Autumn eeting 19 th ovember 2019 Talks to the Press · 153 r-LSV and 116 nr-LSV procedures were identified. Primary patency at year 1 and 3 was no different between groups; 62% vs

Fergus Walsh has been a journalist at the

BBC for 35 years. Since 2004 he has been the BBC’s Medical Correspondent concentrating on health innovation and ethics.

Fergus has written and presented numerous

documentaries on medical issues for the BBC. He has been much praised for his ability to

communicate complex medical science in an accessible way. Fergus is a strong supporter

of medical research.

Mr Peter McDonald has been a Consultant General Surgeon at Northwick Park and St Mark’s (NPM) since

1991.

His clinical research interests have included cancer, Crohn’s disease and proctological conditions.

He writes, speaks and broadcasts extensively about many topics; has published a novel and is the author

of the Oxford Dictionary of Medical Quotations.

In Collaboration with The Royal College of Surgeons of England Autumn Meeting Warwick Hospital Lakin Road Warwickshire CV34 5BW

West Midlands Surgical Society Autumn Meeting 19th November 2019

Talks to the Press

West Midlands Surgical Society Autumn 2019 2

WMSS Committee Members

PROF. DAVID GOUREVITCH: President

MR PAUL MURPHY: President Elect

MR MICHAEL WALL: Honorary Secretary

Ms DEBORAH NICOL: Treasurer

MR ANDREW GARNHAM: Director of West Midlands Training Programme

MRS PAULA LIGHTWOOD : Joint Conference Manager

MRS VICKY WOOD: Joint Conference Manager

MR KASUN WANIGASOORIYA: Head of WMSS Website & Networking

MR ARDARSH SHAH: Lead Registrar for WMSS

WEBSITE ADDRESS: www.westmidssurgicalsociety.org

EMAIL ADDRESS: [email protected]

http://www.westmidssurgicalsociety.org/


Special thanks to our sponsors:

Karl Storz Endoscopy UK Ltd

Wesleyan

Special thanks to our Guest Reviewers:

Mr Devaraj Srinivasamurhry

Mr Kai Leong

Mr Mash Kahn

Mr Bala Piramanayagam

Mr Simon Fallis

Mr Robin Calderwood

Mr Henry Ferguson

Mr Paul Marriott

Mr Stephen Lake

Mr Richard Lovegrove

Mr Andrew Torrance

Mr Dion Morton

Mr Mangta Manu

Prizes will not be awarded in abstentia


WEST MIDLANDS SURGICAL SOCIETY Autumn MEETING

Tuesday 19th November 2019

Warwick Hospital

Programme

09.00 REGISTRATION AND COFFEE

09.25 WELCOME

David Gourevitch – President WMSS

Scientific Short Papers

0930 A comparison of superficial reversed LSV (r-LSV) and deep non-reversed (nr-LSV) graft tunnelling choice in infra-inguinal outcomes Owain Fisher, Lewis Meecham, Ruth Benson, Alexander Crichton, Michael Wall, Devraj Srinivasamurthy University Hospitals of Coventry and Warwick & Black Country Vascular Network

0939 A review of inputs and outputs from a specialist pelvic floor clinic over a one-year period Salman Sadiq, Deepashree Bapu, Mark Chapman Good Hope Hospital, Sutton Coldfield

0948 Does the use of Genomic Assays reduce the rates of Chemotherapy? A single institution experience Ben Wilkinson, Jamie Vatish, Zaid Al-Ishaq, Ojas Pujji, Senthuran Mylvaganam, Tapan Sicar Royal Wolverhampton NHS trust, Wolverhampton

0957 1006

A quality improvement project (QIP) on the quality of discharge summaries and financial implications with improved coding practices in vascular surgery Miraen Kiandee, Sriram Rajagopalan, Michelle Cook, Rundeep Pawar University Hospital North Midlands, Stoke-On-Trent Colorectal cancer detection for patients following updated NICE guidelines for urgent referral David Naumann, Quratul Ain, Charles Evans, Adeel Bajwa University Hospitals of Coventry and Warwick, Coventry

1015 ‘Hazard to Help’ – A quality improvement project Sam Hughes Royal Wolverhampton NHS trust, Wolverhampton


1024 NELA audit: Best practice tariff standards and how to meet them

Jenni Gronroos, Charalampos Konstantinou, Hannah Binns, Simon Fallis George Eliot Hospital, Nuneaton & Good Hope Hospital, Sutton Coldfield

1033 Factors prolonging length of stay in elective colorectal patients is “Social” The Culprit? Kashuf Arooj Khan, Lakna Harindi Alawattegama, Syakira Kamal, Sanaa Elgaddal Royal Wolverhampton NHS Trust & The Royal Shrewsbury & Telford Hospitals NHS trust

