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Background Pre-operative endoscopic retrograde cholangiopancreatography (ERCP), stone removal and interval cholecystectomy is the widely practiced management for choledocholithiasis with concomitant gallstones. Biliary stenting is performed with plastic or metallic stents which require removal after 3–6 months. The sequelae from the forgotten biliary stent following laparoscopic cholecystectomy, stent occlusion, migration or cholangitis, carry significant morbidity and cost implications. Methods Pre-operative endoscopic retrograde cholangiopancreatography (ERCP), stone removal and interval cholecystectomy is the widely practiced management for choledocholithiasis with concomitant gallstones. Biliary stenting is performed with plastic or metallic stents which require removal after 3–6 months. The sequelae from the forgotten biliary stent following laparoscopic cholecystectomy, stent occlusion, migration or cholangitis, carry significant morbidity and cost implications. Results 308 laparoscopic cholecystectomies were performed in the study period. 25 (8%) underwent pre-operative biliary stenting, of these 16 underwent successful stent removal. 7 patients are still awaiting removal and 2 were discharged without stent removal and lost to follow up. One of these required emergency admission and removal of the stent at a tertiary centre due to stent complication. The average time from biliary stenting with ERCP to cholecystectomy was 99 days. The average time from cholecystectomy to removal of biliary stents was 113 days. The average length of time from insertion of biliary stent to removal was 195 days. Conclusions Where common bile duct exploration at the time of cholecystectomy is not possible we recommend ERCP units provide a stent registry system with a deadline for biliary stents in the registry system for each patient.

Background Venous thromboembolism (VTE) after emergency laparotomy is a significant cause of morbidity and mortality. Where extended thromboprophylaxis is used in the post-operative care of patients with colorectal malignancy or pelvic surgery, no such guideline exists for the patient undergoing emergency laparotomy. Arguably emergency laparotomy has one of the highest associated death rates of all types of surgery, greater than that of major elective GI surgery and involves high risk patients. The objective of this study is to ascertain the incidence of symptomatic VTE after emergency laparotomy within current thromboprophylaxis regimens at a district general hospital and consider the benefits of extended regimes in this patient cohort. Methods A database of all patients who underwent emergency laparotomy over a 12 month period from January 2019 to December 2019 was retrospectively analysed. The primary outcome was the incidence of symptomatic VTE within 90 days of emergency laparotomy. This was cross-referenced to known patient risk factors for thromboembolism. Results A total of 113 patients underwent emergency laparotomy during this period. Those who had multiple laparotomies and were duplicated or who died were excluded, leaving a total of 94 patients, 55 female and 39 male. 80 patients underwent a VTE prophylaxis regimen using perioperative and postoperative low-molecular-weight heparin (LMWH) based on their weight. The average length of stay was 18 days. 20 patients had an inpatient stay greater than 28 days and, therefore, received extended prophylaxis during their admission. 21 patients were given prolonged anticoagulation on discharge to complete a total of 28 days, 14 of these had suspected cancer intraoperatively, 6 were previously already anticoagulated. The postoperative VTE incidence was 6, 4 were diagnosed during admission and so received prolonged anticoagulation on discharge. 2 patients were not given prolonged VTE prophylaxis on discharge. Conclusions An extended VTE prophylaxis regimen using low-molecular-weight heparin is simple and effective and an accepted practice in the management of post operative colorectal cancer patients. A randomised control trial is likely needed to further explore the use of extended low molecular weight heparin in the postoperative care of emergency laparotomy patients.

Aim The litigious burden in the NHS has been increasing yearly, costing an estimated £2.5 billion per year in financial settlements. We investigated the causes of general surgical settlements and attributed costs at a district general hospital over a five-year period. Method A retrospective analysis of all general surgical claims between 2016–2021 using the NHS Resolutions Case Management System. Selected cases were those which resulted in out of court financial settlements; whilst these claims have been settled, the trust admitted no negligence in each case. Results A total of 12 settlements were made with a total cost of £249,918 (£8000-£60,000, mean £20,827). Eight of the claims (67%) related to elective cases with four (33%) emergency cases. Of the total cases, 41% and 33% related to management of gallstones and appendicitis respectively. The majority of claims (58%) related to delays in treatment with a total cost of £103,500 (£8000-£35,000), accounting for 41% of total settlement costs. Five cases (42%) were due to harm with a combined total of £146,418 (£9000-£60,000), 59% of the total settlement. Of the claims due to harm, 80% suffered recognised complications of the procedure. Conclusions Increasing litigation in the NHS over the last decade now accounts for 2% of the total NHS budget. The majority of settlements reviewed here were for avoidable delays in elective treatment, with higher financial settlements for well documented surgical complications related to the consent process. Better access to investigations, earlier clinical review, and reductions in delays to elective surgeries may reduce the financial burden of litigation.

Aims Heart rate variability (HRV) is a validated marker of physiological stress, a lower HRV indicating increased stress. We aim to evaluate the HRV of an on call surgical registrar during a laparoscopic appendicectomy to determine which step of an operation is most stressful and any attributing factors to trainee stress. Methods An observational study was performed using a commercially available chest strap to measure HRV. HRV was recorded on different surgical registrars performing laparoscopic appendicectomy at a DGH. HRV was analysed during four critical steps: insertion of ports, dissection of mesoappendix, endoloop placement and ligation of appendix. Impact of registrar grade and consultant presence were also evaluated. Results 15 recordings from seven different registrar's (ST3 – ST8) were obtained. Average heart rate was 74–130bpm. HRV was observed to be less during port insertion (9.22) and mesoappendix dissection (8.42) compared to the rest of the operation (9.86) indicating a higher level of stress. Ligation of the appendix showed an increased HRV indicating less stress (9.34). A significant difference was observed between ST3/4 and ST5+ grade for mesoappendix dissection (7.39 and 9.46 respectively), the step associated with most stress (p Conclusions HRV is highest during mesoappendix dissection compared to that of the whole operation. HRV increases after this step showing that trainees experience increased stress up to and including this step of the operation. The ST3/4 group showed a significantly lower HRV during this step compared to the ST5+ group. Consultant presence did not significantly affect HRV.

Aims Laparoscopic magnetic sphincter augmentation (MSA) or LINX® procedure is gaining popularity as a treatment for gastro-oesophageal reflux disease. We looked at the long-term outcomes of this procedure with regards to its efficacy, in particular studying the dysphagia rate in relation to the LINX® device size. Methods Postal questionnaires were sent to all patients who underwent MSA procedure between 2012-2019 at a single institution. Patients were asked to quantify, as a percentage, their symptom resolution, proton pump inhibitor (PPI) intake and side effects. Results 124 patients (male:female ratio was 45:55) underwent MSA procedure, with 82 responding to the questionnaire. Patients' age range was 18-71 years (median 49). Over 90% of patients reported improvements in reflux symptoms with 75% reporting complete resolution. 67% of patients no longer required PPI medication, whilst 21% of patients had >50% reduction in their medication. Post-operative dysphagia occurred in 59% of patients at 3 months, which decreased to 16% at 1 year. There was no significant difference in size of LINX® device used between patients with dysphagia at ≥ 1 year versus those without dysphagia at ≥ 1 year (p = 0.554). In total 3 patients (2%) required explantation of the LINX® device. Overall 86% of patients rated their outcomes as satisfactory or very satisfactory. Conclusions Our 7 years of experience with laparoscopic MSA has demonstrated that this procedure is safe with high patient satisfaction rates. Dysphagia, although common in the early post-operative period, usually resolves within 3-6 months and is unrelated to LINX® device size.