SUSC 2010 Conference Booklet

SCALPEL UNDERGRADUATE SURGICAL C O N F E R E N C E 2010

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CONTENTS Welcome address

4

Conference organisation

5

Sponsors

6

Programme

7

Workshops

10

Speaker biographies

11

Abstracts

12

Oral presentations

12

Poster presentations

26

Index of presenters

33

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WELCOME TO THE SCALPEL UNDERGRADUATE SURGICAL CONFERENCE 2010 Dear Colleagues,

Welcome to the second Scalpel Undergraduate Surgical Conference!

Scalpel, the University of Manchester Surgical Society, aims to educate, entertain and provide a forum for like-minded undergraduates and graduates in the field of surgery. We hold a variety of events throughout the year and we try to cater for all areas of interest within the broad and fascinating world of surgery.

So far this year our events have covered a wide spectrum of surgical specialties as well as giving our members opportunities that usually remain inaccessible.

Last year we hosted the first Scalpel Undergraduate Surgical Conference. As a committee we felt this was very successful and we are pleased to be building on last year‟s achievements. Our conference aims to give delegates from across the country the opportunity to meet, learn and celebrate the vast field of student surgical endeavour.

I hope you are able to use this conference to develop professionally, establish personal ties with others in surgery, and gain experience in presenting your work – make the most of today!

I would like to thank all delegates, the fabulously hard-working committee, the judging panels and the keynote speakers. I would also like to say a special thank you to Professor Gus McGrouther, who will be chairing the conference today, and Mr Stuart Enoch and the Doctor‟s Academy for the skills workshops.

Whether you‟re here to present work, to learn from our excellent speakers, or to pick up a scalpel for the first time: enjoy!

Elspeth Hill Scalpel President 2010

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CONFERENCE ORGANISATION ORGANISING COMMITTEE Elspeth Hill President of Scalpel Manchester

Partners

Nicholas Boxall Grant Coleman Zeni Haveliwala Oisin Keenan Adrian Lim Francesca Liuzzi Lucy McLellan Richard Salisbury Samuel Shillito Je Song Shin Nusiba Taufik Michelle Ting Bhamini Vadhwana

JUDGES Prof DA McGrouther Professor of Plastic Surgery Mr M Jones Consultant Cardiothoracic Surgeon Mr J Holland Consultant Neurosurgeon Miss J Walls Consultant Breast Surgeon Mr R Craigie Consultant Paediatric Surgeon Miss S Kalipershad Specialist Registrar, General Surgery Mr J Ghosh Specialist Registrar, Vascular Surgery Miss T Walker Specialist Registrar, Student Judges Miss E Hill Miss F Liuzzi Mr R Salisbury Miss B Vadhwana

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SPONSORS

PROGRAMME 08:30

Registration

09:00

Presidential greetings Miss E Hill, President of Scalpel, Prof DA McGrouther

09:30

Oral presentations (AM) Session A: Research presentations Judges: Prof DA McGrouther (Chair), Miss S Kalipershad, Mr O Keenan 09:30

Surgical safety teaching within UK medical schools, AS Bates

09:40

Blood Pressure and Renal Cytokines Improve in Morbidly Obese Patients After Bariatric Surgery, SS Dubb

09:50

Validation of a global rating scale for shoulder arthroscopy: A pilot study, AC Hoyle

10:00

A pre-procedure team rehearsal may significantly improve safety and efficiency during minimally-invasive vascular intervention, A Morbi

10:10

Clinical audit of factors of early graft failure and mortality in pancreas transplant recipients at Manchester Royal Infirmary, HN Zakaria

Session B: Audit presentations Judges: Miss J Walls (Chair), Mr R Craigie, Miss E Hill 09:30

Has the outcome for distal femoral fractures improved following the introduction of locking plate fixation? C Ashton

09:40

The Perioperative Management of Emergency Laparotomy at CMFT, J Barnett

09:50

Audit into Analgesia for Palatal-Facial Surgery in Royal Manchester Children's Hospital, C Cameron

10:00

The Burden of Periprosthetic Infection Following Hip and Knee Arthroplasty, S Choi

10:10

An Audit Into The Management of Melanoma (2007-2008) in Royal Preston Hospital, MH Damanhuri

10:20

Brain Tumour Management: Has a shift from inpatient to outpatient services led to an improvement in patient satisfaction and care? C Newark

Session C: Case presentations Judges: Mr M Jones, Miss F Liuzzi 09:30

Auditory Brainstem Implant for cochlear nerve atresia, M Dowling

09:40

Bilateral Comminuted Calcaneal Fractures followed by Below Knee Amputations – A Case Study, G King

09:50

A challenging cerebrospinal fluid leak, A Li Ching Ng

10:00

The Use of Clonidine and Probiotics in the Post-Operative Treatment of Paediatric Short Bowel Patients, KM Sun

10:10

Cauda equina syndrome: A complicated case, R Wu

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Session D: Research presentations Judges: Mr J Holland, Mr J Ghosh, Miss B Vadhwana

10:30

09:30

Nutritional Status following Total Oesophagogastric Dissociation Surgery for Gastroesophageal Reflux Disease in Neurologically Impaired Children, T Chasma

09:40

Study of referral patterns of patients with metastatic colorectal cancer, N Grimes

09:50

Is the Recurrence of Dupuytren‟s Disease following Fasciectomy due to Mesenchymal Stem Cells in Palmar Skin and Fat? C Manning

10:00

A Novel Role of Toll-Like Receptor-3 in Vascular Surgery, A Mitra

10:10

The Microbiology of Prosthetic Joint Infection at the Avon Orthopaedic Centre, L O’Kane

10:20

Muscle-derived stromal cells promote fracture repair by migrating to the site of injury, S Parker

Keynote lecture – climate change Dr David Pencheon, Director of NHS Sustainable Development Unit England

11:15

Wayside Houses of Ill-Fame Professor H Ellis CBE FRCS, Emeritus Professor of Surgery, University of London

12:00

Group 1: Lunch Group 2: Workshops

13:00

Group 1: Workshops Group 2: Lunch

14:00

Oral Presentations (PM) Session A: Research presentations Judges: Prof DA McGrouther (Chair), Miss S Kalipershad, Mr O Keenan

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14:00

A patient derived outcome study following surgical excision of Morton‟s Neuroma of the foot, M Ciapryna

14:10

Rib fractures of immature bone: a histological, mechanical and finite element analysis study , T Howard

14:20

Local control and survival in 21 sacral chordomas treated with resection and/or adjuvant radiotherapy, J Lim Beng Teck

14:30

Evaluating systemic stress response in single port vs. multi-port laparoscopic cholecystectomy, CGC McGregor

14:40

Investigating HMGB1 as a potential inflammatory mediator in brain death induced lung damage, A Vallance

Session B: Pre-clinical presentations Judges: Miss J Walls (Chair), Mr R Craigie, Miss E Hill 14:00

Laparoscopic Surgery- the Gift that Keeps On Giving, K Chapman

14:10

Lister's Legacy, S Guthrie

14:20

Andreas Vesalius and the dignity of dissection and anatomical teaching, JR Hamill

14:30

No Laughing Matter, MSN Kumar

14:40

Scar-free Surgery: Natural Orifice Transluminal Endoscopic Surgery (NOTES), LED Murchison

14:50

The life and work of John Hunter (1728-1793) was the greatest advancement in surgery in the past 500 years, K Walsh

Session C: Case presentations Judges: Mr M Jones, Miss F Liuzzi 14:00

Worms in the Brain! S Al-Himdani

14:10

A Rare Case of Growing Abdominal Distension, J Farikullah

14:20

A case of extradural schwannoma of the cervical spinal cord with large soft tissue component, C Geehan

14:30

An unusual metastasis of a transglottic squamous cell carcinoma to the forearm, RM Kwasnicki

14:40

Mitchondrial Disorders. Case report of a patient with Mitochondrial Neuro-GastroIntestinal Encephalomyopathy Syndrome (MNGIES), L Magee

14:50

Acute compartment syndrome in a paediatric polytrauma patient, L Sidon

Session D: Research presentations Judges: Mr J Holland, Mr J Ghosh, Miss B Vadhwana 14:00

Sarcopenia in primary operable gastro-oesophageal cancer: prevalence and association with patient physiology, inflammatory status, and outcomes following resection, K Boussouara

14:10

The anatomy of the short head of biceps – not a tendon, J Crichton

14:20

Quality of Life following Autologous Gastrointestinal Reconstruction in children with Short Bowel Syndrome, H Edge

14:30

Why Knees Wear Out: Assessing the basic knee morphology of varus and valgus aligned individuals, R Kular

14:40

Blood Vessels In Healing Intervertebral Discs, I Sychev

15:00

Academic workshops

15:45

“Are men an endangered species in medicine?”

Professor A Mansfield CBE, Emeritus Professor of Vascular Surgery, Imperial College, President of the British Medical Association 2009-2010

16:30

Poster presentations and refreshments

17:30

Close of day programme

18:30

Dinner and prize-giving ceremony

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PRACTICAL WORKSHOPS Basic Surgical Skills Doctors Academy This workshop is aimed at students with little prior surgical experience. Using pig‟s trotters and chicken thighs, participants will learn how to perform simple suturing and knot tying. This will provide excellent preparation for future surgical attachments.

Intermediate Surgical Skills Doctors Academy This workshop is aimed at students with some previous surgical experience. Using pig‟s trotter and chicken thighs, participants will be taught more complex suturing skills, such as mattress suturing and subcuticular suturing.

Advanced Surgical Skills Doctors Academy This workshop is aimed at students with some previous surgical experience. Using pig‟s trotters and chicken thighs, participants will learn skills involved in performing tendon repair and wound debridement.

Surgical Emergencies Casualty This workshop involves a rotating group of surgical emergency scenarios including major abdominal trauma, head injury, lower limb trauma and burns. Students will have a chance to actively participate in these „real-life‟ scenes.

ACADEMIC WORKSHOPS CV Building Clinic Mr P Sutton This workshop will give students the opportunity to have one-on-one critical appraisal of their CV‟s.

Publish or Perish? Should all Surgeons do Research?

Prof GA McGrouther, Prof M Baguneid, Mr N Boxall (Chair) A lively and interactive debate between two eminent surgeons on whether research is a necessity for surgical trainees in this highly-competitive vocation.

Surgical Question Time Miss J Walls, Miss S Kalipershad, Mr J Giles An interesting question and answer session on the challenges of flexible working, working abroad and maintaining an adequate work-life balance in surgery.

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SPEAKER BIOGRAPHIES Prof Harold Ellis– Speaker Professor Harold Ellis CBE FRCS is an Emeritus Professor of Surgery at the University of London and currently works as a Professor of Anatomy at King‟s College London. He has been working in the NHS since its inception in 1948 after graduating from the University of Oxford. Professor Ellis undertook work in the Royal Army Medical Corps between 1950-51 before training in London as a surgical registrar.

Professor Ellis is one of the most notable British surgeons of the past half century, renowned for his inspiring lectures and as the author of the student anatomy textbook, Clinical Anatomy. He has also served as Vice-President for the Royal College of Surgeons of England and of the Royal Society of Medicine, as well as being president of the British Association of Surgical Oncology.

Prof Averil Mansfield– Speaker Professor Averil Mansfield is a graduate of Liverpool University and was formerly Consultant General Surgeon at The Royal Liverpool Hospital.

She developed a particular interest in Vascular Surgery as a house surgeon working for Mr Edgar Parry and when she moved to London she specialised exclusively in Vascular Surgery. In her post as Consultant Surgeon at St Mary‟s she continued to have an interest in stroke prevention and aneurysm surgery especially those that extended into the chest.

She became an examiner for the FRCS at The Royal College of Surgeons of England and later became a member of that College‟s Council and went on to become Vice President. She has been President of The Association of Surgeons of Great Britain and Ireland and of The Vascular Surgical Society and of the Section of Surgery of The Royal Society of Medicine.

In a change of direction she became Director of The Academic Surgical Unit and Professor of Vascular Surgery at St Mary‟s/Imperial College in 1993. In retirement from clinical work she was appointed the Chairman of The Stroke Association from 2003 to 2008. She was President of the BMA from 2009-2010.

Dr David Pencheon– Keynote Speaker Previously, Director of the NHS Eastern Region Public Health Observatory from 2001 to 2007, serving the East of England. He has worked as joint Director of Public Health, a Public Health Training Programme Director in the East of England, with the NHS R&D programme, and in China in the early 1990s with Save the Children Fund (UK). Prior to that he was a clinician in secondary care.

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ABSTRACTS Oral presentations -Research A01 Surgical safety teaching within UK medical schools Bates AS (University of Bristol), Davis C & Cole M Background: Surgical safety is a global health issue, with the majority of in-hospital adverse events occurring in the operating theatre. Surgical errors result in patient mortality, morbidity and malpractice suits. In order to create a safe generation of surgeons, undergraduate training in surgical safety is essential. This national study quantified teaching of surgical safety in medical schools in the United Kingdom.

Purpose: To investigate patient safety education in UK medical school curricula.

Methods: All medical schools (n=32) were invited to complete a questionnaire through their University Surgical Society representative affiliated with the Royal College of Surgeons of England (RCS). The questionnaire quantified whether the surgical safety components of three national documents were taught to their medical students: The WHO (World Health Organisation) Surgical safety Checklist, WHO Guidelines for Safe Surgery 2009 and The Principles of the Productive Operating Theatre.

