SUSC 2014 Conference Booklet

â&#x20AC;Š

6th Annual

SCALPEL UNDERGRADUATE

SURGICAL C O N F E R E N C E

Saturday 18th October 2014 Roscoe Building, University of Manchester, Brunswick Street, M13 9PL

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Contents

! ! Welcome

Day Plan

Room Plan

Organising Committee

Tutors

Keynote Speakers

Practical Workshops

Academic Workshops

Abstracts

Research

Audits

Case Reports

Reviews

Posters

Notes

Welcome Dear colleagues, It gives me great pleasure to welcome you to Scalpel's 6th undergraduate surgical conference, the work that the committee have put in throughout the year organising this event means it is sure to be an excellent day, I hope you enjoy it! This is my third year working on the Scalpel committee so I have seen the excellent standards that the conference always reaches. This year we have built on those, taking the conference from strength to strength. However, the enthusiasm of the delegates is what makes the conference what it is and I am excited to meet similarly minded students from around the UK and further afield. We are delighted and honoured to have three excellent speakers - Miss Sarah O'Dwyer, Professor A Ross Naylor and Mr Jonathan Ghosh - presenting at our conference. They are some of the most highly respected surgeons in their field. There are so many opportunities to take from the conference: presenting your work, learning about research in the various surgical fields, getting the chance to have some hands experience of surgical practical skills as well as various academic workshops to help you further your surgical career. I hope you all take something from the day. There are many people to thank, without whom - this event could not have taken place. To start I would like to thank our sponsors (noted on the back page), without their financial support it would have been a lot more difficult to organise the day. I would especially like to thank Manchester Medical School, MedSoc and the students' union for the support they have shown us throughout the year. Our events would not be possible without the continued support of the surgical trainees across the year, their standards teaching and passion for surgery inspire all of the attendees at our events. This year we have had three excellent patrons, Mr Ghosh, Mr Evans and Mr Barr, all of whom have given us invaluable support throughout the year. Finally I have to say how impressed I am by the level of dedication, passion and team work shown by the committee working together throughout the year and especially for the conference. I would like to take the opportunity to give them the biggest thanks and thank them for all of the work they have done in the past year. Enjoy the day!

! ! ! ! ! !

Lauren Bolton â&#x20AC;Š

Scalpel President 2014

Day Plan 0800-0900

Registration

0900-0915

Presidential Greetings and Welcome

0915-1000

“Current applications for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the UK”

Lauren Bolton (Scalpel President)

Miss Sarah O’Dwyer

Group A

Group B

Practical Workshops

Presentations

1000-1115

Coffee

1115-1130

1130-1230

“The War Against Error and Other Weapons of Myth and Distraction” Professor Ross Naylor

Lunch

1230-1315

Presentations

Practical Workshops

1315-1430 2a

Coffee

1430-1445

Academic Workshops 1445-1545 1

1545-1645

1645-1715

“How to Shape Your Training” Mr Jonathan Ghosh

Prize Giving and Close

Room Plan Practical Workshops

• Knot Tying - 1.001 • Basic Suturing - 1.003 • Orthopaedics - 1.007

Ground Floor

• Vascular - 1.008 • Skin lesions - 1.009

Lecture Theatre A

• Neurosurgery - 1.010

Academic Workshops • CV Clinic - 2.2 • Academic Surgery - 2.3 • Journal Club - 2.4 • ASiT Battle of the Specialities - 1.001

Presentations • Sessions 1A & 2A - 2.4 • Sessions 1B & 2B- 2.3 • Session 1C- 2.2

Level 1

Level 2 1.007

2.10

2.5

1.008

2.4

1.009

2.3

1.010

2.2

1.003

1.001

Organising Committee Look out for our pale blue lanyards and scalpel badges!

Rachael Morley (Conference director)

Adam Fareed (Treasurer)

Lauren Bolton (President)

Rayko Kalenderov (Membership and IT)

Mandeep Minhas (Vice-president)

Tariq Ramtoola (Secretary)

Thomas Alexander (Comms and publicity)

Ed Cornish (Workshop director)

Jack Turnbull (MRI representative)

Claire Gillon (Lectures lead)

Yousef Majeed (UHSM representative)

Djamila Rojoa (Phase 1/Year 3 rep)

Natasha Westbrook (Salford Representative)

Mark Poustie (Phase 1 rep)

Tutorsâ&#x20AC;Š Lorna Ewan

Hud Shaker

Melanie Dowling

Laura Derbyshire

Hema Sekhar

Ben Starmer

Pete Coe

Rachel Clifford

Molly Jakeman

Richard McBride

Joanne Todd

David Ormesher

Jim Walkden

Zeni Haveliwala

and moreâ&#x20AC;Ś

Nick Boxall

Carla Renfigo

Thisara Weerasuriya

Jason Wong

Francis Chan

Sophy Rymaruk

Emmanuel Katsogridakis

Laura Moncreiffe

Joshua Burke

Aliya Mastan

Hariette Packer

Indy Samra

Aliya Mastan

Samuel Debono

Moez Zeiton

Tejal Parekh

Rukhtam Saqib

Antonia Hoyle

Keynote Speakers Miss Sarah O’Dwyer !

Divisional Director of Cancer Centre Services, Consultant Colo-Rectal Surgeon, The Christie NHS Foundation Trust

!An experienced consultant surgeon, Miss Sarah O’Dwyer is nationally and internationally acclaimed in the fields of colorectal disease and !peritoneal malignancy. She has long promoted screening for early detection of pre-cancerous polyps and bowel cancer, in parallel with evaluation of cancer risk and family cancer syndromes. !She completed her undergraduate training at University of St Andrew’s and Manchester Medical School, postgraduate clinical ! and undertook a Research Fellowship in Harvard University. training in the North West of England Miss O’Dwyer is an Intercollegiate Examiner for Completion of Surgical Training in General/Colorectal Surgery, NICE Specialty Adviser for Peritoneal Carcinomatosis and is actively engaged with the Department of Health Specialist Commissioning Groups advising on Colorectal Services.

! !!Professor Ross Naylor Honorary Professor of Vascular Surgery & Consultant Vascular University of Leicester !Surgeon, Featured on the Times Top Surgeons list, Prof Naylor is respected in the field of carotid artery surgery; !internationally known for improving the safety of carotid endarterectomy, used to strokes. Led research to create an early-warning system to !prevent help prevent potentially fatal strokes during or soon after operations, which is now routinely used in Leicester’s hospitals. !He is the author of 340 publications in peer-reviewed journals; president-elect of the Vascular Society, and senior editor of the European Journal of Vascular and Endovascular Surgery. ! Prof Naylor will be giving a talk entitled, “The War Against Error and other Weapons of Myth and Distraction.”

