8th Scalpel Undergraduate Surgical Conference 5 November 2016
Contents Welcome
2
Day Plan
3
Keynote speakers
4
Tutors, Workshops, Sponsors
5
Oral presentations
6
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Welcome Dear Colleagues, It is a great privilege to welcome you to Scalpel’s 8th annual Undergraduate Surgical Conference. In my four years as part of the committee of Scalpel, I have seen the event develop year by year and have been particularly impressed with this year’s conference director – Judith Osuji. Judith and the rest of the team have devoted a great deal of time and effort to make sure we continue the positive trend in 2016. Once again, we are privileged to welcome esteemed key note speakers in the face of Ms Swee Ang and Mr Steve Mannion who have extensive experience in both the NHS and in austere conditions globally. A more detailed description of the speakers can be found later in this booklet. I have no doubt that they will deliver inspiring talks for any budding surgeon. I would like to take the time to thank our incredible faculty who support the event. Their help is invaluable to the delivery of the conference and we are incredibly lucky to have them teach, advice and motivate us to develop our own skills. Furthermore, the day would not be possible without the generous help of our sponsors who have been a great partner to the society. The Scalpel Undergraduate Surgical Conference has always strived to encourage students to explore and hone their interest in the field of Surgery. What I have found particularly inspiring is to meet all the delegates, many of whom come from different parts of the country. I sincerely hope that you enjoy the day and please do not hesitate to say hello when you see me in the breaks. Finally, I must thank this year’s Scalpel committee members for all their commitment and hard work throughout the year and especially today!
Rayko Kalenderov (2016 Scalpel President) 2
Day plan Time
Event
08:00 - 08:45
Registration
09:00 – 09:15
Presidential welcome “Sticks and Stones: Orthopaedic and trauma
09:15 – 10:00
surgery in the less developed world”
Mr Steve Mannion 10:00 - 11:15
Practical workshops
Academic workshops
Group A
Group B
11:15 - 11:30 11:30 – 12:45
Break Presentations
Practical workshops
Group A
Group B
12:45 - 13:30 13:30 – 14:45
Lunch and posters Practical workshops
Presentations
Group A
Group B
14:45 – 15:00 15:00 - 15:45 15:45 - 17:00 17:00 – 17:30
Break “A Surgeon Needs More Than a Scalpel”
Ms Swee Ang Practical workshops
Academic workshops
Group B
Group A
Prize giving and close
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Keynote speakers Mr Steve Mannion Consultant Trauma & Orthopaedics Surgeon Mr Steve Mannion is the founder and Programme Director of Feet First, a charity that aims to treat clubfoot in the developing world. Even before founding the charity in 2003, however, he had dedicated much of his life working in underresourced parts of the world as a trauma and war surgeon. Mr Mannion obtained his medical degree at the University of Cambridge before undertaking surgical training and specialising in orthopaedic surgery. In between working within the NHS, he has worked in surgical programmes for agencies in conflict situations including Afghanistan, Cambodia, Ethiopia, Rwanda, Sri Lanka, and Angola. Working with CBM, a charity committed to transforming the lives of people with disabilities in developing parts of the world, Mr Mannion has also spent three years as a medical missionary in Malawi and made up one of the only two surgeons for 7 million people in the northern part of the country. His work in Malawi focused on training and capacity building in orthopaedic surgery.
Ms Swee Ang Consultant Trauma & Orthopaedics Surgeon Ms Ang, is a founding member of Medical Aid for Palestinians, a charity that began in the 1980s after the Sabra and Shatila massacre. These events triggered Ms Ang to leave her job and begin her focus on her charity, a global surgery career and special medical/humanitarian efforts that have spanned 28 years. During her time working for MAP, Ms Ang also gained the ‘Star of Palestine’.