Results: 23 universities responded (72%). The three documents were formally taught by 17.4% of UK medical schools. Individual components of the documents were taught in greater frequency, with 53.8% of the WHO Guidelines for Safe Surgery 2009 and 43.5% of the WHO Surgical Safety Checklist being taught. University curricula were responsible for significantly more surgical safety teaching compare to surgical societies (P<0.001).

Conclusion: Surgical safety teaching is absent from the majority of medical curricula and surgical societies. In order to create a surgically safe future, more emphasis should be placed on patient safety within undergraduate medical education.

A02 Sarcopenia in primary operable gastro-oesophageal cancer: prevalence and association with patient physiology, inflammatory status, and outcomes following resection Boussouara K (University of Glasgow), Dutta S & McMillan D Background: Gastro-oesophageal cancer is the commonest cause of cancer death worldwide. Comorbidity and the presence of a systemic inflammatory response, which is hypothesised to play a significant role in the development of cancer cachexia, are known to adversely impact survival following potentially curative resection.

Purpose: This study examined the prevalence of sarcopenia (a feature of cachexia whereby muscle mass is progressively lost) in primary operable gastro-oesophageal cancer patients and investigated the association with patient physiology, comorbidity, the systemic inflammatory response, and outcomes.

Study Design: 76 patients who underwent potentially curative resection at the Glasgow Royal Infirmary were included within the study. Staging CT scans were analysed using sliceOmatic image software [Tomovision Inc] to quantify skeletal muscle. Sarcopenia was defined using Baumgartnerâ&#x20AC;&#x;s criteria. Patient physiology was assessed using POSSUM, comorbidity using the Charlson Comorbidity Index (CCI), and systemic inflammation using the Glasgow Prognostic Score (GPS). Outcomes studied were postoperative complications (within 30 days) and survival time.

Results: Sarcopenia was identified in 46 patients (54%). Sarcopenia was associated with increasing T stage (p<0.1) but this was not significant. Sarcopenia was not associated with physiological POSSUM, comorbidity, inflammatory status, or complications within 30 days. No survival difference was shown between the sarcopenic (23.2 months) and non-sarcopenic (23.3 months) groups.

Conclusions: Sarcopenia is prevalent in patients with primary operable gastro-oesophageal cancer, but does not appear to impact on survival in this group. Future research should investigate the differential impact of sarcopenia across different cancers and patient groups (e.g. palliative vs curative).

A03 Nutritional Status following Total Oesophagogastric Dissociation Surgery for Gastroesophageal Reflux Disease in Neurologically Impaired Children Chasma T (University of Manchester), Morabito A & Kauffmann L Background: Neurologically impaired (NI) children with severe gastroesophageal reflux disease (GORD) commonly experience poor weight gain and nutritional difficulties. However, accurate assessment of nutritional status in this cohort is challenging due to physical abnormalities and altered body compositions, with the interpretation of measurements obtained involving comparison against charts developed from a healthy population. The propriety of this can be challenged.

Conventionally, fundoplication is the surgical treatment of choice for severe GORD. However, with high failure rates of 12% to 45% in those with NI, the alternative oesophagogastric dissociation (OGD) procedure is increasingly being considered as a primary treatment option.

Purpose: Following a review of available methods to accurately assess adequate nutrition, this study aims to assess the impact of the OGD procedure on nutritional status in NI children with GORD, using weight-for-age values.

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Method: Between 1996 and 2008, 43 patients underwent OGD. Weight values at operation, 6 months and 12 months postoperatively were elicited from medical records and statistically analysed.

Results: Nutritional status improved with the mean weight-for-age z score showing a statistically significant increase from -1.7 preoperatively to -1.1 at 6 months and -0.6 at 12 months after operation. (Wilcoxon signed rank P value < 0.05) Conclusion: Using weight-for-age values, we can conclude that OGD significantly improves nutritional status, supporting the use of this procedure as a primary treatment of choice for severe GORD in children with NI.

A04 A patient derived outcome study following surgical excision of Morton’s Neuroma of the foot Ciapryna MB (Brighton and Sussex Medical School), Palmer S & Alvey J Background: Morton‟s Neuroma is a proximal neuralgia affecting the web spaces of the toes that is currently definatively treated with surgery. Currently there is a lack of patient derived outcome studies for this intervention which we addressed with this research.

Methods: The validated Manchester Oxford Foot and Ankle Questionnaire (MOXFQ) was used to prospecitvely assess patientderived outcomes of surgery. Participants were asked to fill out the 16 item questionnaire prior to surgery and were then followed up after a minimum of 6 months post-operatively.

Results: The final cohort consisted of 19 feet from 17 participants (F=16, M=1) mean age 56 with 3 patients lost to follow up.

The mean reduction in the total MOXFQ score out of a possible maximum of 64 was significant (p=0.001). The pre-surgical mean score was 38.1 (95% confidence interval = 33.4 - 42.8) and after a mean follow up period of 20 months was 13.1 (95% confidence interval = 7.5 – 18.6). The reductions observed in the three metric scores of pain, walking and social were all significant (p=0.005, p=0.008, p=0.006 respectively). 84% of patients in the study experienced a clinically significantly improved pain domain, 95% in the walking domain and 58% in the social domain of the MOXFQ. Conclusions: This study has shown that surgical excision is an effective intervention for treating Morton‟s interdigital Neuroma of the foot with good outcomes in the pain metric and walking metric. However patient derived social outcomes were slightly more modest than those for walking and pain.

A05 The anatomy of the short head of biceps – not a tendon Crichton J (University of Manchester) & Funk L Background: The short head of biceps brachii has been the subject of little investigation when compared to the long head or distal biceps tendons. The aim of this study was to dissect and describe the origin and proximal portion of the short head of biceps brachii.

Materials and Methods: Three left and two right (n=5) fresh-frozen human cadaver shoulders were dissected and the proximal short head was measured and photographed.

Results: The origin of the short head of biceps consisted of muscle fibres attaching directly to the tip of the coracoid process, with a thin, tendinous aponeurosis covering its anterior surface, rather than a true tendon as previously described.

Conclusion: The short head of biceps does not attach to the coracoid process via a true tendon. These findings have implications for procedures that utilise the short head of biceps.

A06 Blood Pressure and Renal Cytokines Improve in Morbidly Obese Patients After Bariatric Surgery Dubb SS (Imperial College London), Bueter M, Gill A, Joannou L, Ahmed AR, Tam FWK, Frankel AH & Le Roux CW Introduction: Obesity related glomerulopathy (ORG) is an emerging epidemic and contributing factor to the burden of chronic kidney disease (CKD). The pathophysiology of ORG is poorly understood. We hypothesised that metabolic related inflammatory cytokines (monocyte chemotactic protein 1 (MCP-1), macrophage migration inhibitory factor (MIF) and chemokine (C-C motif) ligand 18 (CCL-18) and 15 (CCL-15 as a non-metabolic control cytokine) are associated with ORG and measured changes in these cytokines in bariatric surgery patients.

Methods: Blood pressure was measured and urine and blood samples collected from 34 morbidly obese patients before and 4 weeks after bariatric surgery. Biochemical parameters measured included serum creatinine, albumin, cholesterol, C-reactive protein (CRP), urine albumin and creatinine. Glomerular filtration rate (GFR) was calculated by the Cockcroft-Gault formula (CCG). Urinary levels of the aforementioned chemokines were measured using ELISA. Results: Systolic blood pressure decreased from 142.9±3.22 to 128.1±2.12 mmHg (p<0.001) and diastolic blood pressure decreased from 87.1±1.47 to 79.2±1.11 mmHg (p<0.001) postoperatively (p<0.001). Serum creatinine decreased from 73.6±2.01 to 68.1±1.67 umol/L postoperatively (p<0.05). The inflammatory status of the patients improved with reduction of serum CRP (25.2±4.36 to 8.08±1.14 mg/L, p<0.001). Furthermore urinary MIF (203.1±26.6 to 90.4±12.1 ng/mmol Cr, p<0.001), MCP-1 (26.1±2.6 to 16.7±2.3 ng/mmol, p<0.001), CCL-18 (96.8±29.2 to 22.0±7.5 ng/mmol Cr, p<0.05) were reduced. CCL-15 did not change.

Conclusion: This study demonstrates the early effects of surgically-induced weight loss upon blood pressure and urinary inflammatory cytokines. The relationship of these cytokine changes to the pathogenesis of ORG may identify interventions that halt progression of CKD from ORG.

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A07 Quality of Life following Autologous Gastrointestinal Reconstruction in children with Short Bowel Syndrome Edge H (University of Manchester), & Morabito A Background: Short Bowel Syndrome (SBS) describes the malabsorptive state seen following significant bowel loss. Surgical options such as Autologous Gastrointestinal Reconstruction (AGIR) attempt to reduce the requirement for nutritional supplementation and with natural intestinal adaptation, restore enteral autonomy. Literature on AGIR has focused on objective measurements of its success but of importance to the patient and their caregivers is the quality of life (QoL) they can expect post-surgery which to date, has remained inadequately assessed.

Purpose: To determine the impact of AGIR on the physical condition and QoL of patients as perceived by caregivers.

Methods: Caregivers were asked to complete a validated questionnaire to assess their satisfaction with AGIR and the pre- and post-operative daily care, medical needs and QoL of their child. Data was analyzed using Friedman‟s non-parametric test and Friedman‟s 2-way ANOVA by rank. Statistical significance was set at ≤ 0.05.

Results: Parents were satisfied with the procedure and following surgery saw a significant improvement in their child‟s physical condition and bowel habit with a reduction in their medical requirements. They also felt that following surgery they saw improvements in their own and their child‟s QoL with associated improvements in aspects of their relationship with their child.

Parents also rated themselves as feeling more optimistic about the future of their child and themselves following AGIR. Conclusion: This study concludes that as perceived by parents, AGIR improves the physical wellbeing of children with SBS and offers a better QoL for both child and caregiver.

A08 Study of referral patterns of patients with metastatic colorectal cancer Grimes N (University of Liverpool) & Malik H Background: The criteria defining eligibility for resection of hepatic metastases in colorectal cancer have undergone dramatic change over the past decade due to advances in both surgical techniques and therapies available. NICE guidance states that patients with metastatic colorectal cancer should be managed by a hepatobiliary multi-disciplinary team (MDT), yet there are times when these patients are referred for palliative treatment without being reviewed by a hepatobiliary MDT Aim: To determine if, in those patients referred for palliative chemotherapy by a colorectal MDT without first being reviewed by a hepatobiliary MDT, were any potentially resectable.

Method: The regional oncology unit was contacted to gain a list of patients with metastatic colorectal cancer treated with palliative intent in 2009. The radiology reports and scans of these patients were then reviewed by a hepatobiliary surgeon who decided whether or not the patient would have been amenable to resection.

Results: Seventy two patients were identified. Fourteen had been reviewed by the hepatobiliary MDT and so were excluded.

Patients with widespread disease were also excluded. Forty four patients had either liver-only or liver-predominant disease – eighteen (40.9%) were potentially resectable at presentation while a further thirteen (29.5%) may have been resectable following downsizing chemotherapy. Only thirteen patients (29.5%) were considered unresectable at presentation.

Conclusion: Decisions made by colorectal MDTs may result in patients being inappropriately referred for palliative chemotherapy when they may have been candidates for resection with curative intent. Reviewal by a hepatobiliary MDT is essential for all patients with liver-only or liver-predominant disease.

A09 Rib fractures of immature bone: a histological, mechanical and finite element analysis study Howard T (University of Manchester), Johnson M, Mummery P & Freemont T Rib fractures in infants are an uncommon but very important finding since the presence of a rib fracture is highly suggestive of non-accidental injury (NAI) and is associated with a significant mortality rate. Orthopaedic surgeons are in a good position to identify such cases. Although much research on the mechanical properties of bone has been carried out, there is a distinct paucity of data on the biomechanical failure of juvenile ribs. The aim of this study was to present a methodological approach to characterise the failure of juvenile ribs.

To determine the bulk properties of immature ribs, we mechanically tested 26 whole bovine ribs, and eleven 5mm sections of rib from three animals aged between 16-18 weeks in uniaxial anterior-posterior loading at slow rates.

Scanning electron microscopy and optical microscopy of the fracture surface confirmed the appearance of a tough fractureresistant material. The morphological pattern of failure was assessed histologically in 21 cases.

Nanoindentation was carried out to generate data for the mechanical properties of immature bone producing a Young‟s modulus of 14.3GPa. Tomography was performed using a HMX-ST CT 225 X-ray micro tomography scanner from Metris X-Tek Sysytems Ltd, capable of -destructively characterize the fully spatial 3D architecture of bone. We imaged four whole ribs and three 5mm sections, which subsequently underwent mechanical testing. The tomographic data was reconstructed -static dynamic testing was performed on our finite element models and a good correlation was found between our models and the mechanical data. Additionally, FE analysis has allowed us to determine peak stresses as a function of position to better understand the fracture behaviour.

Further work is planned on our validated FE models to characterize the biomechanical failure of ribs at higher strain rates.

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A10 Validation of a global rating scale for shoulder arthroscopy: A pilot study Hoyle AC (University of Manchester) & Funk L Background: Reliable, valid, feasible and objective assessment is desirable in all aspects of medical training, to monitor progress and ensure high standards. At present, no assessment model for shoulder arthroscopy exists which indisputably meets these criteria. The global rating scale (GRS) has been validated as a measure of technical performance in various surgical procedures.

