DD-06 SPIN (SURGICAL PRACTICES IN INCISIONAL HERNIA REPAIR). A NATIONAL TRAINEE-LED COLLABORATIVE MULTICENTRE PROSPECTIVE OBSERVATIONAL STUDY

Aim

There is currently no established UK database establishing reliable outcome data for surgical repair of incisional herniae (IH). Their heterogeneity (variability in size, patient comorbidity, and multiple repair techniques) has resulted in no surgical management or outcome reporting consensus.

This study aims to utilise national trainee led research collaboratives to perform a multi-centre, observational, prospective study to assess variation in IH defects (by utilising pre-defined criteria from The European Hernia Society (EHS) classification for IH and a Modified Ventral Hernia Working Group) and their subsequent operative management. This study will yield valuable, standardised data on variation in practice and outcomes (complications and 3 and 12-months follow-up) to provide a platform for expanding IH research.

Materials and Methods

All NHS hospitals in England undertaking elective IH repair will be eligible for inclusion. Dissemination of and recruitment to the study will be driven by regional research collaborative networks.

This study will include all elective adult IH repairs with. Data will be collected and managed using REDCap electronic data capture tool. There will be three distinct phases comprising;

The study is currently unfunded. Funds are sought to obtain NHS Trust sponsorship and proceed to phase 3 of the study.

871 Liver Transplant for Colorectal Liver Metastases: A Systematic Review and Meta-Analysis of Proportions

Introduction

Colorectal liver metastases were historically considered a contraindication to liver transplantation, but dismal outcomes for those with metastatic colorectal cancer and advancements in liver transplantation (LT) have led to a renewed interest in the topic. We aim to compare the current evidence for liver transplantation for non-resectable colorectal liver metastases (NRCLM) with the current standard treatment of palliative chemotherapy reported in literature – 5-year survival rate <10%.

Method

A systematic review and meta-analysis of proportions was conducted following screening of MEDLINE, EMBASE, SCOPUS and CENTRAL for studies reporting liver transplantation for colorectal liver metastases. Post-operative outcomes measured included 1-, 3- and 5-year survival, overall survival, disease-free survival, and complication rates.

Results

Three non-randomised studies met the inclusion criteria, reporting a total of 48 patients receiving LT for NRCLM. Survival at 1-, 3- and 5-years was 83.3-100%, 58.3-80% and 50-80% respectively with no significant difference detected (p = 0.22, p = 0.48, p = 0.26). Disease free survival was 35-56% with the most common site of recurrence being lung. Thirteen out of fourteen deaths were due to disease recurrence.

Conclusions

Although current evidence suggests a survival benefit conferred by LT in NRCLM compared to palliative chemotherapy, the ethical implications of organ availability and allocation demand rigorous justification. Eight registered clinical trials will report on 300 more patients undergoing LT for NRCLM over the next 10 years: concomitant improvements in the management of patients following liver resection and of palliative chemotherapy regimens is paramount.

715 The Importance of Social Media to The Academic Surgical Literature: Relationship Between Twitter Activity and Readership Metrics

Aim

Social media (SoMe) has an increasing role within professional surgical practice, including the publishing and engagement of academic literature. This study aims to analyse the relationship between social media use and traditional and alternative metrics amongst academic surgical journals.

Method

Journals were identified through the InCites Journal Citation Reports 2019, and their impact factor (IF), h-index and CiteScore were noted. Social media platforms were examined, and Twitter activity interrogated between 1st January- 31st December 2019. Healthcare Social Graph (HSG) score and an aggregated Altmetric score were also calculated for each journal. Statistical analysis was carried out to look at the correlation between traditional metrics, Twitter activity and altmetrics.

