944 Re Audit: Maintenance Iv Fluids Prescribing

Aim

Many hospital admissions require intravenous (IV) fluid therapy to prevent or correct fluid status and/or electrolyte disturbances. Within our trust the recommended IV maintenance fluid is 0.18% Saline in Glucose 4%. This Re audit aimed to assess the knowledge and improve understanding of junior clinicians for IV maintenance fluid prescribing at Royal Preston Hospital by comparing our current practice to Trust guidelines/NICE guidelines

Method

A multiple choice knowledge questionnaire was used evaluate the knowledge of foundation doctors, core trainee's and advanced care practitioners (n=21). The trusts electronic system was used to review patients prescribed maintenance fluid. (n=50). 1st audit was conducted in October 2020 followed by re audit in April 2021.

Results

In 1st cycle only 16% of the patients had the recommended maintenance fluid prescribed. We displayed posters and sent email reminders of the trust IV fluid prescribing guidelines. Junior's knowledge of the IV fluid prescribing guidelines improved regarding: recommended maintenance fluid (52% to 80%), Daily fluid requirement in ml/kg/day (66% to 70%) and Recommended monitoring (52% to 100%). This ultimately led to the prescribing of 0.18% Saline in Glucose 4% in 38% of patients. Plasma-Lyte remained the most commonly fluid prescribed in both audit cycles (42% vs 50%).

Conclusion

Changes implemented after 1st cycle led to improvement is prescribing fluid of choice but there is still room for improvement. Juniors report consultant lead decisions influencing their prescribing and the availability of fluids on the wards.

P-BN23 Cholecystectomy in Octogenarians – Is there a benevolent bias?

Background

Cholecystectomy is one of the most commonly performed general surgical operations in the UK. Around 50,000 patients undergo cholecystectomy every year. Recently a meta-analysis has raised concerns regarding the increased risk of performing cholecystectomy in octogenarians. Therefore, a study was organised to assess the safety and outcomes of octogenarians undergoing cholecystectomy compared to patients aged 65-79.

Methods

This is a retrospective observational study of a prospective database of all cholecystectomies performed from January’15 to December’20, including patients aged≥65 (elective and emergency). Adjunct cholecystectomies and age<65 were excluded. Patients were divided into OCG (age>80) and UE (age 65-79) groups. The primary outcome was ‘30day mortality’ (TDM). Secondary outcomes were graded ‘post-operative complications’ (POC) based on ‘Clavien-Dindo Classification’ (CDC), Length of Stay (LoS) and the total number of ‘Intensive care unit’(ICU) admissions. The categorical and continuous variables were assessed using Chi-square and Mann-Whitney U’ test, respectively. A p < 0.05 was considered statistically significant.

Results

587 patients were included in this cohort. Majority of the patients were in UE (87.2%,n=512 vs OCG-12.8%,n=75). There was one TDM noted in each group (UE-0.2%,n=1 vs OCG-1.3%,n=1; p = 0.11). Intervention requiring grade-3 CDC were significantly common in OCG (OCG-18.6%,n=14 vs UE-6.8%,n=35; p = 0.00054). However, grade-2 CDC complications were significantly common in UE (UE-16.6%,n=85 vs OCG-2.7%,n=2; p = 0.0015). Number of intensive care stay was similar between the groups (UE-0.9%,n=5 vs OCG-1.3%,n=1; p = 0.77). However, uncomplicated postoperative recovery (p = 0.91) and grade-4 CDS (p = 0.77) were comparable between the studied groups. Median LoS was 1-day in both groups with no statistical difference, p = 0.078.

Conclusions

This study demonstrates that cholecystectomy could be safely offered to a selective group of fit and well octogenarians. Octogenarians who had more complications requiring intervention may be due to factors comprising comorbidities and delayed presentation. However, the TDM and LoS of octogenarians were comparable to the control group. Therefore, age should not be considered as a solitary defining criterion in patient selection for cholecystectomy. Nevertheless, the retrospective nature of this study and skewed patient distribution are the limitations of the study.