Purpose: This pilot study describes an online, remotely assessed global rating scale for shoulder arthroscopy (GRSSA) and aims to demonstrate its potential as an assessment tool as per the Intercollegiate Surgical Curriculum Programme (ISCP) assessment framework.

Materials and Methods: Thirteen shoulder surgeons using the GRSSA rated ten videos of diagnostic shoulder arthroscopy showing different levels of proficiency. Assessments were performed remotely using an online system developed for the study; assessors were blinded to the experience of the surgeon performing the arthroscopy. Construct validity was assessed via Cronbach‟s alpha, and inter-rater reliability was assessed via two-way ANOVA. Results: Results suggest good construct validity (high internal consistency of GRSSA categories – Cronbach‟s alpha = 0.89-0.96).

Two-way ANOVA demonstrated a good discriminatory ability of the GRSSA, but variability between raters (P=0.0002–0.01), suggesting a current lack of inter-rater reliability.

Conclusions: The online format of the GRSSA allows for remote assessment by multiple blinded assessors. The GRSSA appears to be a valid and feasible method for the assessment of diagnostic arthroscopic skills, meriting further research to demonstrate inter-rater reliability.

A11 Why Knees Wear Out: Assessing the basic knee morphology of varus and valgus aligned individuals Kular R (University of Manchester) & Cobb JP Background: Knee osteoarthritis has an extremely high prevalence worldwide, yet information identifying who is most susceptible to the disease is rather limited. Studies looking into the effect of knee joint malalignment concur that varus and valgus alignment contribute to medial and lateral compartment disease respectively. However whether differences in the underlying basic knee shape contribute to the incidence of knee osteoarthritis is unknown.

Aims: The research objectives were to i) assess the key features of the knee ii) compare these features between varus and valgus aligned individuals.

Method: Pre-operative computed topography scans of varus and valgus patients undergoing unicompartmental knee arthroplasty were used. Both femoral and tibial components were measured by fitting the various aspects to predetermined shapes in 3D modelling software. Importantly, a frame of reference was used for accurate and repeatable alignment and orientation of the femur and tibia Results: The results show a significant difference between the two groups in the size of the medial extension facet of the femur.

The varus group recorded a mean radius of 37mm and the valgus a mean of 33mm (p value 0.001).

No significant difference was achieved between the other components measured.

Conclusion: This novel research, highlighting the difference in size of the medial femoral extension facet, suggests an important variation in the underlying knee morphology which may help understand why some individuals develop knee osteoarthritis and yet those with similar risk factors do not. Furthermore, it may help in understanding the disease process and identifying high risk individuals.

A12 Local control and survival in 21 sacral chordomas treated with resection and/or adjuvant radiotherapy Lim Beng Teck J (University of Glasgow), Sharma H, Reid R & Reece AT Background: Sacro-coccygeal chordomas are locally aggressive tumours which originate from ectopic remnants of the primitive notochord. They often present late as a large mass with soft-tissue extensions, making it difficult to achieve adequate resection margins. Although these tumours infrequently present with metastases, they have a high rate of local recurrence. There is an uncertainty regarding the effectiveness of adjuvant treatment. But patients who undergo wide en-bloc resections often manage better than those who undergo intralesional resections.

Purpose: A case series of 21 patients was used to analyse predictors of local control and survival.

Methods: The treatment and outcomes of 21 patients obtained from the Scottish Bone Tumour Registry were retrospectively reviewed.

Results: Lower back pain was the main presenting symptom in most patients. The average age at which biopsy was carried out was 59 years. Surgical treatments include two intralesional resections (both recurred), nine marginal resections (4 recurred) and three wide resections (1 recurred). Fifteen of the twenty-one patients were treated with adjuvant radiation therapy. In seven patients, the Chordomas were inoperable and all except one were treated with adjuvant radiotherapy. Local recurrence and metastases occurred in 7 (50%) and 5 (23.8%) patients. The 5-year and 10-year survival were 38% and 14.2% respectively.

Conclusions: Wide resection combined with post-operative adjuvant radiotherapy provided the most satisfactory results. Local recurrence presents as a major problem in the management of sacral chordomas (50%). Intralesional resection should be avoided as it is associated with 100% local recurrence in our series.

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A13 Is the Recurrence of Dupuytren’s Disease following Fasciectomy due to Mesenchymal Stem Cells in Palmar Skin and Fat? Manning C (University of Manchester) & Bayat A Background: Dupuytren‟s Disease (DD) is a common fibroproliferative disorder characterized by progressive, permanent digital contracture. Unfortunately the mechanisms that initiate DD and lead to its recurrence following surgery are poorly understood. A key cellular component in DD is the myofibroblast; however, the origin of the myofibroblast in DD has not been identified.

Mesenchymal Stem Cells (MSC) are potentially the source of myofibroblasts in DD. Purpose: To identify and profile MSCs from the Cord, Nodule, Skin-overlying Nodule (SON) and Peri-Nodular-Fat (PNF) in DD patients.

Methods: The profile of cells from cord, nodule, skin-overlying nodule (SON) and peri-nodular fat (PNF) was determined.

Fluorescence Activated Cell Sorting (FACS) analysis identified the expression of established MSC markers (CD34, CD73, CD90, CD105), quantitative Polymerase Chain Reaction (qPCR) to compare the gene expression profiles, Differentiation Assay to assess the ability of the cells to differentiate to three mesenchymal lineages, and Immunohistochemistry (IHC) to confirm phenotypic surface markers. 24 DD patients and 14 Carpal Tunnel patients for control tissue were enrolled in the study Results: CD34+CD73+CD90+CD105+ cells are expressed more highly in Cord, Nodule, SON and PNF (P<0.05) and show a greater ability to differentiate to 3 mesenchymal lineages than control. 3 stem cell markers (SCF, OSF-1 and CXCR4) were increased in SON and PNF (P<0.05).

Conclusion: The increased presence of MSC-like cells in DD cord, nodule and palmar skin and fat implicates MSCs in DD pathogenesis. There is a potential role for therapies targeting this cell population to prevent recurrence following surgery.

A14 Evaluating systemic stress response in single port vs. multi-port laparoscopic cholecystectomy McGregor CGC (Imperial College London), Sodergren MH, Aslanyan A, Wright VJ, Purkayastha S, Darzi A & Paraskeva P Background & Aims: Acute phase proteins, as well as inflammatory cytokines mediate a measurable response to surgical trauma.

The magnitude of this response is proportional to the extent of tissue injury and correlates with post-operative outcome. Single incision laparoscopic surgery is a novel technique aiming to minimise the extent of surgical trauma. By comparing systemic stress following multi-port (LC) and single incision laparoscopic cholecystectomy (SILC) we aim to determine whether reduced incision size results in a reduced stress response.

Methods: Thirty-five consecutive patients were included, 11 underwent SILC (mean ±SEM; age 44.8 ±3.88 yrs; BMI 27 ±1.44 kg/m2) and 24 underwent LC (56.17 ±2.80 yrs; 31.72 ±1.07 kg/m2, p<0.05). Primary endpoint measures included interleukin-6, tumour necrosis factor-α, C-reactive protein and white cell count measured pre- and post-operatively. Length of stay (LOS) and postoperative morbidity were secondary endpoints.

Results: No significant difference was found between SILC and LC in interleukin-6, tumour necrosis factor-α, C-reactive protein, white cell count, LOS and duration of surgery. There was no correlation between systemic stress response and operative parameters. There were no intra-operative complications.

Conclusion: SILC appears to be a safe, feasible technique with potential advantages of cosmesis, reduced incisional pain and well-being recommending its use. These data indicate no difference in systemic stress and morbidity between SILC and LC. A larger, multi-centred, randomised prospective trial is warranted to further investigate and confirm this finding.

A15 A Novel Role of Toll-Like Receptor-3 in Vascular Surgery Mitra A (Imperial College London), Cole J & Monaco C Background: In-stent restenosis remains the primary complication of percutaneous vascular interventions. Neointimal hyperplasia is characterised by profuse smooth muscle cell hyperplasia and represents the main feature of restenosis. Innate immune mechanisms are implicated in the pathogenesis of inflammatory vasculopathies. Toll-like receptor-3 is ubiquitously expressed in the vasculature and is a critical regulator of arterial inflammation.

Objectives: To elucidate the role of TLR3 on neointimal hyperplasia. To determine the effects of TLR3 stimulation on proinflammatory gene expression in vascular and lymphoid tissues.

Methods: A perivascular collar was fitted to the left carotid artery in TLR3-/- and C57BL/6 mice to initiate lesion formation.

250μg of the synthetic TLR3 ligand polyI:C or vehicle was administered intraperitoneally for 3 weeks. Quantification of lesion development was performed on collar-treated and contralateral carotid histological images. Expression levels of TLR3, CCL2, CCL5, VCAM1, IFN-β and A20 were quantified using real-time PCR in vascular and secondary lymphoid tissues.

Results: A significant reduction in neointima formation was observed in polyI:C stimulated C57BL/6 mice compared to vehicle (p=0.02). This effect was abolished in TLR3-/- mice. Chronic TLR3 stimulation induced a selective upregulation of TLR3 (p=0.003), CCL5 (p=0.001) and CCL2 (p=0.005) in the aorta but not in lymphoid tissues.

Discussion: TLR3 is protective against neointimal hyperplasia. TLR3 revealed a potent selectivity for proinflammatory gene induction in vascular tissues. A novel therapeutic role of using TLR3 agonists to prevent the pathological phenomenon of in-stent restenosis is demonstrated.

Conclusion: This study illustrates two distinct facets of TLR3 activation on vascular biology.

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A16 A pre-procedure team rehearsal may significantly improve safety and efficiency during minimally-invasive vascular intervention Morbi A (Imperial College London), Riga C, Hamady M, Kashef E, Pearch B, Cheshire N & Bicknell C Introduction: Healthcare errors, particularly during invasive intervention, can cause harm. We aimed to determine the type and frequency of events for the first time, in vascular interventional radiology (VIR) and to design and implement an intervention, to improve efficiency and safety.

Methods: An observer recorded field notes during VIR procedures, over a 5-week period (n=55). Two blinded assessors judged whether field notes were events. Events were categorized into errors, using a 22-part classification system and graded (1-5) in severity for delay and safety (potential to cause harm). The preventability of events was assessed. A pre-procedure team rehearsal (PPTR) was designed and implemented to target the frequent, preventable events identified. Data was collected for a further 5 weeks (n=33) and analysed, to determine the efficacy of the PPTR. Results: Pre-intervention (n=55), 1197 events were recorded; 51.1% were judged to be preventable. Each was classified into ≥1 of 22 error-types, resulting in 2040 errors. Communication (11.2%), staff absence (16.2%), planning (19.7%), equipment unavailability (12.2%) and safety consciousness (6.1%) were the most frequent errors. Mean delay was 1.9/5 and mean safety score was 1.7/5. Post-intervention (n=33), 352 events were recorded. Classification resulted in 477 errors. Mean delay was 1.7/5 and mean safety score was 1.5/5. Events/hr decreased from 18.8 to 9.2 (p<0.001), a 51.1% reduction, with decreases in delay (57.9%) and safety scores (56.8%) per hour. Preventable events decreased from 51.1% to 31.3% (p<0.001).

Conclusions: A PPTR can reduce the frequency of events in VIR, reducing delays and the potential for harm, thus improving safety and efficiency.

A17 The Microbiology of Prosthetic Joint Infection at the Avon Orthopaedic Centre O’Kane L (University of Bristol), Webb J, Brunton L & Murphy T Prosthetic Joint Infection is a serious complication of arthroplasty, affecting up to 2.5% within England and Wales. This represents a unique challenge due to biofilm formation upon the prosthesis, protecting microorganisms from antibiotic treatment and the host‟s defences. Establishing effective antibiotic treatment is therefore extremely valuable. As the population ages and arthroplasty becomes more commonplace, the management of its complications is increasingly relevant.

This audit aims to establish the most common causative organisms; hence ascertaining the most effective antibiotic combination for use within loaded cement at the time of revision surgery for prosthetic joint infection. This allows the development of a “blind shot” treatment. As there is a five day interval between obtaining tissue samples and ascertaining their microbiology, it is essential to develop the antibiotic combination most likely to tackle the infection. The microorganisms and their sensitivities were identified for patients who underwent hip arthroplasty between January 2006 and March 2010 within the Avon Orthopaedic Centre. In total, 71 patients‟ microbiology records were analyzed.

Coagulase Negative Staphylococcus was the most commonly isolated organism within the population (42%), followed by Staphylococcus aureus (25%). Vancomycin was shown to have a 100% sensitivity rate, and sensitivities to all antibiotics tested were shown to have decreased since a similar study within the same centre between 2001 and 2003. In particular, methicillin resistance was shown to have decreased from 49% to 35% overall. From these results, the most effective “blind shot” treatment was shown to be Vancomycin in combination with Gentamicin.

A18 Muscle-derived stromal cells promote fracture repair by migrating to the site of injury Parker S (Imperial College London) & Horwood N Introduction: Fracture repair is initiated by the early inflammatory response that mediates the recruitment and differentiation of local osteoprogenitors. It has recently been suggested that muscle-derived stromal cells (MDSCs), as well as the widely studied mesenchymal stem cell (MSC), contribute to the osteoblast population, but the factors governing their recruitment toward the fracture site are yet to be elucidated. We hypothesise that MDSC populations will migrate towards an in vitro inflammatory stimulus similar to that of the fracture environment. We aim to indentify the key factors responsible for mediating their migration.

