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The emergence of the COVID-19 pandemic has placed increased demands on the NHS workforce, especially in medical and intensive care units The subsequent redistribution of surgical house officers to accommodate this in a single-centre NHS hospital has possibly negatively impacted on the effective discharge notification of acute surgical patients Discharge summaries of all patients directly discharged from a Surgical Assessment Unit were collected on the day of discharge and analysed to identify the date of completion and staff grade of the responsible clinician Data collection was carried out before the initiation of lockdown measures and continued for a further three weeks during the peak of the COVID-19 pandemic with an interventional period in between A poster was created and displayed in areas where discharge software could be accessed In the initial audit, 36 2% of the 246 patients had delayed discharge summaries with an average of 7 days to complete On re-evaluation, 45 3% of the 223 patients had delayed discharge summaries, taking an average of 12 days to complete A survey conducted post-re-audit identified that the most common reason for delayed discharge summaries was due to time constraints associated with the increased workload The reallocation of surgical staff in response to the COVID-19 pandemic has affected communication between primary and secondary care, with a rise in delayed discharge letters of acute surgical patients Given the potential repercussions of these delays, healthcare systems should be aware of this consequence of the pandemic, especially in preparation for any resurgences [ABSTRACT FROM AUTHOR] Copyright of Journal of Patient Safety & Risk Management is the property of Sage Publications, Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use This abstract may be abridged No warranty is given about the accuracy of the copy Users should refer to the original published version of the material for the full abstract (Copyright applies to all Abstracts )

Aim The Covid‐19 pandemic has delayed elective colorectal cancer (CRC) surgery. The aim of this study was to see whether or not this may affect overall survival (OS) and disease‐free survival (DFS). Method A systematic review was carried out according to PRISMA guidelines (PROSPERO ID: CRD42020189158). Medline, EMBASE and Scopus were interrogated. Patients aged over 18 years with a diagnosis of colon or rectal cancer who received elective surgery as their primary treatment were included. Delay to elective surgery was defined as the period between CRC diagnosis and the day of surgery. Meta‐analysis of the outcomes OS and DFS were conducted. Forest plots, funnel plots and tests of heterogeneity were produced. An estimated number needed to harm (NNH) was calculated for statistically significant pooled hazard ratios (HRs). Results Of 3753 articles identified, seven met the inclusion criteria. Encompassing 314 560 patients, three of the seven studies showed that a delay to elective resection is associated with poorer OS or DFS. OS was assessed at a 1 month delay, the HR for six datasets was 1.13 (95% CI 1.02–1.26, p = 0.020) and at 3 months the pooled HR for three datasets was 1.57 (95% CI 1.16–2.12, p = 0.004). The estimated NNH for a delay at 1 month and 3 months was 35 and 10 respectively. Delay was nonsignificantly negatively associated with DFS on meta‐analysis. Conclusion This review recommends that elective surgery for CRC patients is not postponed longer than 4 weeks, as available evidence suggests extended delays from diagnosis are associated with poorer outcomes. Focused research is essential so patient groups can be prioritized based on risk factors in future delays or pandemics.

Aim The involvement of pelvic sidewall (PSW) lymph nodes in rectal cancer is a marker of locally advanced disease and poor prognosis. Eastern countries generally advocate lateral lymph node dissection (LLND) over the Western approach of neoadjuvant chemoradiotherapy and more limited surgery. The aim of this study was to evaluate how these advanced cancers were treated in three UK Health Boards. Methodology This was a retrospective review of three colorectal multidisciplinary team meetings from 2008 to 2016. All patients with rectal cancer and suspicious PSW lymph nodes on pretreatment MRI were included. Results There were 153 (6.2%) patients who met the inclusion criteria from a total of 2461 diagnosed rectal cancers. There was significant variability between the three centres with surgical intervention ranging from 59.2% to 84.4%, P = 0.015. There were 81 patients who had neoadjuvant chemoradiotherapy prior to surgery; of these 67 (82.7%) still had positive PSW nodes on the restaging MRI, but only 13 (19.4%) had LLND. There was no difference in local recurrence (15.3% vs 11.8%, P = 0.66), 5-year overall survival (69.2% vs 80.1%, P = 0.16) or 5-year disease-free survival (69.2% vs 79.4%, P = 0.72) between patients having LLND and those receiving standard neoadjuvant treatment followed by total mesorectal excision surgery. Conclusions This study has demonstrated that rectal cancer patients with PSW positive nodal disease have advanced disease, mostly of the lower rectum, and receive a highly heterogeneous spectrum of therapies, even within a relatively small geographical area. Greater accuracy in our preoperative staging is needed to select those patients who will benefit from LLND surgery.

AIM Delayed closure of ileostomy following an anterior resection for rectal cancer in the UK is common. The aims of this study were (i) to investigate the variation in patient pathways between hospitals, (ii) to identify the key learning points from units with the shortest time to closure and (iii) to develop guidance for a pathway to minimize delay in ileostomy closure. METHOD This was a mixed methods study. Thirty-eight colorectal units in the UK completed a short online survey. Nine colorectal units in Wales filled in an additional, expanded version of the survey. Semi-structured interviews were performed with clinicians from the six best performing units in terms of timely ileostomy closure. The optimal pathway suggested is based on the best evidence available and the Association of Coloproctology of Great Britain and Ireland guidelines. RESULTS Qualitative analysis revealed that 5% of units (n = 2) have a local target time for ileostomy closure. Of all units, 90% (n = 34) would consider implementing a pathway if guidelines were developed. In-depth interviews highlighted the importance of a multidisciplinary approach, a dedicated coordinator to facilitate timely booking, and consensus on whether closure should be performed before or after adjuvant chemotherapy. CONCLUSION There is a lack of national guidance in timing of contrast studies and ileostomy closure. Key aspects to consider are better information at consent regarding stoma closure timing, a dedicated person to track patients and the planning of contrast studies at discharge from initial surgery. With a dedicated approach closure of ileostomy within 10-12 weeks is feasible for most units.

Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.Los adultos mayores sometidos a cirugía abdominal de urgencia tienen resultados significativamente peores que los adultos jóvenes. Para aquellos pacientes que sobreviven, el nivel de atención que requieren tras el alta hospitalaria se desconoce y esta información podría servir de guía en la toma de decisiones. El estudio ELF (Emergency Laparotomy and Frailty) tenía como objetivo determinar si la fragilidad preoperatoria en adultos mayores se asociaba con un aumento de la dependencia en el momento del alta. MÉTODOS: El estudio ELF era un estudio multicéntrico extenso efectuado en el Reino Unido (n = 49) que incluyó una cohorte prospectiva de 934 pacientes mayores ( 65 años) sometidos a laparotomía de urgencia durante marzo-junio de 2017. El objetivo fue establecer si la fragilidad preoperatoria aumentaba el nivel de asistencia en el momento del alta en comparación con el nivel de asistencia preoperatorio. Para el análisis se utilizó una regresión logística multinivel ajustada a características previas al ingreso: fragilidad, edad del paciente, género, y nivel de asistencia.La edad media de los pacientes fue 76,2 años (DE = 6,83), con un 57% de mujeres, un 20,2% de pacientes frágiles y un 37,4% de adultos mayores que presentaron un aumento en el nivel de asistencia en el momento del alta. Un aumento de la fragilidad se asoció con un incremento en el nivel de asistencia en el momento del alta (y mayor poder predictivo que la edad). La razón de oportunidades (odds ratio, OR) ajustada por el aumento del nivel de asistencia fue 4,48 (i.c. del 95% 2,03-9,91) para pacientes aparentemente vulnerables (Clinical Frailty Scale, CFS 4); 5,94 (i.c. del 95% 2,54-13,90) para aquellos ligeramente frágiles (CFS 5); y 7,88 (i.c. del 95% 2,97-20,79) para aquellos con fragilidad moderada o grave (CFS 6 and 7) en comparación con pacientes en buenas condiciones. CONCLUSIÓN: Este es el primer estudio que documenta que más del 37% de adultos mayores sometidos a laparotomía de urgencia precisaron un aumento en el nivel de asistencia en el momento del alta. La evaluación de la fragilidad debería integrarse en todas las unidades quirúrgicas de agudos para ayudar a compartir la toma de decisiones y los planes de tratamiento.

INTRODUCTION: Colon ischaemia (CI) is a significant complication of open (OR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA). With a rapid increase in EVAR uptake, contemporary data demonstrating the differing rates and outcomes of CI between EVAR and OR, particularly in the elective setting, are lacking. The aim was to characterise the risk and consequences of CI in elective AAA repair comparing EVAR with OR.METHODS: A systematic review and meta-analysis of the literature was performed using the Cochrane collaboration protocol and reported according to the PRISMA guidelines. PubMed, MedLine, and EMBASE were searched for studies reporting CI rates after elective AAA repair. Ruptured AAAs were excluded from analysis.RESULTS: Thirteen studies reporting specific outcomes of CI after elective AAA repair, containing 162,750 evaluable patients (78,151 EVAR and 84,599 OR) were included. All studies found a higher risk of CI with OR than with EVAR. Three studies performed confounder adjustment with CI rates of 0.5-1% versus 2.1-3.6% (EVAR vs. OR) and combined odds ratio of 2.7 (2.0-3.5) for the development of CI with OR versus EVAR. The majority of cases of CI occurred within 30 days and were associated with variable mortality (0-73%) and re-intervention rates (27-54%). GRADE assessment of evidence strength was very low for all outcomes. There was a high degree of heterogeneity between studies both methodologically and in terms of CI rates, re-intervention, mortality, and time to development of CI.CONCLUSIONS: EVAR is associated with a reduced incidence of CI compared with OR.

Given the lack of a recent meta-analysis on this topic, we attempted to quantify the delay from diagnosis to surgical treatment in elective colorectal cancer from the available literature. The evidence base available to the authors was of poor quality as acknowledged by the ROBINS-I score which declared three papers at serious risk of bias.

We read with great interest Moncur and colleagues'1 recent systematic review investigating the impact and outcomes of postoperative anaemia in colorectal cancer patients. We congratulate the authors on an interesting review of the current literature that clearly establishes a clinical and academic need to ascertain the true effect of postoperative anaemia, given its high prevalence and potential negative effects on patient outcomes. However, we feel that the novel bias tool, utilised to add improved academic rigor to reviews of this kind, was performed incorrectly in this case.

INTRODUCTION: Several articles have been published about the reorganisation of surgical activity during the COVID-19 pandemic but few, if any, have focused on the impact that this has had on emergency and trauma surgery. Our aim was to review the most current data on COVID-19 to provide essential suggestions on how to manage the acute abdomen during the pandemic. METHODS: A systematic review was conducted of the most relevant English language articles on COVID-19 and surgery published between 15 December 2019 and 30 March 2020. FINDINGS: Access to the operating theatre is almost exclusively restricted to emergencies and oncological procedures. The use of laparoscopy in COVID-19 positive patients should be cautiously considered. The main risk lies in the presence of the virus in the pneumoperitoneum: the aerosol released in the operating theatre could contaminate both staff and the environment. CONCLUSIONS: During the COVID-19 pandemic, all efforts should be deployed in order to evaluate the feasibility of postponing surgery until the patient is no longer considered potentially infectious or at risk of perioperative complications. If surgery is deemed necessary, the emergency surgeon must minimise the risk of exposure to the virus by involving a minimal number of healthcare staff and shortening the occupation of the operating theatre. In case of a lack of security measures to enable safe laparoscopy, open surgery should be considered.

Aim There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. Methods Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. Results All aspects of surgical care for IBD have been included along with 157 recommendations for management. Conclusion These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Population screening for colorectal cancer (CRC) was introduced to Wales in October 2008. The aim of this study was to evaluate the early impact of screening on CRC services.Prospectively collected data from the Bowel Screening Wales (BSW) programme and the Welsh Bowel Cancer Audit (WBCA) were used to identify all screen-detected (SD) CRC diagnoses in Wales between April 2009 and March 2011. Data from the WBCA were used to calculate surgical outcomes.444 SD cancers were registered during the study period representing 11% of all CRC diagnoses. There was a 9.9% increase in CRC incidence following the introduction of the BSW. SD patients presented with earlier stage disease; SD Dukes' A 35.1% vs 13.9% symptomatic patients (p0.001) and SD Dukes' D 7.4% vs 21.8% symptomatic, (p0.001). There were more colonic cancers among the SD population (p0.001). The resection rate for SD cancers was 89%, significantly higher than symptomatic cancers (67.7%; p0.0001). There was variability in the use of polypectomy as a definitive procedure to treat CRC between units. Overall laparoscopic resection was used in 52% of cases but with considerable interunit variability (0-92%).The introduction of screening has increased the workload of the colorectal multidisciplinary teams in Wales. This has occurred through both an increase in case volume and the identification of more patients with early stage disease. There is considerable interunit variability in the use of techniques of local excision and rates of laparoscopic resection that need to be addressed.

