Abstract Aim To identify compliance with mandatory VTE assessment on admission and its re-assessment for General surgery (GS) inpatients at a District General Hospital. Method All adult patients (≥18 years) admitted under the General Surgery department from 21/08/2023 to 25/08/2023 were included. Patients admitted due to long stays following elective surgery with any operative approach were also included. The patient’s VTE assessment charts were reviewed for 24 hours. This was done to identify if an assessment was completed within 14 hours of admission and reassessment after 24 hours. Results 40 patients were included in the audit. Admission Assessment ResultsN=24/40 did not have a tick in either 'no contraindication' or 'contraindication' boxesN=11/24 did not have any tick in 'risk factors’ or bleeding risk' boxesN=20/40 had no documentation of date, time, name, or signature 24hr Later Assessment ResultsN=6/40 patient had re-assessment100% of patients who had reassessment had either 'continue' or 'change' ticked Conclusions Venous thromboembolism (VTE) is a frequent disease affecting more than 1 in 12 individuals during their lifetime. VTE is associated with long-term complications such as recurrence, post-thrombotic, and post-pulmonary embolism syndrome. Despite VTE prophylaxis being administered for patients, documentation of risk factors and contraindications for VTE prophylaxis administration was poor. The worst performing areas were VTE re-assessment 24 hrs after admission and indicating if there is 'no contraindication' or 'contraindication' to VTE-prophylaxis on admission. It is important to stay vigilant and check the assessment during ward rounds. Adherence to VTE assessment still needs to be studied at a later date.

Abstract Introduction Optimising the process of referrals from the Emergency Department (ED) can improve patient care. Currently, referrals to General Surgery (GS) are accepted by the Senior House Officer (SHO) and Registrar (SpR) on-call. This leads to two ongoing lists of referrals and the possibility of patients being missed. ED uses symphony to track referrals, but GS does not currently use this system. Method A survey was sent to all GS SHOs/SpRs to assess the process and tracking of referrals. Symphony was implemented as a virtual system to streamline the referral process. A repeat survey to evaluate the effectiveness of this intervention was conducted 1 month later. Results In the pre-intervention survey, 36% of doctors used a paper list to track referrals. The referral system was rated on average as 2.6/5 (1 – terrible, 5 - excellent). 50% reported feeling that patient safety had been compromised >5 times in the last month due to miscommunication between ED and GS. In the post-intervention survey, there was a significant decrease in the number of times patient safety was reported as being compromised in the last month (p=0.047). Pre-intervention, the theme of the majority of suggestions for improvement included an electronic system for tracking referrals, whereas post-intervention, most suggestions were about the history/ investigations done for each referral. Conclusion The use of the same system, symphony, by ED and GS has improved patient safety, although the Symphony program itself as well as the quality of referrals could be improved.

Abstract Aims Surgery for colorectal cancer is associated with risks of complications and death. These are associated with higher mortality and morbidity rates, lower quality of life and increased expenditure in healthcare. We aimed to determine the impact of prehabilitation on patient outcomes with regards to length of hospital stay and postoperative complications. Methods The prehabilitation programme was introduced to our unit in March 2021. We compared outcomes of all patients undergoing elective colorectal cancer surgery before and after introduction of the programme from a prospectively maintained database. Records of patients in the non prehabilitation group (NP) between January to June 2019 and those in the prehabiltation group (PhP) between April to October 2021 were analysed. Our primary aim was to compare the length of stay between the groups with a secondary aim to compare postoperative complications. Results A total of 151 elective colorectal cancer patients were included. There were 64 patients in the NP group and 87 patients in the PhP group. The median length of stay in the NP group was 7 days and in the PhP group was 5 days. 30% of patients in the NP group developed post-operative complications while only 19% of patients in the PhP group developed post-operative complications. Conclusion Prehabilitation is a vital component in a patient's treatment journey. Results from our study have shown an improvement in postoperative outcomes. It should therefore be an element of all enhanced recovery programmes. Further research in this domain could include individualised programs to obtain more benefits

