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Scalpel Surgical Society

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#SUSC2013

th 5 Annual

Undergraduate Surgical Conference Saturday 26th October 2013 8.30am-5.30pm: Renold Building, Altrincham St M1 7JA

@scalpel_mcr

scalpel.manchester

www.scalpelmanchester.com


Contents Welcome

3

Day Plan

4

Keynote Speakers

5

Practical Workshops

6

Academic Workshops

6

Research

7

Audits

8

Case Reports

10

Posters

13

Notes

16

Clinical Tutors

18

Scalpel Committee 2013

19

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Welcome Dear colleagues, It is with great pleasure that I welcome you all to Scalpel’s 5th Undergraduate surgical conference in Manchester. I have witnessed this conference enhance from its foundation in 2009 to a reputable national conference today receiving delegates from as far as Europe! This year we are privileged have the world renowned speakers such as Professor Martin Elliot, Mr Peter Clarke and Miss Victoria Beale as well as variety of informative and very “hands on” practical workshops. I hope this conference helps you all develop professionally, network and give an informed insight into what a career in Surgery encompasses regardless of whether you feel it is or isn’t for you. I would like to take this opportunity to thanks all the delegates for submitting their valuable work and our judging panels, workshop helpers and to the keynote speakers for freely giving up their valuable time. Furthermore I would like to acknowledge all of our sponsors for the conference; RCSEng, RCSEd, Limbs and Things, Stryker, CRP Press, BMJ OnExamination, Doctors Academy, PasTest, Ethicon and the MPS. Finally it would be unjust not to thank the hardworking committee for their constant hard work and dedication for not only this conference but throughout the year for all of our events. Every individual on the committee played a key role allowing us to reach the prestigious position we are in today. As Margaret Mead a famous American anthropologist said, “ Never doubt a small group of committed people can change the world. Indeed it is the only thing that ever has.” This is really exciting time to get involved in Scalpel and I hope you all thoroughly enjoy the day whether it be from the informative lectures, the practical workshops, presentations or for just getting an idea of what Surgery is about.

Hasan Mohammad Scalpel President president@scalpelmanchester.com

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Day Plan 0815-0900

Registration & Coffee

0900-0915

Presidential Greetings and Welcome

0915-1000

“One Patient – Simple Problem; Complex Solution“

1000-1100

Professor Martin Elliott

Research Presentations

Audit Presentations

1100-1115

Case Report Presentations

Coffee Break

- not just cutting out cancer 1115-1200 Head & Neck Cancer Surgery Mr Peter Clarke

1200-1300

Practical Workshops Session A

Lunch

1300-1400

Lunch

1400-1500

Audit Presentations

Practical Workshops Session B Case Report Presentations

1500-1545

Poster Presentations and Coffee

1545-1645

Academic Workshops

1645-1730

Maxillofacial Surgery - What's It All About?

1730-1745

Prize Giving and Conference Close

Miss Beale

Practical Workshops ‣ Basic Suturing

‣ CV Clinic

‣ Advanced Suturing

‣ How to Create A Poster

‣ Knot Tying

‣ Academic Surgery

‣ Orthopaedic Skills ‣ Skin Flap Techniques (Maxfax)

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Academic Workshops


Keynote Speakers Professor M. Elliott Martin Elliott is professor of Paediatric Cardiothoracic Surgery at University College London and Co-Medical Director at The Great Ormond Street Hospital for Children NHS Trust (GOS), where has worked here since 1984. His achievements include developing modified ultrafiltration, helping establish paediatric heart and lung transplantation at GOS, and becoming Medical Director here in 2010. The Tracheal Service at GOS is the largest in Europe, and the Team has pioneered a number of innovative techniques, including slide tracheoplasty, tracheal homograft patch transplantation, the development of absorbable stents and, most recently, the world’s first stem cell supported tracheal transplantation in a child. Professor Elliot’s speech will be on “One Patient – Simple Problem; Complex Solution.”

Professor P. Clarke Peter Clarke is a  consultant head and neck surgeon at Charing Cross Hospital and The Royal Marsden Hospital. He specialises is in head, neck and skull base surgery, conducting research in surgical voice restoration (SVR) and dysphagia after laryngectomy. His practice is national, attracting patient referrals from Newcastle, Plymouth, Norwich, Bristol as well as much of the South East. Peter is an elected member of the ENT UK Head and Neck group, a council member of ENT UK and the Laryngology Secxtion of the Royal Society of Medicine, a member of BAHNO,the European Laryngological Society, European Group for Laryngectomy Research (EGFL), European Skull Base Society and am regional advisor to the Royal College of Surgeons of England. He was included in The Times’ “100 Best Surgeons” and Tatler’s 100 Best Doctors. Mr Clarke’s speech will be on “Head and Neck Cancer.”