Aim Lymph node (LN) metastases are present in up to 17% of early colorectal cancers (pT1). Identification of associated histopathological factors would enable counselling of patients regarding this risk. Method Pubmed and Embase were employed utilizing the terms ‘early colorectal cancer’, ‘lymph node metastasis’, ‘submucosal invasion’, ‘lymphovascular invasion’, ‘tumour budding’ and ‘histological differentiation’. Analysis was performed using REVIEW MANAGER 5.1. Results Twenty-three cohort studies including 4510 patients were analysed. There was a significantly higher risk of LN metastasis with a depth of submucosal invasion > 1 mm than with lesser degrees of penetration (OR 3.87, 95% CI 1.50–10.00, P = 0.005). Lymphovascular invasion was significantly associated with LN metastasis (OR 4.81, 95% CI 3.14–7.37, P 1 mm, lymphovascular invasion, poor differentiation and tumour budding are significantly associated with LN metastasis.

OBJECTIVE To determine if diffuse hepatic uptake (DHU) of radioactive iodine (I-131) following radioactive iodine treatment has prognostic implications in otherwise scan-negative patients. METHODS This is a retrospective review of patients treated for differentiated thyroid cancer (DTC) at Beth Israel Deaconess Medical Center between January 1990 and June 2006. This group included patients receiving therapy to ablate presumed remnant tissue, as well as treatment for persistent disease as measured by thyroglobulin or imaging. All patients included in the study had no remnant uptake and otherwise negative posttherapy scans. A total of 57 patients with 63 scans met these criteria. The scans were then scored for DHU on a scale of 0 to 5, with 0 being no uptake and 5 being intense uptake relative to background. RESULTS Sixteen of 63 treatments were remnant ablations. Ten of 57 patients had positive thyroglobulin antibodies. Average DHU was similar in the ablation and therapeutic groups (1.9 vs. 2.3, P = .3). There was no correlation with either I-131 dose or the presence of thyroglobulin antibodies. There was a difference for DHU in the rate of disease-free survival, (undetectable thyroglobulin and no clinical or radiographic evidence of metastasis); 50% of patients with hepatic uptake scores of 0-2 were disease-free compared to 15% with scores of 3-5 (P

Aim The risk of peripheral nerve injury associated with laparoscopic colorectal surgery has not been well established. We aimed to identify the number and type of peripheral nerve injuries associated with patient positioning in laparoscopic surgery. Method A systematic review of MEDLINE and Embase was undertaken of English and non-English language articles. Search terms included the key words: laparoscopic, colorectal, nerve injury, nerve damage, brachial plexus, peripheral neuropathy, peripheral nerve injury, nerve and colonic injury. Articles were included where at least one peripheral nerve injury had been documented related to patient positioning at laparoscopic colorectal surgery. Data extraction for articles was conducted by two authors, using predefined data fields. Results Ten cases have been reported in the literature. All injuries involved the brachial plexus. They were associated with a lengthy procedure and abduction of the arm. Conclusion Although rare, the surgeon and theatre team must be aware of the risk of peripheral nerve injury when positioning patients for laparoscopic colorectal procedures.

Introduction Malrotation of the midgut and appendiceal mucocoele are both extremely rare pathological conditions in adults. To our knowledge, there are only two reported cases in the English literature with a combination of both conditions. Case History A 65-year-old man presented with a 10-day history of upper abdominal pain associated with abdominal bloating and weight loss. He was otherwise fit and healthy with no significant past medical history. On examination, his abdomen was soft with tenderness and palpable fullness over the left upper quadrant. The initial blood test, chest x-ray and abdominal x-ray demonstrated no significant abnormality. Computed tomography showed a 17cm x 8cm x 6cm elongated cystic mass with possible malrotation of the intestines. Histopathology showed a low grade mucinous tumour of the appendix. At 12 months following surgery, there was no evidence of recurrence or postoperative complications and the patient was discharged from the care of the colorectal team. Conclusions We report a patient with a combination of two rare conditions. This case illustrates how a combination of pathologies can present a challenge to the unwary general surgeon.

Aim Parastomal hernias are difficult to manage and recent attention has focused on their prevention including the use of prophylactic mesh at the time of initial surgery. Method A novel ‘anatomical’ approach to stoma formation, the lateral rectus abdominis positioned stoma (LRAPS), involving minimal anterior abdominal wall disruption is described. Results LRAPS was carried out electively (n = 25) or as an emergency (n = 4) for benign or malignant pathology. Twenty-two had a midline laparotomy and all types of stomas were fashioned. There were two early and three later deaths from advanced malignancy. No parastomal hernias have been detected at a mean follow-up of 13 (range 7–18) months and none detected by CT scanning in 20 of 24 patients with colorectal cancer at a mean follow-up of 14 (range 10–18) months. Conclusion LRAPS reduces the incidence of early stomal herniation.

Myocardial 18F-FDG uptake in PET scans in patients prepared by the usual fasting protocol may result in difficulties in interpretation because variable uptake may yield false-positive results regarding mediastinal abnormalities. We aimed to analyze, retrospectively, the effect of diet on myocardial FDG uptake.The "fasting" group comprised 101 consecutive patients before a clinical change in the patient preparation protocol. The "new diet" group comprised 60 consecutive patients after the clinical protocol change who were directed to consume a very high-fat, low-carbohydrate, protein-permitted (VHFLCPP) diet before FDG injection. All patients were given a questionnaire that was used to verify diet adherence. Nonadherers or patients failing to complete questionnaires were excluded from analysis. Myocardial uptake was evaluated by measuring the maximum standardized uptake value (SUVmax) in areas defined by CT as being cardiac.The average SUVmax for the fasting group (n = 101) was 8.8 +/- 5.7, and the average SUVmax for the VHFLCPP group (n = 60) was 3.9 +/- 3.6. The one-tailed Student's t test yielded a p value of0.00001.A VHFLCPP meal eaten 3-6 hours before FDG injection suppresses myocardial FDG uptake. This should facilitate definition of mediastinal abnormalities on FDG PET, particularly with stand-alone PET. Furthermore, this patient preparation protocol may permit the detection of biologically active coronary artery disease.