1042 Measuring pelvic tilt using inertial measurement units for optimising hip arthroplasty Arham Qureshi, Usama Rahman, Abhinav Vepa, Xueyang Wang, Arnab Palit, Mark Wiliams, Richard King, Mark Elliott University Hospitals of Coventry and Warwick, Coventry

1051 MORNING COFFEE Plus visit to trade stands

1120 Follow-up colonoscopy examination in patients aged 45 and over following acute appendicitis at a rural district general hospital John Carlo Piedad, Adarsh Shah, Edmund Leung Wye Valley NHS Trust, Hereford

1129 Patient outcomes following use of combination therapy for trial without catheter in acute urinary retention patients in a pre-treated population Kashuf Arooj Khan, Aman Harbias, Vinnie During Royal Wolverhampton NHS Trust & Royal Shrewsbury & Telford NHS trust, Shrewsbury.


1138 Psychological treatments for Post-Traumatic Stress Disorder following major physical civilian trauma: A systematic review Arham Quereshi, Edward Dickenson, Peter Wall University Hospitals of Coventry and Warwick, Coventry

1147 Role of allied services in provision of hot gallbladder service in accordance with AUGIS pathway Muhammad Umair Rashid, Yuen Liao, Syed Soulat Raza, Vamshi Palluri Jagadesham, Tejinderjit Athwal, Duncan Beardsmore Royal Stoke University Hospital, Stoke-on-Trent

1156 Rationale for an endovascular first approach in treating infrapopliteal arterial disease: A single centre experience Goran Ahmed, Hilary Murray, Sidi Rashid Worcester Acute Hospital NHS Trust, Worcester

1205 Tailoring care pathways to fit infrastructure – an audit of jaundice pathway; its impact on overall patient care and costs Pratik Bhattacharys, Danielle Simpson, Shirej Chatha, Diwakar Sarma, Reza Zakaria, Shafquat Zaman, Vijay Thumbe Sandwell and West Birmingham NHS trust, West Bromwich

1214 The experience of transperianal template prostate biopsy in the uro-oncology service at Hereford County Hospital John Carlo Piedad, Mehmood Akhtar Wye Valley NHS Trust, Hereford

1223 Trauma laparotomy in the West Midlands: A multicentre prospective observational study of 3 major trauma centres David Naumann, Nabeela Malik, Michael Greenway, Michael Smith, Colin Bergin, Mohammed Ali, Ewen Griffiths, Joseph Hardwicke University Hospitals Birmingham NHS Trust, University Hospitals of North Midlands NHS Trust and Coventry and Warwickshire Partnership NHS Trust

1232

The spectrum of diagnoses for renal colic when following a renal colic pathway: a clinical service evaluation audit Adnan Asghar, Aman Harbia, Adarsh Shah, Wasim Mahmalji Wye Vallley NHS Trust, Hereford.

1241 Training Update

Mr Andrew Garnham TPD for Vascular Surgery and Acting TPD for General Surgery

1300 Lunch


Symposium “WMSS Talks to the Press” West Midlands Surgical Society

Tuesday 19th November 2019 Warwick Hospital

AFTERNOON PROGRAMME

Time

2.00pm AGM and Inauguration of Society President for 2020

2.20pm Mr Peter McDonald – “Dr Slot on Medical Journalism”

2.50pm Mr Fergus Walsh – “Medicine in the media, present and Future Challenges”

4.15pm Prizes and Award

4.45pm Society Drinks at The Wild Boar, 27 Lakin Road, Warwick, CV34 5BU


POSTER LIST

Avoiding lower limb amputation in non-healing ulceration: Can Integra Dermal Regeneration template offer a limb solution? Jessica Chang, Kashuf Khan, Catherine Mason Royal Shrewsbury and Telford NHS trust

Incidence of surgical site infection following laparoscopic cholecystectomy Omowumi Folaranmi, Chaminda Sellahewa University of Birmingham Medical School The Dudley Group NHS Foundation Trust

Management of acute pancreatitis and its complications – A district hospital experience Amaar Aamery, Sam Hughes, Shyam Menon, Jules Dyer, Manu Mangta The Royal Wolverhampton NHS Trust

Suitability of APACHE II score in risk stratification for patients with acute cholycystitis and applicability of CHOCOLATE trial to UK practice Javed Latif, Anisa Kushairi, Jag Gill, Pritesh Mistry, Peter Thurley, Imran Bhatti, Altaf Awan University Hospitals of Derby and Burton NHS Trust

A closed loop audit: Is a pre-operative group and save necessary for the orthopaedic patients with emergency upper and lower limb pathologies? Arham Qureshi, Chetan Khatri, Imran Ahmed, Kanai Garala, Peter Wall, Robert Jordan, Gurdip Chahal, Jayne Ward – University Hospital Coventry and Warwick

Distal radius fractures – Does our infrastructure allow us to meet standards? Jia Choong, Alexander Bolt, Akshay Malhorta Royal Stoke University Hospital