Colorectal DiseaseVolume 20, Issue 10 p. 931-931 Correspondence Response to Bell et al., ‘The effect of increasing body mass index on laparoscopic surgery for colon and rectal cancer’ S. K. Sood, S. K. Sood timusdoos@yahoo.com Department of General Surgery, Northampton General Hospital NHS Trust, Northampton, NN1 5BD UKSearch for more papers by this authorP. Kang, P. Kang Department of General Surgery, Northampton General Hospital NHS Trust, Northampton, NN1 5BD UKSearch for more papers by this authorU. Ihedioha, U. Ihedioha Department of General Surgery, Northampton General Hospital NHS Trust, Northampton, NN1 5BD UKSearch for more papers by this authorJ. Evans, J. Evans Department of General Surgery, Northampton General Hospital NHS Trust, Northampton, NN1 5BD UKSearch for more papers by this author S. K. Sood, S. K. Sood timusdoos@yahoo.com Department of General Surgery, Northampton General Hospital NHS Trust, Northampton, NN1 5BD UKSearch for more papers by this authorP. Kang, P. Kang Department of General Surgery, Northampton General Hospital NHS Trust, Northampton, NN1 5BD UKSearch for more papers by this authorU. Ihedioha, U. Ihedioha Department of General Surgery, Northampton General Hospital NHS Trust, Northampton, NN1 5BD UKSearch for more papers by this authorJ. Evans, J. Evans Department of General Surgery, Northampton General Hospital NHS Trust, Northampton, NN1 5BD UKSearch for more papers by this author First published: 09 August 2018 https://doi.org/10.1111/codi.14345Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume20, Issue10October 2018Pages 931-931 RelatedInformation

Gallbladder perforation with subsequent gallstone spillage can occur with higher frequency in laparoscopic cholecystectomy than in traditional open approach. Gallstone abscess formation from stone spillage post-cholecystectomy is extremely rare. We present a case of para-spinal abscess formation 5 years after spilled gallstones following laparoscopic cholecystectomy.

Introduction Advanced age is often associated with higher incidence of co-morbidities, advanced cancer and post-operative complications. The aim of this study was to compare the differences in pre-operative, co-morbidities, cancer stage and surgical outcome measures between patients over the age of 80 and those below 80 undergoing elective laparoscopic colorectal resection. Method Data were analysed from a prospectively maintained database between February 2011 and June 2012 and patients were subdivided into two groups (over 80 and under 80). All patients underwent laparoscopic colorectal surgery. Their length of stay, high dependency unit/intensive therapy unit stay, American Society of Anaesthesiologists grade, co-morbidities, conversion rates, Dukes’ stage and post-operative complication rates were compared. Results Of the 67 patients in the study, 57 were <80 at the time of surgery. Their American Society of Anaesthesiologists grade prior to surgery, as expected, was better than that of the >80 group, with 23% having an American Society of Anaesthesiologists grade of 3 compared to 60% in the >80%. The prognosis of the patients in the two groups based on Dukes’ stage was similar, with 63% of the <80 s having a good prognosis, compared to 80% in the >80 s. (Good prognosis = Dukes’ A or B). The conversion rates were similar (26% of the <80 s compared to 20% of the > 80 s) Post-operative length of stay was also similar in both groups (<80 s vs. >80 s: median 5 vs. 5; p = 0.33). Post-operative complication rates were similar (17% of the <80 s vs. 20% of the >80 s). Conclusion The short-term outcomes following laparoscopic colorectal surgery in the elderly are similar to that of younger patients. Laparoscopic surgery should therefore be offered to all patients irrespective of age.