Certain stress-induced ancillary findings on myocardial perfusion scintigraphy increase the likelihood that the patient has coronary artery disease (CAD); furthermore, among CAD patients, they indicate more severe and extensive disease, placing these patients at higher risk for future cardiac events. Indeed, in studies with no obvious perfusion defect yet with serious CAD--for example, balanced ischemia--it can be these high-risk findings that necessitate invasive intervention.Besides reversible perfusion defects, such findings include increased pulmonary radiotracer uptake, transient cavity dilatation, increased end-diastolic or end-systolic volume, decreased post-stress ejection fraction, and increased right ventricular tracer uptake on stress images. The pathophysiology underlying these findings is clearly different as they do not always occur together, and each independently predicts more severe and extensive CAD. In the current review, these findings are defined and their significance in diagnosing patients with suspected or known CAD is discussed.

Objective Individuals with a strong family history have a high risk of developing colorectal cancer. They could well benefit from targeted screening and their increased risk warrants an invasive procedure such as colonoscopy. This study aims to assess the anxieties of symptom-free relatives offered screening by colonoscopy. Method A simple questionnaire was sent to 50 consecutive people who had colorectal cancer screening by colonoscopy because of a strong family history. Results Forty-five questionnaires were answered. On assessing their anxiety levels before and after colonoscopy, 56% noticed an improvement after the test, 33% were still as anxious and 11% had raised anxiety levels despite screening. Although most of the screening colonoscopies were normal, 44% of asymptomatic relatives undergoing invasive screening had no improvement of their cancer anxieties. Conclusion Screening people with a strong family history of colorectal cancer may be an efficient, cost-effective and focussed way of detecting early neoplasms rather than screening the general population. Using colonoscopy alone however, a large proportion of people still have cancer anxieties after being screened. This small study suggests that in order to attempt to alleviate anxieties, a colonoscopy alone is insufficient for some in this high-risk group.

To retrospectively determine the prognostic importance of small hypoattenuating hepatic lesions at contrast material-enhanced computed tomography (CT) in patients with breast cancer.This retrospective study was approved by the committee on human research. Written informed consent was not required. The authors retrospectively identified 153 patients with breast cancer who underwent serial abdominal CT and who did not have definite liver metastases present at initial CT. The mean age was 56 years (age range, 27-93 years). Two readers independently recorded the presence, size, and number of small (15 mm or less in diameter) hypoattenuating hepatic lesions at initial CT. Another reader independently recorded the presence or absence of definite hepatic metastases at final CT. The association between the presence, size, and number of small hypoattenuating hepatic lesions at initial CT and the subsequent development of metastases was analyzed by using Kaplan-Meier analysis.One or more small hypoattenuating hepatic lesions were seen at initial CT in 54 of 153 patients (35%). After a median follow-up of 584 days (range, 16-1827 days), definite hepatic metastases developed in 43 of 153 patients (28%), including 15 of 54 patients (28%) with hypoattenuating lesions at initial CT and 28 of 99 patients (28%) without hypoattenuating lesions at initial CT. Findings from the Kaplan-Meier analysis showed no association between the presence (P = .56), size (P = .55), or number (P = .30) of small hypoattenuating hepatic lesions at initial CT and the subsequent development of hepatic metastases.In patients with breast cancer who do not have definite hepatic metastases at initial examination, there is no evidence that small hypoattenuating hepatic lesions seen at initial CT contribute to an increased risk of subsequently developing hepatic metastases.

Objectives To determine if the femur length of fetuses with myelomeningocele is shorter in the second and third trimesters compared with that of normal fetuses. Methods We retrospectively collected measurements of femur length, head circumference, biparietal diameter and abdominal circumference from detailed obstetric ultrasound studies performed during the second and third trimesters in 31 fetuses with myelomeningocele and 43 fetuses with no detectable anomaly. The gestational age predicted by each parameter (based on Hadlock's tables) was compared with the true gestational age (based on last menstrual period), using the ANCOVA test to determine if there was a statistically significant difference between the two groups of fetuses. Results There was no significant difference in femur length (P = 0.60) or in abdominal circumference (P = 0.85) between fetuses with myelomeningocele and normal fetuses. Fetuses with myelomeningocele did have a significantly lower biparietal diameter and head circumference (P ≤ 0.001). Conclusions Myelomeningocele is not associated with reduced femur length in the second and third trimesters, suggesting that the known postnatal lower extremity foreshortening in patients with myelomeningocele develops late in gestation or after birth. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Aim The prevalence of abdominal wall herniation at the site of a previous temporary stoma is uncertain. This cohort study investigated the frequency of radiological abnormalities at the site of a closed diverting loop ileostomy. Method All patients in whom an ileostomy was raised and later closed during a 5-year period formed the study group. When colorectal cancer surveillance computed tomography (CT) was undertaken the images were scrutinized and graded as to defined anatomical abnormalities. Results One hundred and seventy-nine patients had an ileostomy, of which 92 were diverting. Fifty-nine (64%) were closed at various intervals (median time to closure 6 (2–22) months and 43 underwent a surveillance CT at 1–3 (median 2) years. At 1 year an abnormality (atrophy or defect) at the site of closure was seen in 16 (37%) CT scans. These were more frequent with increasing duration of follow-up. One asymptomatic hernia was detected at 2 years but there was no deterioration in the abdominal wall at 3 years when compared with that at 2 years. Conclusion Abnormalities in the abdominal wall at the site of a closed diverting ileostomy are common but true herniation is unusual. The routine use of prophylactic mesh at ileostomy closure may be unnecessary.

We report two patients with non-healing surgical wounds, which healed after the withdrawal of Nicorandil therapy. Nicorandil should be recognised as an aetiological factor for non-healing wounds or ulcers once other inflammatory and malignant causes have been excluded. This may avoid surgery for high-risk patients and may also reduce complications for patients who undergo surgery for non-healing wounds. As Nicorandil is used in patients with severe coronary artery disease, it is recommended that the advice of a cardiologist is sought prior to cessation or adjustment to its dose.

Migration has been highlighted as a serious complication of open inguinal hernia repair with the “plug-and-patch” technique. We used an English language Medline search from 1995 to 2006. Review of the literature found that three cases showed poor surgical technique, one case did not show true migration, another was a case of the wrong operation being done, and in the final case, the patient was in overall very poor health. Mesh plug migration after open inguinal hernia repair can be avoided if proper attention to detail is used at the time of initial repair.