Results

Journals with higher IF were more likely to use a greater number of SoMe platforms (R2=0.648; p < 0.0001). Journals with dedicated Twitter profiles had a higher IF than journals without (median, 2.96 vs 1.88; MWU=390; p < 0.001) however over a one-year period (2018-2019) having a twitter presence did not alter IF (MWU=744.5; p = 0.885). Increased Twitter activity was positively correlated with IF. Longitudinal analysis over six years suggested cumulative tweets correlated with an increased IF (R2=0.324, p = 0.004). Novel alternative measures including HSG score (R2=0.472, p = 0.005) and Altmetric score (R2=0.779, p = 0.001) positively correlated with IF.

Conclusions

Higher IF is associated with SoMe presence and activity, particularly on Twitter, with long term activity being of particular importance. Modern alternative metrics correlate with IF. This relationship is complex and future studies should look to understand this further.

720 Pringle Versus Selective Hepatic Vascular Exclusion in Major Hepatectomy: A Systematic Review and Meta-Analysis

Aim

Mortality and morbidity following hepatic resection is significantly affected by major intra-operative blood loss. Multiple techniques have been developed in an attempt to minimise blood loss by occluding hepatic inflow and outflow. This systematic review and meta-analysis evaluates whether selective hepatic vascular exclusion compared to a Pringle manoeuvre in hepatic resection reduces rates of morbidity and mortality.

Method

A systematic review and meta-analysis were conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL, SCOPUS and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Intra- and post-operative outcome measures were investigated. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models.

Results

Five studies were identified including two randomized controlled trials and three observational studies reporting a total of 2,198 patients. Data synthesis showed significantly decreased rates of mortality, overall complications, patients requiring blood transfusion, air embolism, warm ischaemia time, liver failure and multi-organ failure when performing SHVE compared to a Pringle manoeuvre. Rates of hepatic vein rupture and post-operative haemorrhage remained the same. Performing SHVE resulted in a significantly longer operation time.

Conclusions

Performing SHVE in major hepatectomy may result in reduced rates of morbidity and mortality when compared to a Pringle manoeuvre, although may prolong operating time. The results of this meta-analysis are based on a few high-quality studies where tumours were adjacent to major vessels. Further RCTs are required to validate these results and determine the best technique for hepatic vascular control in this patient cohort.

717 Roux-En-Y Versus Single Loop Reconstruction in Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis

Aim

Post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) both remain problematic complications following pancreaticoduodenectomy. This systematic review and meta-analysis evaluates whether Roux-en-Y compared to a single loop reconstruction in pancreaticoduodenectomy significantly reduces rates of these complications.

Method

A systematic review and meta-analysis were conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Post-operative outcome measures included: POPF, DGE, bile leak, operating time, blood loss, need for transfusion, wound infection, intra-abdominal collection, post-pancreatectomy haemorrhage, overall morbidity, re-operation, overall mortality, hospital length of stay. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models.

Results

Fourteen studies were identified including four randomized controlled trials (RCTs) and 10 observational studies reporting a total of 2 031 patients. Data synthesis showed no statistically significant difference between the two groups in any of the outcome measures except operating time, which was longer in those undergoing Roux-en-Y reconstruction.

Conclusions

Roux-en-Y is not superior to single loop reconstruction in pancreaticoduodenectomy but may prolong operating time. Future high-quality randomized studies with appropriate study design and sample size power calculation may be required to further validate this conclusion.

Cranio-cervical junction malformation causing cord compression in infant with achondroplasia: a bigger picture

Introduction: Achondroplasia is a genetic disorder known for short stature and skeletal abnormalities.Case Report: We present a case of narrowing of the foramen magnum from a large opisthion extending to the spinal canal.Conclusion: Foramen magnum stenosis and cervicomedullary stenosis are potentially life threatening neurological manifestations of achondroplasia.

Developing classification criteria for skin-predominant dermatomyositis: the Delphi process

BACKGROUND

The European League Against Rheumatism/American College of Rheumatology classification criteria for inflammatory myopathies are able to classify patients with skin-predominant dermatomyositis (DM). However, approximately 25% of patients with skin-predominant DM do not meet two of the three hallmark skin signs and fail to meet the criteria.

OBJECTIVES

To develop a set of skin-focused classification criteria that will distinguish cutaneous DM from mimickers and allow a more inclusive definition of skin-predominant disease.