Ms
Ang
obtained
her
primary
medical
qualification and a master’s degree in occupational medicine at the University of Singapore before moving to the UK. She then trained in orthopaedic surgery in Newcastle-Upon-Tyne and was the first female consultant orthopaedic surgeon to be appointed at St Bartholomew’s Hospital. More recently, Ms Ang was involved in looking after some of the victims of the 7 July 2005 suicide bomb victims in the Royal London Hospital. 4
Tutors and workshops Practical workshops Basic suturing
Knot tying
Dr Molly Jakeman, Dr Kathleen O’Shea, Dr
Dr Alex Costley-White, Dr Rukhtam Saqib
Rosie Writght, Dr Maria Harrington-Vogt
Advanced suturing
Laparoscopic skills
Mr Richard McBride, Mr Andrej Salibi
Mr Ian Farnell, Dr Jack Turnbull
Skin Flaps
Chest Drains
Mr Goswamy, Mr Onyekwelu,
Mr Machaal Ali, Ms Charlene Tennyson
Mr Senarath-Yapa, Dr Majeed
Academic workshops Less-than-full-time CV Clinic
Training / WinS
Dr Rachael Morley
Ms Sonia Bathla Ms Allison Waghorn
Sponsors
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Surgery for Médecins Sans Frontières Professor John Buckels
Oral Presentations 1. Ardit Begaj â&#x20AC;&#x201C; Audit Introduction: Significant innovations have been achieved in the past 50 years, which has improved the outcomes for patients that sustain injuries to their flexor tendons, however zone II flexor tendon injury still remains a challenge to the hand surgeon. This is due to the high postoperative complication rate compared to other zones of the hand. Recent literature has described the application of the wide-awake approach in primary flexor tendon repair, which allows the surgeon to provide analgesia and a bloodless field with the application of a local anaesthetic with epinephrine. The aim of this study is to compare patient outcomes between the conventional surgery done under general anaesthesia and the one performed with the wide-awake technique. Method: A retrospective cohort study was conducted on 84 patients who had sustained injuries to their zone II flexor tendons and went for primary repair at UHSM between 2011 and 2016. Data on patient demographics, flexion and extension deficit at the PIP and DIP joint were collected and used for Mann- Whitney U statistical analysis. The threshold for statistical significance was p<0.05.
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Results: Of 84 patients, 57 were treated under general anesthesia with a tourniquet and 27 under local anaesthesia. The median range of movement at the 12 week follow up was 96 [61129] degrees for the general anaesthesia group and 97 [78-133] degrees for the local anaesthetic with epinephrine group. No statistical difference was found between the groups (p>0.695). Overall, there were 2 ruptures in the general anaesthetic group and none in the wideawake group. According to Strickland’s classification, 32.2% of our patients had good or excellent results 12 weeks post-operatively. Conclusion: There appears to be a lack of a difference between wide-awake and general anaesthetic surgery for flexor tendon repair in zone II of the hand. This unexpected finding serves as a pilot study for further research with higher evidence level to take place.
2. Ying Mao Gn, Bernard Pac Soo, Dr Suganya Reddy – Audit Introduction: In view of the rising prevalence in antimicrobial resistance and post-surgical infection, the importance of adherence to local antibiotic prophylaxis (AP) guidelines cannot be overlooked. This audit evaluated the adherence to local AP guidelines in Royal Preston Hospital. Methods: This is a retrospective study of 119 patients who received surgery between Jan 2015 and July 2016. The audit focused on general surgical procedures including laparoscopic cholecystectomy,
Nissen
fundoplication,
hiatus
hernia
repair,
cardiomyotomy,
cardio-
oesophagectomy, gastrectomy, appendicectomy, and elective lower gastrointestinal (GI) surgery. Adherence was assessed by reviewing medical records. The following aspects were examined: antibiotic agent, dosage, duration and timing. Any divergence from local guidelines was considered as disconcordant. Results: 68% of the patients were given AP that was adherent to local guidelines. Adherence varied
from
100%
in
cardiomyomectomy
and
cardio-oesophagectomy
to
18.8%
in
appendicectomy. An incorrect agent was the most common cause of poor adherence, and appendicectomy accounted for the majority of these cases. Co-amoxiclav was prescribed instead of the recommended cefuroxime-metronidaole regime in all cases of appendicectomy which were non-adherent to local guidelines. This consistent trend could be attributed to surgeon’s preference. Conclusion: Adherence to guidelines was suboptimal at 68%. In particular, there was a tendency for surgeons to incorrectly use co-amoxiclav in appendicectomy. A further audit to identify the barriers in adherence is needed to find practical solutions to increase the quality of AP in surgery.