BACKGROUND:Studies have shown that laparoscopic surgery for colorectal cancer is often associated with significantly reduced intra-operative blood loss compared to the corresponding open procedures. Increased intra-operative blood loss can be associated with increased risk of post-operative morbidity and mortality. We sought to determine whether estimated intra-operative blood loss was a reliable predictor of post-operative surgical outcomes. METHOD:Prospective data were collected for patients undergoing elective laparoscopic colorectal cancer resections from July 2011 to November 2013. Weighing swabs and measuring blood volume in suction devices calculated the estimated intra-operative blood loss. The operative outcome data including post-operative 30 day morbidity and mortality, length of hospital stay, re-admission and re-operation within 30 days were collected. The operative blood loss was grouped into Group 1 (less than 50 ml, Group 2 (50-150 ml) and Group 3 (over 150 ml). Patients who underwent open operations and laparoscopic conversions were excluded. RESULTS:The median age, length of hospital stay, male to female ratio and body mass index were similar in the three groups. There was no 30-day mortality in any of the groups. The number of re-admissions within 30 days was similar in all groups. The re-operation rates within 30 days were higher in Groups 2 and 3 at 11% and 8.6%, respectively. The post-operative complications were 12.5%, 16.7%, and 26% in groups 1, 2 and 3, respectively. There were no anastomotic leaks requiring re-operation noted in Group 3. DISCUSSION:This study has shown that intra-operative blood loss was not associated with increased median length of stay nor did it increase the 30 day re-admission rate. However, increased intra-operative blood loss was associated with increased incidence of post-operative morbidity and risk of reoperation within 30 days.

OBJECTIVES:Since the introduction and favourable early results of the enhanced recovery programme more than a decade ago, it has become increasingly popular following major abdominal surgery. The programme has now been adopted in the UK. The aim of our study was to see if the day of surgery affected hospital stay and we compared patients who had colorectal surgery early in the week (Monday to Wednesday) with those who had it later in the week (Thursday to Friday). DESIGN:Patient outcomes were studied between May 2010 and April 2011 from a prospectively maintained database. All colorectal surgeons involved in the enhanced recovery programme in our unit have a flexible rota and so no surgeon was operating on a particular day to avoid bias. An enhanced recovery programme protocol was utilised for all the patients with no bowel preparation, early feeding and early mobilisation. SETTING:Study was carried out at the University Hospitals of Leicester. PARTICIPANTS:Patients undergoing elective colorectal resection between Monday and Friday. MAIN OUTCOME MEASURE:Hospital stay. RESULTS:Two hundred and twenty-seven patients underwent surgery and were on the enhanced recovery programme during this period. Two (0.9%) patients who had surgery on a Sunday were excluded. Two hundred and twenty-five patients were analysed of which 155 (69%) were in the group (Monday to Wednesday) and 70 (31%) in the group (Thursday to Friday). No significant differences were observed amongst the groups for age (p = 0.129), sex (p = 0.555), tumour location (p = 0.140), operation performed (p = 0.127), type of surgery (laparoscopy or open, p = 0.892), complications (p = 0.428). However, a significant shorter length of stay was present in the first group six days (interquartile range: 4-10) versus eight days (interquartile range: 5-11) (p = 0.045). CONCLUSION:Operating on colorectal patients early in the week is associated with a significant decreased hospital stay. This should be put into consideration by units practising enhanced recovery programme if the maximal benefit of this is to be attained.

Background Preoperative localisation of tumour is an essential requirement in laparoscopic colorectal surgery. Since the introduction of laparoscopic colorectal resections in NGH in February 2010, the difficulties of tumour localisation at the time of surgery without tattoo have been highlighted. Furthermore, endoscopic documentation of site of tattoo with respect to the tumour can be inconsistent and at times misleading or difficult to interpret. Tattooing guidelines should be simple to follow and consistent for all lesions irrespective of the location of the tumour. The recommendations were to place at least three spots of tattoo one mucosal fold distal to the lesion and clearly document site of tattoo with respect to tumour in the endoscopy report. Method We identified 100 patients undergoing elective laparoscopic colorectal cancer resections over a two-year period. Data were collected regarding presence of tattoo preoperatively as documented in the colonoscopy report and subsequently the visibility of the tattoo at time of laparoscopy and its accuracy in relation to the tumour. Abdominoperineal resections and emergency colorectal operations were excluded. Results Only 59% of the patients had a visible and accurate tattoo. In 17% of the patients, the tattoo was not visible at all, although it was documented in the endoscopy report that it had been administered. In 4% of patients, it was visible but inaccurately placed. In 20% of the patients, there were no tattoos at all, necessitating on table endoscopy and intraoperative specimen analysis to confirm that the tumour/lesion was within the resection specimen. Discussion Preoperative tumour localisation is extremely important to correctly identify the site of tumour or lesion at laparoscopy. A standardised departmental protocol should be implemented by all endoscopists to place three spots of tattoo one mucosal fold distal to any significant lesions found. Failure to tattoo lesions/cancers preoperatively can lead to intraoperative delays and potential harm to patients from on-table endoscopy.