METHODS

An extensive literature review was done to generate items for the Delphi process. Items were grouped into categories of distribution, morphology, symptoms, antibodies, histology and contextual factors. Using REDCap™, participants rated these items in terms of appropriateness and distinguishing ability from mimickers. The relevance score ranged from 1 to 100, and the median score determined a rank-ordered list. A prespecified median score cut-off was decided by the steering committee and the participants. There was a pre-Delphi and two rounds of actual Delphi.

RESULTS

There were 50 participating dermatologists and rheumatologists from North America, South America, Europe and Asia. After a cut-off score of 70 during the first round, 37 of the initial 54 items were retained and carried over to the next round. The cut-off was raised to 80 during round two and a list of 25 items was generated.

CONCLUSIONS

This project is a key step in the development of prospectively validated classification criteria that will create a more inclusive population of patients with DM for clinical research. What's already known about this topic? Proper classification of patients with skin-predominant dermatomyositis (DM) is indispensable in the appropriate conduct of clinical/translational research in the field. The only validated European League Against Rheumatism/American College of Rheumatology criteria for idiopathic inflammatory myopathies are able to classify skin-predominant DM. However, a quarter of amyopathic patients still fail the criteria and does not meet the disease classification. What does this study add? A list of 25 potential criteria divided into categories of distribution, morphology, symptomatology, pathology and contextual factors has been generated after several rounds of consensus exercise among experts in the field of DM. This Delphi project is a prerequisite to the development of a validated classification criteria set for skin-predominant DM.

The diagnosis and classification of amyopathic dermatomyositis: a historical review and assessment of existing criteria

BACKGROUND

Diagnostic criteria are used to identify a patient having a disease in a clinical setting, whereas classification criteria create a well-defined population for research purposes. The diagnosis and classification of amyopathic dermatomyositis (ADM) have not been recognized by most existing criteria for idiopathic inflammatory myopathies (IIMs). To address this, several criteria were proposed to define ADM either as a distinct disease entity or as a subset of the spectrum of IIMs.

OBJECTIVES

To discuss the diagnosis and classification of ADM and to assesses the available criteria in identifying cases of ADM and/or distinguishing it from dermatological mimickers such as lupus erythematosus.

METHODS

We conducted an extensive literature search using the PubMed database from June 2016 to August 2018, using the search terms 'amyopathic dermatomyositis', 'diagnosis' and 'classification'.

RESULTS

The European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) criteria, which are the only validated classification criteria for adult and juvenile IIM and their major subgroups, include three cutaneous items (Göttron sign, Göttron papules, heliotrope rash) to be able to classify ADM. This international and multispecialty effort is a huge step forward in the classification of skin-predominant disease in dermatomyositis. However, about 25% of the population with ADM do not meet two out of the three skin features and are misdiagnosed or classified as having a different disease entity, most commonly lupus erythematosus.

CONCLUSIONS

These gaps rationalize the continuous assessment and improvement of existing criteria and/or the development of validated, separate and skin-focused criteria for DM.

Literature review and case series of haemorrhagic cholecystitis

A diagnosis of haemorrhagic cholecystitis is difficult to make as it is rare and mimics other common disorders. We present three patients who presented with haemorrhagic cholecystitis, two of whom were on anti-coagulation at presentation. All 3 patients were treated conservatively, 2 with percutaneous cholecystostomy drainage and 1 patient with intravenous antibiotics. There are few guidelines on the management of such a condition.

Fatigue in systemic lupus erythematosus and other autoimmune skin diseases

BACKGROUND

Fatigue is a well-established symptom in systemic lupus erythematosus (SLE), but has not been well characterized in other skin-limited autoimmune diseases such as cutaneous lupus erythematosus (CLE), amyopathic dermatomyositis (ADM) or autoimmune blistering diseases (AIBD).