! Mr Jonathan Ghosh North West Core Surgical Training Lead. Cons. Vascular & Endovascular Surgeon Whythenshawe Hospital Jon Ghosh has been a Consultant Surgeon since 2011 and is an Honorary Senior Lecturer at the Universities of Manchester and Salford. Mr Ghosh provides a consultant led, team-based comprehensive service for the medical, endovascular and surgical management of all vascular diseases. He has active roles in medical education and research. Mr Ghosh acts as Undergraduate lead for Surgery at University Hospital of South Manchester. He is lead for the North West Core Surgical Trainee Education Programme and an enthusiastic educator of open surgery, endovenous thermoablation, endovascular surgery and workstation skills. He is a tutor to 3rd and 5th year undergraduates, teaches professional development modules, and acts as clinical and acts as an educational supervisor for postgraduate trainees at all levels. He is course director for the regional RCS Basic Surgical Skills course and Emergency Surgery module lead for the Salford University MSc Surgical Science programme and lectures for Manchester University MSc programmes.

Practical Workshops Basic Suturing with Miss Lorna Ewan

Advanced Suturing with Miss Laura Derbyshire

Knot Tying with Mr Peter Coe

Orthopaedic Skills with Mr Thisara Weerasuriya and Mr Francis Chan Equipment provided by Stryker.

Vascular Techniques with Mr. Richard McBride

Neurosurgical Techniques with Mr. Jim Walkden Equipment provided by Brainlab

Academic Workshops CV Clinic with Mr Nick Boxall

Academic Foundation Programme with Mr. Emmanuel Katsogridakis

ASiT Battle of the Specialities with Miss Laura Derbyshire and co.

MMRSoc Critical Appraisal Workshop with Mr Pete Coeâ&#x20AC;Š

Abstracts 10.00-11.15 Session 1A (Chair: Josh Burke -MMRSoc President) - R1, R2, R3, R4, R5 Session 1B (Chair: Lauren Bolton - Scalpel President) - C1, C2, C3, C4, C5 Session 1C (Chair: Daniel Fitzpatrick - SEMSoc President) - A1, A2, A3, A4, A5 13.15-14.30 Session 2A (Chair: Josh Burke -MMRSoc President) - R6, R7, A6 Session 2B (Chair: Lauren Bolton - Scalpel President) - C6, REV1-3

Research R1 Jessica Daniels Is the preoperative radiograph a reliable tool in deciding whether to offer total hip replacement for osteoarthritis? Jessica Daniels, Wiqqas Jamil, Winston Kim Hip osteoarthritis is a functionally limiting condition which surgeons assess clinically and radiologically to guide the timing of total hip replacement (THR). However, there is evidence suggesting radiological osteoarthritis does not reflect clinical severity. We aimed to determine whether x-rays reliably reflect clinical osteoarthritis using the oxford hip score (OHS). 63 patients were included who underwent THR between 2009 and 2013. Each completed the OHS over the telephone at least 1 year postoperatively. Joint space was measured radiographically at its narrowest, superiolateraly, apically and superiomedially, these measurements were correlated with pre and postoperative OHS. Median preoperative OHS was 17 and improved to 41 following THR, mean improvement in OHS was 42%. No correlation existed between joint space and pre or postoperative OHS. Surgeons require other methods to aid difficult surgical decisions, especially when managing patients with minimal radiological changes.

R2 Reuban D’Cruz Is Faster Better? Operative duration in Emergent Appendicectomy Background:   For many years, acute appendicitis has been regarded as a condition that required urgent surgical treatment. Emergent appendicectomy has been accepted generally as the most appropriate treatment, despite the lack of objective proof. The timing of appendicectomy has been investigated in the adult population but no definite conclusion has been made.   Purpose:  The objective of this study was to investigate the effect of operative duration of appendicectomy on outcomes such as complications and length of stay.   Methods:  Retrospective study of 271 patients who had undergone appendicectomy in Year 2013 was conducted. Data that includes time of presentation to Emergency Department, presenting complaint, diagnostic investigations, time of operation, length of hospital stay and complications were collected. These patients were subsequently put into categories based on the duration of appendicectomy.   Results:

182 patients had at least one form of diagnostic imaging modality performed. Pre-operative laboratory investigations were conducted in most patients. 193 out of 261 patients (73.9%) had their surgery within 24 hours of presentation. 253 patients (93.3%) had undergone laparoscopic appendicectomy. The average operating time was 63.8 mins.   There was a linear correlation between the operative duration and the length of hospital stay. There was no significant difference in the incidence of complications of acute appendicitis.   Conclusions:  The timing of appendicectomy was associated with increased length of stay. The optimal timing of completion of appendicectomy for acute appendicitis would be within 60 mins from the time of skin incision. However, operative duration did not affect the incidence of complications of acute appendicitis.

R3 Sophie Rogers Objectives: A comparison of 65 year old male patients with screen-detected abdominal aortic aneurysms (SDA65) to a non-aneurysmal, age matched 65 year old patient cohort (NAAM65) to investigate whether 65 year old males with abdominal aortic aneurysms (AAA) are inherently less physiologically fit, with an increased surgical risk in comparison to their age matched peers. Additionally, comparison of 65 year old male patients with screen-detected AAA (SDA65) was made to a case matched patient cohort of non-screen detected AAA, 75 year old male patients (NSDA75) to investigate any differences in physiological fitness and surgical risk at AAA repair despite a 10 year age gap.  Methods: A retrospective, single centre study at Manchester Royal Infirmary. SDA65 n=21, NAAM65 n =21, NSDA75 n=24. A proforma of physiological parameters was developed from pre-existing preoperative risk assessment tools with the addition of cardiopulmonary exercise testing (CPET) variables.  Results: SDA65 vs NAAM65 showed a total of 8 statistically significant results; p<0.05 (smoking, hypertension, lung disease, eGFR, creatinine, VO2@AT <11ml/kg/min, EqCO2 >34, EqCO2). 6 additional parameters had a p value <0.1. SDA65 vs NSDA75 showed a total of 2 statistically significant results (urea, peak VO2).  Conclusion: Statistical analysis has shown that the physiological fitness and surgical risk of 65 year old male patients with screen-detected AAA is inferior when compared to non-aneurysmal, age matched patients. In addition, statistical analysis showed that the physiological fitness and surgical risk of AAA patients with a 10 year age gap was comparable.

