British Journal of Surgery

Burton, O; Georgi, M; Asif, A; Fricker, M; Patel, S; Raja, A K; Gargan, A; Gargan, K; Lee, K; Kamboj, R; Thamilmaran, A; Leung, K H C; Abdi, Z; Haque, S; Tse, F; Moore, C; Nathan, A

doi: 10.1093/bjs/znad258.778pmid: N/A

AimAlthough the proportion of female medical students worldwide is increasing, only an estimated 35% of UK surgical trainees are female, and only 14% of consultant surgeons – these statistics are similar globally. This study aims to quantify the gender distribution in invited speakers and panellists at international pan-specialty surgical conferences in recent years.MethodRetrospective analysis of annual meetings organised by 5 international surgical organizations between January 2016 and December 2021 was conducted. Male and female faculty were academically stratified according to mean publications, citations, and H-index. A manel was defined as a session with ≥ 2 speakers, all of whom are men. Sex was determined by specific speaker title in conference program, online autobiography, or Gender Balance Assessment Tool (GBAT).ResultsBetween 22 conferences, there were 1978 invited speakers, of which 25.6% (n = 506) were female. Of the included 74 panel sessions, 48.6% (n = 36) were manels. When considering the gender of invited lecture speakers, there was no significant difference in their mean H-indices (M = 33.4, F = 27.8, p = 0.063) or mean total publications (M = 205.6, F = 169.9). Male invited lecturers had a significantly higher number of citations (M = 7944.7, F = 4211.7, p = 0.025). There was a significant decrease in the proportion of manels between 2016 and 2021 (p = 0.01).ConclusionsDespite the increasing representation of women in surgery, only one quarter of invited speakers were female and almost half of panels with two or more speakers were manels despite no difference in speaker H-index or publications. This study highlights the need for new strategies and concerted efforts to increase female representation at surgical conferences.

Javed, M; Manchip, G; Chiara Corriero, A; Limbu, T; Wellington, J

doi: 10.1093/bjs/znad258.038pmid: N/A

AimPeople experiencing homelessness (PEH) are a vulnerable group in which physical health morbidities are much more common than the general population. Despite this, the inability to access healthcare remains a main concern. This literature review aims to identify the barriers and facilitators PEH face towards accessing safe surgical care, and to provide actionable strategies.MethodA literature search was carried out on multiple databases. Thematic analysis of the included papers identified themes relating to barriers, facilitators, and actionable strategies.ResultTwelve papers were identified. Eleven themes related to barriers and facilitators were identified and five for actionable strategies. The themes related to barriers included access to community care, fragmented follow-up care, transportation, lack of recovery shelters, infections, and post-operative complications. Themes related to facilitators included street medicine programmes and the utilisation of patient navigators. Actionable strategies identified for health workers included the improvement of education, enhancing existing social safety nets, improved screening, tailoring discharge and surgical plans with the view of unfeasible follow up.ConclusionsCurrent papers are not based on UK data and there are limited data sources available. However, analysis of the available data has shown many barriers and limited facilitators towards surgical care, highlighting the need for further studies. With a rising population of PEH in the UK these findings highlight the need for further research to create strategies that allow for safe surgical care in this population.

Ryan, E; Tyrrell-Price, J; Phillips, J

doi: 10.1093/bjs/znad258.421pmid: N/A

AimAcute severe ulcerative colitis (ASUC) is a medical emergency which, if left untreated, can be fatal. Some cases require colectomy. The timing of this operation is important to reduce post-operative morbidity. The primary study aim is to assess whether the timing of this operation impacts upon post-operative outcome. The secondary aim of this study is to determine whether pre-operative blood albumin level may be able to predict post-operative complication rates.MethodAll patients who underwent colectomy and ileostomy formation for ASUC at Bristol Royal Infirmary between 2010-2020 were identified. Patient demographic information, duration of pre-operative hospital stays, blood results and post-operative complications up until the most recent follow up were recorded. Patients undergoing elective colectomy for ulcerative colitis were analysed separately.ResultsTwenty-one ASUC admissions were identified who were all treated with intravenous steroids for a median of 9 (range 1-18) days before colectomy. 16 patients (76%) received either ciclosporin or infliximab rescue therapies. Median admission CRP was 41 (range 4-231). Median admission blood albumin was 29 (range 16-38). <30-day and >30-day post-operative complication rates were 52% (11/21) and 25% (5/20) respectively.ConclusionsPrevious literature shows significant association between the length of pre-operative medical therapy and post-operative complications. Surgeons can learn from them, so far, negative findings of our study. A surgeon’s own clinical judgement is the most important factor in the decision of when to take an ASUC patient to theatre. Biomarkers can aid a decision but cannot be used as a solitary justifier for the timing of colectomy.