Reliability of the laboratory risk indicator in nectrotising fasciitis (LRINEC) score Muhamad Abdullah Dudley Group NHS Foundation Trust

Guidelines for lower GI bleeding in question: the sensitivity and selection of patients for CT-angiography Samuel Snelling, Steve Ward, Rania Ghaffar University Hospitals Birmingham

High dependency care for children after emergency appendicectomy admission stratification Liam Phelan, Georgia Layton, Edward Ackling, Mark Dilworth Birmingham Heartlands Hospital


A comparison of superficial reversed LSV (r-LSV) and deep non-reversed LSV (nr-LSV) graft tunnelling choice in infra-inguinal bypass outcomes Owain Fisher1, Lewis Meecham1, Ruth Benson2, Alexander Crichton2, Micheal Wall2, Deveraj

Srinivasamurthy1

1UHCW, Coventry . 2Black Country Vascular Network, Dudley,

Introduction / Background / Aims

Historically there has been conflicting evidence regarding outcomes (in terms of patency) of infra-inguinal bypass grafts dependant on choice of anatomical location and orientation of graft conduit. This pre-exists modern surveillance protocols and best medical therapy. Here we present contemporary outcomes of r-LSV and nr-LSV bypass grafts.

Method

Prospectively maintained databases of infra-inguinal vein bypass grafts from two vascular hubs were interrogated for perioperative and long term outcomes including re-intervention, primary and secondary patency.

Results

153 r-LSV and 116 nr-LSV procedures were identified. Primary patency at year 1 and 3 was no different between groups; 62% vs 60% and 61% vs 40% respectively(p=0.34) Secondary patency at the same time points was 81% vs 77% and 80% vs 68%(p=0.46). There was a trend towards better patency in r-LSV. Separate analysis of fem-pop and fem-distal procedures also failed to find significant differences in 1 and 3 year patency.

Conclusion

Both r-LSV and nr-LSV techniques provide durable results in the medium term. This study has failed to identify superiority of one method, therefore choice of graft remains at surgeons discretion. Graft surveillance using radiological or clinical examination appears to be the most important variable to identify patients needing intervention to maintain patency.


A review of inputs and outputs from a specialist pelvic floor clinic over a one-year period

Salman Sadiq, Deepashree Bapu, Mark Chapman

Good Hope Hospital, Sutton Coldfield,


Patients with pelvic floor problems are referred either directly to pelvic floor clinic (PFC) or to secondary care specialists (SCS) like gastroenterologists, gynaecologists and colorectal surgeons who then refer patients on to PFC.

The aim of this study was to determine the route of referral to PFC, compare the differences in investigations, definitive treatment and delay in definitive management when patients were referred directly to PFC compared to those referred to SCS

Method

Records of patients attending PFC over 12 months was analysed. The route of referral, difference in the number and modality of investigations, final management and any delay in definitive management between the two groups was analysed.

Results

103 patients attended pelvic floor clinic in the study period, 38% referred directly to PFC and 62% from SCS. Overall, patients referred initially to SCS had more investigations including expensive tests like MRI defaecating proctogram. 66% of patients referred to PFC had definitive management compared to 27% referred to SCS with an average delay of 182 days to be seen by a pelvic floor specialist

Conclusion

Primary care referrals to this pelvic floor clinic are undergoing less investigations with quicker definitive management plans when compared to secondary care referrals.


Does the use of Genomic Assays reduce rates of Chemotherapy? A single institution experience.

Ben Wilkinson, Jamie Vatish, Zaid Al-Ishaq, Ojas Pujji, Senthurun Mylvaganam, Tapan Sircar

New Cross Hospital, Wolverhampton,


NICE recommends the use of tumour profiling tests to guide adjuvant chemotherapy in Breast Cancer. The Oncotype DX™ score (Genomic Health) has superseded more traditional tools such as PREDICT in appropriate patients (ER+ve, HER2-ve, lymph node negative and with a Nottingham Prognostic Index ≥ 3.4). We looked to see whether the introduction of Oncotype DX within our institution resulted in an overall reduction in rates of chemotherapy?

Method

Data was collected retrospectively using the Somerset Cancer Register, Pathology department databases and the institution’s own online medical records system. Two groups were compared: 1. Pre-Oncotype (Jan 2012 – Dec 2014), 2. Post-Oncotype (Jan 2016 – July 2018).

Results

During the Pre-Oncotype period, 28/82 (34%) patients who would have been eligible for testing received chemotherapy compared to 34/135 (25%) who were sent for Oncotype during the second study period (p=0.15). For Grade 3 cancers, and those aged under 50 the results were more marked: Grade 3 Pre-Oncotype 23/43 (53%) , Post-Oncotype 29/76 (38%) (p=0.10); Aged under 50 Pre-Oncotype 8/15 (53%), Post –Oncotype 10/31 (32%) (p=0.17).

