%, female 46%). Of the referrals analysed 62.7% were requested as a 2 Robert Davies 2 week wait group, over 4 in 10 patients had been taking a PPI at referral. 24% of week wait[s1] . Of this those patients on a PPI did not stop their PPI 2 weeks before endoscopy (of this group, a third were not verbally advised to stop PPI ASiT the endoscopy information leaflet less than 2 weeks before endoscopy) prior to endoscopy and 46% received Honorary Treasurer Conclusions: Lack of patient information may lead to the need for repeat procedures and potentially false negative endoscopies. This Vascular Surgery Registrar, West Midlands study highlights the importance of giving information leaflets during the consultation and verbally reinforcing the information. 0073 COMPLICATIONS OF LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LABG) PERFORMED BY ONE SURGEON OVER A 10-YEAR PERIOD Corinne Owers, Sophy Rymaruk, Roger Ackroyd Sheffield Teaching Hospitals, JamesSouth Yorkshire, UK Sheffield, Milburn Background: Between November 2001 and September 2011, 1100 laparoscopic adjustable gastric banding operations (LABGs) were ASiT Vice-President performed by one surgeon. Our study examined the long-term complication rate. General Surgery Registrar, Inverness Methods: All available medical notes (1079 patients) were reviewed. Results: Mean weight was 120 kg, BMI 43.3. After 10 years of follow-up, complications occurred in 347 patients. 143 patients experienced band slippage; re-operation was required in half of these cases. 82 patients had their band removed due to complications, slippage in 60, erosion in 17 and band intolerance in 5. 136 patients experienced port problems; 37 were flipped on clinical or radiological fills, 17 patients had port infection. 50 ports required repositioning due to discomfort or difficulty with clinical fills; 16 were removed or replaced, including 5 for cutaneous erosion. 4 patients required other procedures to deal with intra-operative complications. 18 patients had a concurrent procedure. The only post-operative death was due to biliary peritonitis in a patient who had undergone simultaJoseph Shalhoub neous cholecystectomy. ASiT Vice-President Conclusion: Complication rates reflect the literature. Slippage rate may appear higher in our patients, but this is because most patients Vascular Surgery Registrar, London undergo radiological band fills hence many non-symptomatic slippages are detected. Only half of our slippages were clinically apparent or needed any intervention. 0138 POST-OPERATIVE RECOVERY FROM CHOLECYSTECTOMY AT A DISTRICT GENERAL HOSPITAL Andrew Hannah, Jake Foster, Michael Terry Steve Hornby Isle of Wight NHS Trust, Isle of Wight, UK ASiT of the most common general Laparoscopic cholecystectomy is oneDirector of Educationsurgical operations; however the majority of patients undergoing this procedure receive no routine surgical follow-up. Registrar, of the recovery period and quoted rates of potential complications General Surgery Descriptions South West Peninsula when counselling patients for this procedure are hence potentially inaccurate. We sent a postal questionnaire to all patients who had undergone a cholecystectomy at our institution over a 6 month period (median 5 months post-op) in order to investigate patients recovery from this procedure. 60% of 100 patients contacted returned the questionnaire. Median time to return to work and driving was 2 weeks. 48% of patients reported With a post-operativethe local they consulted theirRegional Representatives: prescribed antibiotics. having thanks to problem that ASiT Welsh GP or A&E regarding: 50% of these were Reported complications included LRTI in 3.5% of responders, and surgical site infection in 22%. A single patient required re-operation, Miss Rhiannon Harries, General and 6 patients (10%) reported re-admission to hospital. Surgery Registrar, Ysbyty Gwynedd, Bangor Little information specific toBeamish, previously been available Fellow, University Hospital of Wales, Cardiff Mr Andrew our unit has Clinical Research to aid in counselling patients undergoing cholecystectomy. Rates of surgical site infection and post-operative antibiotic requirements were much higher than our estimates. Knowledge of this may have an impact upon the way in which we practice and perform this operation in the future.

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0183 CENTRALISATION OF UPPER GI CANCER SERVICES - IS THE HUB BETTER THAN THE SPOKE? Simon Monkhouse, Jana Torres-Grau, Daniel Bawden, Claire Ross, Richard Krysztopik Royal United Hospital, Bath, UK Aims: To assess whether patients diagnosed with oesophageal or gastric cancer at a local district general hospital (the "spoke") have a similar temporal pathway through the decision making and treatment process compared to those patients presenting at the centralised, tertiary hospital (the "hub"). Methods: Between April 2010 and April 2011, patients with a new diagnosis of oesophago-gastric cancer from both the hub and spoke hospitals were included. Data regarding diagnosis, time from diagnosis to multidisciplinary (MDM) discussion and time from MDM decision to first treatment were all recorded and prospectively analysed. Results: There was a statistically significant increase in the time from diagnosis to MDM discussion at the spoke hospital compared to the hub. (13.3 days vs.+ 25.67 days; P=0.001). However, time to first was significantly increased in the hub hospital compared to the spoke (43.4 days vs 25.5 days; P=0.023). Conclusions: Witholding its limitations, this study is the first of its kind to show that there is a disparity in the management pathways of patients who first present to a regional hospital rather than the tertiary centre. Patients at the spoke hospital have a longer lead time into MDM but non-operative treatment appears to be delivered more quickly locally.
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0203 OUTCOMES AT ONE YEAR FOLLOWING LAPAROSCOPIC SLEEVE GASTRECTOMY IN WALES Andrew J Beamish, Jessica J Foster, Nia Eyre, William Beasley, Scott Caplin, John Baxter, Jonathan Barry Welsh Institute of Metabolic and Obesity Surgery, Morriston Hospital, Swansea, Wales, UK Aim: Seven of the UKs ten worst areas for morbid obesity occur within Wales and bariatric surgery is the only proven treatment strategy. This study aimed to compare percentage excess weight loss (%EWL) and comorbidity resolution following laparoscopic sleeve gastrectomy (LSG) against UK National Bariatric Surgery Registry 2010 (NBSR) figures. Methods: Retrospective analysis was performed on patients undergoing LSG at a single centre. Weight and Body Mass Indices (BMIs) were measured pre-operatively, at 3-6 months (n=28) and at 12 months (n=20). Obesity-related comorbidities of type-II diabetes mellitus (T2DM), hypertension and obstructive sleep apnoea (OSA) were recorded preoperatively and at 12 months. Results: Twenty-eight patients (median age 45.5 years [17-63yrs], m:f=7:21) were studied. At 3-6 months median %EWL was 28.0% (9.267.2%); median BMI reduced from 46.5kgm -2 to 37.8kgm-2. At 12 months (20 patients), median %EWL was 55.7% (24.4-88.0%); median BMI reduced from 45.0kgm -2 to 32.3kgm-2. At 12 months, 100% of patients (7 pts) with T2DM, 100% (6 pts) with hypertension and 80% (5 pts) with OSA demonstrated improvement or complete resolution of comorbidity. Conclusion: Percentage EWL and comorbidity resolution at twelve months compare favourably with those of the NBSR (%EWL=56% vs. 54%; T2DM resolution=100% vs. 50%) after LSG. 0231 A 10 YEAR RETROSPECTIVE ANALYSIS OF OUTCOMES FOLLOWING PERFORATED GASTRIC OR DUODENAL ULCER Kathryn Lynes, Sobana Vicknesvaran, Ali Al-Temimi, Kislaya Thakur Queen Elizabeth Hospital; South London Healthcare NHS Trust, Woolwich, London, UK Aim: Despite improved medical management for peptic ulcer disease, incidence of perforated ulcer remains unchanged, resulting in high mortality and morbidity. This study aims to establish outcomes following surgery for perforated ulcer and identify factors predicting mortality and morbidity. Method: Records of 48 patients undergoing surgery for perforated peptic ulcer from 2001 to 2010 were retrospectively reviewed. Factors significantly increasing mortality and morbidity were determined with multivariate logistic regression. Factors analysed included: age; ASA grade; pre-operative shock; co-morbidities and delayed presentation. Results: There were 36 male and 12 female patients with mean age of 55 (range 20-89). 44 patients had a duodenal perforation. Only 2 perforations were repaired laparoscopically. ASA grade and pre-operative shock independently predicted mortality (p <0.01). ASA grade predicted morbidity (p <0.01). Patients with Boey Score of 0, 1, 2 and 3 had 0, 6, 55 and 100% mortality respectively. Conclusions: Our 30-day mortality of 14.6% compares to published figures of 4-31%. Morbidity of 50% was higher than expected which may be due to definition or case mix. The development of guidelines for managing perforated ulcer would permit comparison of outcomes between centres. Future directions for improving care include management of sepsis and use of laparoscopic surgery. 0482 DOES A RELATIONSHIP EXIST BETWEEN BLOOD GROUPS AND GASTRO-OESOPHAGEAL JUNCTIONAL TUMOURS? Rachel Barnes, Rhiannon Bowen, Timothy Havard, Xavier Escofet Royal Glamorgan Hospital, Llantrisant, UK Aims: Many studies have been carried out to investigate the association of blood group antigens and disease. Cancers in general appear to be associated with group A and to a lesser extent group B. This study aimed to establish whether there is a positive association between inherited blood group antigens and the development of Gastro-oesophageal junctional (GOJ) tumours. Methods: A retrospective analysis of a prospectively maintained database to identify all patients with GOJ tumours from 2000-2010. The blood groups and data on other risk factors were collected and compared with information from the Welsh Blood Service on the relevant catchment area. Statistical analysis was performed using the Chi squared test. Results: 210 patients were diagnosed with GOJ tumour (79% male). Age range 31- 89 years (mean 68 years). All patients were Caucasian. The distribution of blood groups within the patient cohort was comparable to that of the general population within the catchment area (p= 0.062- 0.9). Conclusion: There appears to be no association between blood groups and the development of gastro-oesophageal cancer. Larger scale studies will be required.
0530 FAST TRACK UPPER GASTROINTESTINAL SURGERY - A SYSTEMATIC REVIEW Dilan Dabare, Vanash Patel, Emmanouil Zacharakis Queen Alexandra Hospital, Southsea, Portsmouth, UK tives: Aims: The aim of this systematic review was to evaluate the feasibility of fast track surgery in upper gastrointestinal surgery. edd, Bangor Methods: A systematic review was performed by searching EMBASE, Medline, PsycINFO and Cochrane Library. The search strategy included al of Wales, Cardiff the keywords: fast track, enhanced recovery and multimodal rehabilitation/optimization/perioperative care. We included all original studies and classified them according to the 17 fast-track interventions proposed by the Enhanced Recovery After Surgery Group. The primary endpoints were median length of hospital stay (LOS), readmissions, morbidity and mortality. Results: 13 m: info@asit.org studies reporting on a total of 1621 patients were found: 2 randomised control trials and a case-series in gastric surgery; 2 case-control studies and a case-series in hepatic surgery; 2 case-series in oesophageal surgery; 2 case-control studies and 3 case-
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series in pancreatic surgery. The highest number of interventions implemented in gastric, hepatic, oesophageal and pancreatic surgery were 13, 15, 5 and 12 respectively. In all types of upper gastrointestinal surgery studies demonstrated a reduction in median length of stay ranging from 2-6 days, without an increase in readmission rates, morbidity and mortality. Conclusions: Initial studies show that fast-track surgery is feasible and may reduce length of stay. However, high quality studies are required.
0552 Goldie Khera AN AUDIT OF THE USE OF PET-CT AND FITNESS ASSESSMENT IN PATIENTS WITH OESOPHAGO-GASTRIC CANCER Emily Hotton, Srikant Ganesh, NataliePresident ASiT Blencowe, Robert Whistance, Sean Strong, Jane Blazeby University of Bristol, Bristol, UK Bariatric Fellow, North Tyneside Aim: Accurate staging in oesophago-gastric (OG) cancer is essential for patients considered for radical treatment. National guidelines recommend that Positron Emission Tomography Computed Tomography (PET-CT) be performed in all OG cancer patients without CT evidence of metastatic disease and who are deemed fit for curative treatment. This study assessed adherence of the upper gastrointestinal (UGI) cancer multi-disciplinary team (MDT) to this audit standard. Methods: A retrospective review of prospectively kept MDT records was performed for consecutive patients with OG cancer discussed at the central MDT between July 2008 and July 2010. Data collection included investigations performed, treatment outcomes and patient fitness. Ed Fitzgerald Results: 102 MDT meetings discussed 460 patients with OG cancer of whom 241 were primarily considered for curative treatment. Of ASiT Conference Organiser & Past-President these, 3 patients did not undergo PET-CT and reasons for this were unknown. 24 patients (10.0%) were subsequently considered unfit for curative treatment. The audit target was met in 214 patients (88.7%). General Surgery Registrar, London Conclusion: Adherence to national PET-CT guidelines by the UGI MDT was good. Unnecssary PET-CT staging was performed in a number of patients ultimately deemed unfit for curative treatment. Early fitness assessment in the treatment pathway could improve compliance with national guidelines. 0553 AN AUDIT OF STAGING INVESTIGATIONS FOR PATIENTS UNDERGOING CURATIVE TREATMENT IN OESOPHAGOJonny Wild GASTRIC CANCER Srikant Ganesh, Emily Hotton, NatalieHonorary Secretary & Sponsorship Strong ASiT Blencowe, Robert Whistance, Jane Blazeby, Sean Co-ordinator University of Bristol, Bristol, UK General Surgery Registrar, Sheffield Aim: Current guidelines recommend the use of Positron Emission Tomography Computed Tomography (PET-CT) in all fit patients with oesophago-gastric cancer (OGC), as part of the staging process. This study assessed investigations performed on recommendation of the upper gastrointestinal (UGI) cancer multi-disciplinary team (MDT) in patients scheduled for curative treatment. Unnecessary investigations were defined as those undertaken in patients ultimately deemed unfit for curative treatment. Method: A review of MDT records was performed for consecutive patients with OG cancer discussed between 2008 and 2010. Details of all staging investigations and final management decisions were evaluated. Results: 460 OGC patients were discussed. 241 were initially considered for curative treatment of which 24 were subsequently considRobert Davies ered unfit. In these patients, 31 unnecessary investigations were performed including 18 endoscopic ultrasounds (75.0%), 4 second ASiT Honorary and 4 additional CT scans (16.7%), 5 staging laparoscopies (20.8%) Treasurer investigations (16.7%). Conclusion: Unnecessary staging investigations couldRegistrar, Westin approximately 10% of patients with cost saving implicaVascular Surgery have been avoided Midlands tions. 0581 COMPLICATIONS AFTER BARIATRIC SURGERY Michail Chatzikonstantinou, Tereza Remesova, Cemal Kavasogullari, Pratik Sufi Whittington Hospital NHS trust, London, UK James Milburn Aim/Objective: To audit outcomes of bariatric surgery at North London Obesity Surgery Service (NLOSS). Participants: All patients who underwent elective bariatric surgery at NLOSS between January 2007 and October 2011 ASiT Vice-President Main Outcome Measures. Mortality, overall un-planned readmission, median length of stay in hospital according to type of operations, General Surgery Registrar, Inverness gender and age. Methods and data collection: A retrospective analysis of patient outcomes was performed using 4-year discharge data. Of 463 patients, 313 were Laparoscopic Roux-en Y Gastric Bypass (67,6%), 129 Gastric Band (57,8%) and 21 sleeve gastrectomy (5,4%). The patients for every procedure were divided into three age groups, 17-40 years, 41-60 and older than 60 years old. We examined these three procedures separately and compared mortality rates, median length of admission, and readmissions by age and gender. Results: The overall mortality rate was 0.86. The median length of stay for gastric bypass and band was 4 days (0-34) and 2 (0-7) respectively and the unplanned 28 day readmission rate was 10.8% and 8.7% respectively. Joseph Shalhoub Conclusions:Our statistical results were similar to international guidelines, with no significant difference with literature references.
Vascular Surgery Registrar, London 0758 REMISSION OF TYPE 2 DIABETES FOLLOWING ROUX-EN-Y GASTRIC BYPASS ACCORDING TO NEW GUIDELINES Haritharan Nageswaran, Martin Nnaji, Dimitri J Pournaras, David Mahon, Richard Welbourn Taunton and Somerset Foundation Trust, Taunton, Somerset, UK Aim: Bariatric surgery is considered a long-term solution to the rising incidence of Type 2 Diabetes (T2DM) secondary to obesity, with a meta-analysis suggesting 83.8% remission following Roux-en-Y Gastric Bypass (RYGB)1. We examine remission rates following Steve Hornby RYGB at a centre of excellence according to guidelines published recently by the American Diabetes Association (ADA) 2. ASiT Director of Education Method: Retrospective analysis was performed on patients with T2DM undergoing RYGB at Musgrove Park Hospital. Full remission was defined as hemoglobin (Hb) A1c 6% and fasting glucose levels 5.6 mmol/L at least 1 year after surgery without hypoglycemic General Surgery Registrar, South West Peninsula medication. Partial remission was defined as HbA1c < 6.5% and fasting glucose 5.6-6.9 mmol/L. Results: A total of 73 consecutive patients were analysed. Mean HbA1c was significantly lower (10.8% vs 6.03%, p<0.0001) postoperatively. Full remission according to ADA guidelines was seen in 33 patients (45%) with partial remission in 9 (12%). When compared with previous guidelines (off medication with glucose <5.6 OR HbA1c 6), this rate was lower but not significantly; 33(45%) vs 42(58%),With thanks to the local ASiT Welsh Regional Representatives: p=0.19 Discussion: Although bariatric surgery undoubtedly improves glycaemic control, remission rates may not be as high as previously Larger studies are required to provide patients with accurate expectations regarding diabetes resolution following surgery. suggested. Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor
0805 THE INCIDENCE OF CYSTIC DUCT STONES FOUND DURING LAPAROSCOPIC CHOLECYSTECTOMY Amir Kambal, Tomos Richards, Jayamanne Harsha, Zeyad Sallami, Ashraf Rasheed, Lazim Taha With thanks to the wonderful ASiT Conference Admin team: info@asit.org Royal Gwent Hospital, Newport, UK
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Aim: Cystic duct stones (CDS) are implicated in the post cholecystectomy pain syndrome and the subsequent development of common bile duct (CBD) stones. Their detection is hindered by the loss of tactile element brought by the advent laparoscopic surgery. This study aims to quantify the frequency of CDS during laparoscopic cholecystectomy (LC). Methods: A cohort of consecutive patients undergoing LC during the period from November 2006 to May 2010 was used with data collected prospectively. The procedure entailed careful dissection of the cystic duct (CD) and the milking of any stones towards the gallbladder. Results: The study included 330 patients, 80 male and 250 female, with CDS present in 64 cases (19%). Of these 64 patients with CDS, 47 (75%) showed deranged liver function tests compared to 152 (57%) with no CDS. Conclusions: The results demonstrate that pre-operative investigations are not helpful in diagnosing the common occurrence of CDS. Careful upward milking of the cystic duct before applying clips is a simple, safe and effective way of detecting and extracting these stones. This study changed our practice as this procedure is now included in all our Laparoscopic cholecystectomies.
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0841 CLINICAL INDICATIONS FOR GASTROSCOPY AND FINDINGS IN PATIENTS AFTER BARIATRIC SURGERY Nazir Irfan, Nafeesa Mitha, Tereza Remesova, Dugal Heath, Pratik Sufi Whittington Hospital, London, UK Gastric bypass (LRYGB), gastric band (GB) and sleeve gastrectomy (SG) are common interventions for morbid obesity1 and postoperative gastrointestinal (GI) symptoms are also common2,3. The aim of this paper was to the study indications for performing upper GI endoscopy (OGD) and findings in these patients in our institution. Method: This retrospective study investigated OGD in patients with GI symptoms after gastric bariatric surgery performed at W hittington hospital NHS Trust in 04/2007 -11/2011. Results: There were 26 OGDs post GB, 12 OGDs post GS and 178 OGDs post LRYGB. The most frequent clinical indications for OGD were abdominal pain (46 patients, 21.3%), dysphagia (43 patients, 19.9%) nausea and vomiting (26 patients, 12%). The most common finding was ulcer (29 patients, 8.7%), stricture (17 patients, 7.8%). Each procedure had specific complications - such as slippage of the band in GB or leak in SG or LRYGB. Conclusion: Abdominal pain, dysphagia and nausea/ vomiting were the commonest complaints in patients. Ulcer was the commonest abnormality. 0906 CURRENT SURGICAL OPINIONS OF RECENT ADVANCES IN MINIMALLY INVASIVE SURGERY Jonathan Clarke2, Simon Langmead1, Kimberley Hallett1, Emma Pritchard1, Adrian Harris3 1 University of Cambridge, Cambridge, UK 2 North West London Hospitals NHS Trust, London, UK 3 Hinchingbrooke Healthcare NHS Trust, Huntingdon, UK Background: The past decade has seen advances in minimally invasive surgery, in particular Natural Orifice Translumenal Endoscopic Surgery (NOTES) and Single Incision Laparoscopic Surgery (SILS), however their use remains controversial. Aims: To investigate the current opinions and perceived future prospects of NOTES and SILS techniques amongst consultant surgeons. Methods: An online survey was created asking for opinions of the current state of NOTES and SILS and also for predictions of the future utility of these techniques. Additionally information was gathered on specialty, laparoscopic workload and previous experience of NOTES or SILS. Surveys were directly emailed to consultants. Responses were collated and analysed using statistical software. Results: 652 consultants contacted, 73 responses received (11.1%). 46.6% were General Surgeons. 86% practiced laparoscopic surgery. 21% to 32% of respondents were unsure about the current and future state of NOTES and SILS. Most respondents felt both techniques were valuable, SILS more so than NOTES (p=NS). NOTES or SILS experience increased optimism about NOTES (p=0.0003) and SILS (p=0.043). Conclusions: Surgeons remain uncertain about the future of NOTES and SILS. Optimism about these techniques is increased with previous experience of NOTES or SILS, however it is unaffected by laparoscopic workload or surgical specialty. 0927 ABSENCE OF CORRELATION BETWEEN SERUM CRP LEVELS AND MITOCHONDRIAL D-LOOP DNA MUTATIONS IN GASTRO-OESOPHAGEAL ADENOCARCINOMA Benjamin Tan1, Richard Skipworth1, Nicholas Wheelhouse2, Kenneth Fearon1, James Ross1 1 University of Edinburgh, Edinburgh, UK 2 Moredun Research Institute, Penicuik, UK Introduction: Both inflammation and mitochondrial DNA (mtDNA) mutations are thought to play a role in the many human cancers. The aim of this study was to evaluate the relationship between inflammation and the accumulation of mtDNA mutations in the D-loop region in carcinogenesis of gastro-oesophageal adenocarcinomas Methods: 20 patients with gastro-oesophageal adenocarcinoma had blood taken for measurement of serum CRP concentration. Direct sequencing of mtDNA in the D-loop region was done in the 20 adenocarcinoma samples and their corresponding surrounding noncancerous tissue. Sequences were compared with existing mtDNA databases to identify mutations. Results: mtDNA mutations in the D-loop region occur commonly with almost identical frequency in both non-cancerous tissue (3.0 1.6) and adenocarcinoma (3.1 1.9) (p = 0.916, paired t-test). There was no discernable relationship between CRP and the number of D-loop mutations in both adenocarcinoma (p = 0.596, Student's t-test) and non-cancerous tissue samples (p = 0.594, Student's t-test). Five new mutations were identified that were not recorded previously in mtDNA databases. Conclusion: D-loop mtDNA mutations are common in both gastro-oesophageal adenocarcinoma and surrounding non-cancerous tissue. However, the accumulation of such mutations appears to occur independently of systemic inflammation.
0930 DOES EARLY PREGNANCY INFLUENCE WEIGHT LOSS AFTER BARIATRIC SURGERY? Tereza Remesova, Bernadette Pereira, Lucy Jones, Dugal Heath, Pratik Sufi Whittington Hospital, London, UK tives: Background: Bariatric surgery is effective in treating obesity and becoming popular. The current recommendation is to delay pregedd, Bangor nancy for 12-18 months during the rapid weight loss phase and until the weight loss stabilises. There are no controlled studies that have examined the effects of pregnancy on weight loss in patients who have undergone bariatric surgery. al of Wales, Cardiff Methods: We followed up 10 patients who became pregnant within one year post gastric bypass. The weight loss was compared with a cohort of age-matched 10 non-pregnant (NP) patients. Results: The m: info@asit.org NP patients had an average Excess Body Weight (EBW) loss of 54.1% at 6 months, 73.8% at 12 months and 74.7% at 24 months after surgery. The patients who conceived in the first year after surgery had an excess body weight (EBW) loss of 54.2% at
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6months, 65.9% at 12 months and 64.4% at 24 months after surgery. ANOVA analysis method found no significant difference in the weight loss outcomes. Conclusion: There was no statistically significant difference in weight loss between the two groups. However, it may be prudent to continue with the recommendation to delay pregnancy for at least 12-18 months post-operatively, until further evidence is available.
0947 PRE-OPERATIVE DIETARY WEIGHT LOSS DOES NOT CORRELATE WITH BETTER POST-OPERATIVE OUTCOMES FROM Goldie Khera LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING James Plowright, Mohan Singh, Paul President ASiT Super Heartlands Hospital, Birmingham, Birmingham, UK Bariatric Fellow, North gastric banding (LAGB) are encouraged to lose weight pre-operatively. Introduction: Patients considered for laparoscopic adjustableTyneside This study assesses whether pre-operative weight loss is a true predictor of post-operative weight loss. Methods: A retrospective analysis of patients who underwent LAGB in 2007 at our institution, using actual body weight lost preoperatively and comparing this to their BMI at one and two years post-operatively. Results: 69 patients were included (M =23, F=46), with a mean age of 45.7. The average BMI at the bariatric surgical clinic was 54.01 and 52.13 on the pre-operative day. This reflected a mean reduction in BMI of 1.88 or a mean excess percent BMI loss (EBL) of 7.4 kg/m2. At 1 year, the mean reduction in BMI was 11.1 [EBL of 33.6 kg/m 2]. At 2 years, the mean reduction in BMI was 13.29 [EBL of Ed Fitzgerald 41.5 kg/m2]. Correlation between pre-operative weight loss versus weight lost at 1 and 2 years was performed. At 1 year & 2 years ASiT Correlation was 0.154 [p = 0.208] Past-President post-operatively, the Spearman RankConference Organiser & and 0.069 [p = 0.573] respectively (no statistical significant correlation). General Surgery Registrar, London Conclusion: In this study, pre-operative dietary weight loss does not correlate with better outcomes following laparoscopic adjustable gastric banding. 1023 GASTRIC NEUROMODULATION FOR DRUG RESISTANT GASTROPARESIS, AND PERSISTENT NAUSEA AND VOMITING Muhammad Akbar, Sana Ullah, Sajid Mehmood, Peter Sedman, John MacFie Jonny Wild Academic Surgical Unit, Castle Hill Hospital, Hull, UK Aims: Gastric neuromodulation (GN) Honorary Secretary refractory gastroparesis or persistent nausea/ vomiting after excluASiT can offer treatment for drug & Sponsorship Co-ordinator sion of mechanical obstruction. We examined the efficacy of GN, both following temporary GN (TGN) and permanent GN (PGN). General Surgery years ] underwent TGN. TGN was performed endoscopically and left in situ for 7 Methods: Eleven patients, [M:F=5:6, median age 49 Registrar, Sheffield days. The patients deriving significant therapeutic benefit from TGN were offered PGN. Endpoints including Gastroparesis score (GSS), vomiting frequency score (VFS), health-related quality of life (QOL) scores using SF12 questionnaire, gastric emptying (GE), nutritional status and weight were compared before and after both TGN and PGN. Results: TGN demonstrated improvement in GSS from baseline 13 to 3(P=0.0001) and VFS from 3 to 0. QOL analysis demonstrated improvements in physical composite score from 27 to 36 (P=0.006) and mental composite score from 35 to 45 (P=0.01). Median weight gain of one kilogram Robert Davies0-2.4). GE improved from 98 to 65 minutes (P=0.22). Four patients from above was observed (range group underwent PGN who demonstrated sustained improvements. ASiT Honorary Treasurer Conclusions: GN improves GSS, QOL and nutritional status in patients with gastroparesis, and intractable nausea and vomiting. TGN provides a template to allow appropriate patient selection for permanent gastric neuromodulation. Vascular Surgery Registrar, West Midlands 1046 HOW DOES A NORTHERN TRUST WITH UNIQUE GEOGRAPHICAL CHALLENGES COMPARE WITH SCOTTISH NATIONAL DATA FOR ALL CANCERS IN KEEPING TERMINALLY ILL UPPER GI CANCER PATIENTS OUT OF HOSPITAL - TO DIE AT HOME? Angharad Jones1, Ron Coggins1, Jen Godsman2 1 James Highland, North of Scotland, UK Raigmore Hospital, Inverness, UK, 2NHSMilburn Aim: To study end of life care ASiT Vice-Presidentdiagnosed within geographically diverse northern NHS Highland. for Upper GI cancer patients Methods: Four national databases were searched using ICD10 codes for Upper GI cancer for years 2005-2010. For patients diagGeneral Surgery Registrar, Inverness was recorded and compared with Scottish national nosed in this region, place of death (home, hospital, hospice or other institution') data for all cancers. Results: 978 Upper GI cancer patients were diagnosed within the study period. 298 were excluded as place of death was unknown. Of the remaining 680 patients 237 (34.9%) died at home, 295 (43.4%) died in hospital, 96 (14.1%) died in hospice and 49 (7.2%) died in another institution. Of 75522 cancer deaths in Scotland between 2004-2008 equivalent percentages were 24.3% (home), 51.9% (hospital), 17.6% (hospice) and 6.2% (other'). Highly significant differences between NHS Highland and national data were found in both at home' and in hospital' deaths (p<0.0001). Joseph Shalhoub Conclusions: Over half of cancer patients in Scotland die in hospital and a quarter die at home. In our study group, fewer patients die ASiT Vice-President in hospital with over one third dying at home. Despite Highland geographical challenges, ability to deliver end of life care for Upper GI Vascular Surgery Registrar, London cancer patients is uncompromised. 1155 ONE-STOP CHOLECYSTECTOMY CLINIC: A WAY FORWARD FOR THE FUTURE? K Siddique, Sameh el-abyed, Sanjoy Basu Wirral University Hospital, Wirral, UK Hornby Steve Objective: To assess whether a 'one stop cholecystectomy clinic' had an impact on the waiting time, pre-operative visits and admisASiT Director of Education sions for patients with gallbladder diseases and thus improved their 18 week pathway. Patients and Method:A retrospective observational study of patients attending the 'one stop cholecystectomy clinic'(Group A) and the General Surgery Registrar, South West Peninsula traditional routine clinics (Group B)for patients with gallbladder diseases during 2010 was completed. Patients were preassessed & wait listed for surgery. Primary outcome measured was the waiting time, secondary outcome measured were the pre- operative visits & the emergency hospital admissions whilst awaiting surgery. Results: Study included 129 patients with a mean age of 49 (SD 16) years & female to male ratio of 101:28.Of the 129, 59 (46%) belonged to Group A had a to the local ASiT CI 6.2 - 8.5) weeks compared to 16.6 (95% CI 14.0 - 19.2) weeks for the 70 With thanks waiting time of 7.3* (95% Welsh Regional Representatives: (54%) belonging to Group B( p-value <0.001). One unnecessary hospital visit for pre-assessment was avoided in all Group A compared to Miss Rhiannon 9 (15%) Group A patients needed Registrar, Ysbyty compared to 19 (27%) Group B patients Group B patients and Harries, General Surgery emergency admission Gwynedd, Bangor meaning Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff significant cost implications. Conclusion: One-stop cholecystectomy clinic achieves improved patient journey through reduction in emergency admissions, waiting times and unnecessary hospital visits.