Aim The Wales-Trent Bowel Cancer Audit (WTBA) was carried out in 1993, and since 2001 Welsh Bowel Cancer Audits (WBCA) have taken place annually. Screening for bowel cancer in Wales was introduced in 2008. This study compared patient variables, the role of surgery and operative mortality rates over the 15-year interval between the WTBA and the last WBCA before the introduction of population screening. Method Data from the WTBA in 1993 were compared with those of the WBCA including patients diagnosed between April 2007 and March 2008. Results In 1993, 1536 patients were diagnosed with colorectal cancer (CRC) compared with 1793 in 2007–2008. Patient demographics and American Society of Anesthesiology (ASA) score did not change during these periods. Surgical treatment for CRC decreased (93% in 1993 vs 80% in 2007–2008; P

Transverse abdominal wall incisions are favoured as part of enhanced recovery programmes. We explored the use of rectus-preserving extraction site incisions in laparoscopic right colectomy. The approach involved minimal anterior abdominal wall disruption with preservation of the rectus abdominis muscle: the rectus abdominis muscle extraction site (RAMES). In 15 patients, a RAMES was used electively in right colectomy for malignancy. The median wound length was 6 cms. There was no clinical or radiological evidence of incisional herniation in the 15 patients at 12-month and in the 12 survivors at 24-month follow-up. An anatomical dissection at specimen extraction site reduces early incisional herniation rates and should be of benefit in the longer term.

The efficacy of capecitabine as adjuvant therapy in colon cancer is well demonstrated and its lower toxicity rates when compared with 5-FU make it an increasingly more favourable option for patients. This case highlights the awareness of a potentially severe side effect related to the use of capecitabine, yet through the early identification of symptoms patients can be managed conservatively.

Various techniques have been used to repair lumbar hernias. We describe here a sutureless repair with a flat ‘memory ring’ patch performed as a day case.

Although brown adipose tissue in infants and young children is important for regulation of energy expenditure, there has been considerable debate on whether brown adipose tissue normally exists in adult humans and has physiologic relevance in this population. In the last decade, radiologic studies in adults have identified areas of adipose tissue with high 18F-fluorodeoxyglucose (18F-FDG) uptake, putatively identified as brown fat. This radiologic study assessed the presence of physiologically significant brown adipose tissue among 1972 adult patients who had 3640 consecutive 18F-FDG positron-emission tomographic and computed tomographic whole-body scans between 2003 and 2006. Brown adipose tissue was defined as areas of tissue that were more than 4 mm in diameter, had the CT density of adipose tissue, and had maximal standardized uptake values of 18F-FDG of at least 2.0 gm per mL. A sample of 204 date-matched patients without brown adipose tissue served as the control group. Using these criteria, positron-emission tomographic and computed tomographic scans identified brown adipose tissue in 106 of the 1972 patients (5.4%). The most common location for substantial amounts of brown adipose tissue was the region extending from the anterior neck to supraclavicular region. Immunohistochemical staining for uncoupling protein 1 in this region confirmed the identity of immunopositive, multilocular adipocytes as brown adipose tissue. More brown adipose tissue was detected in women (7.5% [76/1013]) than in men (3.1% [30/959]); the female:male ratio was 2.4:1.0 (P 64) (P 64 years) (P for trend = 0.007). These findings show that functional brown adipose tissue is prevalent in adult humans, and significantly more frequently in women. The inverse correlation of body mass index with the amount of brown adipose tissue, especially in older patients, suggests to the investigators a possible role of brown adipose tissue in protecting against obesity.

PET/CT imaging with 18F-FDG has been used to detect inflammation in carotid and aortic plaque; its use in detecting coronary plaque has been limited by avid 18F-FDG uptake by the myocardium. We investigated whether 18F-FDG PET/CT could be used to image inflammation in coronary arteries as a potential noninvasive method to detect vulnerable plaque. Methods: We retrospectively studied 32 patients treated for malignancy who underwent 18F-FDG PET/CT and concomitant cardiac catheterization. As part of the recently described protocol, all patients were instructed to eat a low-carbohydrate, high-fat meal the night before and drink a vegetable oil drink the morning of the study. We reviewed the patients9 baseline characteristics and their 18F-FDG PET/CT scans for adequacy of myocardial uptake suppression and correlated the presence of angiographically apparent plaque with 18F-FDG uptake in the major coronary arteries. Two independent observers assessed the angiographic images and 18F-FDG PET scans. Results: A total of 95% of patients had 2 or more coronary disease risk factors, and 25% had unstable symptoms; 30% of index catheterizations resulted in intervention. In 20 of 32 patients (63%), myocardial suppression was good (12) or adequate (8). Inadequate suppression was due to self-reported dietary nonadherence. Patients with good, adequate, and poor suppression had maximal myocardial standardized uptake values of 2.8 ± 0.7, 5.0 ± 1.3, and 17.0 ± 9.7, respectively. We identified 18F-FDG uptake in 15 patients in 1 or more coronary segments. A trend to significance in correlation between presence of angiographic disease and signal in the vessel was observed (P = 0.07; 80 vessels examined). A total of 7 patients with significant coronary artery disease had aortic 18F-FDG uptake. Conclusion: In this retrospective study, we demonstrated the potential use of 18F-FDG PET in imaging of inflammation in coronary arteries. The potential of 18F-FDG PET is also being investigated in a prospective study.

Objective To determine whether focal 18F-fluorodeoxyglucose (FDG) uptake could be detected along the course of coronary arteries in patients with known coronary artery disease (CAD) and/or coronary artery calcification (CAC) by PET/computed tomography (CT) using a new patient preparation protocol that reduces background myocardial FDG uptake. Materials and methods In this retrospective, Health Insurance Portability and Accountability Act-compliant study approved by our institutional internal review board, 60 FDG-PET/CT studies performed for noncardiac indications were reviewed and CAC and focal FDG uptake were determined. Cardiac histories were obtained. Age range was 21-88 years (64+/-16 years); 35 women/25 men; six had CAD documented by myocardial perfusion imaging, cardiac catheterization, or history of percutaneous coronary intervention or coronary artery bypass grafting. Chi-square probabilities were calculated. Results Fifteen of the 60 patients studied showed focal FDG uptake along the course of coronary arteries; fourteen of these showed significant CAC scores and four had documented CAD. The concordance of focal FDG coronary artery uptake was 58% with CAC, 77% with cardiac history, and 90% with extracardiac vascular focal FDG uptake. There were 20 focal FDG and coronary artery lesions in 15 patients and 11 of the 20 colocalized with calcification. No preferred anatomic location was found (junction, end of calcification or along coronary artery). Conclusion This limited retrospective study shows that with a new patient preparation to reduce high FDG uptake by the myocardium on PET/CT scans, foci of increased FDG cardiac uptake can be seen in association with CAC and in patients with a history of CAD. These results provide initial evidence that it may be possible to use FDG-PET/CT to monitor sites of coronary plaque formation. Larger and invasive prospective studies will be necessary to fully determine the suitability of this technique for that purpose.