P-EGS22 Emergency cholecystectomy: A comparative study of patient outcomes during COVID-19 pandemic with pre-COVID-19 period

Background

Emergency cholecystectomy is recommended for all acute admissions with symptomatic gall stones. The Royal College of Surgeons and AUGIS on 25th March 2020 recommended that all laparoscopic procedures should be avoided during the COVID-19 pandemic with the view to minimise the risk of virus transmission from aerosol-generating procedures. This retrospective study compares the outcomes of patients undergoing emergency cholecystectomy during the COVID-19 period with the pre-COVID-19 period.

Methods

All patients who underwent emergency cholecystectomy (EC) from March 2019 to March 2021 were included. ‘Pre-COVID-19’ period was defined as 25th March 2019 to 24th March 2020, whereas the ‘COVID-19’ period was from 25th March 2020 to 24th March 2021. Mortality was considered as the primary outcome. Secondary outcomes include the 30-day postoperative complications based on the Calvien-Dindo classification (CDC) and the length of stay (LOS). Mortality and postoperative complications were assessed using the Chi-squared test, whilst LOS was studied using the Mann-Whitney U test. A p-value of < 0.05 was considered statistically significant.

Results

A total of 143patients underwent EC during the 24-month study period (75patients pre-COVID-19 and 68patients during COVID-19). The 30-day mortality was nil. 9patients;12% in pre-COVID-19 period and 11patients;16% in COVID-19 period underwent conversion to open cholecystectomy (p = 0.47). 18patients;24% from pre-COVID-19 and 19patients;27.9% from COVID-19 periods developed postoperative complications (p = 0.59). Grade-2-CDC complications were seen in 12patients;17.6% during COVID-19 period and 5patients;6.7% in pre-COVID-19 period (p = 0.0043). However, grade-3,4 CDC complications requiring intervention (p = 0.39), and ICU-admission (p = 0.62) were comparable in both periods. 1patient developed COVID-19 infection but made a full recovery. Mean LOS was 6-days in both periods, with no statistical difference (p = 0.28).

Conclusions

This study demonstrated no significant difference in patient outcomes who underwent emergency cholecystectomy during the COVID-19 pandemic compared to the pre-COVID-19 period. Emergency cholecystectomy should be offered to all surgically fit patients with symptomatic gall stones.

O-EGS04 Is group and save necessary for all patients undergoing emergency cholecystectomy: A 6-year retrospective audit

Background

Emergency cholecystectomy (EC) has a low perioperative bleeding risk. There is no current national guideline to suggest routine preoperative Group and Save (G&S) is necessary. Our Trust guideline recommends preoperative G&S for all EC operations. In 2018, a Trust-wide policy was adopted based on an audit, which concluded that routine preoperative G&S is unnecessary for elective cholecystectomy. All G&S require 2samples taken separately, which can delay surgery. The cost to process one sample for G&S is £28. Therefore, a study was set up to assess the need for routine G&S in patients undergoing EC.

Methods

This retrospective observational study was based on a prospectively collected hospital database from March 2015 to March 2021 using MS-Excel. All patients who underwent EC (laparoscopic and/or open) within 10 days during index admission were included. All elective cholecystectomies were excluded. Patients were divided into GS-patients (patients with G&S) and NGS-patients (patients without G&S). The primary outcome is the difference between the incidence of ‘Perioperative blood transfusion’ (PBT) between the studied groups. The overall cost-effectiveness is considered as a secondary outcome. The categorical data were analysed using the Chi-square test; a p-value &lt;0.05 is considered statistically significant.

Results

In this 6year period, 2210patients underwent cholecystectomy. Of these, 496patients (22.4%) who underwent EC were included. 447patients (90.1%) were in GS group and 49patients (9.9%) were in the NGS group. None from the NGS group required PBT, whereas 3patients (0.6%) in the GS group received blood transfusion. However, PBT was truly indicated in 1patient due to the associated cardiovascular comorbidities. On the contrary, 2patients did not fit the ‘restrictive transfusion threshold’ criteria of JPAC. There was no statistically significant difference in PBT requirement between the studied groups (p = 0.331). Deferring routine G&S for EC could have saved our institution £24,976.