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1185 SHOULD CT COLONOSCOPY REPLACE FLEXIBLE SIGMOIDOSCOPY? Urszula Simoniuk, Mike Zeiderman, Ampat Chippang, Anna Justyna Milewska, Thomas Barnes Southport Hospital, southport, UK Aims: It is recommended that all patients undergoing barium enema have a flexible sigmoidoscopy (FS) to exclude disease distal to the rectosigmoid junction. With the introduction of CT colonoscopy (CTC) is sigmoidoscopy still required for the investigation of suspected colorectal cancer (CRC). Methods: The findings of CTC in 520 consecutive patients were reviewed by a GI radiologist blinded to the findings at FS. Patients with not adequate bowel preparation for FS, colonoscopy, polypectomy, abnormal MRI or CTC as first line investigation, more than six months period between CTC and FS were excluded. Statistical analyses were performed with Chi-Squared and Fisher test. Results: 306 patients were excluded. In 188(88%) patients there was concordance between the findings on FS and CTC. Sensitivity and specificity of FS was 74% and 99% respectively (p<0.001)[ppv- 0.93, npv- 0.94].FS did not identify 6 cancers when CTC missed only 2 malignant pathologies (classified as inadequate picture due to collapse colon, further investigation has been advised). We could identify statistically significant (p<0.05) dependence between bowel symptoms like PR bleeding and iron deficiency anaemia and diagnosis of bowel cancer in patients undergo FS. Conclusions: A negative CTC excludes the presence of colorectal cancer.
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1208 ANAEMIA AND BARIATRIC SURGERY: A DOUBLE WHAMMY Mustafa Khanbhai1, Karishma Patel2, Sukhpreet Dubb2, Ahmed Ahmed2, Toby Richards1 1 University College London, London, UK 2 Imperial College London, London, UK Background: As bariatric surgery rates continue to climb, anaemia will become an increasing concern. We assessed the prevalence of anaemia and length of hospital stay in patients undergoing bariatric surgery. Methods: Prospective data (anaemia [Haemoglobin <12 g/dL], haematinics and length of hospital stay) was analysed on 400 hundred patients undergoing elective laparoscopic bariatric surgery. Results were compared to a prospective database of 1530 patients undergoing elective general surgery as a baseline. Results: Fifty-seven patients (14%) were anaemic pre-operatively. Median MCV (fL) and overall median Ferritin (g/L) was lower in anaemic patients (83 vs. 86, p=0.001) and (28 vs. 61, p<0.0001) respectively. Compared to elective general surgery patients, prevalence of anaemia was similar (14% vs. 16%) but absolute iron deficiency was more common in those undergoing bariatric surgery; microcytosis p<0.0001, Ferritin <30 p<0.0001. Mean length of stay (days) was increased in the anaemic compared to in the nonanaemic group (2.7 vs. 1.9). Interestingly, patients who were anaemic immediately post-operatively, also had an increased length of stay (2.7 vs. 1.9), p<0.05. Conclusion: Absolute iron deficiency was more common in patients undergoing bariatric surgery. In bariatric patients with anaemia there was an overall increased length of hospital stay, suggesting a role in pre-optimisation. UROLOGY 0016 Management of acute epididymo-orchitis: Should we change our practice? Aditya Manjunath1, Thiru Gunendran2 1 Weston General Hospital, Weston-Super-Mare, UK 2 University Hospitals of South Manchester, Manchester, UK Aim: The latest antibiotic guideline for epididymo-orchitis from the British Association of Sexual Health and HIV was released in June 2010. We reviewed the management of patients presenting with epididymo-orchitis over a 2 year period to see if the new guideline should be incorporated locally. Method: Data was collected retrospectively looking at all patients presenting to hospital with a diagnosis of epididymo-orchitis from July 2008 to August 2010. Information collected included; patient age; admission date; mid-stream urine for routine culture and/or Chlamydia PCR; scrotal ultrasound findings; treatment and re-presentation to hospital. Results: 66 patients were identified. The mean age was 47.29 years with twenty patients being below 35 years. Antibiotic treatment regimes used included Gentamicin and Ciprofloxacin (15.2% of cases), Ciprofloxacin alone (48.5%) and Doxycycline +/- Ciprofloxacin (15.2%). 9 patients had operative intervention. 3 cases were untreated. 3 patients re-presented to hospital with unresolved symptoms or complications. Conclusion: Our current antibiotic policy seems to be successful as indicated by the few re-presentations and complications. Similar regimes are in use region wide. The 2010 guideline would suggest changing practice. However, we feel that this is currently not indicated as our hospital regime appears to be effective in managing patients with acute epididymo-orchitis.
0024 PRIMARY HYPERPARATHYROIDISM AND UROLITHIASIS: OUR EARLY EXPERIENCE Jun-Hong Lim, Kattedath Madhavan Pilgrim Hospital, United Lincolnshire Hospital NHS Trust, Lincolnshire, UK Background: Hyperparathyriodism is associated with an increase risk of developing renal calculi. The aim of this study was to quantify the incidence of renal calculi in patients undergoing parathyroidectomy. Method: A retrospective study of 38 patients that have undergone parathyroidectomy between 2002 and 2009 was performed. Patient age, mode of discovery, serum levels of biochemical markers and types of renal imaging were evaluated. Results: 38 patients (7 male), median age 59 (range 31-79) were reviewed. All patients were diagnosed with primary hyperparathyroidism incidentally. Histology of parathyroids showed 9 nodular hyperplasias and 29 parathyroid adenomas. Median adjusted calcium is 2.87 (range 2.62 - 5.3), median parathyroid hormone level is 15.2 (range 6.6 - 114.8). 6 (15%) had a 24 hour urine calcium level test and 4 (10%) had renal stone. 13 (31%) out of 18 patients (USS=5, CT KUB=3, IVU=3, abdominal x-ray=2) who have undergone renal imaging had renal calculi. 6 (16%) had renal calculi detected before confirmatory blood test for hyperparathyroidism. tives: Conclusion: Ultrasound scan of the kidneys could be recommended for all parathyroidectomy patients. A prospective study with 24 edd, Bangor hours urinary metabolic work up might help to answer the relationship between primary hyperparthyroidism and urolithiasis. 0052 THE NATURAL HISTORY OF UNTREATED PROSTATE MRI LESIONS IN AN ACTIVE SURVEILLANCE PROSTATE CANCER POPULATION 260 PATIENT-YEARS info@asit.org Daniel J Stevens, Caroline M Moore, Hashim U Ahmed, Clare Allen, Alex Kirkham, Jan van der Meulen, Mark Emberton
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UCL Division of Surgery and Interventional Science, London, UK Aim: Lesions detected by multi-parametric (mpMRI) are positively associated with higher volume and higher grade of prostate cancer. This attribute of mpMRI makes it an ideal candidate as a tool in active surveillance (AS) to identify disease progression. Method: Men on an AS programme were eligible provided they had 2 mpMRIs at least 3 months apart without any prostate cancer treatment. Images were assessed for the presence of a visible lesion (on T2, DCE or ADC map), and progression (by size/intensity of an existing lesion or detection of a new lesion). Results: 98 men with histologically proven prostate cancer and a combined follow-up of 260 patient years were eligible. 51 men demonstrated no MRI progressionGoldie Khera all continued on active surveillance. 14/98 men underwent treatment. 11/14 either during follow-up and had a visible baseline lesion or developed one during follow-up. ASiT President Conclusions: Those men who did not radiologically progress at any point remained on active surveillance. The role of mpMRI in active Bariatric surveillance merits further investigation. Fellow, North Tyneside
0068 OUTCOME OF NEPHRECTOMIES IN THE OVER-EIGHTIES IN A LARGE DISTRICT GENERAL HOSPITAL Jihne El Kafsi, Adam Jones Royal Berkshire Hospital, Reading, UK Purpose: We investigated the morbidity and outcome of open and laparoscopic nephrectomies in patients 80 years old and over. Ed Fitzgerald Materials and Methods: The records of octogenarians who underwent a nephrectomy from 1983 to 2009 were reviewed. Of 410 ASiT Conference Organiser & Past-President nephrectomies, 61 patients were originally identified, but 33 met our inclusion criteria. Patient records were analysed for morbidity and outcome. General Surgery Registrar, London Results: 33 patients were included with a median age of 82 years (range 80-89), (20 M; 13F). 21 patients had significant comorbidities, including 5 with 2 or more medical problems. Indications for surgery included malignant disease in 31 patients and benign disease in two patients. There was a 58% complication rate, including 18% intraoperative, 36% cardiovascular and respiratory and 12% renal complications. Of 13 laparoscopic cases one was converted to open. There were no returns to theatre.. 30-day mortality was 3%. Overall median survival was 36 months, with a urological cancer related death rate of 32%. Jonny Wild Conclusion: The overall benefit of nephrectomies in patients over 80 years of age outweighs the risks of surgery. Although the morbidity rate is 58%, the overall median survivalof 36 months suggests that surgery remains justified. ASiT Honorary Secretary & Sponsorship Co-ordinator
General Surgery Registrar, Sheffield 0208 ROLE OF EXTERNAL SPHINCTEROTOMY IN THE LONG TERM MANAGEMENT OF PATIENTS WITH SPINAL INJURY Vijay Rao Gudla, Meena Agarwal Cardiff and Vale NHS trust, Cardiff, UK Introduction: Urological problems are the second most common cause of death in spinal injury patients. The optimal bladder management methods should preserve renal function and minimize urinary tract complications. Clean intermittent catheterisation is a gold standard. External sphincterotomy is also Davies methods to keep the patients free from catheter. The aim of this study is to look at Robert one of the the catheter free period and associated long term complications. Methods: A database review ASiTpatients undergoing external sphincterotomy in our hospital was done. Results: A total of 24 paof the Honorary Treasurer tients were included in the study (12 with paraplegia, 11 with tetraplegia). The mean follow up after the first sphincterotomy was 13.75 Vascular Surgery Registrar, West Midlands years (range 1- 36). Sixteen (67%) patients during the follow up needed the repeat sphincterotomy. Sixteen (67%) patients with the average duration of 16 (1-30) years were catheter free. Three (13%) patients needed to have an ileal conduit diversion, 5(20%) patients were converted into long term catheters. Conclusion: External sphincterotomy has an important role in the treatment of the spinal cord injury patients with a neuropathic bladder. It is the treatment of choice for patients with a hypereflexic bladder who are unable to catheterize themselves but can use condom drainage.
0285 ASiT Vice-President PROSPECTIVE STUDY COMPARING WHITELIGHT CYSTOSCOPY VERSUS BLUELIGHT FLUORESCENCE CYSTOSCOPY IN General Surgery Registrar, Inverness DETECTING HIGH GRADE BLADDER TUMOUR Ajay Sud, Kohmal Solanki, Nishanthan Manickavasagar, benjamin Lamb, John Peters Whipps Cross University Hospital, London, UK Aims: Fluoroscopic-assisted (e.g. Hexvix) cystoscopy improve diagnostic yield primary transitional cell carcinoma in situ (CIS), detection rates for superficial bladder cancers; but not for the detection of high grade recurrence. The aims of this study were to validate bluelight (BL) fluorescence cystoscopy after the intra-vesical application of hexaminolevulinate hydrochloride against conventional whitelight (WL) cystoscopy. Joseph Shalhoub Methods: Prospective data from April to October 2010 was collected for primary high grade transitional cell bladder carcinoma (TCC), ASiT Vice-President which were initially managed with transurethral resection of bladder tumour and/or chemotherapy. Vascular Surgery Registrar, London Results: There was histopathologically confirmed recurrence in nine patients. WL and BL both detected recurrence in eight patients but also missed a CIS recurrence within random scar biopsy. There was no statistically significant difference between WL and BL in terms of sensitivity (89% and 86%), specificity (62% and 50%), false positive rates (38% and 47%) or false negative rates (14.3% and 11%). Conclusions: WL and BL cystoscopy utilised for the surveillance of high grade bladder TCC demonstrated no significant difference. BL adjuvant does not impart an improved diagnostic yield. The one false negative case for recurrent CIS disease with CIS recurrence is Steve Hornby clinically significant and does demonstrate the importance of random biopsies in suspected CIS. 0287 General Surgery Registrar, South West Peninsula CURRENT STATUS OF VALIDATION FOR ROBOTIC SURGERY SIMULATORS A SYSTEMATIC REVIEW Hamid Abboudi, Mohammed Shamim Khan, Omar Aboumarzouk, Khurshid Guru, Ben Challacombe, Prokar Dasgupta, Kamran Ahmed Guy's Hospital, London, UK Objectives: We analyzed studies the local effectiveness of robotic surgery simulators. With thanks to validating the ASiT Welsh Regional Representatives: Materials and Methods: The MEDLINE, EMBASETM and PsycINFO data-bases were systematically searched until September Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor 2011. Simulator name, training tasks, participant level, training duration and evaluation scoring were extracted. Results: Mr Andrewstudies investigating simulation options Fellow, University Hospital of Wales, Cardiff We identified 19 Beamish, Clinical Research in robotic surgery. Eleven studies compared performance between two different groups; Expert and Novice. Experts ranged in experience from 21-2200 robotic cases. The novice groups consisted of participants with no prior experience on a robotic platform. The MdVT, ProMIS, SEP and Intuitive systems have shown face, content and construct validity. The RoSS the wonderful ASiT Conference All of the simulators except SEP have shown eduWith thanks to system has only been face and content validated. Admin team: info@asit.org cational impact. Feasibility, educational impact and cost-effectiveness of simulation systems was not evaluated by the studies. Virtual
James Milburn
Laura Andrews
Kristina Gloufchev
Harriet Innes
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reality simulators were demonstrated to be effective training tools for junior trainees. Conclusions: Simulation training holds the greatest potential to be used as an adjunct to traditional training methods in order to equip the next generation of robotic surgeons with the skills required to operate safely. More research is needed to validate simulated environments and investigate the effectiveness of animal and cadaveric training in robotic surgery.
0337 STAGING IT BEFORE DIAGNOSING IT. A NOVEL RISK ASSESSMENT TOOL FOR PROSTATE CANCER Rozh Jalil1, Nirav Patel2, John O'Neil2, James Green2 1 Imperial College, London, UK 2 Whipps Cross University Hospital, London, UK Introduction: A 4-6 weeks waiting lapse is necessary if staging MRI is performed after TRUS-Prostate biopsy due to the challenging interpretation of MRI because of the haemorrhage and swelling. To improve treatment times, we discuss a novel idea of identifying patients who would benefit most from a staging-type MRI before TRUS-P biopsy using a simple risk assessment tool. Materials and Methods: A retrospective study enrolled 503 patients who were referred to our hospital on the 2 week wait prostate pathway. After analysing data from these patients, a tool was developed primarily using age and PSA. Ages 60-80 (grouped into 6064, 65-69, 70-74 and 75-79) were included due to the feasibility of radical treatment. Each group was allocated a specific PSA range in an attempt to render most possible cancer patients who had MRI. Results: The application of this tool identified a subgroup of patients aged 60-79 (n=124) with MRI rates of 48.4% and a cancer rate of 57.3%. These comprised 43.3 % of all cancers in this age group 60-79. Conclusions: Applying this tool will identify patients that can benefit from upfront staging MRI and hence early commencement of definitive treatment. Subsequently the cancer target wait is easier to achieve. 0346 NEWLY DIAGNOSED PROSTATE CANCER: ARE MEN BEING REFERRED SAFELY AND APPROPRIATELY FROM PRIMARY CARE? M Fullarton, T Balling, NI Osman, BA Petersson, CS Powell Countess of Chester Hospital, Chester, UK Aim: Many GPs find prostate cancer (CaP) diagnosis difficult. Although referral guidelines are available, anecdotal evidence suggests a disparity in approach between GPs and urologists. We determined whether men with histological CaP were referred appropriately from primary care. Methods: We conducted a retrospective case-note review of 77 consecutive patients undergoing Trans-rectal prostate biopsies after 1st outpatient visit. Type, reason and quality of referral were determined. Results: 77 men underwent biopsies with a mean-age of 71.1. 27.3% were routine referrals, 13% urgent and 59.7% 2-week rule. 5 patients had no PSA testing pre-referral, 42 had 1, 26 had 2 and 4 had >2. 90.3% were referred with a raised PSA. 67.5 % had rectal examinations (RE) pre-referral. 31.2% patients had urinalysis pre-referral. 64.9% had histological CaP, 1.3% PIN, 33.8% benign histology (1 patient failed to attend biopsy). 72% of those with histological CaP were referred by 2 week-rule, 70% of whom had RE. Conclusions: Most patients with suspected or proven CaP were referred under 2-week rule. Although quality of referral varied, most were appropriate. Areas for improvement include performance of RE and urinalysis. To avoid delays in diagnosis, education is needed to bring the practices of GPs and urologists in concordance. 0353 CONTEMPORARY OCCUPATIONAL BLADDER CANCER: A SYSTEMATIC REVIEW OF CURRENT EXPOSURES Marcus Cumberbatch, James Catto, Simon Pickvance University of Sheffield, Sheffield, UK Background: Bladder cancer is a common disease that often arises following occupational exposure to carcinogens. Improved workplace hygiene and industrial sanctions have controlled or substituted the use of known bladder carcinogens. However, between 5 and 25% of contemporary tumours still arise following workplace carcinogen exposure, suggesting either unknown or uncontrolled exposure is still common. Aim: To systematically review recent evidence (since 1990) for occupational bladder cancer and to identify contemporary occupations implicated in its aetiology. Method: A systematic review using Pubmed with strings to search for occupation and bladder cancer was conducted using limits to control for study design and select contemporary studies. After review using strict exclusion criteria, and following reference checks, 87 studies were included for analysis. Results: Contemporary at risk occupations include: agricultural workers, drivers, engineers, fire-fighters, laundry workers, metal and metal-fluid workers, miners, nurses, plastics workers, pharmaceutical workers, print workers, textile workers, tool-makers, waiters, and wood workers. Conclusion: Many of these are modern additions to our database of at risk occupations to bladder cancer and alterations in disease demographics suggest a variety of possible carcinogens requiring investigation. Occupational exposure remains an important public health problem that should be understood and incorporated into patient management.
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0370 DOES OPERATOR EXPERIENCE AFFECT THE OUTCOME OF TRANSRECTAL PROSTATE BIOPSY? Adam Hussein, Sergey Tadtayev, Gregory Boustead Lister Hospital, Stevenage, UK Cancer detection rate (CDR) is the single most important outcome measure of transrectal ultrasound-guided (TRUS) prostate biopsies. It is established that a number of factors influence outcome of the biopsy, but there is a paucity of data on the effect of operator experience. We conducted a retrospective review of 344 patients who underwent their first TRUS biopsy in a single institution over a 12 month period. Biopsies were undertaken by 6 consultants (103). 8 senior trainees parcticing TRUS for >1year (139) and 3 junior trainees who just started TRUS training (102). Fisher's test was used for statistical analysis. There was a significant difference in the CDR between consultants and juniors (p<0.005), and senior and junior trainees (p=0.008) at the expense of more Gleason 6 cancer found in the first vs third group (p=0.03). We could not identify evidence of a learning curve tives: amongst juniors. We have demonstrated higher CDR by more experienced TRUS operators, likely due to superior sampling. This edd, Bangor finding implies that mentoring, self-audit and close follow-up are essential. The TRUS learning curve is likely to exceed 30 cases. CDR in our study al of Wales, Cardiff is similar to values published in comparable cohorts (30-40%). 0481
IMPROVED m: info@asit.org FIVE YEAR SURVIVAL ESTIMATES OF RADICAL CYSTECTOMIES PERFORMED AT A HIGH VOLUME DISTRICT GENERAL HOSPITAL