Conclusion

Within our single institution, overall rates of chemotherapy have reduced since the introduction of Oncotype DX with the results more marked in subgroups of traditional indicators of tumour aggression.


A quality improvement project (QIP) on the quality of discharge summaries and financial implications with improved coding practices in vascular surgery

Miraen M Kiandee, Sriram Rajagopalan, Michelle Cook, Rundeep Pawar

University Hospital North Midlands, Stoke on Trent,


Poorly written discharge summaries lack valuable clinical information and thus inaccurately describes the admission. Each admission is given a healthcare resource group (HRG) and a tariff. Some HRG tariffs can be inflated by complexities and co-morbidities (CCs), omission of these result in loss of revenue for the department. We aim to identify common pitfalls in discharge summaries and design strategies to improve.

Method

A QIP wih retrospective and prospective components. Initial study identified common omissions on discharge summaries. This informed our educational intervention. A further review of discharge summaries in September 2018 in vascular surgery was then conducted prospectively. The HRGs were then re-coded by clinical coders to include any missed CCs.

Results

In the prospective study, 98% (53) of summaries were written by foundation year doctors. 7 were excluded as it had fixed tariffs. 16 out of 47 discharge summaries (34%) received an inflated tariff. In total we recuperated £56,672 with the identification of additional CCs present in the admission but not included in the discharge summaries.

Conclusion

Good discharge summaries improve subsequent patient care and allows appropriate payment to the department. We aim to review the quality of discharge summaries in 6 months following training we have delivered to foundation doctors.


Colorectal cancer detection for patients following updated NICE guidelines for urgent referral

David Naumann, Quratul Ain, Charles Evans, Adeel Bajwa

University Hospitals Coventry and Warwickshire NHS Trust, Coventry,


Patients with ‘red flag’ symptoms for colorectal cancer are referred urgently by GPs to colorectal services according to NICE guidelines. NICE recently decreased the threshold for urgent referral. Detection rates were previously reported as 7.7% (cancer) and 10.8% (polyps). We re-assessed these rates after the updated guidelines, and investigated whether any referral category increased detection rates.

An observational study investigated colorectal clinic patients at a single NHS Trust from May 2017 – Aug 2018. Urgent referral category was taken from NICE Guideline NG12 (including anaemia, change in bowel habit, rectal bleeding). Odds ratios (OR) for detection of polyps/cancer were analysed using binary multivariate logistic regression using the variables age, gender and referral category.

Results

605 patients (47.9% male) had a median age of 66 (IQR 54–76) years, of whom 83 (13.7%) had either a polyp (n=64; 10.6%) or cancer (n=19; 3.1%). Male gender increased the likelihood of polyp/cancer detection (OR 1.72; 95% CI 1.07, 2.80; p=0.028). No individual referral criterion increased the likelihood of detection.

Conclusion

Compared to reports prior to the NICE Guidance update, our colorectal detection rate has reduced but polyp detection rate remained consistent. No specific referral criterion is superior in predicting the presence of polyp/cancer.


'Hazard to Help' - A quality improvement project.

Sam Hughes

Royal Wolverhampton Hospitals NHS trust


100% of fourth year medical students currently on placement at New Cross Hospital felt consistently ‘lost’ or ‘in the way’ whilst on the wards. The objective of this Quality Improvement Project was to equip students with the skills, knowledge & confidence to undertake a more ‘active’ role. The following 5 aims were established:

1. Know how to write in patient notes.

2. Correctly interpret an Early Warning Score.

3. Confidently present patients to a senior.

4. Utilise the ‘SBAR’ tool to handover patients.

5. Understand how to ‘clerk’ patients.

Method

A cohort of 8 students completed an interactive teaching programme comprising of 3 interventions / PDSA Cycles over a 1 month period with a weekly survey to identify their confidence in each of the 5 aims listed above.

Results

At the beginning of the programme: 85% of students had never written in patient's notes, 0% felt confident at interpreting an EWS & 92% did not know the meaning of 'clerking'. Upon completion of the programme:- 100% had written in patient's notes, 80% felt confident interpreting an EWS & 100% had an improved understanding of the 'clerking' process.

Conclusion

A simple teaching programme for medical students, resulting in students feeling “3 times” more ‘useful’ on placement.


NELA audit: Best practice tariff standards and how to meet them

Jenni Gronroos1, Charalampos Konstantinou2, Hannah Binns2, Simon Fallis2

1George Eliot Hospital, Nuneaton, . 2Good Hope Hospital, Birmingham,


Emergency laparotomy best practice tariff has been introduced this year. It is now a standard that 80% of high-risk patients (NELA score >5% mortality) are admitted to HDU postoperatively. Our aim was to see current compliance, identify reasons for non-compliance and change the practice to address the issue, then close the cycle with re-auditing.

Method

All high risk missed patients were identified and all notes examined.