Feathers, J; Mabrouk, A; Mahmood, A; West, R; Pandit, H; Lamb, J

doi: 10.1093/bjs/znad258.031pmid: N/A

AimTo compare the incidence of post-operative periprosthetic femoral fractures (POPFF) following hip replacement with either a cemented polished taper stem (PTS) or cemented composite beam stem (CB) in comparative studies.MethodA systematic review of comparative studies, written in English, and published in peer-reviewed journals since year 2000 to 2021 was conducted using Ovid MEDLINE, EMBASE, Web of Science, and Scopus. Methodology followed the Preferred Reporting items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Study quality was assessed using the Newcastle-Ottawa scale. Cohorts were classified as high or low risk of POPFF based on patient risk factors. Metanalysis was performed using a random effects model and relative incidence with 95% confidence intervals were reported.ResultsThe overall study quality was good. 913,021 patients from 18 cohorts were included in the meta-analysis. 294,540 patients received a CB stem and 618,481 received a PTS stem. For patients at low risk of POPFF the incidence rate ratio (IRR) was 3.14 (CI: 2.48, 3.98) for the PTS group versus CB group. For patients at high risk of POPFF the IRR of 9.87 (CI: 3.63, 26.80) for the PTS group versus the CB group.ConclusionsThe risk of POPFF is lower when hip arthroplasty was performed using a composite beam stem versus a polished taper slip stem. This protective effect was greatest in patients with a higher risk of POPFF. Surgeons should consider the effect of cemented stem choice on risk of subsequent periprosthetic femur fracture, particularly in frail or elderly patients at risk of periprosthetic femoral fracture.

Weight, G; Tsoi, H

doi: 10.1093/bjs/znad258.733pmid: N/A

AimGreenlight-laser prostatectomy (GLLP) is becoming a popular treatment option for bladder outlet obstruction. In this retrospective study, we aim to explore the patient selection, perioperative morbidity, and functional outcomes of GLLP.MethodPatients who underwent GLLP at a UK tertiary centre between June 2018 and November 2021 were included in this study. Retrospective data covering patient demographics, perioperative parameters and postoperative outcomes were collected using the electronic records systems.Results305 patients were included in this study with a median age of 74 (range 30-90) years. The most common indication (62.6%) for the procedure was patient’s wish to be free from long-term catheters (LTC) or intermittent catheterisation (ISC), followed by failed medical therapy for LUTS (36.4%). 84.6% of patients had an ASA ≥2, and 32.1% took anticoagulant or antiplatelet therapy. Inpatient stays were minimal, with the majority (68.2%) of patients were performed as day case, and 21.3% of patients discharged on the next day. The 3-month readmission rate was 10.8%, with the most common causes being haematuria and urinary-tract infection. The successful TWOC rate at follow up was 91.2%. Amongst the 19 patients who failed TWOC, 14 had LTC prior to the procedure and 4 had been performing ISC.ConclusionsOur study shows that GLLP is a safe and effective day case treatment, and that with appropriate anaesthetic input it can be suitable for elderly and comorbid patients. Patients requiring LTC or ISC pre-operatively should be counselled carefully about the risk of not being catheter-free post procedure.

Zhang, J; Stevenson, A; Lu, V; Zhou, A; Bradshaw, F; Duchniewicz, M; Krkovic, M

doi: 10.1093/bjs/znad258.691pmid: N/A

AimPelvic fractures are highly traumatic and debilitating injuries for patients, with an arduous rehabilitation process. Our study analyses the predictors for opioid requirements in pelvic fractures.MethodData was collected from all pelvic fractures treated at a Major Trauma Centre from 2015-2021, including fracture location, demographics, and comorbidities. Opioid prescriptions in the first post-injury year were calculated every month up to 6 months, and then from the 7th-12th month period. We calculated the total strength in Morphine Milligram Equivalents (MME), and days with at least one opioid prescribed (“coverage”). Multivariate regression was performed on the outcomes.ResultsA total of 3137 patients with pelvic fractures were included, with mean 954 MME (95%, CI = 899-999) in the first year. Acetabulum fractures showed lower strength in the 1st, and 7–12-month periods, with lower coverage in the 1st- 3rd months (p<0.05). Pubis fractures needed higher strength opioids for more days across all time intervals (p<0.01). On multivariate comorbidity analysis, in every subinterval after 1st month and overall, higher BMI and age, pulmonary disease, and drug abuse were associated with higher strength. In every subinterval after 4th month and overall, liver disease was associated with higher strength (p<0.05). Higher age and BMI were associated with increased coverage overall and every individual month (p<0.01), with chronic kidney disease and rheumatological conditions associated with increased coverage after the 2nd month (p<0.05).ConclusionsOur study highlights the various injury, demographic and comorbidity factors that predispose patients to requiring higher strength and coverage of opioids during their rehabilitation from pelvic fractures.