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Robert Pallas, James Osbourne, James Wilson, Adam Carter Royal Gwent Hospital, Newport, UK Radical cystectomy is a major operation with significant complications. There has been suggestion of centralising this operation to high volume cancer centres. All cystectomies for cancer performed at our centre between 2000 and 2010 were retrospectively analysed for survival data. Results were compared to published data from gold standard insitutions. A total of 160 cystectomies were performed by six surgeons, an average of 12 per year between 2000 and 2006, and 18 per year since 2007. Data was gathered from theatre database operation codes and correlated with follow up data from electronic hospital Goldie Khera records. Survival was estimated using Kaplan-Meier estimation, and sub-divided based on T-grading. Results of cystectomies performed prior to 2007 were compared to subsequent operations. ASiT President There is a statistically signicant difference between 5 year survival of T1/T2 and T3/4 patients. Cases performed between 2000-2006 Bariatric Fellow, North Tyneside had a 5-year survival rate of 45%, this improved to 57% in patients operated 2007-2010. The 5-year survival and 30 day mortality figures are comparable to publications from major institutions. Recent cystectomies have improved 5 year survival estimates, but follow up limits comparison of actual survival. However, a recent study has suggested that 2 year follow up data correlates well with 5-year survival.
0486 "SATURATION PROSTATE BIOPSY IN PATIENTS WITH RAISED AGE-RELATED PSA AND NON-MALIGNANT PREVIOUS Ed Fitzgerald TRUS BIOPSIES" ASiT Conference Organiser & Past-President Michelle Christodoulidou, Mohsen El-Gammal Southport and Ormskirk Hospital NHS Trust, Southport,Merseyside,London General Surgery Registrar, UK Aim: To review the demographic data of patients that underwent Saturation Prostate Biopsies over an 18 month period with emphasis on the indications, antibiotic cover, complications and histological outcome. Method: Patients were traced by the Theatres Register and GALAXY system. Data were collected from case notes. Results: 28 Saturation Biopsies were performed between July 2010 and December 2011. Median age was 67, 54% of patients had LUTS and 7% had family history of prostate cancer. 14% had abnormal DRE. Median value of 2 TRUS biopsies were taken prior to the Saturation Biopsy. All patients were given 160mg Gentamicin IV and a 3 day course of Ciprofloxacin orally. Only one case preJonny Wild sented with Urosepsis requiring IV antibiotics. Saturation biopsy diagnosed malignancy in 36% of patients. 1 patient who had benign saturation biopsy subsequently underwent a Template biopsy that showed malignancy. ASiT Honorary Secretary & Sponsorship Co-ordinator Conclusions: Saturation Biopsy is useful in diagnosing prostate cancer in about 36% of cases after 2 inconclusive TRUS Biopsies. The General rd TRUS biopsy. The currently adopted antibiotic prophylaxis appears appropriate with 3.6% pick up rate of cancer is higher than a 3 Surgery Registrar, Sheffield risk of urosepsis. When Saturation Biopsy is non malignant and PSA is still rising, template biopsy maybe considered. 0524 USE OF THE SWOP CALCULATOR TO REDUCE UNNECESSARY PROSTATE BIOPSIES IN MEN WITH ELEVATED PSA Andrew Birch1, John Withington1, Janette Kinsella2, Peter Acher1, Ben Challacombe2 1 East Sussex Healthcare NHS Trust, EastDavies Robert Sussex, UK 2 Guy's and St. Thomas' NHS Foundation Trust, London, UK ASiT Honorary derived from the Background: The SWOP calculator is a nomogram Treasurer European Randomised Study of Screening for Prostate Cancer which predicts the percentage probability Surgery Registrar, West using the variables of age, DRE finding, PSA, ultrasound Vascular of malignant prostate biopsy by Midlands appearance and prostate volume. Aim: To investigate whether using a 10% or 15% risk threshold could avert unnecessary biopsies. Method: Data from 207 eligible patients (median age 60) biopsied from 2004-2010 were entered retrospectively into the risk calculator. The clinical outcomes for patients with 15% SWOP risk were investigated. Results: Of the 42 patients with 15% SWOP risk 13 patients (31%) had malignant histology at biopsy (9 Gleason 3+3, 4 Gleason 3+4), 7 received radical treatment (5 radical prostatectomies, 2 brachytherapy) and 5 entered active surveillance. Of the 17 patients James Milburn with a SWOP risk 10% 4 (24%) had positive biopsies (Gleason 3+3); none required treatment, 3 entered active surveillance (one patient has no follow-up data). ASiT Vice-President Conclusions: These data show that were a 15% risk threshold applied, then significant prostate cancers requiring treatment would General Surgery Registrar, Inverness have been missed but a 10% risk-threshold may have avoided unnecessary biopsies. The SWOP calculator may be useful for avoiding unnecessary biopsies in low-risk patients; this has significant implications for reducing biopsy and treatment morbidity and cost. 0551 TRANSPERINEAL TEMPLATE-GUIDED SATURATION BIOPSIES OF THE PROSTATE - EARLY EXPERIENCES IN A DISTRICT GENERAL HOSPITAL OF A NOVEL TECHNIQUE OF SATURATION BIOPSY Jaspal Phull, Alison Townsend, Megan Whitaker, Llinos Davies, Andy Thomas Joseph Shalhoub Princess of Wales Hospital, Bridgend, UK ASiT Vice-President Aims: Transrectal ultrasound-guided (TRUS) biopsy may miss 30% of significant prostate cancer, likely to be in the anterior zone. Vascular biopsies (TTB) is a NICE approved Transperineal template-guided saturation Surgery Registrar, London means of saturation-biopsy. We assessed detection rates with TTB. Methods: A prospective, non-randomized, cohort study of TTBs between July 2010 and August 2011. All cases were peer-reviewed at MDT, and would seek radical treatment if positive. The primary outcome was detection of malignancy. Results: 22 TTBs were performed. 81.8% (n=18) had >1 negative TRUS, 9.1% (n=2) were on active surveillance, 4.5% (n=1) was post Steve Hornby -radiotherapy PSA-relapse, and 4.5% (n=1) chose to have TTB as the primary biopsy method. ASiT Director of Education 12 of the 22 cases (54.5%) had new-diagnosis carcinoma only detected at TTB. 7 were benign (31.8%). Of the malignant histology (n=15) 13.3% Surgery Registrar, South West Peninsula General were Gleason 6 (n=2), 73.3% were Gleason 7 (n=11), and 13.3% were Gleason 8 carcinomas (n=2). Conclusion: TTB should be considered for men with rising PSAs and negative TRUS biopsy. We advocate TTB as the preferred technique for saturation biopsy for detection of significant prostate cancer in men who would benefit from further treatment. 0572 With thanks to the local ASiT Welsh Regional Representatives: OUT-PATIENT FLEXIBLE CYSTOSCOPY CAUSES PSYCHOLOGICAL DISTRESS TO A SIGNIFICANT NUMBER OF PATIENTS Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor BEING INVESTIGATED FOR BLADDER CANCER Gidon Ellis1Mr Andrew Beamish, ClinicalSam Osaghae3, Sam Smith4, Thomas McNicholas5, James Green1Cardiff , Jamie Fairweather1, Ninaad Awsare2, Research Fellow, University Hospital of Wales, 1 Whipps Cross University Hosptial, London, UK 2 Morriston Hospital, Swansea, UK 3 Pilgrim Hospital,thanks to the wonderful ASiT Conference Admin team: info@asit.org With Lincolnshire, UK 4 University College London, London, UK
Laura Andrews
Kristina Gloufchev
Harriet Innes
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5 Lister Hospital, Stevenage, UK Introduction: Many patients undergoing outpatient flexible cystoscopy experience psychological distress. This may relate to the impending procedure and to the possibility of discovering cancer. We set out to investigate the prevalence of significant psychological distress in a cohort of patients undergoing flexible cystoscopy and to identify subsets of the population who may be at higher risk. Methods: We recruited 173 patients undergoing out-patient flexible cystoscopy who completed questionnaires containing the Hospital Anxiety and Depression Score-A (HADS) and HADS-D to assess anxiety and depression respectively. A score of 11/21 on either scale was regarded as clinically significant. Results: The overall prevalence of anxiety was 15%, which was higher in females (p=0.025), in the young (p=0.001) and in unmarried individuals (p= 0.02). The prevalence of depression was 3.5%, which was higher in the young (0.001) and in unmarried individuals (p=0.02). Conclusion: The prevalence of clinically significant anxiety and depression in this cohort is notable; in particular amongst women, younger and unmarried patients. Accelerating the diagnostic pathway, improving patient information and offering counselling to those affected may help to reduce distress. Resources could be targeted at the higher risk groups identified here. The HADS questionnaires are a useful first-line screening tool for psychological distress.
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0605 SMALL SIZE NEPHROSTOMY TUBE USE POST PCNL Ben Rossi, Michal Sut, Asheesh Kaul, Abdul Rahim Khan, Aasem Chaudry Bedford Hospital NHS Trust, Bedford, UK Objective: To assess safety and outcomes of a small size 8F/8.5F nephrostomy tube use following Percutaneous Nephrolithotomy. Materials and methods: Retrospective data collection from 15 PCNL cases performed in Bedford Hospital NHS Trust over a period of 10 months. Stone clearance, hospital stay, complication rate, hemoglobin drop, analgesia and transfusion requirements were reviewed. Data was compared to recently published outcomes for tubeless PCNL and large bore nephrostomy use. Results: Median hemoglobin drop was 1.3 g.dL and length of stay was 72 hours. Those were comparable to previously reported results for tubeless PCNL and large bore nephrostomy tube use. Complication rate was low at 13% with only one patient requiring admission and treatment for urinary sepsis and one patient requiring repeat procedure due to pain related to residual stone. Stone clearance on day 1 was 60%. Average analgesia requirement was 1050mg of tramadol which was significantly higher than in previously reported studies and was likely related to our prescribing protocol. Conclusions: Small size nephrostomy PCNL is a safe procedure with acceptable Hb drop and length of stay. Decreased analgesia requirements proven previously were not reproduced in our group of patients. 0622 UROLOGY CANCER PATIENTS' VIEWS ON MULTIDISCIPLINARY TEAM (MDT) WORKING. A PILOT STUDY Benjamin Lamb1, Rozh Jalil1, Sujay Shah1, James Green2, Paula Allchorne2, Nick Sevdalis1 1 Imperial College, London, UK 2 Whipps Cross University Hospital, London, UK Introduction: Patient-centred care and patient satisfaction are increasingly recognised as being integral to high quality urological care. However, little evidence exists for whether the understanding experience of patients reflects the perceptions of healthcare professionals. This study aimed to explore urology patients' experience of the urology MDT. Method: Focus groups were set up to explore qualitatively participants' experiences and opinions. Questions covered patients' experience of being treated by a urology-MDT, awareness of the MDT's role, information the MDT should consider, and patient representation at MDT meetings. Results: Three focus groups were attended by 21 participants. Awareness of the MDT was low, but participants found the idea reassuring. Participants felt that it was important for the MDT to consider psychosocial information and their preferences, although this was not always their experience. Participants felt that the urology specialist nurse should act as their advocate in the meeting and that case discussion should be delayed if no one who had seen and knew the patient was present. Discussion: The concept of the MDT is popular with patients and could be promoted to increase patient satisfaction and improve patient experience. Further research is needed to link patients' MDT views with patient outcome and experience measures. 0630 RELIABILITY OF TRUS CALCULATIONS OF PROSTATE VOLUME Kaylie Hughes, David Ellis, Richard Stephenson Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK Aim: Prostate size is an important parameter in the assessment and treatment of prostate cancer. Prostate specific antigen (PSA) density can influence investigation approach and volume limits are often included in acceptance criteria for template biopsy and brachytherapy. We aim to assess the accuracy of volumes calculated by trans-urethral ultrasound (TRUS) compared with those from MRI. Method: All patients in our hospital undergoing TRUS imaging and prostatic biopsies were identified for the period of twelve months from December 2010 to 2011. Our standard protocol for potential candidates for curative therapy includes MRI quickly followed by TRUS biopsy. This allows a reasonable timeframe for comparison. Sizes were calculated using the standard ellipse method. Findings: We identified 196 patients for whom MRI and TRUS volumes were documented within six weeks of each other. Results were compared with a Wilcoxon-signed rank test. No significant difference was identified (p=0.108). Conclusion: Our results suggest that MRI prostate offers no added benefit when it comes to measuring prostate size. We feel that consistency between volumes produced by different imaging modalities is more important than absolute precision, as any thresholds will have been derived from the same methods.
0646 IS THE FREE/TOTAL PSA RATIO USEFUL AT PREDICTING THE PRESENCE OF PROSTATE CANCER ON TRANSPERINEAL PROSTATE MAPPING BIOPSIES? Neil Kotecha, Shahid Aziz Anwar Khan, A.M Emara, S.R.J. Bott, R.G Hindley Hampshire Hospital, Basingstoke, UK tives: Aim: We evaluated the role of Free/Total (F/T) PSA ratio in improving the prediction of prostate cancer in the transperineal prostate edd, Bangor mapping biopsy (TPM) setting. Methods: al of Wales, Cardiff The F/T PSA ratio were available in 145 patients with a total PSA< 20ng/ml. All patients underwent a standard TPM under GA. The cancer detection rate, pathologic features of the cancers detected, and the probability of cancer detection in relation to the F/ T PSA ratio were estimated. Results: m: info@asit.orgMean Age and PSA were 64.4 years and 9.5ng/l respectively (Range 1.6-20ng/ml). Overall cancer detection rate was 51.8%. 55/145 had a F/T ratio < 10 % of which 34/55 (61.8%) confirmed cancer (n=10 had Gleason 7, n=24 had Gleason 6). 66/145
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had a F/T PSA ratio between 10-20% with 50% of them having positive biopsies (n=26 had Gleason 6, n=38 had Gleason 7 and only 2 had Gleason 8). 24/145 had a F/T PSA ratio > 20% and only had evidence of cancer (all Gleason 6). Conclusion: The F/T PSA ratio in our series failed to confer a significant benefit in improving the cancer detection rate. However, in patients with a ratio of >20% only 1/3 had cancer present but were of a favourable grade.
0682 FEASIBILITY OF RANDOMISATION IN THE RANDOMISED CONTROLLED TRIAL OF OPEN, ROBOTIC AND LAPAROSCOPIC Goldie Khera (CORAL) RADICAL CYSTECTOMY TRIAL Grace Cheung, Amit Patel, Fahim Ismail, Peter Rimmington, Shamim Khan, Prokar Dasgupta ASiT President Guy's Hospital, London, UK Bariatric Fellow, North Tyneside Introduction: Minimally-invasive techniques for radical cystectomy are increasing in prevalence in the urological community. However, current evidence is lacking in which surgical technique is best. Methods: A single-centre randomised-controlled trial comparing open, laparoscopic and robotic-assisted radical cystectomy (RARC) for muscle-invasive or high-grade bladder cancer is currently underway at our centre, to investigate the short and long-term outcomes for each of these techniques. Results: 83 patients were eligible to be enrolled in the trial since March 2009. 54 patients agreed to participate. There was no difference between the trial and non-trial patients in terms of age (<70 years compared with > 70 years, p=0.8), gender Ed Fitzgerald or body mass index (BMI) (BMI<25 compared with BMI > 25, p=0.5). ASiT Conference 16 chose RARC. Past-President Of the non-trial patients, 13 chose open cystectomy andOrganiser & None in this group chose the laparoscopic technique. Conclusion: The majority of eligible patients agreed Registrar, London there appears to be no difference between non-trial General Surgery to random allocation, and participants towards choosing an open or robotic approach. There is no obvious selection bias in terms of age, gender or BMI for randomisation in this trial. 0704 LAPAROSCOPIC NEPHRECTOMY IN PATIENTS WITH BENIGN RENAL DISEASE AND ITS EFFECT ON HYPERTENSION Anna Mainwaring, Ninaad Awsare, Neil Fenn Morriston Hospital, Swansea, Jonny Wild UK Aim: We investigated the safety and efficacy of laparoscopic nephrectomy (LN) in the treatment of refractory hypertension in patients ASiT Honorary Secretary & Sponsorship Co-ordinator with a unilateral poorly functioning kidney. General Surgery Registrar, Sheffield Method: A retrospective review of patients undergoing laparoscopic simple nephrectomy for benign disease between 2005 and 2011 was performed using information from hospital and general practice patient records, operating theatre and pathology databases. 49 patients underwent LN for the following indications: (n=13) difficulty controlling hypertension, (n=20) chronic renal pain, (n=11) recurrent urinary tract infection and (n=5) had both pain/infection. Data collected included operative details, complications recorded using the Clavien Classification and symptom control. Results: All procedures were completed laparoscopically with no open conversions. There was no change in post operative creatinine levels. Complications occurred in 10(20%) patients with Clavien Classification as; Grade 1:(4) patients; Grade 2:(4) patients, Grade Robert Davies 3b:(1) patient, Grade 4:(1) patient. In the hypertension group there was no immediate reduction in post-operative blood pressure, howASiT Honorary Treasurer ever on follow up 2(15%) stopped all antihypertensive medication, 6(46%) reduced their medication with no change in 5(39%) patients. Vascular Surgery Registrar, West Midlands Conclusions: Laparoscopic nephrectomy for symptomatic benign renal disease is safe. The high success rate in reduction of antihypertensive medication confirms its efficacy and provides useful information when counselling patients preoperatively. 0716 THE SURGICAL CARE PRACTITIONER - ASSISTING, NOT COMPETING WITH, THE EXPERIENCED REGISTRAR AS PART OF MODULAR TRAINING FOR OPEN RADICAL RETROPUBIC-PROSTATECTOMY James Osborne, Jaspal Phull,James Milburn Jim Wilson, Adam Carter Royal Gwent Hospital, Newport, UK Vice-President ASiT Aim: Open radical retropubic-prostatectomy (RRP) requires both an experienced surgeon and assistant. We compare a Surgical Care General Surgery Registrar, Inverness Practitioner (SCP) as primary assistant against an experienced SpR (year4) assistant. We test the feasibility of using a SCP as assistant to a senior SpR in RRP by comparing their respective outcomes as first assistant. Methods: Retrospective review of all RRPs between January 2010 and October 2011. The first assistant was recorded (SCP or SpR). Outcomes were (1) intra-operative re-transfusion volume, (2) post-operative haemoglobin drop, and (3) operating time. Results: 99 RRPs were identified. 91 cases were suitable for analysis. The first assistant was the SCP in n=55 and Year 4/5 SpR in n=36. Between the SCP and SpR groups there Shalhoub Joseph was no difference in (1) mean intra-operative re-transfusion (598ml vs 636ml p=0.44), (2) mean post-operative haemoglobin drop (2.32g/dl vs 2.29g/dl, p=0.92), and (3) mean operating time (137.9min vs 141.7min, p=0.57). ASiT Vice-President Conclusions: As an assistant, there is no difference between the SCP and SpR. Our data supports using the SCP as an experienced Vascular Surgery Registrar, London first assistant to the experienced SpR for training. 0723 SURGICAL OUTCOMES OF NEPHRON SPARING SURGERY FOR RENAL TUMOURS Anna Mainwaring, Ninaad Awsare, Pradeep Bose, Neil Fenn, Jonathan Featherstone Morriston Hospital, Swansea, UK Steve Hornby Aim: Nephron sparing surgery (NSS) is increasingly being performed to treat renal tumours. We reviewed our surgical outcomes following partial nephrectomy. ASiT Director of Education Methods: A retrospective review of 51 consecutive patients (median age 59West undergoing NSS for renal tumours between 1999 General Surgery Registrar, South years) Peninsula and 2011. Indications for NSS were absolute (n=14), relative (n=16) or elective (n=21). Data collected included peri-operative, histological, disease-free and overall survival data. Complications were recorded using the Clavien classification. Results: Most procedures were performed open (n=46). More recently selected cases have been performed laparoscopically (n=5). There were no peri-operative deaths and no patients required renal dialysis. Sixteen patients (31%) had post-operative complications. Of these, 8 were thanks to the local ASiT Grade 3a according to the Representatives: With Grade 1, 5 were Grade 2 and 3 were Welsh Regional Clavien classification. Histology confirmed 37(73%) tumours were malignant and 14(27%) were benign. During follow up there were no local recurrences, but 1 patient (3%) developed Miss Rhiannon Harries, at a median follow up Registrar, Ysbyty Gwynedd, Bangor metastatic disease. The overall survival rateGeneral Surgery of 31 months was 92% with only one death attributable to metastatic renal cancer. Mr Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Conclusion: NSS for renal tumours is safe with an acceptable peri-operative morbidity rate. Preservation of renal function and low recurrence rates confirm it is an effective treatment option.