Results

First cycle was carried out between October 2018 and March 2019. 68% (target 80%) of high-risk patients were admitted to HDU postoperatively. Other important findings were: 66% of missed patients did not have preop risk documented in the notes and 58% had NELA score between 5-6%. Reasons for not admitting identified were that the surgical team did not flag up high risk patients and anaesthetic team were using clinical judgment post operatively, resulting at times in missed ICU admission.

Intervention: Audit results were presented and discussed with surgical and anaesthetic colleagues to increase awareness regarding accurate risk assessment of all patients and ICU admission of all NELA score >5% patients.

Conclusion

Results of re-audit: Re-audit was carried out April 2019 – September 2019 and found that 88% of high-risk patients were admitted to HDU postoperatively.


Factors Prolonging Length of Stay in Elective Colorectal Patients, is "Social" The Culprit?

Kashuf Arooj Khan1,2, Lakna Harindi Alawattegama1,2, Syakira Binti Mohd Mustafa Kamal1, Sanaa

Elgaddal1

1Royal Wolverhampton NHS Trust, Wolverhampton, . 2The Royal Shrewsbury & Telford Hospitals,

Shrewsbury,


The NHS is facing financial constraints and there is considerable interest in ensuring the shortest but optimal hospital stays possible. In 2017, Getting It Right First Time (GIRFT) published a General Surgery Report1, recommending a reduction in the Length of Stay (LoS) for elective colorectal surgery patients from the current average of 10.2 days to 5.5 days.

This study investigates factors that significantly prolong post-operative LoS for colorectal procedures to identify areas of improvement.

Method

Patients undergoing elective colorectal operations from December 2017 - December 2018 with LoS greater than 6 days were analysed retrospectively.

Results

194 patients with average LoS of 15.4 days. The commonest factor prolonging LoS was Rehabilitation PT/OT (72.2%) while 9.2% required discharge planning services. 51% of patients remained in hospital after being deemed MFFD. The most common post-operative medical factors were infection (42.2%) and other specialty review (34%).

Conclusion

Our unit has a higher than average LoS for elective colorectal surgery patients. Despite the perception that discharge planning is the main reason for prolonged LoS, post-operative medical factors also play a vital role. Prompt optimisation of anaemia with pre-op anaemia clinics, electrolyte abnormalities, infection control, cross-speciality review/liaison services may improve LoS.


Measuring pelvic tilt using inertial measurement units for optimising total hip arthroplasty

Arham Qureshi1, Usama Rahman1, Abhinav Vepa1, Xueyang Wang2, Arnab Palit2, Mark Williams2,

Richard King1, Mark Elliott2

1University Hospital Coventry and Warwick, Coventry, . 2University of Warwick, Coventry,


Malorientation of the acetabular component in Total Hip Arthroplasty (THA) may contribute to premature failure due to mechanisms such as edge loading and prosthetic impingement. The pelvis flexes and extends during activities of daily living (ADLs), and excessive pelvic motion can contribute to functional acetabular malorientation. Preoperative radiographs can be performed to measure changes in pelvic tilt during ADLs to identify high risk individuals however involve time-consuming radiation exposure, and are unable to provide truly dynamic 3-dimensional analysis. The purpose of this study was to develop and evaluate a motion capture method using inertial measurement units (IMUs).

Method

Patients awaiting THA were fitted with a bespoke device consisting of a 3D-printed clamp which housed the IMU. Pelvic tilt was measured in standing, flexed seated and step-up positions while undergoing X-rays with the IMU capturing the data in parallel. Statistical analysis included measures of correlation between the X-ray and IMU measurements.

Results

Measurements from 30 patients indicated a moderate-strong correlation (R2 = .87) between IMU and radiological measures of AP pelvic tilt.

Conclusion

A novel device has been developed that can suitably track pelvic movements. This could potentially be used to identify patients with large changes in pelvic tilt, and thereby inform surgical planning.


Follow-up colonoscopy examination in patients aged 45 years and over following acute appendicitis at a rural district general hospital

John Carlo Piedad, Adarsh Shah, Edmund Leung

Department of General Surgery, Hereford County Hospital, Wye Valley NHS Trust, Hereford,


The bimodal age distribution in presentation of acute appendicitis prompts consideration of other aetiologies in patients outside the typical age distribution. This study aimed to investigate the modalities to diagnose bowel cancer in >45-year-olds post-appendicectomy.

Method

Retrospective case reviews were performed on all patients over 45 years who underwent emergency appendicectomy, with histologically-confirmed appendicitis, during the 10-year period between Jan 2007 to Dec 2016. Biochemical, imaging and histopathology data were gathered using a combination of electronic medical records and software.