Methods: MSC and MDSC migration assays were performed through 8µm transwells towards fracture supernatant, inflammatory macrophages, exogenous chemokines, and monocytes in the presence of antibody to selected chemokines. MSC and MDSC chemokine receptor expression was ascertained using RT-PCR. Results: Both MSCs and MDSCs demonstrated significant migration towards fracture supernatant (p≤0.005), as well as GM-CSF and M-CSF differentiated macrophages. RT-PCR highlighted MSC and MDSC expression of a wide range of chemokine receptors, and both cell types demonstrated significant migration towards CXCL12 (SDF-1) and PDGF. Migration assays towards fracture supernatant and monocytes in the presence of neutralising-antibodies confirmed the importance of these chemokines, as well as highlighting CCL4 and CXCL5 as having chemoattractant activity.

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Conclusion: Our data demonstrate that both MSCs and MDSCs migrate towards an in vitro inflammatory stimulus, with specific identification of the activity of CCL4, CXCL5, CXCL12 and PDGF. These represent the first demonstration of MDSC migration towards the fracture environment, implicating their potential for novel therapeutic strategies.

A19 Blood Vessels In Healing Intervertebral Discs Sychev I (University of Bristol), Stefanakis M & Adams M Background: Experimental evidence suggests that intervertebral discs may cause severe and chronic back pain.

Neovascularisation is an important feature of healing. Fissures are thought to provide a pathway for blood vessel ingrowth into the normally avascular disc. Nerves follow blood vessel ingrowth. Sensitisation of the accompanying nerves can explain persistent back pain.

Purpose: To study if painful discs have more, deeper ingrowing blood vessels, which are never found away from fissures.

Methods: 22 discs from patients with discogenic back pain and 16 control discs from scoliotic patients were investigated using immunohistochemistry for an endothelial cell marker- CD31. Blood vessel ingrowth and number were quantified using light microscopy. Discs were graded histologically using simple H&E histology.

Results: 70% of experimental and 44% of control discs had blood vessels. Painful discs had significantly more blood vessels than controls. There was no difference in blood vessel ingrowth distance between groups. Blood vessels not associated with fissures were seen in both groups.

Conclusion: The finding that painful discs had more blood vessels than controls suggests an important role for blood vessel density in the pathogenesis of back pain. Presence of blood vessels away from fissures indicated that structural disruption is not always necessary for ingrowth. Blood vessel ingrowth into the disc could be facilitated by factors such as altered stress concentrations within the disc, leading to low hydrostatic pressure, which may not be sufficient to collapse hollow capillaries, and loss of proteoglycans from the disc matrix, creating ideal conditions of low pressure for ingrowth.

A20 Investigating HMGB1 as a potential inflammatory mediator in brain death induced lung damage Vallance AE (Newcastle University), Fisher AJ & Walden HR Donor lung inflammation which occurs following induction of brain death (BD) is associated with poor post-transplant outcomes.

Donor pre-conditioning with a toll like receptor (TLR) -4 ligand significantly ameliorates lung inflammation after BD suggesting ligation following BD contributes to donor lung inflammation. We hypothesised that the alarmin HMGB1, a known TLR-4 ligand, may act as an inflammatory mediator in BD induced lung injury.

Broncho-alveolar lavage (BAL), serum and lung tissue were retrieved from a rat model of BD and sham operated controls rats.

The HMGB1 concentration in the rat serum and BAL was measured by ELISA. Real-time PCR was used to assess HMGB1 mRNA expression in lung tissue following BD. HMGB1 immunolocalisation studies were performed on rat and human lung tissue from BD and non BD groups.

The BAL HMGB1 concentration was significantly higher in the BD group (965Âą302ng/ml) than the sham group (655Âą274ng/ml) (p=0.0172). There was no difference in HMGB1 gene expression. HMGB1 positive staining was dispersed throughout the rat and human lung at a greater density around the bronchioles. There was a significantly higher area of positive staining in BD than sham rat lung tissue (p=0.0345).

In conclusion, HMGB1 is likely to be released from cells in the lung suffering sustained damage during BD. As HMGB1 gene transcription is unchanged up to 5 hours following BD, lung tissue is most likely releasing presynthesised HMGB1. This study provides evidence of the presence of an alarmin which is likely to potentiate inflammation in the donor lung via the TLR-4 pathway.

A21 Clinical audit of factors of early graft failure and mortality in pancreas transplant recipients at Manchester Royal Infirmary Zakaria HN (University of Manchester), Augustine T & Tavakoli A Background: Pancreas transplantation is possibly the gold standard treatment for difficult type 1 diabetes mellitus. In our centre, we have experienced a high number of early graft failures especially within 30 days post-transplant. These outcomes were constantly reviewed and protocols and necessary changes were made in a view to improve this life-changing procedure.

Purpose: This audit aims to determine factors causing early pancreatic graft failure and mortality in our centre over a 9-year period (from 20 June 2001 till 20 June 2010).

Methods: We primarily focused on comparing 36 early graft failures within 30 days post-transplant to 74 pancreas transplant with uncomplicated outcomes. Factors analysed were recipient and donors demographics as well as surgical factors. We also evaluated the cause of early mortality in transplants recipients. We statistically analysed the patterns and differences found.

Results: Thrombosis was the main cause of early graft failure within 30 days post-transplant (P<0.001). This has been significantly reduced by the implementation of post-transplant heparin protocol (P=0.039). Simultaneous pancreas-kidney (SPK)

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transplantation have a lower rate of early graft failure (P=0.049). Factors which improve outcomes are younger donor age, lower donor BMI, fewer re-operations and surgical complications (less than two). Peripheral neuropathy increases the risk of early graft failure (P=0.002).

Conclusion: In conclusion, there are many factors that influence the outcome of pancreas transplantation with bleeding being the main cause of early mortality. We hope by highlighting and addressing these factors, future outcomes for pancreas transplants in our centre would significantly improve.

Oral presentations -Audit B01 Has the outcome for distal femoral fractures improved following the introduction of locking plate fixation?

Ashton C (University of Manchester) & Canty S Although the management of distal femoral fractures has evolved over many years they are still difficult to treat and there is little consensus on the most appropriate fixation method for particular situations.

This study aims to determine whether the outcome has improved following the introduction of locking plate fixation as opposed to intramedullary (IM) nailing for the surgical treatment of distal femoral fractures. It is also hoped that any factors that render one treatment more appropriate than the other will become apparent.

The records of 42 patients with 43 distal femoral fractures who had undergone IM nailing or locking plating over a 4-year period were reviewed retrospectively. Pre-operative, operative and post-operative information was obtained from in-patient notes and information regarding recovery and return to function was obtained from clinic letters in order to compare the outcome of the two groups following surgery. There were 20 fractures fixated by IM nailing and 23 fractures fixated by locking plating.

The results show that IM nailing is preferred when there is an ipsilateral total knee replacement. IM nailing more commonly resulted in implant failure than locking plating. It appears that locking plating may yield better outcomes but following a longer healing time than IM nailing. The data also suggests that certain pre-operative variables are important when considering which implant to use.

Despite the limitations of this study, the findings support the idea that there is no perfect fracture fixation method, but rather that certain fixation methods are superior in particular situations.

B02 The Perioperative Management of Emergency Laparotomy at CMFT Barnett J (University of Manchester) & Greer R Background: Urgent and emergency laparotomies are common with a higher mortality than elective procedures. In those over 65 years, there is a 44% mortality rate. It is important that sepsis is recognised and that patients are fluid resuscitated according to defined standards. Renal failure is a common complication within this patient group.

Purpose: To assess whether the perioperative management of emergency laparotomy at Central Manchester Foundation Trust follows current standards of evidence based practice.

Methods: Patients on the urgency theatre list who were listed for laparotomy were prospectively audited. The anaesthetic charts, operation notes, medical notes and nursing notes were the main data sources. The data was entered into an excel spreadsheet.

Results: A total of 37 patients were identified and ranged in age from 25 to 85 years. 67% of the patients had sepsis. The average pre-operative fluid intake was 4051 mL. 72% of patients were given antibiotics in the 24 hours before surgery and 94% at induction of anaesthesia. 33% of the population were classified in the RIFLE criteria.

Conclusion: The average fluid balance has increased from 2829 mL in 2009 to 4051 mL in 2010 which is an improvement in the care of these patients. Sepsis was only documented in half of cases which implies that it is under-diagnosed. This report suggests a system to identify SIRS in the surgical assessment notes. There were a large number of cases at risk of acute kidney injury; this should be screened for using the RIFLE criteria on the wards.

B03 Audit into Analgesia for Palatal-Facial Surgery in Royal Manchester Children's Hospital Cameron C (University of Manchester) & Abdelrahman M Background: 1 in 800 children are affected by cleft lip or palate in the UK. The new Royal Manchester Childrenâ&#x20AC;&#x;s Hospital has become a main centre for repair in the North West. Repair is performed in infancy, and is a painful procedure requiring potent analgesia. Both inadequate and excessive analgesia have associated complications post-operatively. Consequently, high quality pain relief is imperative.

Aims: To assess the adequacy of analgesia in palatal-facial surgery in children to ensure high quality pain management is occurring. It looks at the quality of pain relief achieved, and whether clinical practice complies with Central Manchester University Hospitals Trust Guidelines. Advantages of drugs over others were documented and patterns of prescription and administration recorded too.

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Methods: This retrospective audit involved all patients who underwent cleft palate or lip surgery since the new RMCH opened.

Data was collected on 116 procedures from case notes. Details of intra- and post-operative analgesia requirements, and pain scores were recorded. Data was subjected to descriptive statistical analysis.

Results: High standards of pain management were found with good compliance to Trust Guidelines. Variation existed in analgesic agents favoured during surgery and discrepancies occurred between anaesthetist‟s prescription and nursing staff‟s administration. Oral Morphine was administered particularly inconsistently and response to raised pain scores was diverse.

Conclusion: In response to observations, further recommendations have been made to update and clarify guidelines to provide more efficient pain control and reduce the requirement for opioids. These will be implemented by distributing to relevant staff.

B04 The Burden of Periprosthetic Infection Following Hip and Knee Arthroplasty Choi S (University of Manchester) & McLauchlan G Joint replacement surgery has the potential to restore function and provide long-term relief of pain due to joint disease, but devastating complications such as postoperative joint infection, can leave patients with even higher degrees of disability and discomfort. The management of these infections represents a significant cost to the National Health Service (NHS) in the United Kingdom (UK). The aim of this report was to calculate the incidence of deep joint infection within a single teaching hospital trust in England, as well as to estimate the burden that a single episode of infection presents to the NHS. Twenty-nine patients were identified, retrospectively, as having presented with infection between 2006 and 2009. Data relating to investigations performed, outpatient clinic appointments attended, hospital admissions, use of operating theatres, and patient-specific prostheses, were collected using paper- and computer-based patient records; these figures were compiled with cost data, and the cost of a single deep hip or knee joint infection was approximated at £14155.08. During 2008 and 2009, 690 total hip arthroplasties (THA) and 843 total knee arthroplasties (TKA) were performed within Lancashire Teaching Hospitals Trust (LTHTr), and following presentation of infection in three patients with THAs and three with TKAs, the incidences of infection were calculated the be 0.43% and 0.36% for hips and knees respectively.

Due to difficulties in eradicating deep joint infection, prevention is perhaps the best way to reduce the burden on both the patients and the NHS.

B05 An Audit Into The Management of Melanoma (2007-2008) in Royal Preston Hospital Damanhuri MH(University of Manchester), Miswan AH & Dalal M Background: The UK guideline for the management of melanoma and the National Minimum Dataset (NMD) for histopathological reporting were published in 2002. Additionally, the cancer waiting time targets was introduced by the government for a number of malignancies, including melanoma.

Purpose: This study was conducted to assess our compliances with the above guidelines and to complete the audit loop for the completeness of histopathological reporting conducted in 2007. Factors contributing to the lack of compliance and suggestions for improvements were also discussed.

Methods: A total of 188 histology reports and 164 case notes were assessed retrospectively over a two-year period from January 2007 until December 2008.

Results: 75 patients were referred without biopsy, following which 90.7% had excision biopsy and the remaining had incision biopsy. In the remaining patients who had a biopsy taken prior to referral, there were 8 punch, 1 curettage and 3 shave biopsies performed which are inconsistent to the recommended guideline. Out of 188 histopathology reports, 66% were noncompliant with the dataset. In total, 87.9% lesions were excised with „appropriate‟ margins and 12% were excised „inappropriately‟. The median time to the first clinic appointment was nine days whilst the median time to definitive treatment from date of diagnosis was 25 days which are acceptable.

Conclusion: Although most aspects of the guidelines were closely adhered to, the majority of melanoma histopathology reporting was noncompliant to the NMD. Improvement in this aspect would better guide clinicians in determining the most accurate treatment for patients and melanoma prognostication.

B06 Brain Tumour Management: Has a shift from inpatient to outpatient services led to an improvement in patient satisfaction and care?

Newark C (University of Manchester) & Hall G Background: In June 2009, the Royal Preston Hospital (RPH) neuro-surgical department altered the pathway of care for patients diagnosed with a brain tumour. The pathway was modified from an inpatient to an outpatient model. RPH is currently the only neuro-surgical centre in the country to manage brain tumour patients in this way.

Purpose: This report will compare the length of hospital stay, referral-to-treatment time (RTT), and patient satisfaction for both inpatient and outpatient models of care.