Guven, T; Gillams, K; Pignatari, R; Aldesouki, A; Beck, R

doi: 10.1093/bjs/znad258.725pmid: N/A

AimMost patients who have a TURP should be advised to discontinue medication for bladder outflow obstruction secondary to benign prostate hyperplasia (BPH) after their surgery. This closed loop QIP audited whether this was the case, presented the findings to the department and re-audited to see whether there had been a decrease in continuing unnecessary post-TURP medication.MethodThe QIP began in October 2020 with a retrospective review of 50 patients that underwent a TURP at a large district general hospital. Patient records were reviewed to ascertain if patients were taking alpha-blockers (ABs) or 5 alpha-reductase inhibitors (5ARIs) pre-operatively, and if these were discontinued post-procedure. Any instruction to continue medication post-operatively was noted in the data collection.This data was presented at a departmental research and audit meeting. The second QIP cycle used the same data collection methodology for the subsequent 50 patients who underwent a TURP (June 2021).ResultsThe presentation resulted in a statistically significant decrease in unclear documentation 30% to 10% (p = .0124). Although there was an increase medication discontinuation post-TURP (27.3% to 48%) this wasn’t statistically significant (p = .246). The percentage of patients who were continued on an AB or 5ARI post-op without documentation decreased from 63.3% to 48%, but this change was also not statistically significant (p = .384).ConclusionsSimple departmental audits help improve patient safety through clearer documentation and presentation of new literature. It would be beneficial to produce clear guidelines to patients and their primary care physicians to advise to discontinue BPH medication TURP unless otherwise advised by the urologist.

Quek, F F; Cyclewala, S; Smith, J

doi: 10.1093/bjs/znad258.549pmid: N/A

AimWith an estimated incidence rate of 1 to 2 cases per 1,000 population, venous thromboembolism (VTE) remains a significant cause of morbidity and mortality in the United Kingdom. It is reported that VTE is responsible for approximately 60,000 deaths per annum. Furthermore, VTE has a huge financial impact on the NHS. It is reported that VTE treatment costs the NHS approximately £640 million every year.Notably, at least two-thirds of hospital-acquired VTE are preventable. NICE guideline recommends that all patients should be risk-assessed on admission and re-assessed at the point of consultant review [NG89]. The purpose of this closed-loop audit was to evaluate the effectiveness of simple interventions in improving the efficiency of VTE risk assessments at a large teaching hospital.MethodResults from the first cycle were analysed and interventions were implemented with the aim to improve the standard of practice. These include the utilisation of technology in VTE risk assessments, mandatory teaching sessions and the development of prompts within clerking proformas. A repeat audit was subsequently performed to re-assess the new standard of practice and the effectiveness of these interventions.ResultsOur VTE risk assessment completion rates increased substantially from 16.67% to 100% and the median time taken to complete VTE risk re-assessments also improved notably from 97 to 21 hours. Positive feedbacks have been received on the effectiveness of these interventions.ConclusionsBy implementing these simple interventions, we can see a substantial improvement in the standards of VTE risk assessments, in compliance with the NHS Standard Contract and NICE guidelines.

Abualnaja, S; Rehman, U; McKenna, G

doi: 10.1093/bjs/znad258.440pmid: N/A

AimIntracranial aneurysms (ICA) are a common complication of polycystic kidney disease (PKD). Due to the lack of screening protocols that exist for PKD patients, without the appropriate preventative measures ICA rupture leads to significant morbidity and mortality. The aim is to analyse existing screening protocols by referencing the lead time between ICA diagnosis and rupture in PKD patients, the purpose and importance of screening, the types of imaging modalities used, and patient outcomes. We will also consider cost-effectiveness and its relation in establishing a screening protocol.MethodA literature search was conducted in April 2022 for articles published between 1990-2022 with special interest in ICA, PKD, and screening protocols. Only exclusion criteria were patients who were diagnosed with PKD <30 years of age. An independent reviewer screened the relevant full papers prior to inclusion.ResultsOur findings suggest that if a PKD presents with either a positive family history of ICA and/or cerebrovascular events and/or is above 40 years of age, then they should have a magnetic resonance angiography (MRA) scan every 5 years to monitor ICA development with annual follow-ups. This will significantly decrease patient morbidity and mortality in PKD positive patients.ConclusionsWhile there is significant evidence proving that screening protocols decrease the morbidity and mortality of PKD patients, none have been suggested. The screening protocol suggested in this review should be used as a guideline for future studies that will try and establish a national or international guidelines that can be used by nephrologists and neurosurgeons worldwide.

Drury, D

doi: 10.1093/bjs/znad258.472pmid: N/A

AimTo determine whether requesting images for plastic surgery trauma referrals reduced the number of patients transferred to hospital for on the day assessment and management.MethodTwo data collection periods between 31/08/22 - 18/09/22 (round 1) and 24/10/22 – 17/11/22 (round 2) were undertaken. For round one on call plastic surgery SHOs were asked to keep track of all trauma referrals outside of their base hospital which they accepted for on the day review. Once the patient had been reviewed SHOs were asked whether they felt the patient required on the day management or if the patient could have been safely triaged to be seen the following day. During round two SHOs were additionally asked to request images from the referrer were able and to note whether this altered or confirmed their initial management plan.ResultsRound one: 15 patients were transferred for on the day review with 80% deemed as requiring on the day management whilst 20% did not. Round two: 13 patients were transferred for on the day review with 92% deemed as requiring on the day management whilst 8% did not. Images were sent for 9 patients, altered the initial decision in three cases and confirmed the initial management in 6.ConclusionsRequesting images for plastic trauma referrals can reduce the number of patients unnecessarily seen on the day, reducing patient stress, and making better use of hospital resources.