Results

There were 504 appendicectomies performed in patients >45. Three-hundred -and-fifty-eight had histologically-confirmed acute appendicitis. Only 149 had a pre-operative CT that excluded any obvious colonic malignancy, with 19.5% of patients having a complicated appendicitis. Fifty-seven patients underwent a post-operative colonoscopy. Only 22.8% were specifically for post-appendicectomy examination. Median colonoscopy follow-up time was 4 months (range 1-14 months). Of all colonoscopy patients, low-grade dysplastic caecal polyps were noted in 2 patients. Two patients in our cohort with proximal colon cancer presented with appendicitis, and one had ascending colonic cancer found 5 months post-appendicectomy.

Conclusion

Follow-up colonoscopy has been recommended in patients >45 years presenting with acute appendicitis. Our rural DGH findings provides opportunity for departmental protocol review to optimise comprehensive bowel cancer care.


Patient Outcomes Following Use of Combination Therapy for Trial Without Catheter in Acute Urinary Retention Patients in a Pre-Treated Population

Kashuf Arooj Khan1,2, Aman Harbias1,3, Vinnie During1

1Royal Wolverhampton NHS Trust, Wolverhampton, . 2Royal Shrewsbury & Telford Hospitals,

Shrewsbury, . 3Hereford County Hospital, Hereford,


NICE recommends use of Combination Therapy (CT); α-Blocker (AB) and 5α-Reductase Inhibitor (5ARI), for persistent cases of Acute Urinary Retention (AUR).

This study aims to determine the efficacy of CT in a population pre-treated with AB, its impact on a patients unfit for surgery, and to provide evidence in the knowledge gap.

Method

Patients presented with AUR in our unit are catheterized, started on AB, and referred for TWOC. If unsuccessful, long-term catheter, surgery, or CT with delayed TWOC are options offered to patients. Data was collected prospectively for those treated with CT and delayed TWOC.

Results

95 patients were included from January 2017 - February 2019, average age 78.2yrs. 56.8% of patients had successful TWOC following CT with average length of time on CT of 2.44 months. 42.1% patients who had successful TWOC were deemed unfit/>80 years. All but 2 patients in this cohort had previous AB and retention/failed TWOC prior to commencement of CT.

Conclusion

This study suggests that CT is a previously unstudied option for successful TWOC in patients with retention who have previously failed TWOC with AB alone. This could be a useful strategy for those who are unfit/unwilling to undergo surgery.


Psychological treatments for Post-Traumatic Stress Disorder following major physical civilian trauma: A systematic review and meta-analysis

Arham Qureshi, Edward Dickenson, Peter Wall

University Hospital Coventry, Coventry,


Approximately 16% of the world’s burden of disease is attributable to traumatic injury. Psychological symptoms, including Post Traumatic Stress Disorder (PTSD), are prevalent in this population and impact on the recovery from physical injury.

Method

Systematic searches of computerised databases were conducted. Randomised controlled trials of psychological treatments for PTSD following major physical civilian trauma were included. The main outcome measure was clinician assessed symptoms of PTSD (CAPS). Included studies data was extracted and entered using Revman 5.3 software. Quality assessments were performed and data was analysed for summary effects.

Results

10 studies were included. With regards to CAPS <6 months, individual CBT did significantly better than usual care/wait list (SMD (95% CI) = -1.24 [-1.82, -0.67]) and non-CBT treatments (SMD (95% CI) = -1.32 [-2.64, -0.04]). Non-CBT treatments were not significantly better than usual care/wait list (SMD (95% CI) -1.40 [-2.91, 0.11]).

Conclusion

Individual CBT did significantly better than waitlist/usual care and non-CBT treatments in reducing clinician and self-rated PTSD symptoms in the shorter term, however the latter comparison was based on few studies with small sample sizes. Longer term treatment effects remain uncertain. There is a need for (further) RCTs to better characerise these effects.


Role of allied services in provision of hot gallbladder service in accordance with AUGIS pathway

Muhammad Umair Rashid, Yuen Liao, Syed Soulat Raza, Vamshi Palluri Jagadesham, Tejinderjit

Athwal, Duncan Beardsmore

Royal Stoke University Hospital, Stoke-on-Trent,


AUGIS pathway for management of acute gallstones disease (2015) suggest risk stratification of patients to have pre-operative imaging for bile duct stones which is also the basis of SUNFLOWER trial. AUGIS also recommends that patients with common bile duct (CBD) stones and sepsis should undergo urgent (<48-72 hours) ERCP to decompress CBD. We aimed to compared our practice to AUGIS pathway to improve the quality of service.

Method

In total 198 patients were included between September 2018 and May 2019. Patients were grouped on basis of blood results and findings on imaging. Data analysed included demographics, imaging, blood results, operative findings, and histology in line with the AUGIS pathway.

Results

Ultrasound service was efficient and had 87% accuracy in diagnosis. MRCP had the highest yield (70%) in detection of CBD stones in patients with abnormal LFTs and dilated CBD. Raised bilirubin alone was identified in 52% of patients with CBD stones. None of the patients with gallstones related jaundice had ERCP within 72 hours.