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3. Akash Jangan – Research Background: AAA surveillance aims to identify patients that may benefit from prophylactic surgery. Elective repair is considered when an aneurysm reaches 5.5cm (men) and 5cm (women). However, a significant proportion of aneurysms rupture under 5cm. Objectives: We explored the relationship between aneurysm distensibility and growth rate in the hope to identify a measurable parameter than can be used to determine individualised surveillance frequency and surgical threshold. Methods: 38 patients were recruited from the aneurysm surveillance clinic that have growth rate data over a 2-year period. The maximal diameter was measured in systole and diastole in order to calculate pulsatility and distensibility. Aneurysms were categorised into fast growing (≥3mm/year) and slow growing (<3mm/year). Pearson’s correlation coefficient was calculated to identify for any relationship between growth-rate and various independent factors. Mean inter and intra-observer variability was recorded in order to check for reproducibility and repeatability. Results: Fast growing aneurysms have a strong correlation with distensibility (r=-0.79, p=0.0022) and pulsatility (r=0.85, p=0.0005). However, slow growing aneurysms do not have any significant correlations. Mean intra-observer variability for systolic (0.8mm +/-0.7) and diastolic (1.1 +/-0.7) measurements was lower than the mean pulsatility (1.2mm +/-0.7). Conclusion: Aneurysm that have greater distensibility and pulsatility grow faster than aneurysm that are less distensible or pulsatile. Distensibility and pulsatility are reproducible and may have a role in identifying fast growing aneurysms and could be used for individualised surgical threshold monitoring.
4. Georgina Keyte – Preoperative and Intraoperative Care in Revision Arthroplasty Audit The objectives were to firstly assess completeness of patient preoperative work-up prior to hip and knee revision. Secondly to assess completeness of intraoperative sampling comparing findings of both to guidelines set by The American Academy of Orthopaedic Surgeons (AAOS). A retrospective audit (registered with Gateshead NHS Trust) was carried out to collate work-up and intra-operative data for hip and knee revisions from electronic notes. The sample consisted of 132 patients who had hip or knee revisions between 01/01/2014 and 31/12/2015. It was found that only 8% of hip and knee revisions followed all of four AAOS guidelines observed in this audit
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(100% of patients having preoperative CRP and ESR, joint aspiration and six intraoperative cultures), analysis also showed 19% of revisions had 6≤ cultures and 77% had 3≤ cultures. It can be concluded from this audit that although the department is compliant with certain aspects of the AAOS guidelines, such as carrying out CRP in all 1st stage and 2nd stage revisions, guidelines were not completely adhered to in other aspects. It would be constructive to follow up and compare patients where guidelines were not adhered to, assessing the impact of not collecting preoperative data and sufficient cultures focusing on the four classification of prosthetic joint infections. It would also be interesting to investigate what is involved in the clinical judgements that determine whether these guidelines are adhered to.
5. Aziza Mohamed – Case report Degloving injuries of the foot are likely to cause extensive loss of skin with varying degrees of deep tissue loss due to trauma. This type of injury commonly occurs in vehicle-pedestrian accident victims who experience blunt trauma with shearing forces. In this case, a 52 year old male lorry driver was thrown into a metal gate following a malfunction in his vehicle’s operations. Following the accident, he sustained an extensive degloving injury of the dorsum of his foot and multiple fractures sustained around the distal leg and ankle joint. Whilst there are several options that are available for treating soft tissue injuries; no evidencebased guidelines have been published on how to best manage these injuries. This case report will discuss principles that aid in deciding the appropriate management of soft tissue injuries, at each point exploring the indications of using the free latissimus dorsi (LD) muscle flap for the reconstruction of the patient’s injuries.
6. Kiran Nadeem – Research Background: Arterial occlusive disease can result in lower limb ischemic rest pain or myocardial infarction. A graft may be used to bypass the diseased portion and subsequently treat the significant ischemia. Coronary Artery Bypass Grafting (CABG) and Peripheral arterial occlusive disease Bypass Grafting (PBG) are used to restore the blood supply. Current pre-operative evaluation of vein size and quality for bypass graft is completed by standard 2D Duplex Ultrasound (DUS) and is essential to reduce complications, cost and number of incisions. However, its use is limited by its dependency on equipment and operator experience.
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Aim: To assess the utility of Tomographic Ultrasound (tUS) in allowing surgeons to quickly visualise and identify suitable veins for bypass grafting. Methods: We recruited 17 patients due to undergo coronary or peripheral arterial occlusive disease bypass grafting. Pre-operative bilateral DUS vein mapping of the long (LSV) and/or short (SSV) saphenous vein was compared to tUS post procedure. Both DUS and tUS reports were compared to the vein intra-operatively and Post-operative questionnaires were also completed. Results: tUS vein mapping is 90% quicker to perform and 69% faster to report than DUS. It provides adequate reconstructions of vessels, adds more value to clinical decision-making and correlates well with intra-operative findings. The majority agreed that tUS could replace duplex, however it may be limited in some domains. Conclusions: Pre-operative vein mapping using tUS is a more efficient investigation than DUS and allows the surgeon to visualise and assess vein quality directly, reducing procedure time and cost.