Methods: Data for the length of hospital stay and RTT was gathered over 01/12/2008 – 30/04/2010. All patients with a malignant brain tumour who underwent surgery as part of their treatment were included. 114 patients were identified; 52 for the inpatient model, 62 for the outpatient model. Patient satisfaction for both models was surveyed by using a patient satisfaction questionnaire.

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Results: With the change in service, the length of hospital stay has reduced by a mean of 2 days; a direct consequence of a reduction in admission-to-operation length. RTT has lengthened by an average of 3 days. Patient satisfaction has increased across all surveyed domains.

Conclusion: The new outpatient service has led to an improvement in both efficiency and quality of care. The costs saved as a result of this pathway are essential to bring about a 'leaner' NHS. This is a key finding given the current economic climate.

Oral presentations - Cases C01 Worms in the Brain!

Al-Himdani S (University of Manchester) & Cuadrado ML A 40 year old woman presented to A&E with severe headaches, nausea and vomiting and photophobia. She had previously been diagnosed with neurocysticercosis and treated with albendazole for active disease. MRI scan revealed affectation of the lateral ventricles and the frontal lobe with the worm and also showed a marked dilatation of the lateral ventricles. The patient was subsequently referred to neurosurgeons who inserted a ventricular-peritoneal shunt. After insertion the patient showed marked improvement of symptoms.

Neurocysticercosis is the leading cause of epilepsy in South and Central America. This condition is caused by infection with the

by Taenia solium which results from the ingestion of eggs found in uncooked pork. The life cycle of the worm involves humans as definate hosts and pigs as an intermediate hosts. The ova are digested in the stomach and may then penetrate the intestinal wall, into the bloodstream. The tapeworm can have a number of different clinical presentations and may affect many different organ systems.

Neurocysticercosis may present in a variety of different forms depending on the location of the cysts in the brain and the activity of the worms .Therefore it is common for patients to present with a wide varied clinical picture which may also change throughout the course of the disease and depending on the treatment received. Around 60% of individuals infected with the worm go on to develop cysticerci in the brain

C02 Auditory Brainstem Implant for cochlear nerve atresia Dowling M (University of Manchester), Khwaja S & Lloyd S Introduction: Auditory rehabilitation for profoundly deaf individuals has been revolutionised by the introduction of cochlear implantation. However between 2-15% of patients receive limited benefits.

In 1979 the first Auditory Brainstem Implant (ABI) was developed for a patient with bilateral acoustic neuromas, due to neurofibromatosis type 2 (NF2). Thirty years later and the ABI have been used to benefit many non-NF2 patients, with superior results both in terms of auditory ability and lower rates of post-operative complications. The use of the ABI following cochlear implant failure has also produced favourable results.

Case study: We present a 15 months prelingually deaf child due to bilateral cochlear nerve atresia, who was fitted with bilateral cochlear implants in 2007. He received limited benefit from the cochlear implants and hence in July 2010 underwent the insertion of a left brainstem Implant at Central Manchester University Hospital Foundation Trust.

This case study aims to report the technique and outcome of this surgery and discuss the current research concerning the indications and potential complications of the ABI, and also the role of the ABI in the restoration of hearing.

C03 A Rare Case of Growing Abdominal Distension Farikullah J (University of Manchester), Hennayake S & Shenoy M Autosomal recessive polycystic kidney disease (ARPKD) is a rare inherited disease characterised by a malformation complex which includes renal collecting duct cysts and congenital hepatic fibrosis. This disease has the highest mortality rate in the first year of life.

Pre-natally, oligohydramnion, enlarged kidneys and lung hypoplasia become evident. We report an infant diagnosed with ARPKD who developed rapid increase in renal size in the first six months of life which compromised his respiration and nutrition.

A male neonate born at 35 weeks gestation was noted to have abdominal distension and respiratory distress. Motherâ&#x20AC;&#x;s antenatal scan at 20 weeks was normal and no oligohydromnios was present. Ultrasound scan confirmed the presence of bilateral large kidneys. Renal function was normal with a creatinine of 35umol/l.

The child developed increasing abdominal distension due to rapid growth of the kidneys which affected his respiration and lead to vomiting of feeds. CT scan of the lungs was not consistent with pulmonary hypoplasia. At 8 months, open left nephrectomy was performed. Four months following surgery, the child has not required any further hospital admissions.

Our case is unusual in that the rapid growth of the kidneys was not associated with deterioration of kidney function. Also, there were no predisposing factors pre-natally. The indication for unilateral nephrectomy was to reduce abdominal distension and thereby reduce respiratory distress. The procedure has also led to improved feeding and growth. We would therefore suggest that unilateral nephrectomy should be considered as an option in the management of children with ARPKD.

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C04 A case of extradural schwannoma of the cervical spinal cord with large soft tissue component Geehan C (Peninsula College of Medicine and Dentistry) Background: Tumours of the central nervous system can be highly debilitating for the affected patient. If untreated, a growing tumour may cause sensory disturbance, limb weakness and loss of bladder or bowel function, dependant upon location in the cord.

Report: A 62 year old female presented with an eight month history of numbness of her right hand. She also described a sensation of “water running down” her left side with associated temperature loss. These initial symptoms later advanced to include loss of light touch sensation in the right shoulder and left leg, and right leg weakness. On examination, a right lateral neck mass was palpable. MRI indicated a large intraspinal mass at C4/C5, extending through the transverse foramen. This mass, histologically a schwannoma, was partially excised via posterior facetectomy. Early post-operative follow-up revealed an excellent regain of function.

Discussion: This patient‟s early loss of pinprick sensation in the right thumb and first finger indicates radiculopathy of the C6 nerve root. The addition of further abnormalities, such as dysaesthesia of the left lateral thorax, implies spinothalamic tract involvement and thus a lesion within the spinal canal. Features of Brown-Séquard syndrome were also present.

Schwannomas are caused by over-proliferation of schwann cells due to loss of the tumour suppressor protein merlin. Symptoms frequently respond well to surgical treatment.

Conclusion: Schwannomas of the spinal cord may present with signs of both upper and lower motor neurone lesions. This report emphasises that recognition and treatment may resolve symptoms completely.

C05 Bilateral Comminuted Calcaneal Fractures followed by Below Knee Amputations – A Case Study King G (University of Bristol) & Wood A A thirty year old serviceman in the UK Armed Forces was involved in an Improvised Explosive Device incident whilst on vehicle patrol. This resulted in multiple injuries including bilateral severely comminuted calcaneal fractures.

Following initial treatment, rehabilitation was successful for all injuries apart from the calcaneal fractures. These continued to inflict severe pain and significantly decreased exercise tolerance, and it was considered very unlikely that he would return to acceptable levels of activity. Bone necrosis was discovered in the fracture sites and it was agreed that bilateral below knee amputations be performed. After the amputations the patient has already experienced a significant reduction in pain and is due to start rehabilitation at Headley Court, hopefully resulting in running, cycling and swimming with the aid of prostheses.

A literature and guideline review emphasised the lack of consensus opinion to inform the challenging decisions to be taken in the management of calcaneal fractures. It highlighted the lack of options available when treating the more severe fractures and the long term challenges faced by these patients. This patient‟s fractures have been classified, enabling their management to be compared with relevant studies in the literature.

C06 An unusual metastasis of a transglottic squamous cell carcinoma to the forearm Kwasnicki RM (Imperial College London), Ciau D & Carpentier JP Background: In cases of Laryngeal squamous cell carcinoma (SCC), local invasion and cervical node metastases are common, however distant metastatic spread is reported as only 3-8% (pulmonary>bone>liver>skin). Distant muscular metastases are extremely rare with 7 cases reported.

Report: A 60 year-old male presented with two-months of dysphonia. He was found to have a large left vocal cord mass, crossing the anterior comissure and with subglottic extension. There was bilateral cervical lymphadenopathy clinically and on staging CT. Total laryngectomy and bilateral modified radical neck dissection was performed. Histology showed a 3.5cm grade 2 SCC with vascular, neural and cartilaginous invasion and involvement of several nodes bilaterally (T4N2C). The patient was followed up according to local protocol. At 2 months he was found to have a local recurrence. This was resected and chemoradiotherapy was instituted.

At 4 months, the patient reported a swelling in the extensor compartment of the right forearm. CT showed a muscular swelling and fine needle aspiration of the lesion revealed SCC with similar morphology to the laryngeal primary.

Discussion: Distant metastasis is facilitated by either lymphatic or haematogenous spread. Surgical disruption of the lymphatics may cause unusual metastases below the clavicle. However, a distant muscular metastasis more likely indicates successful intravasation of cancer cells and should prompt the initiation of exploratory imaging and chemotherapy.

Conclusion: While muscular metastases are extremely rare in the setting of head and neck cancer, any swelling in such patients should be treated with a high index of suspicion with regard to metastases.

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C07 A challenging cerebrospinal fluid leak Li Ching Ng A (University of Manchester) & Jayabalan S Introduction: Cerebrospinal fluid (CSF) leaks are common complications of neurosurgical cases. Most resolve spontaneously but a 13% risk of meningitis is the main reason for treatment.

Case report: 1month27days old baby K presented acutely to Kovai Medical Centre in Coimbatore (India) with a subdural hematoma. A craniotomy was performed, leaving the dura open for decompression. Unfortunately, 10 days post-operatively, surgical site examination showed CSF leakage and wound gapping. Dura reconstruction with a dura-patch was carried-out but the leak persisted. Hydrocephalus was diagnosed and a theco-peritoneal shunt was inserted. Despite immediate improvement, K was still having intermittent leakage on crying. Revision duraplasty using fascia lata from the thigh was performed on suspicion of graft failure. Perioperatively, the graft taken was too small and an additional temporalis fascia graft was needed. Fibrin glue was also used to seal the dura. At discharge, the patient did not have any further CSF leak.

Discussion: Post-craniotomy CSF leak is mostly due to wound dehissance but hydrocephalus can be another complication. Watertight duraplasty using autologous or allogenic materials enhance wound healing but biomechanics of brain tissue unique to neonates can impair on success of particular dural substitute.

Conclusion: This case illustrates that management of post-operative CSF leak needs to be guided by its etiology. Autologous grafts are more suitable in neonatal neurosurgery as cerebral physiological responses in neonates predispose to artificial graft failure. Size of the defect can, however be a limitation. The use of fibrin glue increases adhesion for a waterproof seal

C08 Thinking outside the box: Mitchondrial Disorders. Case report of a patient with Mitochondrial Neuro-GastroIntestinal Encephalomyopathy Syndrome (MNGIES) Magee L (University of Manchester) & Shaffer J Mitochondrial disorders vary in their presentation, affecting a diverse number of systems. This review outlines the case of a patient with progressively worsening gastro-intestinal (GI) symptoms unresolved by surgical procedures, who then went on to develop neurological symptoms, prompting the correct diagnosis. Mitochondrial Neuro-Gastro-Intestinal Encephalomyopathy Syndrome (MNGIES) was suspected.

MNGIES is a rare autosomal recessive condition, characterised by a genetic mutation, leading to deficiency in thymidinephosphorylase (TP). This causes a toxic build up of the nucleosides thymidine(dThd) &deoxyuridine(dUrd) resulting in symptoms affecting the GI system, extra-ocular muscles and white matter of the nervous system.

The 23-year old male patient underwent several surgical procedures to resolve his symptoms including; • Laproscopic gastro-jejunostomy, • Correction of an anastomotic leak with a Roux loop, • Emergency laparotomy following a perforated bowel after a colonoscopy.

Events leading up to each of these procedures will be detailed. Despite surgery no clear diagnosis was reached as the patient‟s condition worsened, leading to admission to a specialist intestinal failure unit. The similarities of the patient‟s case to MNGIES are discussed and assessed in relation to diagnosing MNGIES. It raises the question: did early surgical intervention compromise subsequent management? The pathophysiology, investigations, prognosis and treatment of MNGIES are also included in the discussion.

MNGIES is a progressive and debilitating disorder. Due to its rarity the diagnosis is often missed. This case highlights the importance of thinking outside of the box when making a clinical diagnosis and the features that suggest when a mitochondrial disorder should be considered.

C09 Acute compartment syndrome in a paediatric polytrauma patient Sidon L (University of Manchester) & Ban K Background: This case study presents a paediatric polytrauma patient, Miss S, admitted after a high impact motorcycle accident.

Report: Two days following her admission Miss S developed an acute compartment syndrome in her right lower leg. Diagnosis was very challenging to make given we were faced with an unconscious paediatric patient from whom it is impossible to elicit pain, the key symptom in acute compartment syndrome. She eventually underwent emergency fasciotomy and was discharged seventeen days post admission with instructions to follow up with rehabilitation services and psychiatry.

Discussion and Conclusions: Acute compartment syndrome is a potentially limb and life threatening surgical emergency. Clinical diagnosis is difficult to make and having a high index of suspicion is key. We looked at the role and limitations of intracompartmental pressure measurement as a diagnostic tool and considered its importance in a paediatric patient or in a patient with an altered mental status. Once diagnosis is established, treatment is an urgent surgical intervention: the twoincision technique fasciotomy. Wound closure is delayed and the „shoe-lace‟ technique used to allow a gradual approximation of the wound edges. More recently, the use of vacuum assisted therapy has significantly improved wound healing times. Finally, we

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looked at outcome and found that despite fasciotomy some patients are left with permanent motor or sensory sequelae. The sooner the fasciotomy is done, the better the outcome. This stresses again the significance of making an early diagnosis.