Introduction Extralevator APER for low rectal cancer is used to avoid the adverse oncological outcomes of inadvertent perforation and a positive circumferential resection margin associated with the conventional APER technique. Removal of the levators leaves a large defect requiring pelvic floor reconstruction. Controversy still exists on the best method of closure. The aim of this study is to present the outcomes of biosynthetic mesh for pelvic floor reconstruction. Method Perineal reconstruction was done using biosynthetic mesh. We evaluated the short term outcomes with regards to perineal wound complications and perineal hernias. Results 25 patients had biosynthetic mesh repairs. 23 of the patients had surgery for rectal cancer and 2 for anal cancer. Median operative time was 3.5 h. At a median follow up period of 26 months, there were 4 perineal complications (2 wound infections, 1 haematoma and 1 wound dehiscence) but no meshes were removed. 1 patient required vacuum assisted dressing for wound dehiscence. There were no perineal hernias. There was no mortality. Conclusion The low complication rate, good outcomes in perineal wound healing and absence of perineal hernia demonstrates that use of biosynthetic mesh for pelvic floor reconstruction is safe and feasible. Disclosure of interest None Declared.

Minimal inflammation of tissues can occur following skin closure with a foreign material. This foreign body reaction can lead to granuloma formation. We report the case of a middle-aged man who, having undergone laparoscopic surgery and had the port site wounds closed with skin glue, was detected to have a non-healing wound. A crystal mass protruding from the incision site was confirmed histologically as a chronic granulomatous reaction to skin glue. A foreign body granulomatous reaction to skin glue has not been described in the literature.

The underdevelopment or absence of the splenic suspensary ligaments can lead to an uncommon condition termed the wandering spleen. It is usually asymptomatic but can present with an acute abdomen when associated with torsion. Most authors advocate surgical treatment. Herein, we report a case of torsion with infarction of the spleen and intestinal obstruction in a 36-year-old female patient which was successfully managed conservatively.

AIM:Recent advances in surgery have focused on peri-operative care and interventions to improve outcome following surgery. Psychological preparation has a positive impact on recovery and incorporates a range of strategies with dissemination of information as one of the key elements. Information can be given verbally, through printed information or through use of a video. Traditionally, reliance has been on the use of written material as an adjunct to patient education in clinic. The current study is a randomized trial on the use of video education in patients undergoing elective colorectal resection within an enhanced recovery programme. METHOD:Sixty-five eligible patients undergoing elective colorectal surgery were identified and 61 were randomized between August 2010 and August 2011 to either video and information leaflets or information leaflets alone. A fast track protocol was established for all the patients. Clinicians in charge of postoperative recovery were blinded. Standard discharge criteria were employed for all patients. RESULTS:Of 61 patients randomized, one dropped out and outcomes on 60 were analysed. There was no difference in baseline characteristics between the groups (age, P = 0.964; body mass index, P = 0.829). Twenty-eight (91%) patients in the video group had left sided resections while two (6%) had right sided resections. Nineteen (66%) in the non-video group had left sided resections while nine (31%) had right sided resections. One (3%) patient in the non-video group and one (3%) in the video group had a total colectomy. Fourteen (45%) patients in the video group and 12 (41%) in the non-video group had surgery completed laparoscopically. There was no difference in the primary (median hospital stay 5 vs 5 days; P = 0.239) or the secondary outcome measures (pain score on movement, P = 0.338; pain score at rest, P = 0.989; nausea score, P = 0.74; epidural use, P = 0.984; paracetamol use, P = 0.44; voltarol use, P = 0.506) between the groups. CONCLUSION:Use of video education in the psychological preparation of patients undergoing elective colorectal surgery does not improve short-term outcomes.