R4 Cal Robinson

Footing the bill for inflated patient expectation: the impact of hallux valgus surgery on footwear outcomes. Cal Robinson, Anand Pillai, Abhijit Bhosale

Background: Surgical intervention is indicated for symptomatic cases of hallux valgus unresponsive to conservative methods. Mid- to long-term outcomes following surgery are favourable, with significant symptomatic relief, functional improvement, and high patient satisfaction. The timely return to comfortable footwear reflects considerable symptomatic relief and corresponds to overall patient satisfaction. As such, it should function as a primary operative objective. It is also recognized that despite the provision of contrary advice, a significant proportion of patients will return to ill-fitting, heeled footwear following hallux valgus correction. However, the long-term impact of hallux valgus surgery on patient footwear remains unclear.   Our objective is to establish the impact of the operation on patient footwear, focusing on what proportion of patients are able to meet the objective of a return to comfortable footwear and its timing post-operatively. We also aim to define the number of patients that do return to heeled footwear, looking at the timing and rationales behind their return.  Methods: A footwear-specific outcome questionnaire was designed and, using the hospital surgical database at UHSM, 108 consecutive female patients that had undergone hallux valgus surgery between 2011 and 2013 were identified. 65 responses were included for participation at a mean 18.5 months follow-up.   Results: Our results show that at long-term follow-up 86.1% of patients were able to make a full return to comfortable footwear. Of these, 27.7% reported they were additionally able to return to wearing all types of footwear following surgery. Of those that expressed the desire to return to heeled footwear, 62% were able to do so, with 77.4% of these patients using heeled footwear as or more frequently to

pre-operatively. Heel size did not change significantly post-operatively. Mean return time to heels was found to be 21.4 weeks. Finally, 93.7% of patients reported improved cosmetic appearance postoperatively and only 9.9% of patients described the cosmetics adversely impacting footwear selection.  Conclusions: Our findings illustrate the high footwear outcomes found in female patients following hallux valgus surgery. They also suggest an “all-or-none phenomenon” where patients reject modifying footwear use until able to do so at the same frequency and heel size as before. These findings demonstrate the importance of pre-operative counselling and management patient expectation in forefoot surgery.

R5 Deevia Kotecha Trans-vaginal Doppler ultrasound for detecting pelvic vein incompetence in women D. Kotecha, V. Hansrani, C. McCollum

Background Reflux venography is seen as the gold standard method for diagnosing pelvic vein incompetence (PVI). However, it is an invasive procedure involving nephrotoxic contrast and radiation in young women of childbearing age. Trans-vaginal Doppler ultrasound (TVU) is growing in popularity as a non-invasive, safe alternative to reflux venography. We compared TVU with reflux venography for the detection of PVI.  Methods   TVU and reflux venography were compared in 32-paired images from 16 patients. Sensitivity, specificity, positive and negative predictive values were calculated for TVU with reflux venography as the ‘gold standard’. Inter-observer reliability analysis using the Kappa statistic was performed. A P-value < 0.05 (two sided) was considered significant. Data were analysed using SPSS version 22.0.   Results   32 paired TVU and reflux venography images were analysed from 16 women with a mean (range) age of 39.8 (29-46). PVI was detected in 12 images with reflux venography and XX scans on TVU. The sensitivity, specificity, positive and negative predictive values of TVU to detect PVI were 92%, 100%, 100% and 75% respectively. The inter-observer reliability of TVU was in almost perfect agreement between the two observers (Kappa =0.81; p= 0.002).  Conclusion   TVU may be an accurate and safe alternative to reflux venography in the diagnosis of PVI.

R6 Ethan Clough Are there any differences between partial thickness burn and partial thickness excisional wound healing? Burn patients suffer different depths of wounds as a result of their injury. Healing of the burn wound is often accelerated by using a partial thickness excisional wound (donor sites of skin grafts). A greater understanding of the differences or similarities on how both wound types heal on a cellular level is essential to ensure appropriate and optimal wound management is provided to burn patients. This pilot observational study sought to investigate in a porcine model the similarities and differences between partial thickness burn and partial thickness excisional wound healing at day 7 and 70 post-wounding. 2.5cm2 partial thickness burn and excisional wounds were created on the backs of anaesthetized Hampshire pigs and harvested at the two time-points. Tissue samples were subjected to routine histology and immunohistochemistry to examine differences in the inflammatory profiles and reepithelialisation rates of both wound types and the architecture and re-pigmentation of resulting scars. Wounds/scars were quantitatively analysed using image analysis software and subjected to statistical analysis. This study has demonstrated that wound healing and resultant scarring is dependent on the mechanism of injury. Partial thickness burn wounds differed significantly in their macrophage profiles, re-epithelialisation rates and neo-epidermal and neo-dermal formations compared to partial thickness excisional wounds. Furthermore, the melanocyte population, activation status, microscopic melanin deposition and subsequent macroscopic appearances of resulting scars were also dependent on the wound type. These initial findings could support possible modulation of the wound environment with novel interventional wound therapies.

R7 Mike Pallot Assessment of performance status in the pre-operative assessment of metastatic spinal cord compression J.M.Pallot, B.M. Davies [MRCS], D.van Popta [FRCS] Introduction Performance status [PS] attempts to quantify a patient’s general well being. The Karnofsky and Eastern Cooperative Oncology Group [ECOG] systems are most commonly used. ECOG has been adopted by the WHO and found in Lung cancer to have better prognostic value than Karnofsky. We review current practice and prognostic value of PS in patients with metastatic spinal cord carcinoma [MSCC]. Subjects Patients (>18 yrs) undergoing surgery for MSCC over 3 years [N=158; F=77, M=75]. Method Retrospective review of post operative MDT meetings to identify the method and grade of performance status. At least 2-year follow up data was available for all patients and used to note survival time. The relationship between PS and survival time was assessed using Spearman’s Rank Correlation Coefficient and its relationship with overall survival using Kalpin-Meir analysis [SPSS, Chicago IL]. Results Performance status was recorded in 58% of cases (91). 55% of patients (87) had an ECOG grade, and 34% of patients (53) had a Karnofsky grade. No alternative PS was used. Where both were recorded the PS scores strongly correlated (Spearman’s Rho=0.88, p<0.001, N=54). PS did not predict long-term survival. Conclusions Pre-operative performance status was not a good indicator of long-term survival.

Audits A1 Sophie Collinson Outcomes of Laparoscopic versus Open Pyeloplasty in children over five Dr. Shagufta Jabeen (clinic fellow RMCH), Sophie Collinson, Miss Anju Goyal and Mr Supul Hennayake

Antenatal hydronephrosis resulting from pelviureteric junction obstruction (PUJO) is a common manifestation identified in pregnancy. Symptomatic disease presents as intermittent loin pain, vomiting and recurrent urinary tract infections. The modern emphasis on primary prevention of disease encourages early intervention for PUJO to limit any decline in renal function. Minimally invasive procedures have been encouraged and laparoscopic pyeloplasties (LP) have emerged in paediatric urology. Previously a thorough analysis of the success of LP at Royal Manchester Children’s Hospital (RMCH) had not been completed. An audit was therefore conducted to assess the complication rate of LP performed in children over 5 over a 7-year period. Results suggest that LP offers no definite advantage over the traditional open approach. Advances in training schemes, scrutiny of operative approach and thorough analysis of previous surgical errors will undoubtedly improve paediatric pyeloplasty outcomes.