C10 The Use of Clonidine and Probiotics in the Post-Operative Treatment of Paediatric Short Bowel Patients Sun KM (University of Manchester) & Morabito A Paediatric short bowel syndrome is a relatively rare condition which carries significant mortality and morbidity. Management of these patients are complex as they often only have minimal lengths of small bowel. In order to maximise intestinal adaptation, parenteral nutrition is used to provide adequate nutrition to these patients. However, long term parenteral nutrition also brings its own complications. These patients also suffer from other sequelae as a result of their short bowel length, including high stool output and frequency, poor nutrition and growth from malabsorption and frequent infections leading to hospitalisation. New methods of managing these complications are currently being trialled, including the use of probiotics and clonidine.

This report looks into the effects of the use of probiotics and clonidine in two paediatric short bowel patients at the Royal Manchester Children‟s Hospital. To date, there have been very few studies in the literature as to the use of either agent in the management of this condition in children. Both patients suffered from high stool output, poor nutrition and were refractory to the use of loperamide.

The use of probiotics in one patient and probiotics and clonidine in another were effective in reducing stool output and frequency and slowing intestinal transit. It also enabled them to tolerate a greater volume and varied foods in their diet, allowing for better nutrition and growth.

This study shows promising nutritional and clinical outcomes for paediatric patients with short bowel syndrome and could be a valid addition in the management of these patients.

C11 Cauda equina syndrome: A complicated case Wu R (University of Birmingham) & Leung D Background: A 74 year old male Caucasian was admitted to hospital after being referred by his general practitioner during late September 2009 with a 5 week history of numbness, left buttock pain radiating to the lower limb and progressive weakness in his left leg.

Report: Within 2-3 days after admission, there was a gradual worsening in his mobility and back pain. Neurological examination revealed reduced power, sensation and absent reflexes in his left leg with perianal paraesthesia. A subsequent CT scan of his spine showed lumbar spinal stenosis with degenerative changes confirming suspicions of cauda equina syndrome. The patient underwent an emergency open decompressive laminectomy at a specialist orthopaedic hospital. Post-operatively, the patient experienced immediate relief of his leg pains but 8 days later developed post-surgical DVT. Over the next 4 weeks he developed cellulitis in his left leg, recurrence of his neuropathic pains, bilobar pneumonia, pleural effusion with empyema and red man syndrome.

Discussion: Cauda equina syndrome is a rare neurological symptom affecting a very small minority of patients with severe low back pain in the UK. Although documented complication rates of spinal decompression are rare, there is lack of data on complication rates for emergency decompression laminectomy. In addition, there is mixed evidence for its efficacy and some evidence for safer operating procedures to be brought to mainstream practice.

Conclusion: This case highlights the complications behind decompressive laminectomy, the need to act rapidly if such a scenario arises and offers insights to other potential surgical management options.

Oral presentations – Pre-clinical debate D01 Laparoscopic Surgery- the Gift that Keeps On Giving Chapman K (University of Glasgow) Surgery is an inherently risky business with blood loss, pain and infection being the three largest issues requiring control during and after an operation. Laparoscopic, or „keyhole‟, surgery minimises these issues and offers other benefits over traditional „open‟ surgery, optimising the operative experience for all parties.

The surgeon benefits from excellent visualisation during surgery and is presented with fewer adhesions on subsequent surgeries.

The patient enjoys decreased pain and post-op analgesics, minimal scarring and gets well sooner. Risk of hospital associated infection and problems from extended bed rest are reduced and the NHS saves money from the shortened stay in hospital.

The first human laparoscopic operation was to diagnose ascites and was performed in 1910 by Hans Christian Jacobaeus. The development of his techniques were hindered however by the technology of the time- it was not until 1985 that a computer chip TV camera was made, allowing the inside of the patient to be seen by the surgical team.

From humble beginnings usage of this technique has boomed- now 96% of all cholecystectomies in the US are done laparoscopically. It has a wide variety of applications and innovative surgeons across the globe are constantly pushing boundaries to find further uses for it.

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Recently devices such as the da Vinci® Surgical System have allowed us tantalizing glimpses of what advancements laparoscopic technology has awaiting it in the future. Not only has laparoscopic technology given surgery its biggest advancement in the last 500 years, but it still has more to give.

D02 Lister's Legacy Guthrie S (University of Glasgow) Before the advent of aseptic conditions in surgery it could be expected that half of all those undergoing surgery would die later as the result of secondary complications of infection. The commonly held belief of the time was that „miasma‟, a form of „bad air‟ identifiable by its putrid smell, was to blame for infection.

Joseph Lister, a professor of surgery at Glasgow University, was introduced by a colleague to the work of Pasteur‟s „Germ theory of disease‟. Lister was able to make the link between Pasteur‟s theory and that of the incredibly high infection rate on his ward.

He began to use carbolic acid directly on wounds, an idea he taken from its industrial use in the purifying of sewage. Lister saw drastic improvements in survival rates and reported his findings in the BMJ. His work was met with a mixed reception and wasn‟t fully accepted for many years.

Numerous scientific minds contributed ideas to the ultimate formation of the use of aseptic conditions in surgery. It was Lister, however, who was able to take these ideas and weave them together into practice, producing a solid scientific argument for its use.

When compared to what we may call a medical advance in surgery now, this was a gargantuan leap. With the acceptance of the importance of aseptic conditions, surgery, and indeed medicine was revolutionised. Not only were post-operative survival rates drastically improved, areas of the body previously untouched by surgery, such as the abdomen, could now be explored.

D03 Andreas Vesalius and the dignity of dissection and anatomical teaching Hamill JR (University of Manchester) & Freemont A The history of human anatomical knowledge encompasses long-running arguments. For 1,500 years European physicians declined to question the second-century teachings of Claudius Galen. Remarkably, his legacy of over 300 pamphlets and books concerning the human body‟s structure and function was encyclopaedic and yet fundamentally flawed. His entire catalogue of anatomical pedagogy was based on his own dissection studies, exclusively garnered from the anatomization of animals such as pigs and Barbary apes. Nevertheless his undisputed beliefs provided a widely used medical reference book for over a millennium.

The publication of Vesalius‟ De Humani Corporis Fabrica (1543) in which the author made anatomical observations conflicting the teachings of Galen marked a shift in the scientific approach to the subject of anatomy. In Fabrica medical students were provided with a concise atlas of the human body. In this age the most widely referred to anatomical textbook is Gray‟s Anatomy.

Marked differences can be seen between the texts, especially in the illustrations of anatomical specimens. The highly decorative Vesalian volume contrasts with the stark annotated drawings of Gray‟s, raising the question as to the reasons for these differing depictions. Not least the question of dignity in the dissection process and in anatomical teaching over the centuries is posed.

Through comparing texts this report highlights changing attitudes to dignity of the body and person and evaluates how influential a factor this has been in the evolution of dissection practices and anatomical teaching crucial to the practice of modern day surgery.

D04 No Laughing Matter Kumar MSN (University of St Andrews) & Lam L "I am sure the air in heaven must be this wonder working gas of delight", wrote poet Bob Southey about Nitrous Oxide, the colourless, odourless gas which was popularly used in the 1800‟s primarily for its recreational purposes. Joseph Priestley‟s discovery in 1793 is of great importance to us today, as it is the founding stone upon which modern anaesthetics are built upon.

Famously used by dentist Horace Wells, the gas showed promising painkilling qualities and Humphrey Davey from the Pneumatic Institute of England was known to say "As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place".

Using surgical intervention to investigate and treat pathological conditions is an age old technique that was usually associated with great pain and suffering for a patient. With the discovery of basic anaesthetics, the reversible loss of sensation phenomenon allowed a break- through in the field of surgery without which, we would not have many procedures possible today.

With this discovery, patient care was brought to a whole new level in the practice of Surgery and as we are so often told as medical students „When it come to patient comfort, it‟s certainly no laughing matter‟.

It is with all this in mind, that we have considered the discovery of Nitrous Oxide to be one of the greatest surgical discoveries in the last 500 years.

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D05 Scar-free Surgery: Natural Orifice Transluminal Endoscopic Surgery (NOTES) Murchison LED (University of Glasgow) Natural orifice transluminal endoscopic surgery (NOTES) is deemed to be “the latest and arguably most significant innovation in surgery” since the development of laparoscopic surgery.

While laparoscopic surgery is described as minimally invasive surgery, NOTES can be described as non-invasive „scarless‟ surgery.

The procedure provides the solution to the age old quest for cosmetic perfection after surgery. In addition, procedures performed via the NOTES method have been found to improve patient health by eliminating many of the complications associated with traditional surgery such as: reduced surgical site infection, decreased incidence of incisional hernias and decreased requirement for anaesthesia. Furthermore, NOTES is expected to be more cost effective.

The procedure itself involves the passage of a flexible endoscope into a natural orifice. This is typically achieved by insertion of the endocope into the oral cavity, then through the upper gastrointestinal tract and, via an incision in the gastric mucosa, into the abdominal cavity - allowing various surgical procedures to be performed.

However, with the technique still being relatively new in its development (the first NOTES procedure was only performed in April 2008) it is debatable whether such a technique could realistically replace laparoscopic surgery.

In this poster/presentation I propose to address the development of NOTES, the surgical technique involved, the advantages and disadvantages of the procedure compared to laparoscopic surgery, its current and future applications and why NOTES could be greatest surgical advance in the last 500 years.

D06 The life and work of John Hunter (1728-1793) was the greatest advancement in surgery in the past 500 years Walsh K (University of Manchester) The life and work of John Hunter (1728-1793) was the greatest advancement in surgery in the past 500 years. Hunter changed the future of surgery by taking it out of the practice of barbers and changed it to become the practice of scientists.

Hunter pushed boundaries and made key surgical landmarks such as tissue transplantation, laying the foundation of the pathogenesis of cancer by being the first to describe the lymphatic system. His skill as a dissector enabled him to show the future of facial surgery with his famous removal of a parotid tumour without damage to the facial nerve.

His contributions go further as he revolutionised surgical philosophy by encouraging scientific methodology over butchery at the hands of the barbers. He set up his own surgical school in which he attracted future pioneering surgeons such as Astley Cooper as well touching on the foundations of the correlations between humans and other species prior to Darwin.

The scientific methodology Hunter brought to surgery encouraged future surgeons to question and investigate, which would lead to the future of anti septic use in surgery and future technological advancements. Although such contributions have been vital to surgery, John Hunter‟s philosophy of “But why think? Why not try the experiment?” laid the foundations for inspired surgeons to follow a similar philosophy and still continues to this day.

The true testament to the importance of John Hunter‟s work is evident by the Hunterian Museum in the Royal College of Surgeons in London.

Poster presentations P01 Fire Alert! An incident with the monopolar electrosurgical cutting needle Ahmad M (University of Manchester), Saha K, Slater R & Ataullah S Purpose: To raise awareness of the potential fire hazard associated with use of monopolar electrosurgical cutting needle. We identify various factors that may have contributed to a fire igniting during a lower eyelid, transcutaneous blepharoplasty.

Methods: A case report of a patient undergoing lower eyelid, transcutaneous, blepharoplasty under local anaesthetic who suffered loss of eyelashes from a fire ignited during surgery. Analysis of the literature.

Results: Possible factors implicated in the fire included: relatively high power monopolar cautery for periocular surgery (16 cut, 16 coagulate compared to the usual 8-10 for cut and coagulate), an oxygen enriched environment, the presence of flammable agents - eyelashes and Lacrilube (42.5% mineral oil and 57.3% paraffin).

Conclusion: The manufacturer recommends electrosurgical units not be used in oxygen enriched environments or in the presence of flammable agents.

Caution must be exercised when performing electrosurgery to prevent fire. We are highlighting the risk of this infrequently reported event. Adherence to manufacturers' recommendations and an awareness of potential risk factors, should prevent this rare but potentially serious complication.

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P02 An audit of outcomes of surgical management of trigeminal neuralgia Ammori MB (University of Manchester), Rutherford SA & King AT Aims: Trigeminal neuralgia (TN) is a relatively rare condition of severe facial pain, for which very effective surgical treatment options are available. This audit evaluates the outcomes of two operative interventions that are offered at Salford Royal Hospital, namely microvascular decompression (MVD) and percutaneous glycerol injection (PGI) of the trigeminal ganglion.

Methods: Patients who underwent therapeutic interventions for TN were identified from the theatre registry. Data were retrospectively collected regarding the preoperative duration of symptoms, characteristics of TN, pre-operative imaging, operative morbidity, relief and recurrence of pain after surgery.

Results: Between 2007 and 2009, 71 consecutive patients (43 female) with a mean age of 59 years underwent 79 procedures (54 MVD, 25 PGI). The mean duration of symptoms was 5.2 years. The response rates for MVD and PGI were 96.2% and 87.5% respectively. The recurrence rates were 9.8% following MVD and 33.3% following PGI at a mean follow up of 17.2 months and 13.4 months respectively. The morbidity rates were 28% for MVD and 12% for PGI. Conclusions: Both MVD and PGI offer effective treatment options for TN. Although MVD carries a higher operative morbidity compared with PGI, it delivers a greater success rate. Longer follow-up is needed to assess long-term recurrence rates.

P03 Audit in the documentation and management in third and fourth degree perineal tears Badger E (University of Manchester), Hill S & Martindale M I am presenting a complete audit cycle of the management and documentation of third and fourth degree tears in the East Lancashire Trust measured against the first auditâ&#x20AC;&#x;s recommendations and the recommendations of the Royal College of Obstetricians and gynaecologistâ&#x20AC;&#x;s guideline number 29.