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0739 ACCESS TO LAP TRAINING, DEVELOPMENT OF A TABLET BASED LAP TRAINER Ali N Bahsoun, Mohsan M Malik, Kamran Ahmed, Oussama El-Hage, Prokar Dasgupta Guy's and St Thomas' Trust, london, UK Aim: Access to facilities that allow one to develop their laparoscopic skills is very limited in the hospital environment and courses can be very expensive. We built an effective trainer which allows laparoscopic skill acquisition in the home or classroom environment using a tablet. Methods: The cavity was made from a cardboard box with both sides and back left open to allow for natural light to enter. An iPad 2 was placed over the box to act as our camera and monitor. Ten experienced laparoscopic surgeons completed a task of passing a suture needle through 3 hoops and filled in a questionnaire to assess Face and Content validity. Results: On a 5 point Likert scale the tablet based laparoscopic trainer scored a mean 4.2 for Face (hand eye co-ordination, development and maintenance of lap skills) and for Content (graphics, video and lighting quality) it scored a mean 4.1. Conclusion: The iPad 2 based laparoscopic trainer was successfully validated for training. It allows students and trainees to practice at their own pace and on the go. For the price of a laparoscopic stack and camera we can buy around 150 iPad 2s for inexpensive training. Future app based skills are planned
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0755 CAN URINE CYTOLOGY BE SAFELY OMITTED FROM ROUTINE WORK-UP FOR HAEMATURIA? Eleni Anastasiadis2, Dhili Arul1, Kara Bruce-Hickman1, Sudhanshu Chitale1, Barry Maraj1 1 Whittington Health, London, UK 2 St George's Healthcare Trust, London, UK Introduction / Aim: Urine cytology has traditionally been part of routine work-up for patients with haematuria but provided relatively limited diagnostic yield at a significant cost. We audited our practice in the local setting to assess the value of urine cytology and the implications of deleting it from the investigative pathway. Method: Clinical data for 191 patients referred for urine cytological examination over a period of 3 months (July September 2010) was collected from the hospital database. Results: Haematuria was the presentation in 138 (73%) of these requests. 69% (95/138) were from Urologists. Of the 138, 77% were reported normal, 4% revealed atypical cells, 3% had malignant cells, 8% had appearances indicative of inflammatory pathology and 8% were unsuitable for analysis. Positive yield was < 10%. Of the 7% (9/138) with proven urothelial cancer (only of bladder in this series), cytology was normal in 44%, atypical in 11%, and malignant in 33%, highlighting that cytology would have missed cancer in >50% of haematuria cases. Conclusion: Urine cytology has very poor sensitivity for diagnosing urothelial cancer, and the cost and effort to conduct this investigation does not justify its use in the routine work-up of patients with haematuria. 0769 INCIDENTAL SYNCHRONOUS PRIMARY TUMOURS DETECTED DURING A MODIFIED MRI PROSTATE PROTOCOL Paul Hughes, Rajesh Nair, Tim Larner Brighton and Sussex University Hospitals NHS Trust, Brighton, UK Introduction: Magnetic resonance imaging (MRI) is the cross-sectional imaging modality of choice in staging prostate cancer. Standard protocol for prostate MRI is limited to the pelvis. We describe benefits of extended MRI protocols in identifying incidental synchronous primary lesions, which potentially influence prostate cancer management. Patients & Methods: A retrospective single-center review of 464 patients (median age 68, range 47-82 years) with a diagnosis of prostate cancer between January 2008 and December 2011 was performed. Outcomes were reviewed in patients that underwent extended-MRI staging in whom synchronous abdominal and pelvic masses were identified. Results: Eight patients had synchronous lesions identified: one adrenal mass, one rectal cancer, two bladder cancers and four renal masses. The adrenal mass was a non-functioning adenoma and one renal mass was identified as a simple cyst. The remaining six cases (1.3%) had confirmed synchronous malignancies. In two patients this did not influence prostate cancer management. The patients with rectal cancer and muscle invasive bladder cancer would have been identified with conventional protocols. The two patients with advanced renal malignancy were identified due to extended MRI. Conclusion: Significant renal lesions were identified on extended-MRI staging protocols for prostate cancer. These synchronous malignancies potentially influence prostate cancer management. 0772 THE ROLE OF CONTRAST ENHANCED ULTRASOUND IN THE ASSESSMENT OF COMPLEX OR EQUIVOCAL RENAL LESIONS Paul Hughes, Rajesh Nair, Emma Simpson, Tim Larner Brighton and Sussex University Hospitals, Brighton, UK Introduction: Contrast enhanced computed tomography (CECT) remains the standard imaging modality for renal lesion characterisation. Circumstances however, exist where diagnostic uncertainty remains. Contrast enhanced ultrasound (CEUS) is a safe, affordable, non-ionising adjunct in the assessment of difficult renal lesions. We describe our experience with this emerging radiological technique. Material and Methods: A single-centre retrospective review of 21 patients, median age of 68 years (range 35-89 years) with equivocal renal lesions was performed. All patients underwent CEUS using sonovue micro-bubbles between November 2010 and August 2011. Renal lesion enhancement, clinical outcomes and histological correlation were analysed. Results: In six patients with complex cystic renal lesions, three demonstrated concerning enhancement. In thirteen cases with equivocal solid lesions, nine were suggestive of renal cell carcinoma (RCC) of which five underwent nephrectomy. Three lesions demonstrated no enhancement. Only in one case was a lesion felt to be equivocal necessitating further imaging. Two cases were postcryotherapy ablation, of which one demonstrated recurrence not accessible on CECT. CEUS aided clinical decision-making in 90% (19/21) of cases. Conclusion: CEUS is an important adjunct to conventional imaging in delineating the nature of complex renal lesions, particularly those with renal impairment, when contrast agents are contra-indicated. 0797 APPEARING BLADDER MUCOSA AT THE EDGE OF PRIMARY TUMOUR
edd, Bangor THE IMPORTANCE OF THE BIOPSY OF NORMAL RESECTION SITE al of Wales, Cardiff
tives:
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Asheesh Kaul, Chris Jacobs, Michal Sut, Aasem Chaudry Bedford Hospital NHS Trust, Bedford, UK Introduction: info@asit.org European Association of Urology guidelines advocate separate biopsy of tumour base and edge during initial transurethral resection of bladder tumour (TURBT). Most evidence available analyse the prognostic value of random bladder biopsies rather
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than edge of resection site specifically. Aim: To evaluate the incidence and significance of positive tumour edge biopsies at primary TURBT. Methods: 22 cases of primary TURBT performed between October 2010 and October 2011 were retrospectively reviewed. All resections included a routine cold-cup biopsy of macroscopically normal mucosa at the resection edge. Data sources included histopathology reports and Multidisciplinary Team Meeting notes. Results: Abnormal biopsy was found in 9 patients (41%). Carcinoma-in-situ (CIS) was found in 7 patients (32%) and in 2 cases (9%) biopsy results were corresponding with primary pathology indicating incomplete tumour resection. Tumour edge biopsy effected Goldie Khera management of 3 cases (22%). 2 patients (9%) with CIS received intravesical chemotherapy with Bacillus Calmette-Guerin (BCG) vaccine and 1 patient with incomplete resection underwent early check cystoscopy and biopsy within 3 ASiT President weeks of primary resection. Those patients would otherwise have been scheduled for check cystoscopy at 3 months. Bariatric Fellow, North Tyneside Conclusion: We believe that tumour edge biopsy should be standard practice at primary TURBT.
General Surgery Registrar, Sheffield 0827 THE INTRODUCTION OF HOLEP TO A DGH: IMPROVED OUTCOMES FOR HOLEP AND CONCURRENT TURP PATIENTS Nicholas Wilson, Michael Mikhail, Anthony Young Southend University Hospital, Southend, UK Introduction: Both Holmium laser enucleation of the prostate (HoLEP) and TURP are recommended by NICE as surgical treatment options for symptomatic benign prostatic enlargement. Three years ago HoLEP was introduced to our institution alongside TURP. The aim of this study was to examine the effect of introducing HoLEP on: resection weight, length of stay (LOS) and transfusion rate, and Robert Davies also examine what impact this had on patients concurrently undergoing TURPs. ASiT Honorary Treasurer Methods: We retrospectively analysed all TURPs (TURP-08-11) and HoLEPs performed at our unit from the introduction of HoLEP in April 2008 to July 2011. We also analysed Surgeryin the 12 months preceding April 2008 to form a historical control (TURP-07). Vascular all TURPs Registrar, West Midlands Results: A total of 769 procedures were performed: 161 TURP-07, 425 TURP-08-11, and 183 HoLEP. The rate of transfusion was 5.5%, 2.2% and 1.6% in the TURP-07, TURP-08-11 and HoLEP groups, respectively. The median LOS for HoLEP was 3 days compared to 5.6 and 4.4 for TURP-07 and TURP-08-11, respectively. Conclusion: The introduction of HoLEP alongside TURP has significantly reduced LOS and transfusion rates for all patients. HoLEP patients had the largest reductions, but notably TURPs done in an institution also performing HoLEP showed significant improvements in outcomes as well.
0880 ASiT Vice-President MAPPING PROSTATE BIOPSIES DOES NOT INCREASE THE ACCURACY OF PROSTATE CANCER STAGING General Surgery Registrar, Inverness Nirav Patel, Evangelos Gkougkousis, James Green Urology department, Whipps Cross Hospital, London, UK Aim: Performing a staging MRI in the presence of positive apical biopsies is a standard practice in many prostate cancer centres. We aimed to assess the value of mapping prostate biopsies. Method: Data from 206 patients diagnosed with prostate cancer between January 2010 and September 2011 were retrospectively collected. Presenting PSA, clinical stage, Gleason score, apical positivity and imaging results were analyzed using Chi square test on SPSS 20. Joseph Shalhoub Results: One hundred and twenty seven of 159 patients with apical involvement and 29 of 47 without had an MRI of the pelvis, with ASiT Vice-President extraprostatic disease found in 43 and 6 patients respectively (p=0.186). This difference was not statistically significant even stratifying Vascular Surgery Registrar, London for PSA level and Gleason score. In multivariate analysis, the largest subgroup comprised patients with PSA 10 and Gleason 6 or 7, where again results were not significant (p=0.516 and 0.525 respectively). Similarly, bone scan results were comparable, with 11 of 87 patients with positive apex and 2 of 18 with negative apex having bone metastases (p=0.283) Conclusion: Our data shows that mapping prostate biopsies and performing an MRI in the presence of apical involvement does not increase the accuracy of prostate cancer staging. 0918 ASiT Director of Education THE ROLE OF AN ENHANCED RECOVERY PROGRAMME FOR PATIENTS UNDERGOING RADICAL CYSTECTOMY Amit Gupta, Raj Nair, Sam Jallad, Philip Thomas, TimRegistrar, South West Peninsula General Surgery Larner Brighton and Sussex University Hospitals NHS Trust, Brighton, UK Aim: An Enhanced Recovery Programme (ERP) reduces hospital stay, and improves peri-operative complication rates in colonic resection patients. Its role in urological surgery however, has been the subject of debate. We examine the role of an ERP tailored to radical cystectomy at a tertiary centre. Method: With thanks to of 32 cystectomies (November 2009 - SeptemberRepresentatives: A retrospective review the local ASiT Welsh Regional 2011).16 ERP cases (median age 69, range 56 76) were compared to 16 non-ERP cases (median age 69, range 65 80). Co-morbidities were quantified using the Charlson Comorbidity Miss Rhiannon measures included time Surgery Registrar, Ysbyty Gwynedd, Bangor Index (CCI). Outcome Harries, General to oral nutrition, bowel action, mobilisation, discharge and complications. Results: Mr was no statistical difference in CCI between the two groups. University discharge was day 14 (range 7 - 44) comThere Andrew Beamish, Clinical Research Fellow, Median ERP Hospital of Wales, Cardiff pared to day 18 (range 9 - 24) in the non-ERP patients. Median date of ERP patients achieving oral consumption was day 6 compared to day 8 in non-ERP patients. Similar results were observed with mobilisation and bowel action. There was no statistical difference in complications in both groups to3the wonderful ASiT Conference Admin team: info@asit.org With thanks at months (range 1 to12). Conclusion: Application of ERP to radical cystectomy has been successfully used. We demonstrate an improved recovery and earlier discharge.
0813 Does the 2 week wait referral process have an impact on Bladder cancer prognosis? Sherief Marzouk, Ali Jibran Mecci, Jo Han Gan, Paula Allchorne, Benjamin Lamb, James Green Whipps Cross University Hospital, London, UK The two week wait (2WW) pathway has been successful in reducing time to treatment for bladder cancer. However there are still a Ed Fitzgerald significant number of patients who present as emergencies with frank haematuria. We sought to establish whether there is a significant difference in prognostic ASiT Conference Organiser &between the patients referred to the 2WW haematuria clinic indicators of bladder TCC at presentation Past-President and those presenting as emergencies. Surgery Registrar, London General We performed a retrospective cohort study of patients referred with haematuria, comparing tumour stage and grade between patients referred as emergencies and to 2WW haematuria clinics. Only diagnoses of TCC were included. 354 patients presented to A&E with frank haematuria from September 2009 to September 2011. 67 had bladder TCC with 51 new diagnoses, whereas 146 TCCs were diagnosed through 2WW clinic. Of the emergency group 55% had muscle invasive tumours compared to 23% from clinic (p = <0.001). The same was true for tumour grade: 79% G3 as emergencies versus 54% from clinic (p = <0.001). Jonny Wild We found that patients with TCC that present as emergencies had far worse prognostic indicators at presentation. This supports the need for the inclusion of haematuria in the out of hours urology guidelines within the Acute Co-ordinator ASiT Honorary Secretary & Sponsorship Oncology Service.
James Milburn
Steve Hornby
Laura Andrews
Kristina Gloufchev
Harriet Innes
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0943 CAN ACUTE RENAL COLIC PRESENTATIONS BE ANTICIPATED DURING THE DAY? A PROSPECTIVE ANALYSIS OF CT-KUB SCANS IN A BUSY EMERGENCY DEPARTMENT Joseph El-Sheikha, Andrew Myatt Castlehill Hospital, Cottingham, UK Background: Renal colic is a common urological emergency and can place a large burden on limited health resources. At our institution if a renal colic is suspected a patient undergoes a CT-KUB in the Emergency department prior to referral. We aim to determine if the presentation of renal colic to the emergency department can be anticipated and therefore assist organisational planning. Method: A prospective analysis of all suspected renal colic patients with a CT-KUB scan between August and December 2011 was undertaken. We recorded demographics, Urine dip, Time of CT-KUB and Stone size (if present). Results: Data from 217 patients was recorded and 93 patients showed CT-KUB evidence of ureteric calculi. Most CT-KUB's were preformed between 1400-1600(33/217) and least between 0200-0400 (11/217). The greatest number of calculi were diagnosed between 1000-1200(9/93) and least 02-0400(4/93). Overall, between 0800 and 2000, 169/217 (78%) CT-KUB requests were made and 69/93 (74%) stones diagnosed. An average of 18.6 calculi were diagnosed a month (12-24) from a monthly average of 43.4 CT-KUBs (33-52). Conclusion: Suspected renal colic is less likely to present to the Emergency department during the night but a significant proportion of calculi and CT-KUB scans present at this time.
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0967 THE SUCCESS AND LIMITATION OF ROBOTIC ASSISTED INTRAVESICAL URETERIC REIMPLANTATION Jun-Hong Lim, Nicholas Gattas, Azad Najmaldin Leeds General Infirmary, Leeds, UK Robotic technology is increasingly being used in surgical procedures. We present our early experience of robotic intravesical ureteric reimplantation. All children who had ureteric reimplantation from April to July 2011 were included in this prospective study. Patient demographics, indications for surgery, vesicoureteric reflux grade, total operating time and console time, reason for conversion to open surgery, timing of discharge and complications were noted. 8 ureters in 5 patients (age 26 months - 7 years) were operated. Reflux grade of 3 to 5 in all but 1 who had a symptomatic grade 1 following deflux injection. One patient with obstructed megaureter was converted to open technique because of limited working space and relatively large instruments. Mean total operating time was 225 minutes (range: 152-257) and console time 113 minutes (range: 80-150). All discharged on post operative day 1. The catheter and stent were removed on day 7. There were no complications. Ultrasound scan and follow up in 1 and 4 months. This early experience support the view that robotic assisted intravesical reimplanation is feasible and safe. The ergonomic of tissue handling and suturing were easier, but greater technical challenges can arise from limited working space and size of instruments 0980 THE EVOLVING ROLE OF SIMULATORS AND TRAINING IN ROBOTIC UROLOGICAL SURGERY: WHICH ASSESSMENT TOOL TO USE? Jonathan K. Makanjuola, Sashi Kommu, Ben Challacombe, Muhammad Shamim Khan, Prokar Dasgupta The Urology Centre, Guy's and St Thomas' NHS Foundation Trust Kingdom and MRC Centre for Transplantation, NIHR Biomedical Research Centre, King's College London, King's Health Partners, London, UK Aim: The evolution of minimally invasive urological surgery from conventional laparoscopy to robotic platforms has entered a new phase, with large numbers of surgical trainees wanting to learn robotic surgery. Currently, there is no consensus on robotic training. We reviewed the present status of robotic training to guide learning. Methods: MEDLINE, EMBASE and the Cochrane Databases were searched from 1999 to 2011 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports on assessment and training in robotic surgery. Results: There were 40 papers found 2 longitudinal studies, 2 case-control studies with the rest editorials and commentaries on robotic surgery training/assessment. There is evidence that fellowship-trained robotic surgeons initially have superior results than nonfellowship-trained counterparts. There are no well-structured prospective studies that correlate the effectiveness of training with patient morbidity or mortality. Conclusion: There is no consensus on the optimal tools to assess the impact of surgical trainees learning curves on patient outcomes. Fellowship training remains the most effective way to gain robotic competences. Studies are needed to provide guidance of roboticskill acquisition. There are three validated robotic simulators but there is need for focused training and assessment pathway guidelines for robotic surgery training.
0995 UPPER URINARY TRACT UROTHELIAL CARCINOMA: PROGNOSTIC FACTORS Talal Altayeb, Joseph El-Sheikha, Sanjeev Katwal, Graeme Cooksey Urology Department, Castle Hill Hospital, Hull, UK Aim: Upper urinary tract urothelial carcinoma (UTUC) comprises approximately 10% of renal neoplasm. Minimally invasive endoscopic procedures are associated with high recurrent rate; therefore, radical nephro-urectomy (RNU) remains the gold standard. The aim of this study was to examine the oncological outcome of patients with UTUC following RNU. Methods: We conducted a retrospective review of prospectively collected data on patients with UTUC underwent RNU from 2001 to2005. SPSS statistical software programme was used for analysis. Results: A total of 26 patients were treated over the study period with median age of 61years and 17 of patients were of male gender. Lower ureteral tumours were of higher grade (pT3/pT4) compared to upper localisation (66.6% versus 38.4) and were associated with increased rate of lymph node metastasis (33.3% contrast 18.3% respectively). Overall recurrence rate of 53.8% (n=14) was observed in this cohort. Most of the cases were intravesical recurrence 64.2% (n=9). Favourable oncological outcome was positively correlated with low grade cancer (pT1/pT2), absence of lymph node involvement and upper ureteral tumour (77%, 100% and 61.5 respectively; p <0.05) tives: Conclusions: This study found that UTUC location and pathological stage are important prognostic factors. These results need to be edd, Bangor validated with larger case series. 0997 TYPE OF ANASTOMOSIS: A COMMON VARIANT AFFECTING HOSPITAL STAY IN RADICAL PROSTATECTOMY? Stephanie info@asit.org Guillaumier, Sarvpreet Ubee, Bhupendra Sarmah Birmingham Heartlands Hospital, Birmingham, UK
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Introduction: To assess if an interrupted or continuous anastomosis during open radical prostatectomy (ORP) affects the duration of post-operative hospital stay. Materials and methods: 103 consecutive patients underwent an ORRP for localised prostate cancer between 2008 and 2011. 51 patients had interrupted type of vesico-uretheral anastomosis (IRP) and the subsequent 52 had continuous anastomosis (CRP). Retrospective data collection was carried out on hospital stay, cystogram, catheter removal, number of lymph nodes excised and urinary continence. Results: Median (Range) of lymph nodes excised was 6(1-23) in IRP and 6(1-19) for CRP. Median day for drain removal for IRP group Goldie Khera was 3 and for CRP was 2. The mean hospital stay for IRP was 4 (4.63) and for CRP was 3 (3.32). 47/51 did not show leakage on cystogram in the IRP group. The mean (median) day for catheter removal was 12.1 (11). 46/52 did not show any leak on a cystogram ASiT President in the CRP group and the mean (median) day for catheter removal was 13.1 (12). Continence was achieved in 6 months by 35/51 in Bariatric Fellow, North Tyneside IRP and 40/52 in CRP. Conclusion: In our experience, continuous anastomosis in ORP appears to be a common variant affecting the post-operative hospital stay.
0998 EXPRESSION PROFILING OF RNA BASED MARKERS OF PROSTATE CANCER IN URINE AND TISSUE SAMPLES Eva Bolton, Diarmaid Moran, Armelle Meunier, Laure Marignol, Donal Hollywood, Thomas Hugh Lynch, Antoinette Perry Ed Fitzgerald Prostate Molecular Oncology Group, Trinity College, Dublin, Ireland ASiT Conference Organiser & Past-President Introduction: A critical challenge in prostate cancer (CaP) research is integration of molecular markers into routine clinical use. Differential microRNA expression has successfully differentiated CaP from normal tissue. Diagnostic potential also rests in the non-invasive General Surgery Registrar, London quantification of other RNA species, such as CaP specific PCA3 transcripts and the TMPRSS2:ERG fusion gene mRNA in urine. Expression of CaP related miRs has not been detailed in urine. Aims: (i) profile urinary expression of 13 miRs, definitively up-regulated in CaP, (ii) (determine performance in CaP detection in conjunction with and compared to gold-standard urinary markers PCA3 and TMPRSS2:ERG Methods: Relative quantification data on miR microarray analysis of 24 human prostate cell line samples identified over-expressed miR's, and validated in 85 FFPE tissue samples). Cellular and cell-free total RNA was isolated from 173 urine samples with suspected Jonny Wild CaP. PCA3 and TMPRSS2:ERG expression were quantified relative to PGK1 and miR expression calculated relative to let-7e and miR429 by qRT-PCR. ASiT Honorary Secretary & Sponsorship Co-ordinator Results: 45% of patients (78/173) have CaP. MiR-100 shows 7.9-13.25 fold upregulation in cancer cell lines and tissues relative to General Surgery Registrar, Sheffield to benign. On this basis expression is under investibenign. Similarly miR-125, miR-24, miR-99a, miR-99b are over-expressed relative gation using custom TLDAs in the urinary cohort. 1007 IS IT WORTH SAMPLING THE TRANSITIONAL ZONE IN TRANSRECTAL ULTRASOUND GUIDED BIOPSIES OF THE PROSTATE? RANDHAWA K, OBEIDAT S, PETTERSSON BA, POWELL CS. COUNTESS OF CHESTER HOSPITAL Karen Randhawa, Samer Obeidat, Bo Adrian Pettersson, Christopher Powell Robert Davies Countess of Chester Hospital, Chester, UK ASiT Honorary Treasurer Aim: The aim of this study was to evaluate the clinical significance of additional routine transitional zone biopsies in patients undergoing transrectal ultrasound-guided prostate Surgery Registrar, West Midlands Gleason grading for cancers found concurVascular biopsies. Comparison was also made between rently in both the transitional and peripheral zones. Method: Between May and November 2011,one hundred and seventy-four transrectal ultrasound-guided prostate biopsies were performed, using a 12-core systematic approach with two additional transitional zone biopsies. A retrospective case note analysis was performed reviewing histology obtained from biopsies. Factors assessed were: PSA level, number of cores, percentage of prostate cancer found in peripheral zone, transitional zone and Gleason grade of cancers present. Seven were excluded. James Milburn Results: Of 167 prostate biopsies performed,81 patients (48.5%) were found to have prostate cancer. Two were transitional zoneconfined of Gleason grade 4+3 and 3+3 respectively. In biopsies with concurrent zone cancers (35 patients) four showed an upgraded ASiT Vice-President Gleason grade in the transitional zone than the peripheral zone. Twenty biopsies confirmed the same Gleason grading in both zones, General Surgery Registrar, Inverness and eleven biopsies showed a downgrading in the transitional zone. Conclusion: Routine transitional zone biopsies do not significantly increase the detection rate of prostate cancer. However, they do provide information regarding the grading of the cancer which can further impact on management 1020 ASSESSMENT OF SYMPTOMATIC OUTCOMES OF SACRAL NEUROMODULATION FOR THE TREATMENT OF DETRUSOR OVERACTIVITY Joseph Shalhoub Aziz Gulamhusein, Fady Youssef, Rachel Simmons, Sheilagh Reid ASiT Vice-President Royal Hallamshire Hospital, Sheffield, UK Vascular Surgery Registrar, London Aims: To assess symptoms in patients who have undergone implantation of the Interstim TM neurostimulator using the ePAQR online questionnaire. Methods: ePAQR is an interactive online instrument developed in Sheffield. It assesses symptoms relating to the pelvic floor and the impacts on quality of life. Five patients with detrusor overactivity with urinary incontinence refractory to medical management completed the online questionnaire pre and post implantation. Urinary symptoms are calculated. A score of 0 indicates no symptoms, whilst a score of 100 indicates maximum possible symptoms. Urinary symptoms are categorized into: pain, voiding, overactive bladder Steve Hornby and stress incontinence. Quality of life is also assessed. ASiT Director of treatment and Results: All patients completed an ePAQR score pre Education proceeded to percutaneous nerve evaluation (PNE) followed by permanent implantation. One General Surgery Registrar, South West and elected for intravesical botox treatment. Mean patient had no improvement in symptoms during PNE Peninsula pre implant scores: 48.15 (11-100); Mean PNE scores: 14.05 (0-67); Mean post implant scores: 8.85 (0-33) Conclusion: A significant improvement in symptoms and quality of life in patients receiving permanent neuromodulation implants was seen. The use of ePAQR provides an efficient and quantitative means to record symptoms. Further patient numbers are required to assess sacral neuromodulation and ePAQR as an assessment tool. 1094 MANAGEMENT OF LOCALISED RENAL Surgery Registrar, Ysbyty Gwynedd, Bangor SURGICALMiss Rhiannon Harries, GeneralCANCER; THE CASE FOR LAPAROSCOPIC PARTIAL NEPHRECTOMY Bathmapriya Balakrishnan, Beamish,Sherwood, Simon T. Williams Mr Andrew Benjamin T. Clinical Research Fellow, University Hospital of Wales, Cardiff Division of Urology, University of Nottingham, Royal Derby Hospital, Nottingham, UK Introduction: Although historically radical nephrectomy has been the mainstay of management for localised renal cell carcinoma (RCC), partial nephrectomy (PN),the wonderful for T1 (<7cm) lesions. With thanks to is now recommended ASiT Conference Admin team: info@asit.org Aim: To determine current practice with respect to management of T1 RCC in a tertiary referral unit.
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
Methods: Retrospective case-note review of patients undergoing surgery for T1 RCC (2009-11). Results: Of 57 patients undergoing surgery, 47 (82.4%) underwent laparoscopic radical nephrectomy (LRN) and 9 patients (15.8%) were treated with PN. One patient underwent open radical nephrectomy (ORN). At the time of multidisciplinary registration, partial nephrectomy was only considered in 10 patients (17.5%). Median length of stay was shorter in LRN (4 vs. 7 days), with fewer complications. Mean increase in creatinine from baseline was 41.0 in patients undergoing LRN/ORN, vs. 12.5 in those undergoing PN (t = 3.4662, p = 0.0011). In the LRN/ORN group, a new decline in eGFR to < 45 was noted in 29% of patients, vs. 11% in the PN group. Conclusion: Mainstay of management for T1 RCC is currently LRN. Whilst a laparoscopic approach provides a LOS advantage and reduces complication rates, the loss of an entire renal unit may give rise to CKD related morbidity.
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1100 HOW TO IMPROVE THE LEARNING CURVE OF COMPLEX PROCEDURES OR NOVEL TECHNIQUES IN LAPAROSCOPY: THE CONCEPT OF WHOLE PROCEDURE EQUIVALENT Jonathan Makanjuola2, Paul Rouse1, AR Rao1, C Brown1, Philippe Grange1 1 Department of Urology, Transplant and Abdomen Clinical Academic Group, Kings College Hospital , Kings Health Partners, London, UK 2 Department of Urology, Guys and St Thomas NHS Foundation Trust, London, UK Aim: In a linear model of apprenticeship, easy procedures are allocated to training. By the end of the curriculum little time is left to learn complex procedures for which demand for training is high. These are partly addressed by sequential-modular training. We propose a novel concept of non-sequential modular model whole procedure equivalent (WPE). Methods: Laparoscopic-prostatectomy is broken down into steps that can be learnt independently without pre-set orders. Trainees record performance on a developed e-portfolio for each step on every case following feedback. There is a colour code of performance; deep blue when the trainee was in a trainer role, green when a step was completed without supervision and amber when performed under supervision. Results: Six surgeons have trained to proficient level: four were sixth-year fellows and two were senior surgeons in personal development. Each surgeon by the end of the training has performed independently with a smaller number of operations with competency gained through a far larger number of WPE, growing rapidly after 24 cases. Conclusion: By exploring ways of facilitating training in challenging surgical procedures a model of learning complex laparoscopic skills has been designed. The non-sequential model allows for a higher ratio performance/attendance than existing models. 1109 ANTERIOR MINI PYELOPLASTY FOR ADULT PUJ OBSTRUCTION: A BETTER ALTERNATIVE THAN LAPAROSCOPIC PYELOPLASTY IN SELECTED CASES? Oliver Fuge, Malcolm Marquette, Rajiv Pillai, John Mcloughlin West Suffolk Hospital, Bury St Edmunds, UK Aim: Open pyeloplasty is the gold standard treatment for pelviureteric junction (PUJ) obstruction. Laparoscopic pyeloplasty is increasingly becoming a popular alternative but has inherent difficulties with laparoscopic suturing and this can often affect the final outcome. We describe a technique of anterior mini pyeloplasty which carries the advantage of minimally invasive surgery and is as effective as the standard open pyeloplasty Method: 12 patients underwent open mini pyeloplasty at our centre for PUJ obstruction. The surgical technique involved approaching the PUJ through an anterior muscle splitting 3-4 cm transverse incision. Results: Mean patient age = 56; average BMI=23; mean operation time= 129 minutes; mean decrease in post op Hb = 1.4 mg/dl ; median hospital stay : 3.6 days. None of the patients required parenteral analgesia after day 2. All symptomatic patients were symptom free postoperatively. All patients showed an improvement in drainage on postoperative MAG3 renogram. Conclusions: Anterior mini pyeloplasty is quite popular in children but this is the first presented series in an adult population. It has all the advantages of minimally invasive surgery and has comparable efficacy to that of standard open pyeloplasty . We conclude that anterior mini pyeloplasty is safe and successful in selected cases. 1150 OPTIMAL MANAGEMENT OF DETRUSOR UNDERACTIVITY IN MEN WITH SYMPTOMS SUGGESTIVE OF BENIGN PROSTATIC OBSTRUCTION Aziz Gulamhusein, Sampi Mehta, Derek Rosario Royal Hallamshire Hospital, Sheffield, UK Aims: To evaluate whether urodynamic assessment of patients with chronic urinary retention following a period of clean intermittent self-catheterization (CISC) would allow better management of patients with detrusor underactivity (DU). Methods: Forty eight patients were recruited. Retention was initially relieved with indwelling catheterization. Patients were subsequently taught CISC and reviewed at three months. Patients with resuming motor or sensory bladder activity proceeded to urodynamics. Those with confirmed DU continued CISC and those with benign prostatic obstruction (BPO) were offered transurethral resection of the prostate (TURP). Results: Mean age was 79 years (30-91). At three month review, 42 (88%) patients were appropriate for urodynamics. Twenty six patients (62%) were found to have BPO of which 22 had a TURP. Following surgery, 21 (95%) were voiding well. Sixteen patients (38%) were found to have DU and subsequently continued treatment with CISC and reviewed in clinic for change in bladder function. Conclusion: CISC is the gold standard treatment for DU. A key cause of poor post TURP results is underlying DU. The use of initial CISC allowing bladder rest followed by urodynamics on selected patients helps identify those most likely to benefit from surgery from those with DU, more suitable for continued CISC.
1153 A COST ANALYSIS OF TRANSURETHRAL RESECTION OF THE PROSTATE AND LASER PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE Niamh Byrne, Brian Kelly, Mary Sweeney, Ailbhe Tummons, Syed Jaffry tives: Department of Urology, Galway University Hospital, Galway, Galway, Ireland edd, Bangor Introduction: The aim of this study is to assess the cost effectiveness of the 120W HPS photoselective vaporization of the prostate (PVP) in al of Wales, Cardiff comparison with transurethral resection of the prostate (TURP). Methods: 60 PVP procedures performed over a 3 year period (Feb 2009 July 2011) were compared with 60 TURP procedures performed during the same time period. The focus of the paper was primarily on the potential cost saving with the PVP procedure due to a shorter m: info@asit.orginpatient hospital stay. Results: Of the 120 procedures performed, 60 were PVPs while 60 were TURPs. 15 (25%) PVPs were performed as a day-case pro-
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cedure, while 45 (75%) were performed as an in-patient procedure. The median length of stay for a PVP in our institution is 4 days (range 0 29 days). The median length of stay for TURP is 7 days (range 3 26 days). In our institution, the mean cost of a TURP is 11,200, the mean cost of a PVP is 7,300 while the day case PVP costs 2,800. Conclusions: This study highlights the potential savings to public hospitals with a shorter in-patient hospital stay for patients undergoing the PVP procedure.