OBJECTIVES

In this retrospective study, we compared fatigue in controls (n = 84) with that in patients enrolled in prospective longitudinal databases with SLE (n = 165), CLE (n = 226), ADM (n = 136) and AIBD (n = 79).

METHODS

We used the 36-Item Short Form Survey (SF-36) vitality scale to analyse median scores and the percentages of patients with clinically significant fatigue (defined as a score ≤ 35) between experimental groups and controls.

RESULTS

Median and interquartile range (IQR) vitality scores demonstrated greater fatigue in the experimental groups (SLE 35, IQR 20-55; CLE 50, IQR 30-70; ADM 50, IQR 30-65; AIBD 55, IQR 35-70) than in controls (73, IQR 65-85) (P < 0·05 for each experimental group vs. control). The SLE group had worse fatigue than all of the other groups (P < 0·05 SLE vs. each group), but there was no difference between the CLE, ADM or AIBD groups (all P > 0·05). In addition, the experimental groups had more clinically significant fatigue (score ≤ 35) (SLE 44·2%, CLE 25·2%, ADM 31·6%, AIBD 24·1%) than controls (2%) (P < 0·01 for each experimental group vs. control). The SLE group had more clinically significant fatigue than the CLE group (P < 0·01); however, there was no difference in clinically significant fatigue between SLE and either ADM (P = 0·17) or AIBD (P = 0·055).

CONCLUSIONS

These findings demonstrate that patients with skin-limited autoimmune disease experience more fatigue than controls. Fatigue is an important symptom that negatively affects quality of life for patients. It should be addressed by clinicians and measured in future clinical trials.

Evaluation of the reliability and validity of the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) in paediatric cutaneous lupus among paediatric dermatologists and rheumatologists

BACKGROUND

The Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) is a reliable outcome measure for cutaneous lupus erythematosus (CLE) in adults used in clinical trials. However, it has not been validated in children, limiting clinical trials for paediatric CLE.

OBJECTIVES

This study aimed to validate the CLASI in paediatrics.

METHODS

Eleven paediatric patients with CLE, six dermatologists and six rheumatologists participated. The physicians were trained to use the CLASI and Physician's Global Assessment (PGA), and individually rated all patients using both tools. Each physician reassessed two randomly selected patients. Within each physician group, the intraclass correlation coefficient (ICC) was calculated to assess the reliability of each measure.

RESULTS

CLASI activity scores demonstrated excellent inter- and intrarater reliability (ICC > 0·90), while the PGA activity scores had good inter-rater reliability (ICC 0·73-0·77) among both specialties. PGA activity scores showed excellent (ICC 0·89) and good intrarater reliability (ICC 0·76) for dermatologists and rheumatologists, respectively. Limitations of this study include the small sample size of patients and potential recall bias during the physician rerating session.

CONCLUSIONS

CLASI activity measurement showed excellent inter- and intrarater reliability in paediatric CLE and superiority over the PGA. These results demonstrate that the CLASI is a reliable and valid outcome instrument for paediatric CLE.

Myofibroblastic infiltration of the bowel: A case report and literature review

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IMTS are aggressive lesions but metastases is rare.

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Abdominal IMTS are difficult to diagnose and manage.

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The therapy of choice is surgical resection of the tumour.

Introduction

Inflammatory myofibroblastic tumours (IMTs), are uncommon tumours which can act with malignant potential. The management of these tumours can be extremely problematic but are often referred to surgical multi-disciplinary team meetings with the intention of surgical and oncological management (Chaudhary [1]).

Case report

A 69-year-old gentleman was admitted with a 2-day history of abdominal pain and vomiting, and a 4-day history of absolute constipation. CT Abdomen Pelvis demonstrated distended loops of small bowel with pronounced fluid levels but no transition point. Intra-operative findings showed a right ileocolic mass adherent to the pelvic side wall and omental caking. Biopsies showed a florid myofibroblastic reaction, not a malignant process.

Conclusion

IMTS are aggressive lesions but metastases is rare. Abdominal IMTS are difficult to diagnose and manage as they are often initially mistaken for lymphoma or peritoneal metastases. The therapy of choice is surgical resection of the tumour (Firat et al. [3]).