A2 Nadin Jallad Service Evaluation of permanent Sacral nerve stimulation for faecal incontinence in patients treated at University Hospital Southampton Nadin Jallad, Janet Hicks, Sophie Pilkington, Karen Nugent, Tom Dudding

Background Sacral nerve stimulation (SNS) is a surgical procedure used in patients with persistent faecal incontinence(FI) following conservative measures. SNS produces neuromodulation to the third sacral nerve and is beneficial in 50-70% of patients. Patient triggered follow-up is used at Southampton University hospital for SNS patients; a previous service evaluation concluded that ongoing support by healthcare practitioners is needed, with an average outpatient appointments of 2.7. Aims The aim of this service evaluation is to assess patient satisfaction, service compliance with NICE guidelines, and long-term outcomes within the Southampton SNS service using postal questionnaires. Methods Between 2000-2013, 100 patients underwent permanent SNS for FI; 92 of which were contacted using

the postal service. To assess long-term efficacy, patient satisfaction and incontinence, participants were asked to fill the Southampton SNS service evaluation questionnaire, faecal incontinence quality of life(FIQL: 1=very affected; 4=not affected) and Cleveland clinic incontinence score(CCS). Visual analogue score (VAS) was used to measure the efficacy of the device and service of 0(not at all) to 10(very much). The modified family and friends test was used to assess patient satisfaction with the service and staff. Faecal incontinence was also assessed by asking patients to fill a 2-week bowel diary. Results Data was collected from sixty-nine patients(64 females; 5 males), with a mean age of 61±13 years. At a mean follow-up of 35±26 months, device efficacy was rated at an average of 73.65% and the service as 86.61%. The median FIQL score for all patients were: Lifestyle: 3.13, coping/behaviour: 2.46, depression/self-perception: 3.33, embarrassment: 2.36. CCS score improved from a preoperative median of 15(2-20) to 9(0-18) at follow-up. At follow-up, patients(n=27) are experiencing an average of 3.9 FI episodes/week. Conclusion High level of patient satisfaction and SNS effectiveness was reported in patients with permanent SNS implant for FI at University Hospital Southampton.

A3 Zayn Sattar Retrospective audit looking at complications following middle ear implant surgery Zayn Sattar, Kevin Green The use of Middle Ear Implants (MEI’s) is a growing trend in the ENT surgical field aimed at patients suffering from moderate to severe sensorineural and mixed hearing loss. It provides an alternative option to those unable to use conventional hearing aids due to repeated infections or congenital deformity. (1)  With such growing use and Manchester Royal Infirmary (MRI) being one of the biggest centres providing such procedures, an audit was conducted in order to establish current practice figures with regards to complication rates. As not much data currently exists on such a topic, it would provide a guide to other centres providing this surgery and raise awareness of possible complications.  Patients for this audit were recruited from procedures carried out by implant specialist ENT Consultant Mr Kevin Green. The notes of post-operative follow up appointments were analysed and compiled to record what complications the patients may have experienced.  In total, this audit included 48 patients of which 17 suffered from no complication. The remainder 31 patients experienced one or more complication post-operatively; the most common amongst those suffering from infection (n=10), displacement of the implant (n=9) and altered taste sensation (n=7).  Out of these 48 patients, 8 eventually required the MEI to be removed. The most common reason for removal was infection (n=4).

A4 Katherine Wadsworth ‘Preventing Postoperative Pulmonary Complications in Surgical Patients’ K. Wadsworth, Dr J. Eddleston Background: Pulmonary complications following elective and emergency surgery are common and can be detrimental to recovery. Central Manchester Foundation Trust is working with Boston Medical Centre in studying the implementation of ‘I COUGH’; 6 simple interventions to prevent pulmonary complications, and observe their effectiveness in reducing complications and thus improving patient care. Aims: This study looked to review current data on postoperative care and evaluate current practice on inpatient surgical wards - focussing on early oral hygiene and mobilisation – to assess how the hospital compared to the ideals of the I COUGH study. It also assessed patient and clinician understanding of the importance of these factors in recovery to identify if there was a need for further education. Methods: A literature review was carried out into the role of oral healthcare and mobility in preventing pulmonary complications of surgery to look at the evidence base behind the interventions. This was followed by a 2 week observational audit of 84 postoperative vascular and general surgical inpatients evaluating mobility, oral health and any current pulmonary pathology. Oral swabs were taken of the final 20 patients to give an idea of the prevalence of bacterial and yeast colonisation of the oral flora to assess effectiveness of current oral hygiene protocols. Conclusions: Simple interventions are effective in reducing incidence of pneumonia. There may be an additional role of antifungal cover in

addition to antibacterial chlorhexidine mouthwash, given an observed 60% prevalence of oral candida albicans.

A5 Michael Pallot Moving towards discharge <24hrs following bariatric surgery: Room For Improvement. J.M.Pallot, B.Hornung (MRCS), B.M.Davies (MRCS), A.Menon (Phd, FRCS) Introduction Minimized post-operative inpatient stay improves patient satisfaction and hospital efficiency. Discharge within 24hrs of bariatric surgery has previously been shown as safe and introduced as a target at our centre. We reviewed current practice and areas for improvement. Subjects Patients (>18 yrs) undergoing sleeve gastrectomy or Roux-en-Y gastric bypass during 2013 at a single centre [N=124; F=71, M=53]. Methods Retrospective review of electronic patient records. Primary outcome was successful discharge <24hrs after leaving theatre recovery. Patient, operative and peri-operative details were analyzed to identify factors associated with failed discharge. Significance was set at p<0.05. Results 17/124 (13.7%) of patients were discharged within 24hrs. We assessed the following co-morbidities (% in successful/% in failed groups): OSA (20/9, p=0.09), Asthma (0/100, p=0.09), Diabetes (11/85, p=0.5), and also additional operative events (hernia repair/ cholecystectomy/adhesiolysis) (0/100, p=0.08); these were not found to be significantly associated with discharge time. Successful discharge was more likely from Level 2 care (27%/Total) than Level 1 care (12%/Total). Time taken for pharmacy to convert medication to bariatric compatible medication was not associated, but time to prescription of discharge medication was (p=0.02). Conclusions Few patients are meeting current discharge targets. Efforts to improve this could include preparation of discharge medication and recognition of high-risk groups/wards.