ASiT President
Goldie Khera VASCULAR / ENDOVASCULAR SURGERY
0042 Bariatric Fellow, North Tyneside VALIDATION OF A REGRESSION MODEL TO ACCURATELY DETERMINE THE EFFECTS OF IPSILATERAL CRITICAL CAROTID STENOSIS ON CONTRALATERAL DUPLEX CAROTID VELOCITIES Obinna Obinwa1, Cliodhna Browne1, Lorraine Byrne1, Mary Dillion1, Tara Coughlan1, Dominick McCabe2, Ronan Collins1, Bridget Egan1, Martin Feeley1, Sean Tierney1 1 The Adelaide and Meath Hospital, Dublin, Ireland 2 UCL Institute of Neurology, London, UK Aim: This study set out to validate our multivariate fractional polynomial regression (MFP) model that predicts the effect of carotid Ed Fitzgerald (non-operated) post-operative carotid artery duplex velocities. endarterectomy (CEA) on contralateral ASiT Conference data = 43/19; N=62). Predicted post-operative contralateral velocities in a valiMethods: Cross-validation study (callibration/validation Organiser & Past-President dation cohort having CEA was obtained Surgery Registrar, London General by applying the pre-existing MFP formula to their pre-operative data. Model validation was assessed with reference to the bias(defined as difference (predicted - actual) contralateral post-operative velocity) and bland altman graphical plots; the median and interquartile range (IQR 25th:75th centile) of the bias were also reported. Results: The median bias for contralateral ICA PSV, ICA EDV and ICA\CCA PSV ratio were - 9 cm/s, -1 cm/s and -0.14 respectively; and the corresponding IQR were (-22: 0) cm/s, (-11:4)cm/s and (-0.57:0.12). In each case, the bland altman plots showed increasing confidence intervals of the mean bias as the average (predicted + actual) velocities increased. Conclusions: Although callibration data suggest that the MFP model may be accurate for determining the effects of the ipsilateral Jonny Wild stenosis on the contralateral flow velocities; the widened confidence intervals displayed in the validation plots may yet limit their clinical use. Further research using a ASiTdataset is required. larger Honorary Secretary & Sponsorship Co-ordinator
General Surgery Registrar, Sheffield 0117 THE BUTTON HOLE METHOD OF FISTULA CANNULATION. DOES IT AFFECT PATENCY RATES? Rosalyn Shearer1, James Milburn1, Alasdair Wilson1, Michael Sharp1, Ann Humphrey1, Jacqui Ross1, Ewan Macaulay2 1 Aberdeen Royal Infirmary, Aberdeen, UK 2 Royal Adelaide Hospital, Adelaide, Australia Objective: The button hole (BH) technique of arteriovenous fistula (AVF) cannulation requires repeated use of a single site to form a mature track. There is little known on how the BH technique affects the patency of AVF. Our aim was to compare patency rates of Robert Davies fistula cannulated by BH compared to laddering techniques. ASiT Honorary Treasurer Method: Patients commencing haemodialysis through Radiocephalic or Brachiocephalic fistulae were identified. Comparison was made to a control group who used the laddering method prior to the introduction of BH. Data was collected prospectively. Groups were Vascular Surgery Registrar, West Midlands compared by chi squared, unpaired t-test and log-rank methods. Results: There were no statistical differences (p>0.05) between BH (n=88) and controls (n=322) with regard to demographics. At 2 years, AVF cannulated by BH had a higher patency rate at all time points (6 months 90.9% v 81.1%, 12 months 80.4% v 74.5%, 2 years 73.3% v 67.1%) but this did not reach statistical significance (p=0.227). Conclusion: We have shown clinical non-inferiority of the BH technique on AVF secondary patency compared to a standard cannulation technique. Previous studies revealed patient and nursing preference for BH over the laddering technique and therefore we sugJames Milburn gest this should become the first line method of AVF cannulation.
0163 General Surgery Registrar, Inverness FACTORS AFFECTING LENGTH OF STAY (LOS) IN ELECTIVE AAA SURGERY 1 Jeremy Lynch , Katherine Cheema2, Jonathon Quayle1, Chris Jukes1, Peter Leopold1, David Gerrard1, Patrick Chong1 1 Frimley Park Hospital, Frimley, Surrey, UK 2 South East Coast NHS Quality Observatory, Southampton, UK Objective: Vascunet Registry data shows that UK elective Abdominal Aortic Aneurysm (AAA) repair patients have the worst length of stay (LOS) data in Europe. This study examines risk factors associated with an increased LOS in AAA surgery. Methods: We examined 75 consecutive elective AAA repairs performed between 1st September 2009 - 31st October 2010. PreJoseph Shalhoub operative, intra-operative and post-operative factors were analysed using multinomial regression analysis. ASiT Vice-President Results: The median LOS was 7 days (2-33) for OS vs. 2 days (1-47) for EVAR. 30-day mortality was 2% for EVAR and there were no Vascular Surgery Registrar, London deaths for open surgery. 31% of EVAR patients stayed > 3 days and 63% of open surgery patients stayed > 7 days. Factors associated with increased LOS were age over 75 (Chi= 29.45, p=0.031) and any post-operative complication (Chi= 35.32, p=0.006) with respiratory infection being the most common complication (7/19 patients). The average LOS more than doubles if any post-operative complication is present (5.6 days versus 11.85 days). Conclusions: Our study suggests that there may be potential for reducing LOS in elective AAA surgery for patients > 75 yrs and those who may be at risk of post-operative respiratory infection by introducing targeted measures in the Vascular Society AAAQIP. Steve Hornby
ASiT Vice-President
ASiT Director of Education 0169 THE FRESH FROZEN PULSATILE HUMAN CADAVER MODEL. A NOVEL TECHNIQUE FOR TRAINING ENDOVASCULAR General Surgery Registrar, South West Peninsula PRACTITIONERS. A TRIAL OF FACE VALIDITY 1 1 C Nesbitt , J McCaslin , S Macdonald1, H Ashour2, G Stansby1 1 Northern Vascular Centre, Newcastle Upon Tyne, UK 2 Queen Elizabeth Hospital, Gateshead, UK Aims: Determine thanks to thepulsatile human cadaver model (PHCM) for training endovascular practitioners. With the face validity of a local ASiT Welsh Regional Representatives: Methods: 11 endovascular clinicians performed two procedures (catheterisation of the left renal artery and left subclavian artery) on Simbionix angiomentor virtual reality simulator (SVR). Registrar, Ysbyty rated statements relating PHCM, andMiss Rhiannon Harries, General Surgery After training participantsGwynedd, Bangor to their experience on a numerical scale from 1 to 5, with 1 representing the strongest agreement with theHospital of Wales, Cardiff Mr Andrew Beamish, Clinical Research Fellow, University statement. Results: Compared to live patients, candidates scored statements on PHCM favourably regarding realism of vascular access (mean 2.27, (SD +/-0.75)), guide-wire manipulation (1.36, (+/- 0.48)), vessel catheterisation (1.64 (+/-0.64),), and performing an angiogramWith thanks to the wonderful ASiT Conference Admin team: info@asit.org (2.7 (+/-1.02)). Compared to SVR, candidates scored PHCM favourably, regarding realism of vascular access (1.73 (+/-0.75)), guide-wire manipu Laura Andrews Kristina Gloufchev Harriet Innes
am 2012
lation (2.18 (+/-0.58)), vessel cathterisation (1.82 (+/-0.71)), and performing an angiogram (2.7 (+/-1.21)). Candidates preferred training on PHCM (1.91 (+/-0.67)), would recommend PHCM to others (1.55 (+/-0.5)) and no candidates objected to training on human cadavers (1.64 (+/-0.88)). Conclusions: This is the first trial in world literature to assess the validity of a PHCM for training endovascular practitioners. It scored favourably compared to both live patients and SVR. The PHCM holds exciting training potential.
0232 PREDICTIVE VALUE OF PEAK SYSTOLIC VELOCITY FOR THE DEVELOPMENT OF GRAFT LIMB COMPLICATIONS AFTER ENDOVASCULAR ANEURYSM REPAIR Sharanya Kumar1, Alan Karthikesalingam 2, Janakan Anandarajah2, Robert Hinchliffe2, Jan Poloniecki2, Matt Thompson2, Peter Holt2, Nida Pasha1 1 St. George's, University of London, London, UK 2 St. George's Vascular Institute, London, UK Aims: Endovascular Aneurysm Repair (EVAR) is associated with a significant re-intervention rate, for which surveillance imaging is mandatory. Duplex ultrasound (DUS) provides velocity and waveform data, yet their relationship with stent-graft limb complications remains poorly understood despite the relatively common incidence of limb kink, stenosis and occlusion. Methods: Of patients undergoing infrarenal EVAR between 2004 and 2010 those who developed a limb complication requiring reintervention (occlusion, kinking, or DUS-defined stenosis) were identified on an intention-to-treat basis. The Peak Systolic Velocity (PSV) recorded from the proximal and distal region of each limb of the stent-graft, was extracted from serial postoperative DUS surveillance scans. Time-dependent Cox proportional hazards modelling was performed after risk adjustment. Results: 478 patients were studied, of whom 38/478 (8%) developed a limb complication. After risk adjustment, increased PSV over time within both the proximal and distal segment of the stent-graft limb was significantly associated with the risk of limb complications (Proximal Hazard ratio 1.015, 95% C.I. 1.003-1.028, p=0.0139; Distal Hazard ratio 1.010, 95% C.I. 1.001-1.020, p=0.0253). Conclusion: Increases in the peak systolic velocity in stent-graft limbs were associated with an increased risk of limb complication. This observation requires external validation and further investigation to define its clinical utility. 0246 TO DRAIN OR NOT TO DRAIN? A PROSPECTIVE AUDIT OF 100 CAROTID ENDARTERECTOMIES. Pankaj K Jha1, Dayle Terrington1, Lenka Kubikova1, JMF Clarke1, Arindam Chaudhuri2 1 Norfolk & Norwich University Hospital, Norwich, Norfolk, UK 2 Bedford Hospital, Bedford, UK Aim: Lack of evidence and controversy exists regarding use of drains following carotid endarterectomy. Despite this, routine drainage of neck wounds post-operatively is practised by many surgeons. We present a prospective audit comparing outcomes following carotid endarterectomy with and without routine drainage. Methods: 100 consecutive endarterectomies of two vascular surgeons during 2007-2011 were compared. One always uses suction drains, and the other never does. Perioperative complications including bruising, non-explored haematoma and re-exploration were compared and statistically analysed. Perioperative antiplatelet use and duration of hospital stay were also analysed. Results: There were 58 patients in the drain group (42 males; mean age 69.7yrs, SD 8.2) and 42 in the non-drain group (28 males; mean age 72.4yrs, SD 9.3). Both cohorts had similar distribution of indications and perioperative antiplatelet use. No statistically significant difference existed in incidence of bruising and haematoma formation between the two groups; 15 and 2 in the drain group compared to 11 and 1 in the non-drain group respectively. Median length of stay was 24hrs in the non-drain group compared to 48hrs in the drain group (p<0.001). Conclusion: This audit suggests routine use of drains following endarterectomy is not justified, possibly contributing to increased cost and hospital duration. 0262 AUDIT: CONTRAST INDUCED NEPHROPATHY HOW DO VASCULAR SURGEONS AND THEIR PATIENT FARE? Yao Pey Yong, Higgins Sarah, Parry Rachel, Jessica Tay, Rebecca Harborne, Peter Tan Doncaster Royal Infirmary, Doncaster, South Yorkshire, UK With increasing litigation in the health service and ever-increasing number of protocols in patient management, we conducted a prospective assessment of vascular surgeons in adherence to protocol in prevention of contrast-induced nephropathy (CIN) in a district general hospital (DGH). Patients who underwent peripheral angiography (PA) and computerised-tomogram angiography (CTA) were audited. Patient demographic, risk factors, contrast volume and serial serum creatinine (SCr) were collected. DGH protocol required patients with precontrast SCr >120umol/L to receive oral N-acetylcysteine (NAC) and intravenous fluids (IVI). 52 patients underwent PA (88%) or CTA. Mean age was 69.410.7, male to female ratio was 2:1. 67% were admitted with nephrotoxic medication(s), only 26% had it stopped before procedure. 83% had Optiray 300, 6% Visipaque 270 and 10% Visipaque 320. Mean volumes were 155.6966.44mls, 8525.98mls and 155.884.56mls respectively. 77% had pre-contrast SCr of <120umol/L, 33% of these patients received IVI and NAC (patients with age >70 or with multiple risk factors). All patients with pre-contrast SCr of >120umol/L received IVI and NAC. None of the patients developed CIN. Incidence of CIN is low. DGH protocol was safe but may over-treat patients. This probably reflects vascular surgeons are being overcautious. Results warrant further study at the current SCr threshold.
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0327 ROUTINE VS. SELECTIVE CEREBROSPINAL FLUID (CSF) DRAINAGE PRIOR TO THORACIC ENDOVASCULAR ANEURYSM REPAIR (TEVAR): A SYSTEMATIC REVIEW Chee Wong1, Donagh Healy1, Catriona Canning1, Calvin Coffey2, Stewart Walsh2 1 Mid Western Regional Hospital, Limerick, Co. Limerick, Ireland 2 University of Limerick, Limerick, Co. Limerick, Ireland Background: The use of thoracic endovascular aneurysm repair (TEVAR) is increasing. Similar to open repair, TEVAR carries a risk of spinal cord ischaemia (SCI). We undertook a systematic review to determine whether pre-operative CSF drainage reduces SCI. tives: Methods: PubMed, the Cochrane Library and conference abstracts were searched using the keywords thoracic endovascular aortic edd, Bangor repair, cerebrospinal fluid, TEVAR, and aneurysm. Studies reporting SCI rates and CSF drain rates for TEVAR patients were eligible for inclusion. al of Wales, Cardiff Results: 78 studies (9226 patients) were identified. Overall, SCI developed in 381 patients (4.13%). Series in which prophylactic CSF drains were routinely rather than selectively placed had lower SCI rates (3.14% versus 5.76%; p = 0.0147). Only eight studies in the selective m: info@asit.orggroup reported SCI rates according to the use of CSF drainage or not. In these eight series, 7.19 % (39/542) of patients in the drain group developed SCI compared to 8.35% (103/1233) in the non-CSF drain group (pooled odds ratio 0.79; 95% CI =
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0.445133 to 1.411427; p = 0.4299). Conclusions: These results suggest that routine prophylactic cerebrospinal drainage may reduce SCI following TEVAR.
0350 COMPLICATIONS FOLLOWING PERIPHERAL ANGIOPLASTY: A 2 YEAR RETROSPECTIVE REVIEW. Emma Wilton, Aakash Pai, Roshani Patel, Andrew Gordon, Peter Rutter Heatherwood and Wexham Park Hospitals NHS Trust, Slough, Berkshire, UK Aims: To determine our ratesGoldie Khera 2 year period for peripheral angioplasties, focusing on requirement for emergency of complication over surgical intervention post-procedure. President ASiT Methods: Retrospective analysis of all peripheral angioplasties attempted at a single centre between August 2009 and August 2011 Bariatric letters and discharge summaries was carried out. Radiology reports, clinic Fellow, North Tyneside were reviewed to identify complications. Where complications occurred, case notes were examined to determine management, including surgical intervention. Results: 297 peripheral angioplasties were attempted in total. Emergency surgical intervention was required following 5/297 procedures (1.5%) due to acute limb ischaemia. Emergency bypass surgery was successful in two cases; two patients required amputation; remaining patient had successful femoral embolectomy. One of these five patients had subintimal angioplasty and remainder underwent transluminal procedures. Major medical morbidity complicated 3/297 (1%) procedures. Angioplasty was abandoned in 15/297 cases for reasons including perforation, calcification and pain; none required emergency surgical intervention. Groin haematomas Ed Fitzgerald occurred in 10/297 (3%) patients; all managed non-operatively. The overall incidence of medical complications and major complications requiring urgent surgicalASiT Conference Organiser & Past-President intervention was 2.5%. Conclusions: Peripheral angioplasty is associated with low risk of major medical and surgical complications. A small centre can proGeneral Surgery Registrar, London vide an effective peripheral angioplasty service, comparing favourably with larger units. 0374 DOES SOCIO-ECONOMIC STATUS INFLUENCE AMPUTATION OUTCOMES? Risha Gohil, Rachel Barnes, Ian Chetter Hull York Medical School, University of Hull, Hull Royal Infirmary, Hull & E Yorkshire Hospital Trust, Hull, UK Jonny Wild Aims: To analyse the effect of socioeconomic deprivation on amputation outcome.Currently 5,000 leg amputations occur annually in England and Wales and have ASiT mortality rate at 2 years. a 50% Honorary Secretary & Sponsorship Co-ordinator Methods: All patients undergoing major lower limb amputation from January 2005 to December 2009 were identified from a prospecGeneral Surgery Registrar, Sheffield tively maintained vascular database. Patient's postcodes were used to determine socioeconomic status using the ACORN classification system (1 highest group to 5 lowest). Non parametric analysis of data was performed using SPSS version 19. Results: We identified 354 patients (218 men; 65.5%), median age 68 (IQR 58-78) years. 47 (14.8%) patients were ACORN grade 1, 4 (1.3%) were grade 2, 65 (20.4%) were grade 3, 56(17.6%) were grade 4 and 146 (45.9%) were grade 5. Significant differences were noted for the cardiovascular risk factors; hyper-cholesterolaemia (p=0.034), diabetes (p=0.020), smoking status (p=0.006). No significant differences were noted between classes for gender, type of admission (emergency or elective) or mortality (peri-operative or 1 year Robert Davies (haemoglobin, white cells, urea, creatinine, sodium and potassium). death rate) or blood test Conclusions: Socio-economic status of amputees does not have an effect on mortality. However, their status does impact on their ASiT Honorary Treasurer cardiovascular risk factors, therefore aggressive modification remains imperative. 0414 ASSOCIATION OF ANAEMIA IN PATIENTS WITH DIABETIC FOOT DISEASE Mustafa Khanbhai, Stavros Loukogeorgakis, Steven Hurel, Richards Toby University College London, London, UK Aims: Anaemia and inflammation have been shown to play a role in diabetic foot disease. We aim to explore the association between anaemia and inflammation, particularly with stage of diabetic foot disease. James Milburn Methods: 175 patients with diabetic foot disease were studied retrospectively. Patients were stratified in groups according to severity of diabetic foot disease according to NICE guidelines; D1 to D4, the lowest risk assigned; D1. Correlation with baseline haemoglobin, ASiT Vice-President C-reactive protein (CRP) and creatinine was evaluated. Longitudinal analysis of stage of diabetic foot disease was analysed. General Surgery Registrar, Inverness Results: Haemoglobin was 13.2, 12.3, 11.0 and 9.3 and CRP was 6.1, 22.8, 32.4 and 39.5 in patients stratified to group D1, D2, D3 and D4 respectively (P<0.0001). There was an inverse correlation between haemoglobin with CRP (p<0.001). Equally, evaluation of disease progression demonstrated that as the diabetic foot deteriorates (D1 vs. D4), haemoglobin declines (13.4 vs. 9.2) and CRP rises (7.6 vs. 41.2) (P<0.0001). No difference was found comparing creatinine levels to disease stage. There was no correlation between haemoglobin and creatinine. Conclusions: Anaemia and inflammation are associated with diabetic foot disease stage. Anaemia was found to be independent of renal function which may be explained by an underlying inflammatory process. Joseph Shalhoub 0518 Vascular Surgery Registrar, London GIANT CELL ARTERITIS; REDEFINING THE ROLE OF TEMPORAL ARTERY BIOPSY (TAB) Ashraf Hassouna, Amina Khan, Adnan Qureshi, Avtar Brar Vascular department Kettering General Hospital, Kettering, UK Purpose: TAB remains the definitive diagnostic test for giant cell arteritis, although its usefulness is often questioned. However given the morbidity of both the arteritis and longterm corticosteroid use, TAB may still be beneficial. We have reviewed our experiences with TAB to redefine its indications. Steve Hornby Methods: Between 2004 and 2011, 98 patients underwent TAB. We evaluated their demographics, histological findings and postASiT Director of Education operative outcomes. Results: There were 28 malesGeneral Surgerybetween 18 to 92 years.West Peninsula and 70 females aged Registrar, South All biopsies were performed under local anaesthetic with positive histological findings in 17% (16/98) cases. Inflammatory marker, ESR was significantly raised in positive biopsies (P <0.01), with a sensitivity of 100% and specificity of 81%. Furthermore raised inflammatory markers and strong clinical symptoms were seen in 100% positive biopsies compared with 27% (22/82) negative ones. Out of these 22 patients, 77% had been on steroid suggesting that steroid treatment may have masked 20% (17/82) of the results in the negative group. The size of biopsy specimen did not alter histological outcome. The biopsy result influenced the subsequent management in 5% cases. With thanks to the local ASiT Welsh Regional Representatives: Conclusions: We found that while TAB is helpful in some patients, more diagnostic importance should be given to biochemical and Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor clinical parameters. 0534 AORTODUODENAL FISTULAE FOLLOWING ENDOVASCULAR ABDOMINAL AORTIC ANEURYSM REPAIR Athanasios Saratzis1, Trifonas Papettas1, Dimitrios Kiskinis2 With thanks to the wonderful ASiT Conference Admin team: info@asit.org 1 Coventry University Hospital, Coventry, UK