Retrospectively we looked at 8 months data between the two hospitals, an operative proforma was designed and the information was obtained. This re-audit showed a decreased compliance with the original audit and the RCOG guidelines. We recommend the introduction of an operative proforma to aid management and documentation of third and fourth degree tear repairs.

P04 An audit on the surgical management of gynaecomastia: a regional plastic surgical unit's 3 years experience Fernandez N (University of Manchester) & Srinivasan J Background: Gynaecomastia is a condition of male breast enlargement that may be treated surgically. Approaches include liposuction, open excision or a combination. Skin excision may be required for redundant skin.

Aims: To determine the regional demographic, features, operations and follow-up details of patients presenting for gynaecomastia surgery at Royal Preston Hospital in the last three years.

Methods: A retrospective audit of patient notes was performed on 137 patients presenting to the Royal Preston Hospital for gynaecomastia surgery between 1st April 2007 and 31st March 2010. Demographic factors, gynaecomastia features, management and post-operative information were collected and analysed.

Results: The median patient age was 25 years (range 13-58) with 75% having idiopathic/pubertal gynaecomastia.

The prevalence of each grade was 12% grade I, 34% grade IIa, 41% grade IIb and 13% grade III (n=133). A 7% complication rate and 28% unsatisfactory result rate were found. Complications were associated with skin excision (P=0.0173). Unsatisfactory results were associated with the surgical approach (P=0.0174) and body mass index (n=100) (P=0.0246).

Conclusions: A young patient population is predominantly searching for gynaecomastia surgery. Despite the majority of patients being satisfied with their operation a proportion suffer complications or unsatisfactory results. Unsatisfactory results are namely residual tissue and skin. Efforts should be made to ensure complete resection of gynaecomastia with appropriate skin reduction.

However with more extensive operations the risks of complications rise. Patients should therefore be counselled pre-operatively about complications, unsatisfactory results and the limitations of surgery, especially in the obese population who may require psychological support.

P05 Platelets in Brain Injury: key players?

Giles J (University of Manchester), Greenhalgh A,Thornton P, Denes A, McColl B, Allan S & Rothwell N Background: Cerebral ischaemia is an important pathological process that occurs as a result of sub-arachnoid haemorrhage and head injury, leading causes of death and disability in young people. Neutrophils are important contributors to brain injury in the context of cerebral ischaemia. In vitro evidence suggests a key role for platelet-derived interleukin-1alpha (IL-1Îą) in mediating neutrophil migration across the cerebrovascular endothelium.

Purpose: To further determine the role of platelets and IL-1 in neutrophil migration using a peripheral model of vascular inflammation.

Methods: A mouse model of peritonitis was used to measure neutrophil transmigration across vascular endothelium. Bacterial endotoxin (LPS) was injected intraperitoneally into male C57BL/6 mice and lavage of the peritoneal cavity was performed. Flow cytometry was used to assess neutrophil levels in the lavage fluid and cardiac blood.

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To determine the role of platelets, platelet depletion was induced via anti-CD41 antibody. To determine the role of IL-1, IL-1α/β double knockout mice were used. Cytokines in serum and lavage fluid were quantified using cytometric bead array.

Results: LPS induced neutrophil infiltration into the peritoneal cavity. Platelet depletion abolished the migration of neutrophils, indicating a key role for platelets. A robust response was seen in serum cytokines and platelet depletion selectively abrogated the increase in serum IL-1α caused by LPS. However, the use of IL-1α/β double knockout mice revealed no difference in neutrophil migration between knockout animals and controls.

Conclusions: In an in vivo model of vascular inflammation, neutrophil migration appears to be dependent on platelets, yet independent of IL-1.

P06 Audit to evaluate data collection at gynae-oncology multi-disciplinary team meetings Greasley C (University of Manchester) & Ahmed AS Background: There have been many changes over the last decade to cancer services in the UK, including specifically gynaecological cancers. Introducing Multi-disciplinary teams (MDTs) has been one of these changes. Data collection for the cancer registries has been highlighted as a crucial area of cancer care, and MDTs are advised that it should be their priority to collect data for these registries.

Aim: To assess the completeness of data collection from MDT meetings, and to assess the effect of suspected cancer site, base hospital and who completed the form on data completeness.

Method: 447 MDT sheets were retrospectively looked at from Jan – April 2010 at a cancer centre, and 3 linked cancer units.

Results: The 5 most important variables (Hospital number, staging, cancer site, treatment plan and co morbidities) recorded during discussions at MDT meetings were all at least 90% complete with little difference between base hospitals. Variables recorded prior to meetings were recorded significantly better at hospitals with an organised, clearer MDT sheet (p value <0.001).

Suspected cancer site and who completed the form were significant only in some instances.

Conclusions: Gynae-oncology MDT meetings are discussing and recording information during MDT meetings regarding a patients malignancy more than satisfactorily. There is room for improvement in collection of GP and referral details in preparation for MDT meeting discussions. As the need for a structured MDT sheet has now been highlighted, a revised, clearer MDT sheet across all 4 hospitals will hopefully unify and further improve the standard of data collection.

P07 An Illuminating Presentation of a Brunescent Cataract Guthrie G (Newcastle University) & Hunter Background: Over 250,000 Cataract operations are performed yearly in Britain. Phacoemulsification transformed the procedure over twenty years ago; improving outcomes, increasing speed and reducing costs. Older methods of cataract surgery, such as extracapsular cataract extraction (ECCE) are now infrequently employed. However they still have an important role to play when the intensity of phaco vibrations could cause serious complications.

Report: An 80 year old female presented with longstanding unilateral painless visual impairment. Her visual acuity was 6/9 left and 6/60 right. Examination revealed a dense black cortical cataract in the right eye. During her phacoemulsification surgery it was noted that her zonules were weak and that the cataract was abnormally dense and mobile. Given the zonular weakness and the relatively shallow depth of her anterior chamber the requirement for prolonged ultrasonic vibrations to break up the hyperdense cataract posed significant risks. Capsular perforation or zonular rupture commonly occurs under these conditions.

The surgeon reverted to ECCE. The cataract was removed without damage to the surrounding structures and an intraocular lens was installed. Visual acuity recovered to 6/9 in the right eye.

Discussion: The literature regarding the benefits of ECCE relative to phacoemulsification in specific clinical incidences will be reviewed. The discussion will also evaluate the possible over reliance upon phacoemulsification for cataract surgery.

Conclusion: Familiarity with ECCE will be shown to remain an essential ophthalmologic skill which should have greater prominence on training programs.

P08 Robot-assisted anterior lumbar interbody fusion (ALIF) using retroperitoneal approach Kim J (University of Manchester), Ha Y, Yang MS, Yoon DH, Kim KN, Kim H, Yang JW & Yi S Background: Over the past few years, robot-assisted surgery has become increasingly popular, affecting virtually all surgical fields. It has been proven to overcome pitfalls of laparoscopic procedures, such as high complication rates and steep learning curve. We have, therefore, performed experimental anterior lumbar interbody fusion (ALIF) using retroperitoneal approach in swine model to test the feasibility of robot-assisted surgery in spinal surgery.

Method: In this report, we describe the setup with the da Vinci® surgical system, operative method, result and discuss technical aspects and the future of robot-assisted ALIF. Findings: Experimental retroperitoneal dissection using robotic surgical system was successfully performed with great visual cue, minimal retraction and minimal bleeding.

Conclusion: Although retroperitoneal approach for spinal fusion has never been attempted with robotic surgical system, we could demonstrate the possibility with swine model. Further studies and development of appropriate instruments will bring minimally invasive spine surgery to a new era.

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P09 A Stitch in Time Saves Nine Konarski A (University of Manchester) & Evans J Athletes, and particularly long distance runners, commonly complain of abdominal pain during strenuous exercise. This may be called Exercise Related Transient Abdominal Pain (ETAP), or more commonly „a stitch,‟ which is generally benign, with the pain being relieved by stopping the activity. Exercise induced abdominal pain can however be a sign of an underlying disease process.

I present a case report of an elite cross country runner suffering from abdominal pain during races, which continued after the races for several days, and was associated with discomfort on eating. After a series of investigations he was diagnosed with Median Arcuate Ligament Syndrome (MALS). This was treated surgically with an open division of the median arcuate ligament.

Following recovery from the surgery, he was able to return to competitive racing, without recurrence of the symptoms.

This is a rare and somewhat controversial condition, with a difficult diagnosis, along with some debate over the best management. The case presents an unusual differential diagnosis for abdominal pain experienced during exercise, which was managed successfully through surgical intervention.

P10 Bilateral nephrectomy and ureterocystoplasty utilising megaureter prior to live related renal transplantation Mastan A (University of Manchester) & Pearce I Background: A 25 year old man was referred for urological opinion regarding his bladder prior to planned elective live related renal transplantation.The patient was in irreversible renal failure and his mother had been shown to be an excellent tissue match suitable for live related donation.

Investigations: Video urodynamic studies revealed grade 5 vesicoureteric reflux into bilateral megaureters which accounted for the recorded cystometric capacity of 738mls. There was no evidence of bladder outflow obstruction.

A concensus emerged that bladder augmentation utlising ureter if possible would be performed with synchronous bilateral nephrectomies. This would reduce the risk of upper renal tract infection, eliminate complications associated with the use of bowel in bladder augmentation.

Procedure: A midline laparotomy incision was made and both kidneys were removed intact with ureteric preservation. Both kidneys were atrophic.

The largest ureter, was dissected and was then de-tubularised distally as far as the vesico-ureteric junction. The ureteric sheet placed over the defect which was then closed with continuous 3/0 pds suture. The abdomen was closed in standard fashion and the patient made an excellent recovery.

Subsequently the patient underwent successful live related renal transplantation without complication to him or the donor.

Comment: This distinctive case shows how the novel use of structurally abnormal urinary tract tissue can be utilized in bladder augmentation to increase volume without the multiple complications associated with the utilization of non terminal ileum.

This case also highlights the benefit of mutidisciplinary discussion that leads to successful management of complex medical cases.

P11 Outcome following poor grade subarachnoid haemorrhage at a tertiary referral centre Neilson S (University of Manchester), Dulhanty L, Patel H & Holland J Background: Poor grade subarachnoid has traditionally been associated with extremely poor prognosis. With the development of radiological coiling and neurosurgical clipping techniques there is increasing evidence that a subsection of these poor grade patients can benefit from aggressive management.

Purpose: to establish the Glasgow Outcome Score (GOS) of all patients admitted to a tertiary referral centre over a 2 year period following poor grade subarachnoid haemorrhage.

Methods: Clinic letters reviewed for Glasgow Outcome Score and this figure was cross checked with specialist nurse‟s assessment.

Results: Of the 98 poor grade subarachnoid haemorrhage patients admitted for neurosurgical management, 52 received coiling, 13 underwent surgical clipping, 4 had EVD insertion only and the remaining 29 were managed conservatively. Good outcome (GOS 4 or 5) was achieved in 44 (44.9%) patients Conclusion: Greater Manchester Neuroscience Centre‟s selective but aggressive admission policy is resulting in a favourable outcome in 44.9% of those patients admitted. This is a favourable proportion of patients but it is important also to incorporate the outcome of those not admitted to develop a complete picture of prognosis following poor grade subarachnoid haemorrhage.

P12 Redo- Redo Aortic and Mitral Valve Replacement to treat severe haemolysis in an 82 year old with incorrectly diagnosed autoimmune haemolytic anaemia Patchava A (University of Cambridge) & Jenkins D An 82 year old gentlemen was admitted with recurrent symptomatic anaemia (Hb=6.1), requiring >150 units of blood over twelve months. The previous 6 months admissions included 3 episodes of maleana, haematuria, intermittent epistaxis, erosive gastritis

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and telangiecstasia. Bioprosthetic valves (AVR and MR) were inserted in 1986 and subsequently replaced using Starr-Edwards mechanical aortic and mitral valves (1993).

Haematological investigations revealed an elevated LDH, negative DAT and raised reticulocyte count. Blood film reported increased red cell size distribution, increased number of polychromatic cells, and the presence of schistocytes. Despite the negative DAT, the misdiagnosis of suspected auto-immune haemolytic anaemia led to commencement of a course of Prednisolone.

Progressive haemolysis necessitated replacement of both the aortic and mitral valves using modern bioprosthesis. The well established association between Starr-Edwards prosthesis manufacture and haemolysis should have ensured that this misdiagnosis was preventable.

The mechanisms involved in mechanical haemolysis including turbulent flux, red cells trapping, construction material and autoimmunity have been significantly discussed in the literature. Furthermore, the quantification of unconjugated bilirubin, free plasmatic hemoglobin, DHL, methemalbumin and urinary haemosiderin, has been recommended to aid this specific diagnosis.

Post-operatively, ongoing haemorrhage in excess of 1 litre, warranted re-explorative surgery, revealing a sternal haematoma.

This case highlights the importance of appreciating associations between previous cardio-thoracic interventions as the aetiology of the current haemotological presentation. In addition, knowledge of other treatment modalities including utility of bed rest, cellular maturity inductors, propanolol and sulfinpyrazone therapy could have been utilized to manage the haemolytic process.

P13 Surgery for transposition of the great arteries Patel M (University of Birmingham), Nepogodiev D & Clift P We present three cases illustrative of the complications that may occur with corrective surgery for transposition of the great arteries. One case was managed by Senning operation, one by arterial switch and one by a combination of both. The Senning repair uses a baffle to enable oxygenated blood from the morphological left atrium to pass in to the systemic circulation via the right ventricle. Senning repairs have now been superseded by arterial switch procedure, whereby the aorta and pulmonary artery are separated from their roots. These are then reconnected to the opposing great vessel.