Purpose To determine the prognostic importance of superior diaphragmatic adenopathy at CT in patients with resectable hepatic metastases from colorectal carcinoma. Materials and methods We retrospectively identified 85 patients who underwent contrast-enhanced abdominal computed tomography (CT) at our institution before surgical resection of hepatic metastases from colorectal carcinoma. The study group consisted of 45 men and 40 women with a mean age of 60 years (range, 27-89 years). The presence, size, and number of superior diaphragmatic nodes were recorded on preoperative CT images. Kaplan-Meier analysis was used to investigate the association between the presence, number, and size of superior diaphragmatic nodes and postoperative outcome. Results One or more superior diaphragmatic nodes were seen on preoperative CT in 43 (51%) of 85 patients, and 29 (34%) patients had nodes of 5 mm or more in short-axis diameter. After a median follow-up of 599 days (range, 3-1960 days), 49 patients were alive, and 36 were dead. Kaplan-Meier analysis showed no association between the presence (P = 0.67), size (P = 0.74), or number (P = 0.95) of superior diaphragmatic nodes and patient outcome. Conclusions The presence, size, or number of superior diaphragmatic nodes at preoperative CT are unrelated to postoperative outcome in patients with resectable hepatic metastases from colorectal carcinoma, suggesting that superior diaphragmatic adenopathy in this setting may be reactive rather than metastatic.

INTRODUCTION The objective of this study was to examine referral patterns from general practitioners for groin hernia surgery and to assess their knowledge of services available to their patients. PATIENTS AND METHODS An anonymous postal questionnaire was sent to 120 general practitioners (GPs) in the South East Wales region who routinely refer patients for inguinal hernia surgery to the Royal Gwent Healthcare NHS Trust. RESULTS A total of 86 questionnaire replies were returned. There was variation in referral patterns between the GPs with the majority (84%) referring their patients for groin hernia repair to either a general surgeon or as an open referral. Only 14% referred directly to a hernia specialist and none regularly referred to a laparoscopic surgeon. CONCLUSIONS Referral patterns for inguinal hernia surgery do not reflect services provided in secondary care. Further education is required so that a patient's care can be optimised.

The rationale of this study was to investigate the feasibility of three-dimensional (3D) methods to analyze 18F-fluoro-deoxy-glucose (FDG) uptake in children with anaplastic astrocytoma (AA) in a multi-institutional trial, to compare 3D and two-dimensional (2D) methods and explore data associations with progression-free survival (PFS). 3D tumor volumes from pretreatment MR images (fluid attenuation inversion recovery and postgadolinium) of children with recurrent AA on a phase I trial of imatinib mesylate were coregistered to FDG positron emission tomography (PET) images. PET data were normalized. Four metrics were defined: the maximum ratio (maximum pixel value within the 3D tumor volume, normalized), the total ratio (cumulative pixel values within the tumor volume, normalized) and tumor mean ratio (total pixel value divided by volume, normalized). 2D analysis methods were compared. Cox proportional hazards models were used to estimate the association between these methods and PFS. Strongest correlations between 2D and 3D methods were with analyses using postcontrast T1 images for volume of interest (VOI). The analyses suggest 3D maximum tumor and mean tumor ratios, whether normalized by gray matter or white matter, were associated with PFS. This study of a series of pretreatment AA patients suggests that 3D PET methods using VOIs based on postcontrast T1 correlate with 2D methods and are related to PFS. These methods yield an estimate of metabolically active tumor burden and may add prognostic information after tumor grade is determined. Future rigorous multi-institutional protocols with larger numbers of patients will be required for validation.

An initial CT of a 59-year-old man with increasing back pain and weight loss showed lymphadenopathy in multiple nodal beds. A biopsy showed diffuse, large B-cell lymphoma (DLBCL). After initial chemotherapy, residual disease prompted an autologous stem cell transplant. After a follow-up FDG-PET/CT scan showed no FDG-avid disease, a subsequent study showed FDG uptake in a nonenlarged left axillary lymph node. Questioning elicited a recent immunization history. A follow-up PET/CT scan showed no uptake in this lymph node and no disease recurrence. Without this history, an unnecessary biopsy or treatment may have ensued. Methods to avoid such occurrences are discussed.

Myocardial perfusion scintigraphy is a well validated noninvasive method of evaluating for significant coronary artery disease, especially in cases where electrocardiographic changes are nondiagnostic, including left bundle-branch block. However, such testing with a technetium Tc 99m agent is often confounded by left ventricular septal-based false-positive perfusion defects. These defects can be either reversible or irreversible in the septal or anteroseptal wall, problematically then, in the territory supplied by the left anterior descending coronary artery. Mechanisms explaining false-positive defects include decreased perfusion via impaired microvessel flow and normal perfusion with apparent decrease in counts in a relatively thin septum (partial-volume effect). Key findings in myocardial perfusion images in the presence of left bundle-branch block that define true positives (ischemia) are reversible perfusion defects (especially at end diastole), a concomitant apical defect, and systolic dysfunction matching the perfusion defect.

To determine the prognostic importance of minor morphologic abnormalities of the adrenal glands at computed tomography (CT) in patients with lung cancer.The study was approved by the committee on human research; written informed consent was not required. The authors retrospectively identified 197 patients with lung cancer who underwent serial chest or abdominal CT and did not have a focal adrenal mass at baseline CT. Two readers independently classified the morphologic features of each adrenal gland as normal, smoothly enlarged, or nodular at initial CT examination. They separately recorded the presence or absence of metastases to the adrenal glands (ie, any new focal adrenal mass) at final CT examination; a third independent reader arbitrated when interpretations were discordant (n = 11). Multivariate Cox proportional hazard models were used to assess for associations between baseline adrenal gland morphologic features and subsequent development of adrenal metastases.At initial CT, reader 1 classified 253 (64%), 70 (18%), and 71 (18%) of the 394 adrenal glands and reader 2 classified 258 (65%), 45 (11%), and 91 (23%) of these glands as normal, smoothly enlarged, or nodular, respectively. The readers had moderate interobserver agreement regarding the classification of adrenal gland morphologic features (kappa = 0.54). Metastases subsequently developed in 13 adrenal glands in 11 patients. Cox proportional hazard models revealed no significant association between baseline adrenal gland morphologic features and subsequent development of adrenal metastases (P = .50 and P = .20 for readers 1 and 2, respectively).In patients with lung cancer, smooth enlargement or nodularity of the adrenal glands at baseline CT is not associated with increased risk of subsequently developing adrenal metastases.