ASiT Vice-President
am 2012
Aristotle University of Thessaloniki, Thessaloniki, Greece Aim: Aortoduodenal fistula (ADF) following endovascular abdominal aortic aneurysm (EVAR) repair is an exceedingly rare complication as there is no contact between the duodenum and the endograft. The aim of this study is to report an 8 year experience with ADF following elective EVAR. Methods: Our prospective registry of elective EVAR (January 2004 - 2012, 1283 patients) was assessed to identify patients who developed an ADF. Results: Six patients (all men; mean age 68.8 years, range 60-75) developed an ADF 18 days to 2 years after successful EVAR. Haematemesis and abdominal pain were the main presenting symptoms. Contrast computed tomography (CTA) confirmed the diagnosis in all cases. Graft infection was the aetiology in 3 patients, 2 ADFs developed due to a type 1A endoleak, no cause has been identified in 1 case. All explanted grafts were macroscopically intact. All patients underwent emergency surgical exploration. Three patients died within 24 hours and 3 are well after 3 to 5 years. Conclusion: This is the largest case-series of ADF following EVAR to date. ADF is a rare but dangerous complication of EVAR, secondary to infection or endoleak. Prompt diagnosis and intervention are crucial to avoid a fatal outcome.
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0550 THE FATE OF PATIENTS REFERRED TO A SPECIALISTVASCULAR UNIT WITH LARGE INFRA-RENAL ABDOMINALAORTIC ANEURYSMS OVER A TWO-YEAR PERIOD Nida Pasha1, Alan Karthikesalingam 1, T Nicoli1, Peter Holt1, Robert Hinchliffe1, Ian Loftus1, Matt Thompson1, Zaki Akhtar1, Sharanya Kumar1 1 St Georges, University of London, London, UK 2 St Georges Vascular Institute, London, UK Introduction: The basic premise in managing patients with abdominal aortic aneurysms(AAA) must be to reduce overall mortality from the disease. Operative mortality is widely reported, but data on patients deemed unsuitable for repair are scarce. The purpose of the present study was to report the fate of patients referred with AAA, to dene the proportion deemed unsuitable for surgery and to investigate the reasons for conservative treatment. Methods: All patients who were referred to a regional vascular centre with large (>5.5cm) infra-renal AAA between 1st January 2008 and 31st December 2009 were included. Patients were classied into two groups; those managed non-operatively, or those offered elective repair. Survival was reported by Kaplane Meier analysis. Multivariate analysis investigated factors leading to non-operative management. Results: 251 patients with a mean (SD) age of 75(8) years were assessed. Thirty-two(13%) patients were deemed unsuitable for repair, mostly because of medical co-morbidity (16/32). 219/251(87%) patients underwent repair(25/251(10%) open repair 194/251 (77%) EVAR)with 1/219(0.5%) 30-day mortality. AAA repair was associated with signicantly greater survival (p<0.001,log-rank test) at 2years. In multivariate analysis Glasgow Aneurysm Score, female gender and respiratory disease were signicant predictors of the decision to treat patients conservatively(p< 0.001). Conclusion: Most patients were suitable for surgical intervention with low perioperative mortality. Data on "turndown" rates should be routinely reported to quantify the denominator for operative success. 0593 MULTI-LEVEL BYPASS GRAFTING - IS IT WORTH IT? Alistair Sharples, Andrew Houghton, Mark Kay Shrewsbury and Telford NHS Trust, Shrewsbury, UK Traditionally multi-level arterial disease has been treated with an inflow procedure only but simultaneous multi-level bypass graft procedures have been attempted. However these procedures are potentially high risk. In many cases the only alternative is amputation. We ask whether the benefits justify the risks. Using a prospectively compiled database we identified patients undergoing simultaneous aortoiliac and infrainguinal bypasses between January 1996 and January 2011 at a single district general hospital. There were 38 multi-level procedures performed on 32 patients. Indication for surgery was acute ischaemia in 10 (26.3%), critical ischaemia without tissue loss in 10 (26.3%), with tissue loss in 10 (26.3%), and claudication in 2 (5.3%). In 26 (68.4%) cases inflow was restored using a direct aortoiliac or aortofemoral reconstruction. In the remaining 12 (31.6%) an extra-anatomic bypass was constructed. 1 (2.6%) patient died within 30 days of surgery. 36 (94.7%) patients survived to discharge. 34 patients (89.5%) were alive 1 year after surgery. Limb salvage was 97.3% at 30 days, 85.3% at 1 year and 76.7% at 5 years. In total 12 (35.3%) patients required at total of 21 further ipsilateral vascular procedures. Our results demonstrate good long term results with acceptable levels of post-operative mortality. 0627 PATIENTS FROM DIFFERENT SURGICAL SPECIALITIES HAVE A UNIQUE PROFILE OF PREDICTED MORBIDITY Alex Wilkins, John Taylor, C Mastrandrea North Devon District Hospital, Devon, UK Aim: POSSUM scores have been extensively utilised as an audit tool to compare predicted with actual outcomes. Copeland's Risk Adjusted BarometerTM' (CRAB) is a commercially available analysis tool which allows calculation of POSSUM risk profiles using validated surrogate markers. It is generally accepted that vascular surgery patients have a high frequency of co-morbidities however there is little data comparing predicted risk profiles of different surgical specialities. Data was analysed to compare predicted morbidity for vascular, colorectal, orthopaedic and general surgical procedures. Methods: Central HES data for 8559 non day case procedures performed at a single district general hospital (March 2010 - August 2011) was analysed using CRAB software (Version 1.2.5.665). Procedures from each speciality were grouped as either: low risk (029% risk of complication), medium risk (30-69%) or high risk (70-100%). Results: Vascular procedures tended to be high risk (25.2%, 30/119) compared to general (6.5%, 320/4932, p =<0.0001), colorectal (10.5%, 70/594, p = 0.0004) or orthopaedic surgery (8.8%, 250/2594, p =<0.0001). Conclusions: Vascular surgical procedures are at higher risk of POSSUM predicted morbidity than general, colorectal or orthopaedic procedures at this hospital. Individual specialities would appear to have unique profiles with respect to predicted complication risk. 0634
edd, Bangor DESIGN AND VALIDATION OF AN ERROR CAPTURE TOOL FOR QUALITY EVALUATION IN THE VASCULAR AND ENDOVASCULAR al of Wales, CardiffSURGICAL THEATRE
tives:
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Sarah Mason, Sitara Kuruvilla, Celia Riga, Manjit Gohel, Shaneel Patel, Mustafa Albayeti, Mohamad Hamady, Nicholas Cheshire, Colin Bicknell Imperial College, London, UK info@asit.org Introduction: The unique and complex vascular/endovascular theatre environment is associated with significant risks of patient harm
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and procedural inefficiency. Evaluation is crucial to improve quality. This study attempted to design an efficient, reproducible tool for error capture and categorisation. Method: Relevant published literature and field notes from over 250 hours of complex arterial surgery were analysed. A comprehensive log of errors was compiled and twelve vascular experts graded these for their potential to disrupt procedural flow and cause harm. This led to the development of the Imperial College Error CAPture (ICECAP) tool. ICECAP was validated (21 consecutive arterial cases) as an observer-led error capture record (two observers) and as a prompt for surgical teams. Results: Six primary categories and 20 error sub-categories were determined as the most frequent and important vascular procedural Goldie Khera errors. Using the ICECAP record, the number of errors correlated well between observers (Spearman rho=0.984, p<0.001). Both observers correctly identified allASiT President errors and categorised these identically. Self-reporting without prompts identified moderate and severe 24.4% of errors, whereas surgical teams reported 69.7% errors using ICECAP error-categories. Bariatric Fellow, North Tyneside errorsof occur during vascular/endovascular procedures Conclusion: The ICECAP tool may be useful for capturing and categorising that and as an error recall prompt for self-reporting by vascular teams.
0635 PREDICTING THE POST-OPERATIVE PATHWAY: DO CLINICAL TEAMS IN VASCULAR SURGICAL UNITS HAVE A SHARED MENTAL MODEL? Jennifer Aston1, Rona Patey1, Steven Yule2, John Duncan1 Ed Fitzgerald 1 University of Aberdeen, Aberdeen, Scotland, UK 2 ASiT Conference Harvard Medical School, Boston, Massachusetts, USA Organiser & Past-President Aim: To ascertain if surgeons, anaesthetists, ward doctors and nurses share a mental model of anticipated post-operative patient outGeneral Surgery Registrar, London comes following major vascular surgery. Method: The mental models of clinicians from two units were assessed, shortly after the surgery, by asking them to rate the likelihood of patient complications in the first 72 hours post-operatively using a Likert scale. They also indicated their source(s) of information. Routine documentation was examined for information on patient outcomes. Kappa Analysis was used to measure agreement and Logistic Regression to analyse predictive value. Results: 58 clinicians caring for 23 patients participated (97.5% response rate). Mental model agreement was moderate across the Jonny and the theatre team, but poor in the ward team Wild team as a whole. Participants reported their views were informed from their own specialitys documentation. Prior ASiT Honorary Secretary & Sponsorship Co-ordinator experience and handovers were also important for the ward team. Only the nurses mental model was predictive of patient outcomes (P=0.009). General Surgery Registrar, Sheffield Conclusion: Situation awareness is essential for post-operative planning, management and ultimately patient outcomes. These findings suggest that the shared mental model of key clinicians caring for post-operative vascular patients is incomplete. Further work is required to explore methods for sharing mental models across clinical teams. 0710 EVAR - PATIENT DECISION MAKING. HOW WELL INFORMED ARE YOUR PATIENTS? 1 Perbinder Grewal1, James Neffendorf2, B Davies Robert Williams 1 Royal Free Hampstead NHS Trust, London, UK 2 ASiT Honorary Treasurer UCL, London, UK Introduction: EVAR technology is pushing Surgery Registrar, Westpatients are increasingly using the internet to obtain mediVascular the boundaries of medicine and Midlands cal information. This study assesses the quality of medical websites with information on EVAR. Methods: We searched the keywords "endovascular aneurysm repair" and "evar" in Google, Yahoo and MSN/Bing and the top 150 websites were evaluated. Exclusion criteria were irrelevant information, repetition or inaccessibility. Readability was assessed using the Gunning-Fog Index (GFI, measure of years of schooling needed to understand content) and the Flesch Reading Ease Score (FRES, index rating-score/100). We then used the LIDA tool to assess the accessibility, usability and reliability of the websites. Results: Twenty six websites James Milburn were analysed: mean GFI=12.12.S.D:1.98 showed the average website was similar to reading the Wall Street Journal. The mean FRES was 50.53(S.D:10.02), below the universally recommended target of 60-70. ASiT Vice-President The results of the LIDA medical website validation tool were; accessibility 76.85%, usability 60.23% and reliability 52.27%. General Surgery Registrar, Inverness Conclusion: We have shown that readability scores of the websites are poor suggesting that they may not be clearly understood. In addition, we have found the reliability to be very variable and generally poor. It is essential that we guide and help patients identify reliable sources of information. 0735 SUCCESSFUL PREDICTION OF ENDO-VENOUS ABLATION (EVA) OF GREAT SAPHENOUS VEIN (GSV) OUTCOMES AND THE REQUIREMENT FOR STAB AVULSIONS WITH THE TOURNIQUET TRENDELENBERG TEST Joseph Shalhoub Charanjit Singh Milkhu, Celia Riga, Sophie Renton, Tahir Hussain, David Greenstein ASiT Vice-President Northwick Park Hospital, Harrow, UK Vascular Surgery Registrar, London Aims: The aim of this study was to assess the predictive value of the tourniquet test for EVA of GSV outcomes and the requirement for stab avulsions. Methods: 19 patients (10 men, 9 women) with GSV reflux and no short saphenous or deep system venous disease were prospectively recruited in the study; mean age 52 yrs (range 32-84). All patients presented with visible varicosities and skin changes; mean CEAP score was 3.36 (range 2-5). Pre-EVA, the number of varicosities before and after the tourniquet Trendelenberg test was recorded. All patients underwent EVA of the GSV under local anaesthetic without stab avulsions. At 6-weeks post-EVA, the number of Steve Hornby residual varicosities were recorded and compared to the pre-operative findings. ASiT Director of Education Results: The mean number of varicosities observed pre-EVA was 5.7 (range 1-11) before and 1.5 (SD 1.4) after the Trendelenberg Test, versus 1.4 (SD 1.2) post-EVA. Mean difference Registrar,pre-EVA and post-EVA groups was -0.2 (95% CI -0.7 - 0.4); p=0.55 General Surgery between the South West Peninsula (paired T-test). The Trendelenberg test showed a positive correlation in predicting the number of varicosities post-EVA (pearson coefficient: 0.64; p<0.001). Conclusions: The tourniquet test is a valuable bedside tool in determining the outcome post-EVA and the need for stab avulsions. 0753 With thanks to the local ASiT Welsh Regional Representatives: RUPTURED ABDOMINAL AORTIC ANEURYSMS: DECREASING INCIDENCE MAY AFFECT THE IMPACT OF SCREENING Stephan Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Dreyer, Paul Burns DepartmentMrVascular Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK of Andrew Beamish, Clinical Research Fellow, University Hospital of Wales, Cardiff Background: Ruptured Abdominal Aortic Aneurysm (AAA) is a significant cause of death and recent evidence has shown that screening is beneficial in reducing mortality. Aim: The aim of thankswas to evaluate the numberASiT Conference Admin team: info@asit.orgtertiary With this study to the wonderful of ruptured AAAs, and the associated mortality, that presented to a vascular surgery unit each year.
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
Methods: A retrospective review of operative records from 1987-2009 was conducted. Results: 888 Patients (Male 728, Female 158) were identified. The number of ruptures remained constant from 1987-2001, with a mean of 43.4 ruptures a year (95% CI 40.1-46.7). This decreased to a mean of 29.63 per annum (95% CI 24.3-34.6) in 2002-2009. The average mortality was 39.8% and showed no significant decrease; a mean of 41.1% (95% CI 38-44.2) in 1995-2001 and 38.6% (95% CI 33.4-43.8) during the period 2002-2009. Conclusion: This data series showed patients that reach hospital have a significant mortality which has not decreased during the study period. This study further suggests that the incidence of ruptured AAAs is decreasing. These results suggest that AAA screening may not be as beneficial and cost effective as previous studies have shown. 0808 ENDOVENOUS RADIOFREQUENCY ABLATION IN OCTOGENARIANS - SAFE, EFFECTIVE AND RECOMMENDED Victor Kung1, Bynvant Sandhu1, Andrew Choong2, Alexander Loh1 1 Barnet General Hospital, Barnet, Hertfordshire, UK 2 Northwick Park Hospital, Harrow, London, UK Aim: Varicose vein surgery aims to reduce venous ulcer recurrence and encourages healing to those resistant to compression therapy. However, it is often avoided in elderly populations due to multiple co-morbitidies. This often results in chronic ulceration and impaired quality of life. We report our experience of varicose vein radiofrequency ablation (RFA) under local anaesthesia (LA) in an octogenarian population. Method: All patients aged 80 undergoing endovenous RFA between 2009 and 2011 were identified from a prospective database. Patient demographics, co-morbidities, indications for surgery, mode of anaesthesia, complications and outcomes at follow-up were documented. Results: 35 patients (Median age 84.5, M:F=1:1.33) had endovenous RFA, with an ASA grade 2 (57%, n=20) and 3 (43%, n=15). 12 patients had active ulcers and 7 had ulcers previously. The majority of operations (69%, n=24) were performed under LA (1 Spinal, 10 GA). There was no operative mortality or morbidity. All 12 ulcers were healed by the end of the follow-up period (Median 51 days. Range=8-220). Only 5 patients had oedema and 1 had residual varicosities post-treatment. No ulcer recurrence was identified. Conclusions: Endovenous RFA under local anaesthesia is safe, effective and recommended in patients aged over 80 in units with suitable endovenous expertise. 0814 PEAK OXYGEN CONSUMPTION IS AN INDEPENDENT PREDICTOR OF MORTALITY FOLLOWING ABDOMINAL AORTIC ANEURYSM SURGERY Andy Kordowicz1, Jeremy Purdell-Lewis1, David Watson1, Anne Johnson1, Julian Scott1, Simon Howell2 1 Leeds Vascular Institute, The General Infirmary at Leeds, Leeds, West Yorkshire, UK 2 Academic Department of Anaesthesia, The General Infirmary at Leeds, Leeds, West Yorkshire, UK Aims: We examined whether peak oxygen consumption (VO 2peak) was an independent predictor of long-term outcome after abdominal aortic aneurysm (AAA) repair. Methods: Between 02/2007 and 09/2009, 115 patients (mean age 74.8years) underwent static echocardiography and cardiopulmonary exercise testing before AAA surgery. Lee scores were calculated for each patient. Mortality data were determined from our database; median follow-up was 932days. Using Cox-regression analysis the associations between VO2peak, anaerobic threshold (AT) and all-cause mortality were examined. Results: 59 open and 56 endovascular AAA repairs were performed. 30-day mortality was 3.5% and 12-month mortality was 11.3%. 25 patients had died by 05/2011 giving a long-term series mortality of 21.7%. The unadjusted hazard ratio (HR) for all-cause mortality was 0.89(95% confidence intervals(CI)=0.82-0.97) for every ml/kg/min reduction of VO2peak(p=0.009). This remained significant when adjusted for age , sex , Lee score and performance on static echocardiogram (HR 0.90(CI=0.82-0.99),p=0.033). The association between AT and mortality was not statistically significant(HR 0.91(CI=0.80-1.04), p=0.187). The association between left ventricular function and mortality was not statistically significant (HR 2.1(CI=0.91-4.71),p= 0.080). Conclusion: VO2peak is an independent predictor of all-cause mortality following AAA repair. A dynamic exercise test to volitional exhaustion adds value in risk stratification prior to AAA surgery. 0828 PREVALENCE OF AAA IN NORTH CENTRAL LONDON - FIRST YEAR RESULTS Bhavina Khatani, Jason Constantinou, Perbinder Grewal, Meryl Davis Royal Free Hospital, London, UK Aim: The National Health Service Abdominal Aorta Aneurysm Screening Programme (NAAASP) was announced in January 2008. North Central London was approved in the first phase of AAA screening implementation and commenced screening in September 2010. Method: Men aged 65 years resident in North Central London were invited for aneurysm screening. Data collected from 01 December 2010 for 12 months are reported. Results: 11785 men were invited, this included first and numerous recall invitations; 4496 (38%) attended while 1620 (13%) declined to be screened and 5082 (43%) did not attend. Forty (0.9%) aneurysms were detected: with one man requiring surgery; this was performed endovascularly and is alive 4 months postoperatively. Conclusion: In North Central London the prevalence of screened AAA (0.9%) is far lower than the rate in the MASS trial (4.9%). Possible reasons for this are the younger age screened as compared to those recruited to the MASS trial. The high DNA rates may hide the true prevalence of aneurysms. It is noted, however that nationally the prevalence of AAA remains low. Further work is needed to improve attendance rates for aneurysm screening in London and this may well provide a more accurate AAA prevalence rate.