If I had a hammer

We present the case of a 64-year-old man who was referred to our service after sustaining a self-inflicted nail-gun injury to his chest. He received three nails penetrated into his chest. Computer tomography revealed no massive haemorrhage or damage to major vessels. He underwent an emergency sternotomy, two nails caused pericardial perforation and myocardial injury were noted easily and removed easily via sternotomy. Myocardial injury showed a trajectory near the junction of the left anterior descending artery and the diagonal artery with no significant bleeding appreciated. The third nail was deep in the lung parenchyma at the hilum. A pacemaker magnet was used to locate the third nail, which was subsequently removed. Our case demonstrates the use of magnets in emergency surgery, to locate and remove metallic foreign bodies.

Anomalous right upper lobe venous drainage

Lung resections are usually not associated with significant bleeding, but can be fatal, especially in cases of video-assisted thoracoscopic surgery (VATS). Anomalous vascular structures could be a major reason for unexpected bleeding in such surgeries. We present a case of an aberrant upper lobe pulmonary vein that was encountered posterior to the right upper lobe bronchus during a right upper lobectomy via thoracotomy. The anomalous pulmonary vein was identified preoperatively on a computed tomography (CT) scan and hence was looked for before dividing the bronchus. Many centres are adopting the VATS approach for performing lung resections. If an anomalous vein is present posterior to the bronchus, it might be in a blind spot and could be damaged inadvertently, leading to profuse and potentially fatal bleeding. We conclude that the identification of anomalous vascular structures prior to surgery with the help of CT helps in avoiding adverse outcomes.

A case of lung volume reduction surgery with decortication for a septic patient in respiratory failure

INTRODUCTION

Decortication and lung volume reduction surgery are both major operations and each has its independent risk of morbidity and mortality.

CASE REPORT

We present the case of a 41 year old gentleman with left sided empyema and giant bullae of the upper lobe with an active air leak that was transferred to our tertiary referral centre for further management. We performed emergency left thoracotomy, decorticated the left lower lobe with extensive lung volume reduction surgery of the upper lobe. Patient's respiratory status significantly improved along with excellent radiological results.

CONCLUSION

Our case demonstrates that a combination of complex procedures is feasible with excellent outcomes.

Frequency of occupational health concerns in general clinics

Studies have suggested that occupational disease and injury are under-recognized by clinicians. To estimate the frequency of occupational factors in disease and injury, 108 patients in a general (not occupational) health care facility were interviewed about the frequency and types of workplace-health interactions. Thirty-nine percent reported possible causation by work, and 66% reported a possible increase in symptoms by work, even if not caused by work. Twenty-seven percent reported changing jobs and/or tasks because of work-health interactions. The majority of men and women reported that worksite changes could improve their functional ability at work. This study therefore indicates that (1) occupational health concerns are common in primary care clinics, even if not addressed by clinicians; (2) the definition of occupational health concerns should be broadened to include disease caused by work, disease symptoms worsened by work, and the need for occupational accommodation even if the disease itself is not caused by work; and (3) inquiring about patient concerns about workplace-health interactions can provide clinicians with significant opportunities for primary, secondary, and tertiary prevention.

Potent and selective bicyclic lactam inhibitors of thrombin. Part 4: transition state inhibitors

Bicyclic piperazinone based thrombin inhibitors of general structure 2 were prepared and evaluated in vitro and in vivo. These inhibitors, having in common an electrophilic basic trans-cyclohexylamine P1 residue, displayed high thrombin affinity, high selectivity against trypsin and good in vivo efficacy in the rat arterial thrombosis model.

Potent bicyclic lactam inhibitors of thrombin: Part I: P3 modifications

Peptidomimetic inhibitors of general structure 1 have been prepared. Optimization of the binding affinities of these compounds through variation of the P3 hydrophobic residue is described. Selected substituted bicylic lactams displayed interesting pharmacological profiles both in vitro and in vivo.