The first patient underwent a Senning operation aged one year. At twenty he presented with cyanosis, a right ventricular heave and a pan systolic murmur. TOE confirmed that a baffle leak had developed. An attempt was made to manage this by elective stenting however this failed to completely cover the baffle leak.

The second patient was born with both TGA and VSD and these malformations were corrected with a Senning operation and VSD closure respectively. Aged ten, his Senning was taken down and an arterial switch performed followed by a Ross procedure. He later developed endocarditis, consequently the conduit between the right ventricle and pulmonary artery was replaced and he recently required cardiac resynchronisation therapy.

The final patient had an arterial switch performed at birth. Despite developing an ejection systolic murmur in the pulmonary area and TTE confirming mild narrowing in the branch pulmonary arteries, he remains asymptomatic.

P14 Audit Investigating the Effect of Pseudomonas Infection on Mortality and Morbidity in Lung Transplant Recipients Phillips A (University of Manchester) & Hope W Lung transplantation is an effective therapeutic option for a number of end-stage pulmonary diseases and has improved life expectancy and quality of life in these patients. However the treatment lags behind other solid organ transplants in terms of long-term survival and one of the main reasons for this is infection of the allograft. The principle aetiological agent for infection in these patients is the bacterium Pseudomonas aeruginosa (PA). There is evidence in the literature that PA directly increases mortality in these patients, both in the early (1-year) post-transplant period and in the longer term by increasing the risk of chronic rejection.

This retrospective audit aims to confirm whether existing PA-related data is true for the transplant centre at the University Hospital of South Manchester, particularly in the effect it has on mortality and morbidity in lung transplant recipients (LTRs). The data for LTRs who were transplanted since January 2007 was collected, including pathology, microbiology and surgical data as well as manually examining case notes for prescription charts.

The audit showed that whilst there was a graphical association between PA infection and higher mortality, it was not statistically significant and possibly suffered from an insufficient sample size. Other factors such as those relating to the surgical procedure, such as ichaemic time and transplant type, did not show a statistically significant association. If the study was altered in scale and became a prospective study it would have the potential to highlight the significant impact PA has on LTRs.

P15 Pre-operative Options for the Reversal of Warfarin Discussed in a Case of Urgent Elbow Washout Surgery Discussed via a Patient with an Elevated International Normalised Ratio Ritson A (Peninsula College of Medicine and Dentistry) & Hopton P Warfarin is an common anticoagulant, prescribed for 500,000 patients in the UK in 2006.1 It prevents production of clotting factors II, VII, IX and X resulting in a functional deficiency of these procoagulants, as well as anticoagulants protein C and S.2 It is

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used therapeutically in patients at increased risk of thrombosis, but increases the risk of haemorrhage, which is especially important in surgery. Due to the number of people on Warfarin, and the haemorrhage risk, effective methods of routinely and urgently reversing warfarin must be available.

Perioperative control of coagulopathy depends on the risk of thromboembolism (dependant on the reason for anticoagulation, the elapsed time and surgery type) and haemorrhage risk - dependant on the surgery site and type.

There are two main options for urgent Warfarin reversal; however some doctors remain unsure of the optimal method. Fresh Frozen Plasma is cheaper but less effective than prothrombin complex concentrate and has the risks associated with transfusing blood components and fluid overloading. Prothrombin complex is expensive but highly effective and recommended for urgent reversal of warfarin when no bleeding is present The case discussed caused debate and confusion about the optimal way to reverse warfarin in a patient with an international normalised ratio (INR) of 3.4 requiring urgent elbow washout surgery for septic arthritis. It highlighted the lack of understanding of current guidelines on reversal methods and therefore the importance of this study in order to educate healthcare professionals on the appropriate management strategies.

P16 The Glucocorticoid Receptor, a key to steroid resistance in Keloid scars Rutkowski D (University of Manchester), McGrouther DA, Bayat, Watson, Ray D & Mathews Introduction: Steroids are commonly used as first line treatment for managing Keloid scars, not always successfully. An abnormality of the glucocorticoid receptor (GR) has been attributed to resistance in several other conditions.

Methods: Non-invasive imaging using spectrophotometric intracutaneous analysis and full field laser perfusion imaging techniques were used to measure changes in levels of collagen, melanin and perfusion in 19 patients. Biopsies were taken preand post-treatment at 2 and 4 weeks. Receptor expression was evaluated using quantitative real time polymerase chain reaction (qRT-PCR), immunohistochemistry and western blottings. Histological changes were evaluated using Alcian blue staining and calculating the epidermal thickness.

Results: Non-invasive imaging of a cohort of Keloid patients (n=19) identified a group of responsive patients (n=12) and a group of non responsive patients (n=7). Responsive patients demonstrated a significant decrease in melanin (p<0.05) and perfusion (p<0.05) at week 4, in addition to a decrease in GAG content (p<0.05) and epidermal thickness (p<0.05) which was not seen in non responsive patients. A significant decrease in GR was seen in non responsive patients in both qRT-PCR and western blotting at week 2 (p<0.05) which was not seen in responsive patients. Immunohistochemistry revealed that GR staining of fibroblasts was significantly decreased in intensity in non responsive patients (p<0.05).

Discussion: Non responsive patients exhibit a reduction in the GR at week 2 which is not seen in responsive patients. It is envisaged that resistance to glucocorticoids could be attributed in part to an abnormality in the autoregulation of the receptor.

P17 A New Approach to the Hypotensive Trauma Patient: Early intervention with fresh plasma to decrease mortality caused by coagulopathic exsanguination Thomas BR, McLean B (St Georgeâ&#x20AC;&#x2122;s, University of London) & Zielinski M Background: In civilian/military trauma centres, 5-10% of severely-injured trauma patients present with coagulopathic bleeding requiring massive transfusion (MT); this carries a mortality of approximately 30%, as 50% of patients exsanguinate within 24hrs.

Recent war-zone military studies suggest early/aggressive intervention with a 1:1 ratio of FFP:RBC for volume/coagulation repletion, as it decreases mortality compared to traditional crystalloid resuscitation.

Purpose: During my elective at the Mayo Clinic, I participated in ongoing, novel research with the Trauma, Critical Care and General Surgery (TCGS) department aimed at preventing MT. Their current practice for severely-injured trauma patients requiring MT is immediate transfusion of fresh plasma (stored fresh in A&E) followed by packed RBC and FFP, a practice limited to a handful of institutions in the U.S. They believe that early intervention with fresh plasma compared to FFP (which must thaw) will prevent MT, thus reducing mortality.

Methods: A retrospective-observational study is currently being conducted at the Mayo Clinic for which I collected data on 1,017 trauma patients. With the data I collated, the TCGS department is currently evaluating whether MT can be predicted using a newly developed scoring-system (ABC Score) and prevented by early administration of fresh plasma.

Conclusion: Expert opinion of Military/Mayo staff supports the early administration of fresh plasma. This study intends to validate such conflict-based practice for use in civilian healthcare. If the TCGS department is correct, early administration of fresh plasma will decrease mortality associated with MT and also change current ATLS resuscitation guidelines by removing the 2L crystalloid bolus.

P18 Management of a benign parotid tumour: Warthinâ&#x20AC;&#x2122;s tumour Tiong DTW (University of Manchester) & Bieger-Farhan Warthinâ&#x20AC;&#x;s tumour is the second most common benign parotid gland neoplasm, accounting for approximately 22% of benign parotid masses. It predominantly affects older people, with a propensity towards men and smoking plays a role in its aetiology. A 55-year-old man consulted his doctor with a non-tender swelling in the neck that had been present for 6 months. Following

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history and a full ENT examination, the patient had an ultrasound scan and MRI scan to confirm the size and exact location of the lesion. The mass was biopsied and it revealed a Warthin‟s tumour. For cosmetic reasons, the patient chose to have surgery instead of leaving it alone. He was subsequently listed for superficial parotidectomy. A modified Blair incision was made and paralytic agents were not used to enable facial nerve monitoring. Halfway during his surgery, the facial nerve detector malfunctioned and as a result the operation was nearly aborted. Among the possible complications of superficial parotidectomy, facial paralysis is one that can have a significant functional and emotional impact on the patient. This case illustrates that although the goal of treatment for benign parotid tumours is to ensure their complete removal, preservation of the facial nerve and its branches is crucial in order to avoid facial nerve paralysis, which would consequently affect the patient‟s quality of life.

Ultimately, optimal care right from diagnosis to treatment and finally, to recovery is central to the management of patients with benign parotid tumours.

P19 A Comparison of Post-operative Analgesia in Paediatric Patients with Circular Frames for Limb Reconstructive Surgery Wells-Cole E (University of Manchester) & Zenios M The aim of this retrospective study is to compare the different pre-operative analgesic techniques in children undergoing circular frame application for lengthening and deformity correction, to determine the best possible analgesic result with fewest complications and without compromising post-operative care.

Data were collected from 68 cases where an external fixator was used to correct a lower limb deformity. Data were collected on severe pain episodes, post-operative duration of analgesia, requirement for top-up analgesia, complications, side-effects and number of osteotomies. The three analgesic methods used were morphine infusion, epidural analgesia and peripheral nerve blocks. Comparisons and statistical analyses were made.

There was a significant difference between the number of episodes of severe pain experienced by the patients receiving a morphine infusion when compared to the epidural and sciatic nerve catherisation groups (M vs. E p<0.0001, M vs. S p=0.018).

Sciatic infusions were associated with the lowest incidence of severe pain episodes and top-up analgesia requirements.

The difference in the incidence of nausea and vomiting between the methods was approaching significance (p=0.06). A significant difference was found when comparing epidural and morphine infusions (p=0.05). Epidural analgesia was associated with significantly more nausea and vomiting (p=0.023), and motor blockade (p<0.01) than continuous sciatic infusions.

The results show the most effective method of post-operative analgesia for our paediatric patients, in light of pain episodes and associated side-effects, is sciatic nerve catheterisation with continuous infusion.

P20 The effect of comorbidity on primary patency of native arteriovenous fistulas for haemodialysis Wu Z (St George’s, University of London), Morsy M, Chemla E Background: Vascular surgery for the construction of a native arteriovenous fistula or access (AVA) is the favoured approach to haemodialysis. The proportion of patients requiring haemodialysis with comorbidity including diabetes and hypertension has increased, thus the importance of assessing their impact on AVA outcome.

Aim: To investigate whether patients with comorbidities should have vascular surgery for creation of an AVA, via assessment of primary patency rates.

Method: Data for this retrospective study was collected via a computerized database on all native AVAs created from 1st January 2007 to 30th June 2007 at St George‟s Hospital, with at least 24 months of follow up. The primary endpoint was primary patency, defined as the time of creation of AVA to the time of first intervention.

Results: Overall primary patency rate at 12 months for radiocephalic and brachiocephalic access was 92% and 80% respectively.

In patients with ischaemic heart disease the patency rate at 24 months was 55% compared to 77% without. Those with hypertension had 64% patency compared to 71% without. However, these figures did not demonstrate statistical significance.

Diabetes and hypercholesterolemia did not have any effect on outcome.

Conclusion: The primary patency rate for radiocephalic and brachiocephalic access compared favourably to rates reported in other studies. The presence of comorbidity did not have a significant effect on the outcome of AVAs. Moreover, the patency rates remained high. This is likely to be a result of a good access protocol at this specialised centre. Thus the presence of comorbidity should not limit the creation of an AVA.

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INDEX OF PRESENTERS Ahmad, Maryam

26

Kular, Ramandeep

15

Al-Himdani, Sarah

21

Kumar, Meera

25

Ammori, Mohannad

27

Kwasnicki, Richard

22

Ashton, Caroline

19

Li Ching Ng, Angela

23

Badger, Emma

27

Lim Beng Teck, Jason

15

Barnett, James

19

Magee, Lucia

23

Bates, Anthony

12

Manning, Christopher

16

Boussouara, Khalid

12

Mastan, Aliya

29

Cameron, Claire

19

McGregor, Colleen

16

Chapman, Kate

24

Mitra, Anuja

16

Chasma, Tasneem

12

Morbi, Abigail

17

Choi, Samantha

20

Murchison, Louise

26

Ciapryna, Myron

13

Newark, Christopher

20

Crichton, James

13

Neilson, Sam

29

Damanhuri, Mayura

20

Oâ&#x20AC;&#x;Kane, Lauren

17

Dowling, Melanie

21

Parker, Simon

17

Dubb, Sukhpreet

13

Patchava, Anushka

30

Edge, Harriet

14

Patel, Mitesh

30

Farikullah, Jasmin

21

Phillips, Adam

30

Fernandez, Nicholas

27

Ritson, Alexandra

31

Geehan, Caoimhe

22

Rutkowski, David

31

Giles, James

27

Sidon, Lauren

23

Greasley, Claire

28

Sun, Kang Min

24

Grimes, Nathan

14

Sychev, Ivan

18

Guthrie, Grant

28

Thomas, Bjorn Rhys

31

Guthrie, Stuart

25

Tiong, Denise

32

Hamill, James Ryan

25

Vallance, Abigail

18

Howard, Thomas

14

Walsh, Karl

26

Hoyle, Antonia Claire

15

Wells-Cole, Eleanor

32

Kim, Jennifer

28

Wu, Rui

24

King, Graham

22

Wu, Zhe

32

Konarski, Alistair

29

Zakaria, Hani Nadhirah

18

Copyright Š 2010 Scalpel Manchester

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