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0849 ENDOVENOUS LASER ABLATION FOR SMALL SAPHENOUS VARICOSE VEINS: EVALUATION OF OUTCOMES OVER TWO YEAR FOLLOW-UP tives: Nehemiah Samuel, Tom Wallace, Rachel Barnes, Risha Gohil, Ian Chetter edd, Bangor Hull York Medical School / University of Hull, Hull, UK Aim: To al of Wales, Cardiff evaluate the safety and efficacy of endovenous laser ablation(EVLA)as an alternative to conventional surgery for small saphenous vein(SSV) incompetence. Methods: Patients with symptomatic, unilateral, primary saphenopopliteal junction(SPJ) incompetence with SSV reflux receiving EVLA (810 nm diode laser) treatment were included. Patients were assessed at baseline and at 1,6,12,52 & 104 weeks. Outcome measures m: info@asit.org included: Venous Clinical Severity Score(VCSS); Quality of life(generic-SF36, EQ5D and disease specific-AVVQ) measures; compli-
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Bariatric Fellow, North Tyneside 0857 RETROSPECTIVE REVIEW OF PATIENTS TREATED WITH ENDOVASCULAR TECHNIQUES AT A SINGLE CENTRE N Foden1, M Davis2, K Tullus1, CA McLaren1, S Marks1, G Hamilton1, D Roebuck1 1 Great Ormond Street Hospital, London, UK, 2Royal Free Hampstead NHS Trust, London, UK Aim: Mid-aortic syndrome (MAS) is a cause of severe hypertension in children. It is essential to make an early diagnosis. We undertook a retrospective study to assess the benefit of endovascular techniques in the treatment of MAS and the importance of a multidisciplinary team (MDT) approach. Ed Fitzgerald Methods: A retrospective review of 22 patients treated by radiological intervention at Great Ormond Street Hospital. ASiT Conference Organiser & Past-President Results: 49 procedures (mean 2.2 procedures: range 1-5) were undertaken on 22 patients (mean age 7.6 years: 14 boys (64%) and 8 girls (36%)). Complications were seen inSurgery Registrar, London to haemorrhage following angioplasty, 2 pseudoaneuGeneral four cases including one death due ryms and one urethral trauma. Radiological intervention followed surgery in 23% (5/22) of cases. 9% were cured' (2/22), 60% improved' with fewer medications or symptoms, 27% had no change and 4% failed.' Conclusion: Radiological intervention provides a viable treatment method for MAS, although it may not be definitive and is not without complications. Surgery is often used as a final intervention but can be used in conjunction with or prior to radiological techniques. An individualized and combined treatment plan for each patient by an MDT comprising radiological, surgical and medical specialties is essential to improve outcome in MAS patients.
0873 ASiT Honorary Secretary & Sponsorship Co-ordinator GSV DIAMETER IS NOT APPROPRIATE FOR DETERMINING PROVISION OF TREATMENT IN SUPERFICIAL VENOUS INSUFGeneral Surgery Registrar, Sheffield FICIENCY Tom Wallace, Nehemiah Samuel, Daniel Carradice, Ian Chetter Acadademic Vascular Surgical Unit, Hull York Medical School, Hull Royal Infirmary, Hull, Yorkshire, UK Introduction: The National Institute for Health and Clinical Excellence (NICE) uses Quality of Life (QoL) to inform decisions on health resource provision; Superficial Venous Insufficiency (SVI) has a significant negative effect on QoL. Some medical insurance companies require a minimum GSV diameter before funding intervention for SVI. The aim of this study was to Robert Davies assess the ability of GSV diameter to accurately predict clinical severity and QoL in patients with SVI. Methods: A prospectively maintained database of patients with primary, symptomatic SVI was interrogated. Pre-procedural duplex ASiT Honorary Treasurer ultrasound measurements of GSV diameter were correlated with clinical severity (CEAP and VCSS), generic and disease-specific QoL using Spearman's rho correlation coefficient. Vascular Surgery Registrar, West Midlands Results: 493 patients (64% female, mean age 49 [S.D. 14] years) were assessed prior to planned intervention. There were weak but statistically significant correlations between increasing GSV diameter and CEAP (r=.302, p<0.01), VCSS (r=.239, p<0.001) and AVVQ (r=.101, p<0.05) but not with generic QoL. Conclusions: There is a complex interplay between factors that affect QoL in SVI, with no obvious single surrogate marker. Detailed regression analyses may further elucidate these relationships. Provision of intervention in SVI should currently be based on patient symptoms and QoL in combination with detailed clinical and ultrasonographic assessment. 0885 ASiT Vice-President A SYSTEMATIC REVIEW OF RANDOMISED CONTROLLED TRIALS EVALUATING ENDOVENOUS THERMAL ABLATIVE General Surgery Registrar, Inverness TECHNIQUES FOR VENOUS ULCER DISEASE Nehemiah Samuel, Tom Wallace, Daniel Carradice, Rachel Barnes, Risha Gohil, Ian Chetter Hull York Medical School / University of Hull, Hull, UK Aims: To undertake a systematic review of RCTs to determine the effects of superficial venous endothermal ablation on the healing, recurrence rates and quality of life (QoL) of people with venous ulcer disease. Methods: A systematic literature search from 1998-2011 was undertaken for prospective RCTs comparing endothermal ablative techniques versus compression therapy aloneShalhoub Joseph for venous ulcers treatment. All types of enodothermal techniques were included and no restrictions were placed on language or publication status. ASiT Vice-President Results: Electronic searches produced 198 references, of which only one RCT comparing endovenous laser ablation(EVLA) with comVascular venous ulcers(C6) was London pression therapy in the treatment of activeSurgery Registrar,identified. Results from this study at 1 year showed a significantly higher proportion of ulcer healing(81.5% Vs. 24% P=0.001); reduction in mean ulcer size(22.2 to 2.7cm Vs. 17.4 to 12.7cm P=0.003) and ulcer recurrence(0 Vs 44.4% P=0.047) in the groups receiving combined EVLA and compression Vs compression therapy alone respectively. Conclusions: The review revealed a paucity of evidence in this important new area of study. A single small study, albeit with unclear risk of bias and short term follow-up demonstrated outcomes in favour of endothermal ablative techniques in venous ulcers manageSteve Hornby ment. Adequately powered and methodologically sound trials are urgently required to draw firm conclusions. 0921 General Surgery Registrar, South West Peninsula PREDICTING IMMEDIATE AND MID-TERM DISTAL VASCULAR BYPASS SURGERY OUTCOME USING PREOPERATIVE MAGNETIC RESONANCE ANGIOGRAPHY (MRA)-DERIVED RUTHERFORDS RUNOFF CLASSIFICATION Buket Ertansel, Abdullah Jibawi, Amour Patel, Michael Brooks Brighton and Sussex University Hospitals, Brighton, UK Aims: to With thanks preoperative MRA-derived RutherfordsRegional Representatives: and mid-term patency validate the use of to the local ASiT Welsh runoff classification in predicting immediate of distal vascular bypass Miss Rhiannon Harries, General Surgery Registrar, Ysbyty Gwynedd, Bangor Methods: MRA and duplex scanning were performed prospectively on patients undergoing distal bypass surgery. Patient demographics, risk factors, Andrew Beamish,graft used and surgical outcome were reviewed. Modified Rutherford score was calculated for Mr type of surgery, type of Clinical Research Fellow, University Hospital of Wales, Cardiff each case as a marker for runoff resistance. Distal-femoral diastolic resistance (DFDR) ratio was calculated using the ratio of enddiastolic velocity (EDV) in the distal vs. femoral arteries. Predictors of graft patency were determined using Cox proportional hazards. Results: With three patients underwent fem-distal bypass surgery between 2008-2011, with mean ageinfo@asit.org Most Twenty thanks to the wonderful ASiT Conference Admin team: of 71, were identified. patients were male (68%), had hypertension (63%) and were current or ex-smokers (90%). The patency rate for all distal bypasses on
cations and recurrence rates. Results: 62 patients(37 women), mean age 46.3(s.d. 13.3) years were assessed. Initial technical success was 100% in all limbs. SPJ incompetence was abolished in 83% & 89%; and treated SSV occluded in 83% & 84% at 1 and 2 years respectively. Clinical recurrence over same period was 11% with 4 limbs(6.4%) developing recanalisation [median(i.q.r.) laser density 94(90-103)J/cm]. Venous severity (CEAP and VCSS), AVVQ, SF36, EQ5D significantly improved and was sustained over the 2 year(P<0.05) follow-up. Temporary paraesthesia was found in 11% which completely resolved. No major complications occurred. Conclusion: Early and mid-term results of EVLA for SSV incompetence demonstrated this treatment to be safe and effective. Clinical Goldie Khera recurrence due to recanalisation may occur despite adequate magnitude of energy delivery; neoreflux in previously competent veins may contribute to this process. ASiT President
Jonny Wild
James Milburn
Laura Andrews
Kristina Gloufchev
Harriet Innes
am 2012
hospital discharge, 4, and 12 weeks postoperatively was 81%, 72%, and 54% respectively. Immediate graft patency correlated well with MRA-derived Rutherfords runoff classification (p=.06) and DFDR ratio (p=.001). Mid-term patency was not significantly correlated with MRA-derived Rutherfords runoff classification (p=.72). Conclusions: preoperative MRA-derived Rutherfords runoff classification and DFDR ratio are fairly accurate and reliable predictors of immediate graft patency
0925 WHAT IS THE OPTIMAL BYPASS GRAFT SURVEILLANCE PROGRAMME? Sophie Wienand-Barnett, Catherine Western, David Birchley Royal Devon and Exeter Hospital, Exeter, UK Aims: To assess patterns of graft patency over time and establish whether current surveillance at 6/52, 3, 6 and 12 months is effective resource use. Methods: Retrospective analysis of a prospectively maintained database. Results: 81 patients entered graft surveillance between 2006 and 2011. Median age was 73 and male:female ratio was 4:1. 71 underwent vein grafting and 10 composite. Overall 11% occluded within 12/12 and a further 7% at >1 year (range 15-48 months). Graft stenosis requiring intervention e.g. angioplasty, occurred in 12% (all vein) within 12/12 and another 2% stenosed after a year. Lifetime amputation rate was 11%. When analysed according to operation, 64% underwent fem-pop bypass (88% 1 year patency, 12% stenosis), 21% fem-distal bypass (88% patency, 11% stenosis), 6% pop-distal bypass (80% patency, 20% stenosis) and 9% other bypass. The majority of fem-pop associated complications (50%) were identified at 6/12, with another 19% arising after surveillance completion. There was no pattern to stenosis/occlusion of fem-distal grafts but pop-distal complications were picked up at 6/12 or >1 year. Conclusions: The majority of occlusions/stenoses were identified at 6/12. However, there were temporal differences according to bypass type, suggesting procedure-specific surveillance programmes could save costs and unnecessary appointments. 0949 USING STATISTICAL PROCESS CONTROL (SPC) CHARTS FOR MONITORING OF SURGICAL PERFORMANCE IN VASCULAR SURGERY: A CASE STUDY AND COMPARISON OF TWO MONITORING METHODS Abdullah Jibawi, Buket Ertansel, Amour Patel Royal Free Hampstead Hospital, London, UK Background: the technique of prospective monitoring of surgical performance has replaced the traditional audit models in different clinical settings. Risk-adjusted cumulative sum (CUSUM)-type charts and variable life-adjusted display (VLAD) charts are of special interest for quality improvement Method: some 25129 patients on the national vascular database who underwent abdominal aortic aneurysm repair were analysed. A risk-adjusted CUSUM chart, a risk-adjusted sequential probability ratio test (SPRT) chart and a VLAD chart with prediction limits chart were used to detect excess deaths. Results: control charts from two centres are shown in order to illustrate the main features of SPC monitoring systems. A risk-adjusted CUSUM model is shown and is compared with non-risk adjusted CUSUM and VLAD techniques. Selecting the control limit based on the simulation results of average run length using the method of fractional polynomials to produce a closed-form relationship between the average run length, control limit, and acceptable rate of failure are also described. Conclusion: risk-adjusted CUSUM technique are shown to be reliable, accurate and intuitive technique that can reliably detect outliers in major vascular surgery. 1015 ENDOVENOUS LASER THERAPY (EVLT) FOR THE TREATMENT OF LONG AND SHORT SAPHENOUS VARICOSE VEINS Pallavi Mudugal, Hayley Heffernan, Iraj Zeynali, PF Mason, DR Jones Southport District General Hospital, Southport, UK Aim: A prospective audit to evaluate the safety, complications and effectiveness of EVLT. Method: A prospective audit which collected data from 2006 till 2011. No exclusion criteria. Incidence of complications, effects on pre -procedure leg ulcers, further procedures needed post-op and the percentage of ablation were recorded. Results: 1689 patients were included. M:F 537:1152. Median age 59 years (range 18-97). Complications were numbness (1.1%), phlebitis and inflammation (6.4%), wound complications (0.23%), neuralgia (0.059%), and DVT (0.11%).The most common complication was residual veins (54%), of these 74% had sclerotherapy. 37% patients had no complications. 17 of 68 leg ulcers healed completely post-procedure. 440 patients had post-procedure duplex scan, 89% had completely ablated veins. Conclusion: Our study demonstrated that EVLT can be safely used for the treatment of varicose veins with low complication rates. EVLT can be used in patients with severe co morbidities. Treat leg ulcers secondary to venous insufficiency. The major disadvantage of EVLT is a significant number of patients need sclerotherapy for residual veins following the procedure and there is a lack of long term follow-up.
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1047 COMPARISON OF OPERATIVE OUTCOMES OF LAPAROSCOPIC VERSUS OPEN REPAIR OF ABDOMINAL AORTIC ANEURYSMS - A PROSPECTIVE STUDY OF A SINGLE CENTRE LEARNING EXPERIENCE Mark Salji, Peter Gogalniceanu, TK Ho, Simon Mackenzie, Peter Patient, Sohail Choksy, Christopher Backhouse, Roger Motson, Adam Howard Colchester Hospital University Foundation Trust, Colchester, UK Aims: To prospectively compare the outcomes of consecutive laparoscopic and laparoscopic-assisted abdominal aortic aneurysm (AAA) repairs (LAR) with open AAA repairs (OAR) during the learning curve for the laparoscopic approach. Method: Prospective data on 80 patients (2007-2012) were analysed. 38 LAR and 42 OAR were recruited. Treatment allocation was by patient choice in individuals not suitable for endovascular repair. Results: LAR had a lower median time to mobilisation (1 vs. 4 days, p 0.03) and shorter scar length (14 vs. 30cm, p < 0.0001). There was no difference in median clamp time (80 vs. 74 min, p 0.24), blood loss (1.3 vs. 1.1 L, p 0.76) or length of stay (6 vs. 9 days, p = 0.92), however LAR featured higher median operative time (5.5 vs. 4hrs, p < 0.0001). The rate of major and minor complications, tives: intraoperative adverse events (p = 0.4) and inpatient mortality (p=0.6) were similar between the two groups. edd, Bangor Conclusion: Early results suggest that LAR offers faster recovery mobilisation with smaller incisions and less pain compared to OAR. The greater al of Wales, Cardiff LAR operative times do not appear to affect intra or post-operative outcomes. Further experience and operative volume is needed to decrease dissection time.
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1054 QUALITY OF LIFE AFTER ENDOVASCULAR ABDOMINAL ANEURYSM REPAIR (EVAR) Sofronis Loizides, Anastasia Hadjivassiliou, Nicholas Law Chase Farm Hospital, London, UK Aims: To assess the quality of life after EVAR. Methods: Between February 2009 and January 2011 43 patients underwent elective EVAR at our Trust. A questionnaire addressing post-operative quality of life was sent to all patients. Goldie questionnaires with mean follow-up of 12.3months. Average age was 77.5years and 78.9% Results: 38 patients (88%) returned the Khera were male. ASiT President When patients were asked to compare their pre and post-operative health 71.1% felt equally as well or better than before surgery. Bariatric Fellow, North Tyneside Physical health limited regular daily activities in 60.5% of patients in the immediate postoperative period reducing to 31.6% in the last 4 weeks prior to completing the questionnaire. Emotional problems limited 63.2% of patients in the immediate post-operative period but in the last 4 weeks before completing the questionnaire only 26.3% of patients reported significant emotional issues. Conclusions: Our results support that patients physical and emotional quality of life is significantly affected in the early post-operative period after EVAR but subsequently improves. EVAR is performed in an old population with other comorbidities, which might act as a confounding factor when reporting on health quality. Enhanced rehabilitation and community support might improve quality of health after EVAR.
ASiT Conference Organiser & Past-President 1124 PERIPHERAL LIMB SALVAGE WITH CONTINUOUS CATHETERLondon General Surgery Registrar, DELIVERED THROMBOLYSIS, AN ALTERNATIVE PERCUTANEOUS RADIOLOGICAL OPTION: A CASE SERIES Pranav Patel, Nizar Damani, Kevin Rosenfeld, Sanjeev Sarin West Herts NHS Trust, Department of Vascular and Interventional Radiology., Watford, Hertfordshire., UK Aim: Intravascular catheter delivered thrombolysis is well recognised for treatment of acute arterial occlusive disease. We aim to report the efficacy of peripherally placed catheters for limb salvage in arterial and veno-occlusive disease. Methods: A prospective analysis was conducted of all patients undergoing percutaneous catheter delivered thrombolysis for peripheral Jonny Wild limb salvage in a single centre. All procedures were performed by two operators between 2009-2011. Indications were acute arterial occlusion (AO) or proximal venous thrombosis (VT)Secretary & cerulea dolens. Serial vascular duplex studies (VDS) were perASiT Honorary with phlegmasia Sponsorship Co-ordinator formed at 1, 5, 10 and 30 days post procedure to assess thrombus regression. End-points were morbidity and successful return of General Surgery Registrar, Sheffield limb function. Results: 19 cases were performed during the period of study, 8 male and 11 female patients. Mean age 69 years (range 32-86 years). 12 patients underwent thrombolysis for acute AO, 7 for VT. All cases showed VDS evidence of thrombosis regression at 5 days. All other patients regained limb function, with minimal residual thrombus on VDS at day 30. Conclusion: Peripheral catheter delivered thrombolysis is a valuable treatment option in complex distal vascular occlusive disease. It may be an initial or staged measure for elderly not suitable for major re-vascularisation.
Ed Fitzgerald
Robert Davies
James Milburn
Joseph Shalhoub
Steve Hornby