A6 Parviz Sorooshian Streaming cataract surgery - an effective pathway of care for the patient Cataract remains as the most common cause of visual impairment and accounts for 47.8% of global blindness. Over the past decade, the number of cataract operations has doubled which can be attributed to an expansion in the elderly population, resulting in a higher incidence of age-related cataracts. This has had various implications on the cataract surgery pathway, including: patient satisfaction, health economics, training, research and innovation. This article reviews the current pathway and specific modifications are discussed that may optimise the delivery of care for cataract patients. From a managerial perspective, the importance of the fluid movement of patients along the cataract pathway is highlighted as the steps involved in the diagnosis, referral and pre-operative assessment of patients are analysed. With the aim of cutting waiting times due to the current socioeconomic depression, the effects on staff availability and performance are covered as well as the attention the NHS gives towards risk stratification and patient safety. Finally, insight is gained in to existing training programmes that junior ophthalmologists use to build their experience and skills in cataract surgery whilst accounting for their influence on operating times. Whilst preserving the vision of patients remains as the top priority in cataract surgery, viewing the care pathway from financial, technical and educational perspectives are crucial for streaming cataract surgery.

Case Reports C1 Dharmarraj Sunthar Burns in Smokers with a focus on Electronic Cigarettes Electronic cigarettes are rapidly increasing in popularity since it was introduced in mid-2000s. Manufacturers see it as a contender and a viable alternative to nicotine replacement therapies. That said, the general efficacy and safety of this product is questionable. There has been no reliable evidence to-date about the use of this device in achieving full cessation from tobacco smoking. There is also a wide range of e-cigarettes available in the market that are manufactured with no standardised quality

control regulations in place posing a safety issue. Further to this, self-exploding e-cigarettes have been reported across the world. With the belief that e-cigarettes are safe, they are consumed in places where conventional cigarettes are previously not allowed, posing a serious fire threat. This case report follows the journey of a patient who sustained extensive facial burn injuries requiring skin grafts from an explosion involving the use of e-cigarette while on oxygen therapy.

C2 Fatima Saeed Malignant Obstructive Jaundice – A Case Report A case report following the clinical presentation, investigations and treatment received by a patient diagnosed with a malignant obstructive jaundice (cholangiocarcinoma/CC). Within this article the relevant hepatic and biliary surgical anatomy and physiology are summarised: the current literature regarding specific management of CC analysed: the possible use of tumours markers such as CA19-9, CEA and CYFRA-21, differing imaging modalities, classification systems available, the value of prognostic markers in the ideal model for classification and the possible use of neoadjuvant chemotherapy are discussed.

C3 Matthew Burrows A 2 year old girl presented to ENT with a 3 week history of a soft tissue swelling within the nasal cavity which completely obliterated the right nostril. Head CT and MRI scans were carried out, and a biopsy under general anaesthetic revealed the mass to be an alveolar rhabdomyosarcoma. The patient was subsequently referred to a Paediatric Oncologist, and has commenced chemotherapy and will be surgically reassessed. The patient was also eligible for proton beam therapy due to the location of the tumour which she is receiving in the United States. This case report summarises the pathology and different types of rhabdomyosarcomas, the current multimodal treatment including chemotherapy, radiotherapy and surgery, and also the novel therapies being explored.

C4 Reuban D’cruz Case Study of Pancreas-preserving Enucleation in the treatment of Isolated Pancreatic Metastases of Renal Cell Carcinoma Background:   Pancreatic metastases accounts for 2.8% of cases in RCC, occurring as a result of haematogenous spread. High affinity of some renal cancer cells for the pancreatic parenchyma present solely as isolated pancreatic metastases.   Literature reviews have highlighted that aggressive surgery for isolated pancreatic metastasis have been shown to increase 5 year survival rates unto 60%; particularly nephrectomy & metastasectomy with adjuvant therapy.  The objective of this case study was to identify the benefits of pancreas-preserving enucleation in treatment of isolated pancreatic RCC metastases over traditional pancreatic resections.   Report:  X is a 77 year old male, presented with 2 day history of frank haematuria & weight loss of 3kg over 6 months with no associated fever, flank pain or dysuria. CT KUB revealed lobulated soft tissue density in the right kidney, suspicious for a tumour. Further staging investigations, CT TAP demonstrated a small enhancing nodule in pancreatic body confirmed as pancreatic metastasis with EUA FNA. The patient subsequently underwent Open Right Radical Nephrectomy with Enucleation of Pancreatic Metastasis.  Discussion:  Comparisons drawn between Pancreatic-sparing Enucleations and standard resection (Complete Pancreatectomy) explore variations in surgical challenges & post-operative complications. While there has been no difference in morbidity and recurrence noted compared to complete pancreatectomy; there has been significant reduction in post-operative diabetes mellitus.  Conclusions:  Previously associated with high rates of morbidity and mortality, reduced operative risk in pancreatic surgery have been demonstrated in recent times. As such, Pancreas-sparing Enucleation & Enucleo-

resection has been considered a worthy option. Preservation of pancreatic tissue allows for better quality of life without diabetes mellitus.

C5 Catherine Chan Takayasu's arteritis (TA), also known as Aortic Arch syndrome or Pulseless Disease, is an extremely rare condition characterized by progressive narrowing of the aorta and first order branches. The manifestations of TA are hugely varied and severe. Narrowing of aortic branches eventually causes ischemia, multiple organ failure and death.   Surgical intervention represents an important form of disease control. Current approaches include angioplasty and stenting, however, in-stent restenosis is frequent. Bypass grafting from the ascending aorta is extremely dangerous as clamping of the aorta can disturb the precarious cerebral perfusion which is already compromised by vessel occlusion. Bypass grafts formed directly onto the ascending aorta(AA) are associated with high rates of inflammatory flare and graft failure. We report a patient who successfully received a bypass graft from the descending aorta (DA) instead.   The patient is a 25 year old woman with a diagnosis of progressive TA. Symptoms of cerebral ischemia recurred despite stenting. Angiography revealed near total occlusion of the left common carotid artery(CA) and poor flow via the right carotid artery. The long saphenous vein was harvested and anastomosed onto the descending aorta using the PAS–Port Proximal Anastomosis System. A subfascial tunnel was created to act as passageway for the saphenous graft to travel between the   descending aorta and left CA.   In conclusion, the descending aorta is often unaffected in TA which makes it a potentially more advantageous grafting site in TA. However, the long term outcome of such bypasses is still unknown and requires further investigation.