To retrospectively determine a biometric algorithm for calculating relative lung volume in fetuses with normal lungs and of a wide range of gestational ages by using proved independent variables and to retrospectively investigate the use of this algorithm in fetuses with pulmonary hypoplasia.Total lung volume (TLV) was measured by using planimetry on single-shot rapid acquisition with relaxation enhancement magnetic resonance (MR) images obtained in 91 fetuses with ultrasonographically (US) normal chests and 28 fetuses with US-determined pulmonary hypoplasia. All fetuses were aged between 18 and 38 weeks gestation. Analysis of covariance was used to identify parameters that were not different between the fetuses with US-determined normal and those with US-determined abnormal chests, and these variables were used to construct an algorithm for calculating predicted lung volume. The relative lung volume-that is, the observed lung volume expressed as a percentage of the predicted lung volume-was then calculated in fetuses with pulmonary hypoplasia.There was no significant difference in mean maternal or gestational age between the two fetus groups. Stepwise regression analysis was used to generate the following equation for predicting fetal lung volume on the basis of independent biometric indexes, with a correlation coefficient of 0.93: TLV = (0.52 . LV) + (0.33 . BD) - (0.06 . FL) - 13.7, with TLV and liver volume (LV) in milliliters and biparietal diameter (BD) and femoral length (FL) in centimeters. In the fetuses with normal chests, relative lung volume varied between 51% and 134%. In the fetuses with pulmonary hypoplasia, relative lung volume varied between 6% and 70%.The predicted lung volume in fetuses of a wide range of gestational ages can be calculated with a high degree of accuracy, enabling prenatal MR imaging lung volumetry in which relative lung volume is used to quantify fetal pulmonary hypoplasia.

Introduction Faecal concretions or faecalomas (’stone of faeces’) are symptomatic of many well-recognised colorectal conditions. Faecalomas are usually located in the colon or rectum and associated with disorders of colorectal transit. We describe an unusual case of ’faecaloma in ano’ secondary to a chronic fissure in ano. A 67-year-old woman with a 10-year history of chronic constipation and intermittent anal discomfort presented with a painless perianal lump of similar duration. Methods The patient’s case notes were reviewed and a literature search was carried out. Results Examination under anaesthesia, sigmoidoscopy and anoscopy did not reveal any mucosal abnormality or an internal opening or any connection with the perianal lump. The mass was enucleated after incising the skin, leaving behind a cavity completely separate from the anal canal and sphincters. Histology revealed inspissated faecal material with evidence of calcification. Conclusions Chronic fissures may be complicated by sepsis and, rarely, a ’fissure fistula’ may develop. We suspect that this was the underlying pathogenesis of this ’faecaloma in ano’. The term faecaloma in ano befits the clinical picture.

The article by Janes et al. [1] is thought-provoking, although we cannot agree with the conclusion expressed by Schafer in his invited commentary [2] in which he stated that based on current evidence prophylactic mesh should be implanted in all patients having a permanent colostomy. This series [1] has demonstrated a clinical parastomal hernia rate of 13% (2/15 patients) when prophylactic mesh was employed versus 81% (17/21 patients) when mesh was not used. The results of this cohort of patients have now been reported three times at differing stages of follow-up (1, 2, and 5 years) (Table 1) [1, 3, 4]. At 5 years of follow-up, the observed parastomal hernia rate of 81% when mesh is not used far exceeds previously reported results, where herniation rates without the routine use of mesh have typically been between 30% and 50% [5]. The reader is thus left to wonder why herniation in the nonmesh group is so much more prevalent than previously reported? It is also noteworthy that most of the patients underwent colostomy because of a malignancy (47/54 patients), and yet no data regarding the radiologic (computed tomography, CT) hernia rate is presented from either arm of the study, despite one of the authors commenting in a recent review article that more parastomal hernias can be detected using CT than with clinical examination alone [5]. Presumably, some of these patients will have had imaging as part of routine follow-up or because of the development of disseminated disease at a later date. In the literature, the most frequently reported parastomal herniation rate is 30%, of whom only 20% or so would develop sufficient symptoms to be considered for further surgery. This means that only 6% of patients who have a colostomy develop a hernia symptomatic enough to warrant repair. This figure may indeed be lower, as most colostomies are formed because of malignant disease where the overall long-term survival is likely to be around 60%, with most deaths during the first 2 years or so. In other words, possibly only 4% of patients are likely to survive long enough to develop significant parastomal herniation. Finally, in this series it is important to note that no mesh-related complications were observed. However, previous reports have reported complication rates of 10% [6], suggesting that the excellent results achieved by Janes et al. [1] may not be reproducible in the hands of all surgeons. Therefore, whether it is acceptable to place mesh in all patients having a colostomy to prevent the 4% to 6% of hernias that may require repair, when complications might be expected in * 10% of patients must be questioned—or are we missing something?

A 69-year-old man with history of end-stage-renal disease (ESRD) underwent successful kidney transplantation from a cadaveric donor in November 2011. However, posttransplant recovery was complicated by delayed graft function and recurrent gross hematuria. Serial Doppler ultrasound (US) of the renal allograft demonstrated a pseudoaneurysm with interval increase in size. However, it could not be visualized with other modalities, including an initial angiogram (postoperative day 49) and a second angiogram (postoperative day 68), followed by surgical exploration (postoperative day 71), which demonstrated complete intra-aneurysmal thrombosis on intraoperative Doppler US. Unfortunately, the patient's hematuria continued and a repeat Doppler US 48 hours later demonstrated a persistent pseudoaneurysm. Therefore, on postoperative day 75, we performed targeted percutaneous intra-aneurysmal thrombin injection under dual image guidance, which showed complete intra-aneurysmal thrombosis on intraprocedural Doppler US. Hematuria recurred the next day. A third angiogram (postoperative day 77) finally illuminated the hidden pseudoaneurysm occult on the first and second angiographic studies (sensitivity [index case] 33%) and surgery. This allowed for successful coil embolization of a subsegmental feeding branch with an excellent outcome. We support a more aggressive management with serial angiography and embolization of the intrarenal symptomatic pseudoaneurysm rather than surgery in renal allograft recipients, with the benefits outweighing the risks.