Conclusions

Our study has demonstrated that preoperative G&S is not indicated for all emergency cholecystectomies. It takes approximately 1 hour for G&S to be processed unless crossmatching is required. Group O-negative or O-positive blood can be provided to patients when urgent blood transfusion is needed depending on their age and gender. Thus, we conclude that G&S should be restricted to patients with low preoperative haemoglobin, bleeding and clotting disorders, those known to have abnormal blood antibodies and significant cardiovascular comorbidities.

EP.WE.381Daycase Parathyroidectomy for Primary Hyperparathyroidism: Our Experience

Aims

Concerns due to postoperative complications following parathyroid surgery have precluded its consideration as a Daycase procedure. However recent BAETS guidelines have supported Daycase parathyroid surgery. To assess the outcomes of Daycase parathyroidectomy pathway we established in our Hospital since April,2018.

Methods

Retrospective review of all patients who underwent parathyroidectomy for Primary Hyperparathyroidism between April,2018 and October,2020. Patients with ASA 3 and above and patients undergoing total-parathyroidectomies were excluded. Outcome measures include length of stay, prerequisite for overnight stay, complications, and readmission rates. All patients were assessed and counselled for suitability for Daycase in surgical clinic and given detailed information leaflets.

Results

In this period, 40patients underwent surgery for primary hyperparathyroidism. Of these, 30 patients (75%), 8 males and 22 females with a median age of 59years fulfilled the criteria for Daycase surgery. 19 patients (63.3%) were successfully discharged on the day of surgery. 11 patients (36.7%) were discharged the following morning. The reasons for overnight stay are - 5patien ts(16.7%) developed post-anaesthetic nausea and drowsiness; in 5patients(16.7%) surgery started after 2pm and delayed postoperative return to ward lead to inadequate time for safe discharge; 1patient(3.3%) needed hospital transport. The readmission and postoperative complication rates were nil.

Conclusions

Daycase parathyroidectomy is safe in carefully selected patients. Adequate preoperative counselling, robust perioperative management to minimize postop morbidity and clear patient support package upon discharge are vital for wider acceptance. All Daycase patients should be operated first on the list and prior to 2pm to ensure safe discharge allowing adequate time for postoperative recovery.

Laparoscopically assisted versus open oesophagectomy for patients with oesophageal cancer-the Randomised Oesophagectomy: Minimally Invasive or Open (ROMIO) study: protocol for a randomised controlled trial (RCT)

INTRODUCTION

Surgery (oesophagectomy), with neoadjuvant chemo(radio)therapy, is the main curative treatment for patients with oesophageal cancer. Several surgical approaches can be used to remove an oesophageal tumour. The Ivor Lewis (two-phase procedure) is usually used in the UK. This can be performed as an open oesophagectomy (OO), a laparoscopically assisted oesophagectomy (LAO) or a totally minimally invasive oesophagectomy (TMIO). All three are performed in the National Health Service, with LAO and OO the most common. However, there is limited evidence about which surgical approach is best for patients in terms of survival and postoperative health-related quality of life.

METHODS AND ANALYSIS

We will undertake a UK multicentre randomised controlled trial to compare LAO with OO in adult patients with oesophageal cancer. The primary outcome is patient-reported physical function at 3 and 6 weeks postoperatively and 3 months after randomisation. Secondary outcomes include: postoperative complications, survival, disease recurrence, other measures of quality of life, spirometry, success of patient blinding and quality assurance measures. A cost-effectiveness analysis will be performed comparing LAO with OO. We will embed a randomised substudy to evaluate the safety and evolution of the TMIO procedure and a qualitative recruitment intervention to optimise patient recruitment. We will analyse the primary outcome using a multi-level regression model. Patients will be monitored for up to 3 years after their surgery.

ETHICS AND DISSEMINATION

This study received ethical approval from the South-West Franchay Research Ethics Committee. We will submit the results for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ISRCTN10386621.

Distal antral gastropexy - a novel technique to prevent recurrence of giant hiatus hernia in selected cases - a cohort study

INTRODUCTION

The recurrence rate of giant hiatus hernias (GHH) following repair is high (30%) and increases with the hernia size and previous revision surgery. The mechanism of recurrence is poorly understood.