BACKGROUND:The management of colorectal cancer in the elderly presents unique challenges. The objective of this study was to determine outcomes following curative colorectal resection in patients aged 80 years and older.PATIENTS AND METHODS:Study design is retrospective. Data were extracted from the university hospital database and medical records of patients aged 80 years and older operated between April 2004 and December 2009. Intervention was curative colorectal resection. Main outcome measures include postoperative morbidity, mortality and individual risk factors associated with them.RESULTS:Three hundred fifty-eight patients (43.8% males, age = 84 ± 3 years) were included; 72.6% received elective surgery. A significantly higher complication rate and 30 day, 1 year and 4 year mortality were present for emergency operations compared to elective (p < 0.001). One-year survival was 65.0% for elective resections and 55.1% for emergency. At 4 years of follow-up, survival was 49.2% for the elective vs. 27.6% for emergency. The American Society of Anesthesiologists (ASA) score is the only factor associated with the 30-day mortality at the multivariate analysis (p < 0.01), Dukes staging with overall mortality (p < 0.005), sex and mode of the operation with major complications (p < 0.05). A limitation of the study is that is retrospective.CONCLUSIONS:The highest mortality rates following colorectal surgery in the elderly are in the early postoperative period, especially for emergency operations and patients with significant comorbidities. However, the 1-year survival following elective curative resection for colorectal cancer approaches 65 %. ASA score and modality of the operation (elective vs. emergency) impacted on postoperative mortality and morbidity and could be used to select patients with more favourable outcomes.

Objective Every patient has a perception about surgery and psychological preparation of the patient has an important impact on their postoperative recovery and outcome. In this study we looked at impact of a visual educational aid, in the form of a patient DVD on outcome following colorectal surgery within an enhanced recovery programme (ERP). Design We carried out a prospective analysis of a consecutive series of patients undergoing elective colorectal resection. All patients were given information about their operation in a clinic setting. Our intervention included a 15 minute patient educational video describing the preoperative assessment, post-operative recovery and advice on discharge. A questionnaire on patients’ views of ERP and video education was given on discharge. Setting University teaching hospital Participants Patients undergoing elective colorectal resection Main Outcome Measures Outcomes studied included length of hospital stay, patient perception of ERP, postoperative complications and readmissions: Results Thirty-two patients underwent elective colorectal surgery over a 3 month period. Median length of stay in hospital was 5 days. The questionnaire response rate was 100%. All patients thought they were well informed of the enhanced recovery programme. Eighty-eight percent responded that the video information provided about their operation was adequate, with 28% finding the video very helpful and more useful than other forms of patient information. There were no major postoperative complications and no readmissions. Conclusion Audiovisual presentation in the form of a patient video is a useful tool in the psychological preparation of patients undergoing colorectal surgery.

Huge inguinoscrotal hernias are a challenging operation.The technical aspects of the procedure can be very difficult and the recovery may be complicated by ventilatory problems.Progressive preoperative pneumoperitoneum (PPP) is a method which has been used for many years to reduce both intra and postoperative complications.However, it is associated with a prolonged preoperative hospital stay which is expensive and often stressful to patients.We report a case of a morbidly obese patient with a huge inguinoscrotal hernia.PPP was not implemented.The operation was uneventful and he was discharged 8 days later with no major postoperative complications.This case therefore questions the necessity of PPP for huge inguinoscrotal hernias.

Colorectal DiseaseVolume 14, Issue 6 p. e358-e359 Case report Rectovesical fistula secondary to B-cell lymphoma of the rectum: a unique presentation of a rare disease A. Khan, A. Khan Department of Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, UKSearch for more papers by this authorG. M. Lloyd, G. M. Lloyd Department of Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, UKSearch for more papers by this authorU. Ihedioha, U. Ihedioha Department of Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, UKSearch for more papers by this authorD. Hemingway, D. Hemingway Department of Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, UKSearch for more papers by this author A. Khan, A. Khan Department of Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, UKSearch for more papers by this authorG. M. Lloyd, G. M. Lloyd Department of Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, UKSearch for more papers by this authorU. Ihedioha, U. Ihedioha Department of Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, UKSearch for more papers by this authorD. Hemingway, D. Hemingway Department of Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, UKSearch for more papers by this author First published: 24 October 2011 https://doi.org/10.1111/j.1463-1318.2011.02868.xCitations: 3 Mr GM Lloyd, Department of Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PA, UK. E-mail: Geraint_l@hotmail.com Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume14, Issue6June 2012Pages e358-e359 RelatedInformation