s / International Journal of Surgery 10 (2012) S1–S52 S26 ABSTRACTS Results:115ECR performed. 9patients excluded. 77/106(73%) patients cross-matched. 28patients required intra-operative or post-operative (within 7days of surgery) blood transfusion. 225units of blood crossmatched, but only 65/225units transfused. Cross-match:transfusion ratio was 3.5:1 with blood utilisation rate of 28.9%. Preoperative radiotherapy, APR and Hartmanns were risk factors for blood transfusion requirement (blood utilisation rate nearing 50%). Conclusions:Our blood cross-matching schedule is outdated with 160units of blood unnecessarily cross-matched. Most of these would have been wasted. Based on British Society of Haematology guidelines (which state that blood needn't be cross-matched if usage is 50%) none of our patients required cross-matching. Adopting these guidelines could result in a cost saving of £20800 per annum (excluding laboratory costs), based on a unit of blood being £130. We agree with current ACPGBI guidelines that GS the remaining 9 cases required further contrast studies. 86% of cases were a result of diverticular disease, while the remaining 14% were secondary to locally invasive carcinoma. 52% of all diverticular cases were treated conservatively with 48% of these patients achieving resolution of their symptoms. A further 16 patients underwent resection surgery, while 7 patients were treated with defunctioning stomas. Only 50% of all neoplastic fistulas underwent resection surgery, the remaining 4 patients received palliative management. Conclusions: CT scan remains the most common modality of diagnosis of CVF. The majority of these CVF are often secondary to complicated diverticular disease. Although surgery provides immediate resolution of symptoms, this study highlights the effectiveness of conservative management in such patients as well. 0625: EXPECTING THE UNEXPECTED EXTRACOLONIC FINDINGS FOUND AT CT COLON R.E. Foulkes, H.M. Owen, P.J. Billings, P. Chandran, C. Corr.Wrexham Maelor Hospital, Wrexham, UK Aim: The aim of this paper is to report our experience of extracolonic findings identified at CT colonography, in particular the high prevalence of important findings including extracolonic malignancies. Methods: Using the PACS system all CT colonograms performed for symptomatic indications between December 2008 and June 2011 were retrieved as part of our ongoing audit, extracolonic findings were then identified and analysed. They were categorized into benign, important benign findings (findings that required further investigation or management) and extracolonic malignancies. Results: 830 patients underwent CT Colon during this time period (518 females, 313 males, average age 74). Extracolonic abnormalities were found in 383 patients (46%). Of those patients with extracolonic findings, 9% had extracolonic malignancies, 26% had important extracolonic findings requiring either further investigation, management or referral and 65% were benign incidental findings requiring no further follow up. Conclusion: CT Colonography has the potential to pick up malignancies and other life threatening lesions such as large non ruptured AAA at a preclinical stage. Whilst we acknowledge that insignificant extra-colonic abnormalities may be identified, we believe that with correct planning and management this should not increase the number of unnecessary investigations or costs. 0645: EFFECTIVE MANAGEMENT IS KEY IN PROVIDING A PRODUCTIVE DAY CASE OPERATING THEATRE C. Lam, S. Cleland, H. Lee, B. Subramanian, M. Saunders. Barnet and Chase Farm Hospital Trust, London, UK Aims: The Department of Health target for all elective work to be performed on a Day Case basis is 75%. Standards include a pre-op efficiency of 90% and an operative efficiency of 91%. By the introduction of simple cost neutral working practices we show how a unit can be transformed. Methods: Initial study carried out over 2 weeks in 2008 identified key areas for service improvement. Only 54% of operating lists commenced within 15mins of starting times. Theatre efficiency was 59.9%, with a high number of on-the-day cancellations. After implemented changes were introduced, including increasing the theatre sessions by 30 minutes and not cancelling patients on overrun lists, they were re-audited in 2010. Results: Theatre intra-operative efficiency increased from 59.9% in 2008 to 94.5% in 2010. Increasing the length of the theatre session by 30mins lead to a 5% increase in the case-load across our theatres. Conclusions: By using LEAN principles the operative efficiency of theatre utilisation can be improved. An increase of sessions by 30mins can lead to a 5% rise in operative case load and capacity. This can be appreciated by an improved rating from 145 to 66th out of all 166 Day Surgery Departments in the country. 0684: A RETROSPECTIVE CASE SERIES STUDY OF A SINGLE CENTRE'S EXPERIENCE OF SURGICAL SITE INFECTION FOLLOWING PURSESTRING CLOSURE VERSUS LINEAR CLOSURE OF ILEOSTOMY SITES Henna Rafique. St Helier's hospital, Surrey, UK Aims: Recognised complications of ileostomy closure include surgical site infection (SSI), small bowel obstruction and anastomotic leak. Incidence of SSIs following ileostomy closure has been reported as up to 41%, placing significant strain on healthcare resources and patient quality of life. Conventionally ileostomy wounds are closed by a linear technique. More recently purse-string closure has been tried to reduce complications. This is a study to compare the SSI rates following purse-string closure versus linear closure of ileostomy wounds. Methods: Thirty-eight patients undergoing closure of ileostomy were included. Seventeen patients underwent purse-string closure, twenty-one patients underwent linear closure. The primary end-point was a documented diagnosis of SSI either during their inpatient stay, or upon discharge or thirty days post operatively. Results: Overall there were fewer diagnoses of SSI following purse-string closure compared with linear closure of ileostomy wounds. Three in seventeen (18%) patients who underwent purse-string closure was

Dear Sir, There is now increasing clinical evidence that protecting the oval-shaped myopectineal oriWce (MPO), through which groin herniation occurs, is the goal of modern day hernia surgery. This is now often accomplished with the use of mesh, but does both sides of the MPO need to be protected [1]? We have used a plug and patch approach for 9 years [2] but have found large direct hernias diYcult and often troublesome to deal with. Whilst our recurrence rates are acceptable, recurrence at a median follow-up of 5 years after repair of primary direct defects (0.64%) is twice that of indirect repairs (0.29%). With this in mind we have placed other prosthetics in the preperitoneal plane using an open anterior approach with favourable short-term results. However, the ease with which the diVerent devices can be placed means there is a learning curve even for experienced surgeons [3], which raise issues regarding the training of junior surgeons as in the laparoscopic debate. Of those devices used to date the ‘memory-ring patch’ described by Pelissier [4, 5] is by far the easiest to use and correctly deploy in the pre-peritoneal space. We Wrmly endorse its use but do not feel that it is necessary when managing those indirect hernias where the deep defect is not particularly wide.