Conclusion

Emergency surgical resource planning cannot be developed in isolation and should be undertaken jointly with radiology and endoscopy to provide hot gallbladder service. This study helped us in implementation of criteria-based prioritisation of MRCP in our institute.


Rationale for an endovascular first approach in treating infrapopliteal arterial disease: A single centre experience

Goran Ahmed1, Hilary Murray2,1, Sidi Rashid1

1Worcestershire Acute Hospitals NHS Trust, Worcester, . 2Worcester Clinical Research Unit,

Worcester,


Managing chronic limb threatening ischaemia (CLTI) in patients with infrapopliteal disease remains a challenge. While most series report better limb salvage (LS) and amputation-free survival (AFS) with arterial bypass, such benefits incur significant risk of major morbidity and mortality. Treating crural lesions endovascularly provides an alternative to surgery, with some centres reporting comparable AFS and LS rates with lower morbidity and mortality.

Method

A prospective database of all patients who underwent infrapopliteal angioplasty from 1st September 2013- 30th June 2018 was analysed. Primary outcomes included overall survival, AFS and LS rates. Secondary outcomes were periprocedural complications and 30-day mortality.

Results

171 angioplasties were performed with a primary technical success rate of 95%. Overall patient survival at 12, 36 and 72 months was 80.1%, 63.5%, and 59.5%; AFS - 69.3%, 54.7%, and 51.1%; LS - 85.3%, 83.1%, and 83.1% respectively. Complications occurred in 14 patients (8.2%) but only 4 (2.3%) required surgery. 30-day mortality was 2.9%.

Conclusion

Based on our local unit’s data, an endovascular first approach achieves outcomes equivalent to those published for surgical bypass but with lower 30-day mortality and morbidity. Therefore in our centre, an endovascular first approach to achieve limb revascularisation in this cohort of patients is justified.


Tailoring care pathways to fit infrastructure – an audit of jaundice pathway its impact on overall patient care and costs

Pratik Bhattacharya, Danielle Simpson, Shirej Chatha, Diwakar Sarma, Reza Zakaria, Shafquat Zaman,

Vijay Thumbe

Sandwell general hospital, West Bromwich,


Various clinical pathways exists across Trusts in the NHS in accordance with national guidelines or local guidelines.While designing pathways care must be taken to have all available infrastructure and facilities available in mind to provide.

Aim : To design and implement a clinical pathway for visibly jaundiced patients in our hospital with a view to reduce length of stay and delays due to inter-departmental referrals.

Method

A standard operating procedure for visibly jaundiced patients was devised which stated all patients with visible jaundice( bil >50 mg/l) were to be initially admitted under the medical team with a view of early gastro-enterology post take and assessment of need of ERCP. This SOP was discussed with the concerned departments,guidelines were uploaded onto trust intranet and distributed to all necessary wards. An audit done in the month of January found poor compliance with the pathway . The reaudit after six months was done to evaluate if change of practice had achieved.

Results

The reaudict showed decrease of admission of visibly jaundiced patients from 34.5% to 17.5%.The overall LOS for visbly jaundiced patients decreased from a 108 to 24 days, translating into savings.

Conclusion

Appropriate tailoring of service is beneficial for patient and hospital.


The experience of transperineal template prostate biopsy in the uro-oncology service at Hereford County Hospital

John Carlo Piedad, Mehmood Akhtar

Department of Urology, Hereford County Hospital, Wye Valley NHS Trust, Hereford,


Transperineal template prostate biopsies (TPTPB) have been offered for prostate adenocarcinoma diagnosis since Mar 2017, in conjunction with the Prostate Imaging Reporting and Data System (PI-RADS) which evaluates the likelihood of clinically-significant cancer based on MRI prostate characteristics. Patients who have a clinical suspicion of prostate adenocarcinoma undergo MRI, with highly suspicious lesions prompting TPTB. This study will evaluate this unit’s experience of the efficacy and safety of TPTPB.

Method

Imaging and histopathology data were gathered using electronic and paper medical records of patients who underwent TPTPB between Mar 2017 to Dec 2018.

Results

There were 154 procedures over 22 months. Ninety-two (59.4%) yielded a positive biopsy. There was a highly significant but moderate correlation between the PI-RADS and the histology grades (Spearman’s rho=.450, P<0.001). Urinary retention complicated 23.0% of procedures. The prostate volumes in the retention group were significantly larger than the non-retention group (median 65 ml vs 40ml, MWU=3,231.5, P<0.001). There were no post-operative infections.

Conclusion

Our 59% pick-up rate is higher than other studies which detect adenocarcinoma in 37-51% of procedures. The retention rates are also higher compared to 2-15% in other studies, which is explained by hyperplastic prostates. TPTPB is a well-implemented procedure within the Hereford uro-oncology service.