7. Kok Weng Ow â&#x20AC;&#x201C; Research Background: Ticagrelor is a more potent platelet inhibitor than clopidogrel but also has a more rapid offset of inhibitory effect. The optimal timing of discontinuation of ticagrelor prior to coronary artery bypass graft (CABG) surgery is unknown. In the ONSET/OFFSET study of patients with stable coronary artery disease, ticagrelor's effects dissipated within 48-120 hours of discontinuation. However, pharmacodynamics of antiplatelet therapy are altered during an acute coronary syndrome (ACS) and the ONSET/OFFSET study results should not be extrapolated to ACS patients. Although the PLATO study suggested that it was safe to discontinue ticagrelor 48 hours prior to CABG surgery, regulatory authorities cautiously recommended that ticagrelor be discontinued 5 days prior to surgery. Methods: ACS patients treated with ticagrelor and referred for CABG were recruited. Venous blood was drawn from patients at 6 timepoints: 2 hours (h)(T0), 24h(T1), 48h(T2), 72h(T3), 96h(T4), and 120h(T5) after the last dose of ticagrelor prior to CABG. Whole-blood aggregometry was carried out using the Multiplate analyser and the final value of area under the curve (AUC) was recorded. Results were analysed using linear mixed models (SPSS Statistics 22). An AUC of >50U supports safe progression to surgery, while values â&#x2030;¤50U indicates need for re-testing 24-48 hours later.
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Results: Only at T4 was the mean (82.8U) and lower limit of the confidence interval (95%CI, 60.4,105.2) >50U. From the analysis, the comparison between T4 and T5 showed no significant difference (P=1.000). Conclusion: ACS patients might be safe to undergo CABG surgery 4 days after the cessation of ticagrelor.
8. Kunal Rajput â&#x20AC;&#x201C; Review Background: Today, robotic major hepatectomies (RMH) are being performed in only few centres and have shown to provide clear advantages toward minimally invasive surgery. Objective: Hence this review aims to report the safety and effectivity of robotics in major liver resection, moreover comparing its potential benefits to LMH and Open major hepatectomies (OMH). Method: Major hepatectomy was defined as resection of more than 3 Couinauds segments. A systematic literature search was performed of various electronic databases. Studies in English, limited to adults, and between January 2000 to June 2016 were selected. Only articles with more than 5 cases were included. Results: Our review includes 7 studies with 114 RMH, among them were 55 right hepatectomies and 38 left hepatectomies. The most common indication for surgery was for resection of liver metastasis (n=44) followed by benign tumour (n=22), hepatocellular carcinoma (n=20), Intrahepatic cholangiocarcinoma (n=5), others (n=15). There were no mortalities, with 28 (25.7%) morbidities. Weighted mean post-operative time was calculated at 402.6min and estimated blood loss at 333.7mL. There were 8 (7.3%) conversions from purely laparoscopic to open surgery and 19 (17.4%) patients overall received blood transfusions. There were 6 metastatic recurrences, and resection margins were found to be R1 in 3 patients. Cost of the operation was noted to be higher in RMH than the laparoscopic or open counterparts. Conclusion: The review can safely conclude that RMH are feasible and effective when operated by experienced surgeons. Therefore, robotics make up a new era in laparoscopic minimally invasive surgery. However, further studies regarding the long term outcomes in patients with metastatic pathology and its financial suitability are necessary.
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9. Haseem Raja - Research 10. Sinthuja Naguleswaran – Winner of Scalpel’s first essay competition – “What does surgical patient care look like for the future?”
Organising committee Conference Director – Judith Osuji President – Rayko Kalenderov Vice President – Robert McFarlane Treasurer / MRI rep – Aiden Moore Secretary – Rachel Khaw Communications and publicity – James Coey Workshop lead – Benjamin Kadler Lectures lead – Emma Das Membership and IT – Bradley Storey Salford rep – Nicholas Ward MRI rep – Sarah McBrinn UHSM rep – Natalie Croghan Phase 1 rep – Ozhin Karadakhy Phase 1 rep – Robbie Kornitschky
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Notes
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