C6 Humzah Amin The dangers of intravesical Bacillus Calmette-Guerin in the management of transitional cell carcinoma of the bladder Intravesical BCG (Bacillus Calmette–Guérin) is recommended for bladder cancers with a high risk of reoccurrence or infiltration. Most side effects are self limiting, however there have been 21 cases of secondary aneurysms. Mr X, a 74 year old gentlemen, was diagnosed with a G3pTa transitional cell carcinoma of the bladder in 2012 after experiencing asymptomatic microscopic haematuria for many months. He underwent a transurethral resection of the bladder followed by 6 intravesical bovine BCG chemotherapy wash-outs. Six weeks later he experienced an abrupt onset of an unknown febrile illness. During the course of investigations an ascending thoracic aortic aneurysm was found. Later, Mr X had a repeat CT scan which showed the lower thoracic aortic aneurysm had increased in size from 5.0cm to 7.5cm and the infrarenal aorta had increased in size from 4.5cm to 7.0cm. The abrupt change in the size of the aorta in 2 areas was in keeping with mycotic aneurysms. Mr X then underwent an endovascular thoracic aorta replacement and was started on a years course of anti tubercular drugs. These entered Mr X into renal failure. In August 2013 he required a cystectomy with an ileal conduit. The response rate of early stage transitional cell carcinoma to intravesical BCG is high. It works through a localised inflammatory response. This case however highlights some devestating side effects; mycotic aneurysms are very rare but potentially fatal and the subsequent anti tubercular drugs which are known nephrotoxic drugs, caused renal failure.

Reviews N.B. Review presentations are not eligible for prizes.

REV1 Harry Apperley Paediatric Genu Varum: Distinguishing the Physiological from the Pathological.

The term genu varum describes an angular deformity of the lower leg, commonly referred to as ‘bow legs’, in which there is either a unilateral or bilateral thrust of the knee away from the midline.   The aetiology is varied. An estimated 40% of referrals of infants with bowed legs to orthopaedic surgeons are found to be physiological cases and spontaneously resolve during development. However, there are numerous pathologies that are indications for intervention.   Efficacious treatment is available, but not always well directed. The role of persistent deformity in osteoarthritis is clear, and makes effective management of varus alignment in all age groups paramount if we are to minimise disability both in childhood, and later life.

REV2 Irina Earnshaw Is it time for fMRI to replace the Wada test in the preoperative assessment of intractable temporal lobe epilepsy? Epilepsy is one of the world’s most common neurological disorders, affecting around 50 million people worldwide. Epilepsy originating from the temporal lobe accounts for a significant number of these cases, and as one of the most pharmacologically unresponsive epilepsies, accounts for the majority of surgical referrals. Due to the number of important functions controlled by the temporal lobe, a variety of possible deficits may occur after temporal lobectomy. One of the most clinically significant of these is a decline in verbal memory (memory involving words and language), which occurs in between 20 and 60% of patients.  Currently, there are a variety of methods for predicting the potential extent of verbal memory decline after surgery, which is necessary for preoperative planning and counselling. This review, part of a larger critical review comparing several different methods, sought to compare the Wada test and functional MRI. The Wada test is one of the oldest methods, developed in the 1950s, however it is still in routine use in epilepsy centres. On the other hand, functional MRI is relatively young, having only been developed in the 1990s, and is rarely used outside of a research context.  Comparison of a number of papers showed that the drawbacks of the Wada test, such as its invasiveness and distressing nature, outweigh its benefits, and point to a conclusion that it is time for fMRI to make the transition from research to clinical practice in the preoperative planning of epilepsy surgery.

REV3 Matthew Lee In Breast Reconstruction Following Mastectomy, is the Deep Inferior Epigastric Perforator (DIEP) Flap Superior to the pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) Flap? 1 in 8 women will be diagnosed with breast cancer at some point in their lifetime. For patients undergoing mastectomy, breast reconstruction can help maintain their quality of life. Abdominal-based reconstructive techniques are commonly used. The traditional pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) flap has been largely replaced by the Deep Inferior Epigastric Perforator (DIEP) flap. However, there is still debate on whether the more complex DIEP flap reconstruction is associated with significantly fewer abdominal wall-related complications.  This review compares the DIEP and pedicled TRAM flap reconstructions to determine if one is superior to the other in terms of complication rates, patient satisfaction, patient safety, and cost.  A MEDLINE search for articles on DIEP and pedicled TRAM flap reconstruction published from January 2000 up to March 2014 was used to identify potentially relevant studies.  4 studies compared the 2 techniques directly. Additionally, information from 30 isolated studies were pooled together and analyzed. In the pooled studies, there were no significant difference in the rates of fat necrosis (pedicled TRAM 9.5%; DIEP 11.9%), partial flap loss (pedicled TRAM 4.8%; DIEP 2.8%), and abdominal hernias/bulges (pedicled TRAM 4.6%; DIEP 2.8%). The rate of total flap loss in pedicled TRAM flap patients was 0.04%, significantly lower than DIEP flap patients (1.6%). Post-operative surveys revealed no significant difference in patient satisfaction between the 2 procedures.   Data from this review suggest pedicled TRAM and DIEP flap reconstructions have similar complication rates. The traditional pedicled TRAM flap remains a reliable, cost effective reconstructive procedure following mastectomy.

Posters P1 Emma Pedlar Short bowel Syndrome and Food Aversion: Therapeutic intervention in children SJ Wood, T Warburton, L Forcythe, R Coletta, E Pedlar, A Morabito Food aversion (FA) affects 25% of children with short bowel syndrome (SBS), with serious implications for the weaning of PN, growth, and normal familial and social integration.   The aim of this study was to assess the efficacy of a play-specialist led intervention for SBS and FA.   Methods: A retrospective cohort study assessed therapy between 2004-12. 12 children were identified. All had been managed with play-specialist led ‘messy play’. Demographics including nutritional source and growth were collected along with their tolerance to oral diet, taste and texture.   Results: All children had been diagnosed with SBS by 1 month of age. The mean length of small bowel was 37cm, with 10 undergoing bowel lengthening.  Mean age at commencement was 16 months with an average duration of 10 months. All children achieved tolerance to mashed foods, roughly mashed foods, and food with separate lumps.   Conclusions: ‘messy play’ can be associated with successful resolution of FA and SBS.

P2 Parviz Sorooshian Streaming cataract surgery - an effective pathway of care for the patient Cataract remains as the most common cause of visual impairment and accounts for 47.8% of global blindness. Over the past decade, the number of cataract operations has doubled which can be attributed to an expansion in the elderly population, resulting in a higher incidence of age-related cataracts. This has had various implications on the cataract surgery pathway, including: patient satisfaction, health economics, training, research and innovation. This article reviews the current pathway and specific modifications are discussed that may optimise the delivery of care for cataract patients. From a managerial perspective, the importance of the fluid movement of patients along the cataract pathway is highlighted as the steps involved in the diagnosis, referral and pre-operative assessment of patients are analysed. With the aim of cutting waiting times due to the current socioeconomic depression, the effects on staff availability and performance are covered as well as the attention the NHS gives towards risk stratification and patient safety. Finally, insight is gained in to existing training programmes that junior ophthalmologists use to build their experience and skills in cataract surgery whilst accounting for their influence on operating times. Whilst preserving the vision of patients remains as the top priority in cataract surgery, viewing the care pathway from financial, technical and educational perspectives are crucial for streaming cataract surgery.