Trauma laparotomy in the West Midlands: A multicentre prospective observational study of 3 Major Trauma Centres

David Naumann1, Nabeela Malik2, Michael Greenway3, Michael Smith1, Colin Bergin2, Mohammed

Ali2, Ewen Griffiths2, Joseph Hardwicke1

1University Hospitals Coventry and Warwickshire NHS Trust, Coventry, . 2University Hospitals

Birmingham NHS Foundation Trust, Birmingham, . 3University Hospitals of North Midlands NHS

Trust, Stoke,


Trauma laparotomy is a potentially life-saving procedure following abdominal trauma. We aimed to provide a contemporary narrative of patient and injury characteristics and outcomes following trauma laparotomy in the West Midlands.

Method

A prospective, observational study investigated patients who underwent trauma laparotomy at the three MTCs in the West Midlands from January to June 2019. Patient and injury characteristics, clinical management and outcomes (length of stay (LOS), complications and mortality) were recorded.

Results

43 patients (88% male) had a mean age of 34 (SD 16) years. Median ISS was 16 (IQR 9–27). The most common injury mechanism was stabbing (n=21, 49%). 7 (10%) underwent damage control surgery. Injuries included small (n=16) and large (n=9) bowel, liver (n=9), spleen (n=9), stomach (n=6), genitourinary (n=6), pancreas (n=3), major vascular (n=2) and rectum (n=1). Median LOS was 7 (IQR 5–23) hospital and 1 (IQR 0–4) ICU days. 9 patients suffered complications. 38 (88%) survived to discharge.

Conclusion

Approximately every 4 days a patient required a trauma laparotomy in an MTC in the West Midlands, and 12% died. These patients are predominantly young, male, and stabbing was the most common injury. Resource utilisation is high, and a wide range of abdominal injuries are common.


The spectrum of diagnoses for renal colic when following a renal colic pathway: a clinical service evaluation audit.

Dr Adnan Asghar1, Ms Aman Harbias1, Mr Adarsh Shah2, Mr Wasim Mahmalji1

1Department of Urology, The County Hospital, Hereford, . 2Department of General Surgery, The

County Hospital, Hereford,


Urolithiasis was attributable for 87,236 acute admissions across the UK in 2017-2018. Our institution implemented a renal colic pathway in 2017. Increased throughput of patients via this pathway prompted an audit aimed at assessing compliance and efficacy of the 2017 pathway – the audit standard

Method

A retrospective audit of all acute admissions in 2018 whose final coded diagnoses encompassed ‘renal colic’. Medical records were reviewed electronically.

Results

339 patients were identified. 291/339 (86%) had a CT scan and the remainder excluded from further analysis. 153/291 (53%) had a radiologically confirmed kidney or ureteric stone. Failure to follow the pathway led to delayed diagnosis and treatment in 6/153 (4%) patients.

138 patients (47%) had an alternative diagnosis. Other urological diagnoses included renal cysts and hydronephrosis from bladder outlet obstruction or malignancy and (n=11; 8%). General surgical and gynaecological pathologies identified in 32/138 (23%) and 13/138 (9%) patients respectively. General medical conditions accounted for 26/138 (19%).

Conclusion

1 in 2 patients presenting acutely with renal colic had a non-urolithiasis related diagnosis, demonstrating the spectrum of pathologies that mimic renal colic. Adherence to a robust pathway safely identifies patients with urolithiasis for outpatient management, thus ensuring better use of exhausted resources.


Presidents of the West Midlands Surgical Society

1979 Mr R Gibbs

1980 Mr R W Tudor

1982 Mr H Young

1983 Prof P Bevan

1984 Mr G Hennessy

1985 Mr R H Sage

1986 Mr G Watts

1987 Prof F Ashton

1988 Mr M Lord

1989 Mr D J Oakland

1990 Mr J Alexander Williams

1991 Mr C H de Castella

1992 Mr G D Oates

1993 Mr L J Lawson

1994 Mr C W O Windsor

1995 Mr A D Barnes

1996 Mr J M Morrison

1997 Mr D S Evans

1998 Prof J Elder

1999 Mr C Williams

2000 Mr W Gillison

2001 Mr N Dorricott

2002 Mr J Black

2003 Mr M L Obeid

2004 Mr J Lotz

2005 Mr I A Donovan

2006 Mr M Simms

2007 Mr A Auckland

2008 Mr A Allan

2009 Mr R Kirby

2010 Mr T Gardecki

2011 Mr M J R Lee

2012 Mr S R Smith

2013 Mr A Khan

2014 Professor J A C Buckels

2015 Mr S H Silverman

2016 Professor C Imray

2017 Mrs C Hall

2018 Mr M Gannon

2019 Mr D Gourevitch

2020 Mr P Murphy


Documents

Autumn eeting 19 th ovember 2019 Talks to the Press · 153 r-LSV and 116 nr-LSV procedures were identified. Primary patency at year 1 and 3 was no different between groups; 62% vs