am 2012
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1 Ethicon 2 Royal Society of Medicine 4 Hodder/ Examdoctor 5 Army Medical Services 6 Africa Health Placements 7 AOUK 8 Covidien 9 RRSSC Microsurgery 10 BJS Society 11 Operation Hernia 12 BMJ OnExamination
16 MHRA 17 Swann Morton 19 Laprosurge 20 Wetlab 21 Doctors Support Network 22 Wesleyan 23 Laprotrain 24 Elsevier 25 Ansell 26 Royal College of Surgeons of Edinburgh
3 Royal College of Surgeons of England 18 Cochrane Collaboration
edd, Bangor 14 Royal Medical Benevolent Fund al of Wales, Cardiff
tives:
13 Royal College of Physicians and Surgeons of Glasgow 15 Medical Protection Society

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Cardiff City Hall Layout - First Floor Plan ASiT Executive Conference Team 2012
Goldie Khera
Ed Fitzgerald
Jonny Wild
Robert Davies
James Milburn
Joseph Shalhoub
Steve Hornby

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ASiT Executive Conference Team 2012

thanks to the local ASiT Welsh Regional Representatives:

With thanks to the wonderful ASiT Conference Admin team: info@asit.org

am 2012 ASiT Executive Conference Team 2012

ASiT Conference Organiser & Past-President General Surgery Registrar, London

ASiT Honorary Treasurer Vascular Surgery Registrar, West Midlands

ASiT Vice-President General Surgery Registrar, Inverness

ASiT Vice-President Vascular Surgery Registrar, London

ASiT Director of Education General Surgery Registrar, South West Peninsula

With thanks to the local ASiT Welsh Regional Representatives:

ASiT Conference | Cardiff | 23 - 25th March 2012

ASiTASiT Conference Programme2012 Executive Conference Team

ASiT Conference Organiser & Past-President General Surgery Registrar, London

ASiT Honorary Treasurer Vascular Surgery Registrar, West Midlands

ASiT Vice-President General Surgery Registrar, Inverness

ASiT Vice-President Vascular Surgery Registrar, London

ASiT Director of Education General Surgery Registrar, South West Peninsula

With thanks to the local ASiT Welsh Regional Representatives:

With thanks to the wonderful ASiT Conference Admin team: info@asit.org

edd, Bangor al of Wales, Cardiff

ASiT Executive Conference Team 2012

ASiT Conference Organiser & Past-President General Surgery Registrar, London

ASiT Honorary Treasurer Vascular Surgery Registrar, West Midlands

ASiT Vice-President General Surgery Registrar, Inverness

ASiT Vice-President Vascular Surgery Registrar, London

ASiT Director of Education General Surgery Registrar, South West Peninsula

With thanks to the local ASiT Welsh Regional Representatives:

With thanks to the wonderful ASiT Conference Admin team: info@asit.org

Student / Foundation Year Session

edd, Bangor al of Wales, Cardiff

ASiT Executive Conference Team 2012 Conference Programme Extras!

WetLab Surgical Skills

ASiT Honorary Treasurer Vascular Surgery Registrar, West Midlands

ASiT Pre-Conference Courses

ASiT / BOTA Foundation Skills in Surgery Course

ASiT / Covidien Core Laparoscopic Skills Course

FRCS Critical Appraisal of Literature Course: Masterclass in Journal Club

ASiT / SARS / BJS Research Skills Course

ASiT GI Anastomotic Stapling and Energised Dissection Course

ASiT Surgical Art Workshop

ASiT Executive Conference Team 2012 ASiT Conference Trainee Prizes

SARS / ASIT Academic & Research Surgery Prize

ASGBI / ASiT Short Paper Prize

ASiT / Elsevier Medical Student Prize ASiT Vice-President

Joseph Surgeons ASiT / Royal College ofShalhoub of England Poster Prize

IJS Case Report Prizes

ASiT Surgical Specialty Prizes

Orthopaedic Research UK Prize

BASO~The Association for Cancer Surgery Prize

ALSGBI Trainee Prize

AUGIS Trainee Prize

edd, Bangor al of Wales, Cardiff

ASiT Executive Conference Team 2012 Specialty Trainee Group Prizes

ASiT-AOT Prize ASiT Conference Organiser & Past-President

ASiT-Rouleaux Club Prize

ASiT-Dukes' Club / ACPGBI Prize

General Surgery Registrar, Inverness

ASiT-Mammary Fold Group Prize

With thanks to the wonderful ASiT Conference Admin team: info@asit.org

am 2012 ASiT Platinum Corporate Sponsor

edd, Bangor al of Wales, Cardiff

ASiT Gold Corporate Sponsors ASiT Executive Conference Team 2012

THE MEDICAL PROTECTION SOCIETY