P3 Ethan Clough Are there any differences between partial thickness burn and partial thickness excisional wound healing? Burn patients suffer different depths of wounds as a result of their injury. Healing of the burn wound is often accelerated by using a partial thickness excisional wound (donor sites of skin grafts). A greater understanding of the differences or similarities on how both wound types heal on a cellular level is essential to ensure appropriate and optimal wound management is provided to burn patients. This pilot observational study sought to investigate in a porcine model the similarities and differences between partial thickness burn and partial thickness excisional wound healing at day 7 and 70 post-wounding. 2.5cm2 partial thickness burn and excisional wounds were created on the backs of anaesthetized Hampshire pigs and harvested at the two time-points. Tissue samples were subjected to routine histology and immunohistochemistry to examine differences in the inflammatory profiles and reepithelialisation rates of both wound types and the architecture and re-pigmentation of resulting scars. Wounds/scars were quantitatively analysed using image analysis software and subjected to statistical analysis. This study has demonstrated that wound healing and resultant scarring is dependent on the

mechanism of injury. Partial thickness burn wounds differed significantly in their macrophage profiles, re-epithelialisation rates and neo-epidermal and neo-dermal formations compared to partial thickness excisional wounds. Furthermore, the melanocyte population, activation status, microscopic melanin deposition and subsequent macroscopic appearances of resulting scars were also dependent on the wound type. These initial findings could support possible modulation of the wound environment with novel interventional wound therapies.

P4 Sophie Collinson Outcomes of Laparoscopic versus Open Pyeloplasty in children over five Dr. Shagufta Jabeen, Sophie Collinson, Miss Anju Goyal and Mr Supul Hennayake Antenatal hydronephrosis resulting from pelviureteric junction obstruction (PUJO) is a common manifestation identified in pregnancy. Symptomatic disease presents as intermittent loin pain, vomiting and recurrent urinary tract infections. The modern emphasis on primary prevention of disease encourages early intervention for PUJO to limit any decline in renal function. Minimally invasive procedures have been encouraged and laparoscopic pyeloplasties (LP) have emerged in paediatric urology. Previously a thorough analysis of the success of LP at Royal Manchester Childrenâ&#x20AC;&#x2122;s Hospital (RMCH) had not been completed. An audit was therefore conducted to assess the complication rate of LP performed in children over 5 over a 7-year period. Results suggest that LP offers no definite advantage over the traditional open approach. Advances in training schemes, scrutiny of operative approach and thorough analysis of previous surgical errors will undoubtedly improve paediatric pyeloplasty outcomes.

P5 Nadin Jallad

Service Evaluation of permanent Sacral nerve stimulation for faecal incontinence in patients treated at University Hospital Southampton Nadin Jallad Janet Hicks, Sophie Pilkington, Karen Nugent, Tom Dudding Background Sacral nerve stimulation (SNS) is a surgical procedure used in patients with persistent faecal incontinence(FI) following conservative measures. SNS produces neuromodulation to the third sacral nerve and is beneficial in 50-70% of patients. Patient triggered follow-up is used at Southampton University hospital for SNS patients; a previous service evaluation concluded that ongoing support by healthcare practitioners is needed, with an average outpatient appointments of 2.7. Aims The aim of this service evaluation is to assess patient satisfaction, service compliance with NICE guidelines, and long-term outcomes within the Southampton SNS service using postal questionnaires. Methods Between 2000-2013, 100 patients underwent permanent SNS for FI; 92 of which were contacted using the postal service. To assess long-term efficacy, patient satisfaction and incontinence, participants were asked to fill the Southampton SNS service evaluation questionnaire, faecal incontinence quality of life(FIQL: 1=very affected; 4=not affected) and Cleveland clinic incontinence score(CCS). Visual analogue score (VAS) was used to measure the efficacy of the device and service of 0(not at all) to 10(very much). The modified family and friends test was used to assess patient satisfaction with the service and staff. Faecal incontinence was also assessed by asking patients to fill a 2-week bowel diary. Results Data was collected from sixty-nine patients(64 females; 5 males), with a mean age of 61Âą13 years. At a mean follow-up of 35Âą26 months, device efficacy was rated at an average of 73.65% and the service as 86.61%. The median FIQL score for all patients were: Lifestyle: 3.13, coping/behaviour: 2.46, depression/self-perception: 3.33, embarrassment: 2.36. CCS score improved from a preoperative median of 15(2-20) to 9(0-18) at follow-up. At follow-up, patients(n=27) are experiencing an average of 3.9 FI episodes/week. Conclusion High level of patient satisfaction and SNS effectiveness was reported in patients with permanent SNS implant for FI at University Hospital Southampton.

P6 Karam Ahmad 'The use of tranexamic acid to reduce the rates of blood transfusion in shoulder arthroplasty.'

Karam Ahmad, B Morgan, I McLaughlin-Symons, P Kenyon Total replacement of the shoulder can be associated with blood loss. This may   require some patients to have a blood transfusion. Several factors can help predict the need for transfusion in these patients, such as their preoperative haemoglobin, age, sex, co-morbidities, indication for surgery and time spent on the operating table. Reduction in bleeding and the requirement for transfusion could be done by following the example used in hip and knee replacements, and administering tranexamic acid to the patient. This may remove the risks associated with transfusions, reduce costs, and the length of stay in hospital for these patients. Little research has been done in this subject area. The aim of this study is to carry out a literature review and audit with regards to the postoperative transfusion rates in shoulder arthroplasty patients and to examine the potential for use of tranexamic acid. From the research and evidence gathered tranexamic acid seems to be a safe and effect

P7 Dillon Horth The World Health Organization's Surgical Safety Checklist, Its Use in Theatres Introduction:  Surgical care is a critical component of health care across the world, as the incidence of disease and trauma requiring surgical intervention increases, the impact surgical care has on public health will only become greater. In April 2013 the Anaesthetic Department of the Central Manchester NHS Foundation Trust (CMFT) audited the use of the World Health Organization’s Surgical Safety Checklist in theatres across the trust. This project consists of a re-audit looking specifically at the Urgency Theatre’s use of the WHO Surgical Safety Checklist.  Method:  A proforma was used to measure the use of the checklist in the Urgency Theatre. Data was then collected, analysed, and compared to the results of the 2013 audit. PubMed and OvidSP were used as search databases to provide supporting information for the project.  Discussion:  The discussion provides background information about the WHO Surgical Safety Checklist. It covers what the checklist consists of, the advantages of its use, the difficulties in implementing the checklist, and the reasons why there is some controversy over its use.  Results and Conclusion:  The results of the re-audit are discussed and compared against the result of the 2013 audit. In conclusion the Urgency Theatre significantly increased its use of the checklist since 2013.