METHODS

This is a retrospective cohort study of all consecutive patients who underwent repair of giant hiatus hernia in a tertiary upper GI referral centre from November 2000 to November 2014. Patients who underwent redo surgery were identified and data on intra-operative findings and procedure performed at primary and redo surgery from their operation notes were collected.

RESULTS

A total of 81 patients underwent primary repair of GHH over the 14 year study period. 10 (12.3%) had symptomatic/radiological recurrence of which 4 were found to have the distal stomach herniating into the chest despite having an intact intra-abdominal wrap/gastropexy. To prevent migration of the distal stomach into the chest, distal gastropexy - fixing the antrum to the anterior abdominal wall, was added to 'conventional' gastropexy in 5 subsequent cases, in whom the antrum was in the chest preoperatively. These cases have no evidence of recurrence at the end of 6 months follow up.

CONCLUSION

Securing the antrum of stomach to the anterior abdominal wall may prevent migration of the distal stomach and other infracolic organs into the chest and thus reduce recurrence of some GHH where antrum had been in chest previously.

Peritonitis from an abdominal wall biloma: a unique reason to avoid prophylactic surgical drainage

Prophylactic drainage of the peritoneal space after major surgery is widely practised despite evidence against its efficacy. We describe the case of a 56-year-old woman who underwent a converted cholecystectomy and whose correctly sited abdominal drain resulted in the formation of a biloma between the external and internal oblique musculature. Subsequent leakage from the biloma into the abdominal cavity presented as peritonitis days after surgery, necessitating an emergency laparotomy. This case represents the first reported description of an abdominal wall biloma as a complication of post-cholecystectomy abdominal drainage. The evidence surrounding prophylactic drainage is discussed.

Angelchik prosthesis with oesophageal adenocarcinoma: our surgical approach

The Angelchik prosthesis is an incomplete doughnut-shaped device composed of silicone elastomer used in the treatment of gastro-oesophageal reflux disease (GORD). It is used to encircle the lower oesophagus at the gastro-oesophageal junction (GOJ). The ease of the operation led to the insertion of over 25,000 such prostheses world-wide. However, a variety of major complications including intractable dysphagia, prosthesis migration and gastric erosion required a quarter of these devices to be removed. Development of adenocarcinoma in patients with Angelchik prosthesis is a rare occurrence. This article describes two patients who developed adenocarcinoma above their prosthesis and whose cardio-oesophagectomy was technically challenging due to the formation of a dense inflammatory capsule around the prosthesis. Our surgical approach to curative oesophageal resection with the Angelchik prosthesis in situ is also discussed.

Persistent anterior hip pain in young adults: current aspects of diagnosis

Persistent anterior hip pain, in young adults, presents a diagnostic and treatment challenge to hip surgeons. Diagnosis, in some cases, is difficult because available diagnostic tools are not very reliable, resulting in a difficult decision making process. This article discusses the possible causes, current knowledge of the condition and outlines a method to approach this difficult problem.

Factors influencing length of stay after primary total hip replacement: the role of anaesthesia and the anaesthetist

We studied 121 consecutive total hip replacements (THRs) in 109 patients in order to establish the influence of anaesthetic technique, anaesthetist concerned, age of the patient, and body mass index (BMI) on the length of hospital stay after primary total hip replacement. Patients received either general anaesthesia alone (50 THRs) or a combination of general and local anaesthesia (lumbar plexus block; 71 THRs) from three separate anaesthetists. Our analysis showed that those patients who received a combination of anaesthesia showed shorter median length of hospital stay (three days) than those who received general anaesthesia alone (five days; p<0.0001). The age of the patient was also critical (p=0.003) as was the anaesthetist concerned (p=0.01). BMI was unimportant.

Development and problems of metal-on-metal hip arthroplasty

For over 40 years, the metal-on-polyethylene bearing has dominated the field of total hip replacement. Problems of wear, osteolysis (dissolution of bone), and ultimately failure of prostheses have led to the development of alternative bearing surfaces. Metal-on-metal hip resurfacing has taken current orthopaedic surgery almost by storm. However, metal ion release following metal-on-metal hip resurfacing remains a major cause for concern. This article looks into the development and examines problems and issues surrounding metal-on-metal resurfacing arthroplasty.