P8 Jessica Daniels Ectopic Medullary Thyroid Cancer: An anatomical conundrum Jessica Daniels, Alex Bowen, Sean Loughran Introduction: Ectopic thyroid tissue is usually a rare incidental finding. However, post-mortem studies have revealed an incidence of 7-10% in adults. This tissue can develop any pathological process that affects the thyroid.   Method: Case report and review of available literature.  Results: A 66 year old male presented with a lateral mass of the neck. This was diagnosed as primary medullary thyroid carcinoma of ectopic lateral cervical thyroid tissue.  Conclusion: We present a case where lateral cervical ectopic thyroid tissue developed medullary thyroid carcinoma, and discuss the surgical management of this rare variant.

P9 Jessica Daniels The management of malignant melanoma in a complex elderly patient: Ageist or appropriate? Jessica Daniels, Jonathan Morton

Ageism is a concern for elderly patients in the NHS, and although clinicians make an effort to prevent chronological age alone from impacting their management, evidence of this exists in the literature. Here, we present a case of malignant melanoma in an 84 year old woman with multiple co-morbidities. The lesion measured 15mm in maximal diameter and was noticed 1 year prior to presentation. Punch biopsy was performed followed by surgical excision. Sentinel node biopsy is offered for lesions such as these; however, our patient declined this. Although aggressive curative treatments should be considered in fit elderly individuals they are not always indicated for others, emphasising the importance of patient centred care. Quality of life is of utmost importance for the elderly, and it is not always appropriate to risk compromising this in the attempt to cure.

P10 Samuel Simpson Bronchopleural fistula: A foreseeable complication of chest drain insertion? This case report was obtained during a Student Selected Component placement in Paediatric General Surgery at the Kanti Children’s Hospital, Kathmandu, Nepal. Working at the only dedicated Paediatric Hospital in Nepal, healthcare professionals must deal with a significantly greater volume of patients than their western counterparts. Crippled by a lack of adequate funding, the hospital is poorly equipped to deal with the huge patient load. As such, many safeguards in place in the NHS are not present in the Kanti.  A previously well 2 year-old male presenting with fever, cough and abdominal pain was diagnosed with pneumonia. Antibiotic therapy and oxygen were given, and a chest drain was inserted to drain the associated pleural effusion. The patient’s condition did not resolve satisfactorily, and a CT scan revealed a thoracic empyema with bronchopleural fistula in the patient’s right lung. Surgical repair of the fistula, drainage of the empyema and decortication were performed. There were no intraoperative complications.   Following the surgical repair, the surgeon concluded that the most likely cause of the BPF was traumatic, following chest drain insertion into the necrotic lung parenchyma. The infected tissue would have been susceptible to the penetrating trauma of the procedure; due to the hospital’s lack of funding safeguards such as ultrasound guidance were not in place. In addition, staff may not have been provided with adequate training to perform the procedure in particularly difficult cases.

P11 Katherine Wadsworth ‘Preventing Postoperative Pulmonary Complications in Surgical Patients’ K. Wadsworth, Dr J. Eddleston Background: Pulmonary complications following elective and emergency surgery are common and can be detrimental to recovery. Central Manchester Foundation Trust is working with Boston Medical Centre in studying the implementation of ‘I COUGH’; 6 simple interventions to prevent pulmonary complications, and observe their effectiveness in reducing complications and thus improving patient care. Aims: This study looked to review current data on postoperative care and evaluate current practice on inpatient surgical wards - focussing on early oral hygiene and mobilisation – to assess how the hospital compared to the ideals of the I COUGH study. It also assessed patient and clinician understanding of the importance of these factors in recovery to identify if there was a need for further education. Methods: A literature review was carried out into the role of oral healthcare and mobility in preventing pulmonary complications of surgery to look at the evidence base behind the interventions. This was followed by a 2 week observational audit of 84 postoperative vascular and general surgical inpatients evaluating mobility, oral health and any current pulmonary pathology. Oral swabs were taken of the final 20 patients to give an idea of the prevalence of bacterial and yeast colonisation of the oral flora to assess effectiveness of current oral hygiene protocols. Conclusions: Simple interventions are effective in reducing incidence of pneumonia. There may be an additional role of antifungal cover in addition to antibacterial chlorhexidine mouthwash, given an observed 60% prevalence of oral candida albicans.

P12 Henry Claireaux Patience wearing thin: Concerns with Metal-on-metal (MoM) hip prosthesis.

Henry Claireaux, Mr. Caspar Aylott Osteoarthritis (OA) is a chronic joint disease affecting 100m+ people in the European Union. In an ageing and increasingly obese population, the burden of OA will only increase. Advanced hip OA is treated with hip replacement or resurfacing arthroplasty.  These implants emerged in 1997 as a solution to the problem of metal-on-polyethylene hip replacements becoming worn. Between ’03-’12, 60 000 MoM devices were fitted in the UK. There is now concern that these implants are not safe for all patients.  Problems with MoM implants will likely grow as patients continue to use their hips; metal debris accumulates and tissue is exposed to debris for longer. Long-term effects of this debris are unknown.  Patients with MoM implants should be regularly reviewed clinically, serologically and radiologically for signs of complication. The cost of ongoing analysis must be considered when decisions of implant are being made.

P13 Humzah Amin The dangers of intravesical Bacillus Calmette-Guerin in the management of transitional cell carcinoma of the bladder Intravesical BCG (Bacillus Calmette–Guérin) is recommended for bladder cancers with a high risk of reoccurrence or infiltration. Most side effects are self limiting, however there have been 21 cases of secondary aneurysms. Mr X, a 74 year old gentlemen, was diagnosed with a G3pTa transitional cell carcinoma of the bladder in 2012 after experiencing asymptomatic microscopic haematuria for many months. He underwent a transurethral resection of the bladder followed by 6 intravesical bovine BCG chemotherapy wash-outs. Six weeks later he experienced an abrupt onset of an unknown febrile illness. During the course of investigations an ascending thoracic aortic aneurysm was found. Later, Mr X had a repeat CT scan which showed the lower thoracic aortic aneurysm had increased in size from 5.0cm to 7.5cm and the infrarenal aorta had increased in size from 4.5cm to 7.0cm. The abrupt change in the size of the aorta in 2 areas was in keeping with mycotic aneurysms. Mr X then underwent an endovascular thoracic aorta replacement and was started on a years course of anti tubercular drugs. These entered Mr X into renal failure. In August 2013 he required a cystectomy with an ileal conduit.

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