Miss V. Beale Miss Beale trained at Newcastle University qualifying initially in Dentistry in 1993 and intent on a career in facial and maxillofacial surgery went on to qualify in Medicine with Distinction in 1999. Her early surgical training was in the North East of  England, then moving to the West of Scotland to join their highly regarded Maxillofacial Higher Surgical Training Program. After a year as a consultant in cleft and maxillofacial surgery at Salisbury District Hospital she moved to join the cleft lip and palate and maxillofacial surgery units in Manchester and has been based at the Royal Manchester Children’s Hospital and the Manchester Royal Infirmary since 2010. Miss Beale’s speech will be on “Maxillofacial Surgery – What’s it all about?”

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Practical Workshops Basic Suturing with Mr. Moez Zeiton Skin pads provided by Limbs & Things. Sutures provided by Ethicon.

Advanced Suturing with Miss Lopa Patel Sutures provided by Ethicon Tissue provided by Wetlabs

Knot Tying with Mr. Peter Coe Knot tying simulators provided by Ethicon.

Orthopaedic Skills with Miss Kim Lammin & Mr. Maulik Gandhi. Equipment provided by Stryker.

Skin Flap Techniques (MaxFax) with Mr. Athanasios Kalantzis Tissue provided by Wetlabs.

Academic Workshops CV Clinic with Mr. Jonathan Ghosh

Poster Workshop with Miss Sara Al-Hamdani

Academic Surgery with Mr. Mustafa Khanbai & Mr. Vivak Hasarani

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Research 10.00-11.00am R1. Bariatric Surgery for Obesity: It's a Matter of Fat

LAKHANI A, MAYERS V, FORTUNE C, CHERNICK J and

BARBER J, University of Manchester.

Introduction Obesity costs the NHS £4.2bn a year. Figures are expected to increase to £50bn by 2050. Obesity is associated with various comorbidities, increasing the cost of the disease. To tackle the problems of obesity, bariatric surgery is currently offered to all patients with a BMI > 40. Stricter and more efficient guidelines need to be set with regard to the BMI cut-off and type of bariatric surgery to combat the growing cost of obesity to the NHS. Method We conducted a review of current literature comparing different types of bariatric surgery (Roux-en-Y gastric bypass, gastric banding, and biliopancreatic diversion) and used the findings to create a poster as an aid for health professionals making decisions about bariatric surgery for patients. We aimed to use these results to improve current guidelines for bariatric surgery in order to reduce the costs of obesity for the NHS Results Biliopancreatic diversion gives the greatest weight loss, but has the worst safety profile. Gastric banding has the best safety profile and is the most cost-effective in the short-term, but produces the least weight loss. Rouxen-Y gastric bypass is slightly less cost-effective than gastric banding, but has a lower re-intervention rate, making it more costeffective than gastric banding in the long-term. Conclusion In order to reduce the long-term costs of obesity, we suggest offering bariatric surgery to all obese individuals with a BMI > 33 and for Roux-en-Y gastric bypass to be the gold standard, lone surgery offered by the NHS to these patients.

R2. Posterior Landmarks of the Knee in Total Knee Replacement

C Docherty and Q Fogg, University of Glasgow.

Aim An accurate anatomical knowledge of the structures of the posterior aspect of the knee is important to avoid complications when penetrating the posterior cortex in total knee replacement. Method The posterior aspect of ten cadaveric knee specimens were dissected and measurements obtained to quantify the position of the popliteal artery, the tibial nerve, the common fibular nerve and the footprint of the attachments of the two heads of the gastrocnemius muscles relative to the midline and the joint line. Results The popliteal artery lay on average 1.5±6.2mm lateral to the midline at the joint line. Notably, however, in one specimen the popliteal artery was positioned 13.7mm medial to the midline. On average the tibial nerve lay 7.6±4.2mm lateral to the midline and the common fibular nerve was 33±3.4mm lateral to the midline at the level of the joint line. Due to the variability in the position of the popliteal artery and the lateral position of the tibial and common fibular nerves it is advised that surgeons take as wide a berth as possible medially from the midline when penetrating the posterior cortex. Conclusion The shape and size of the medial and lateral heads of the gastrocnemius muscle varied greatly between specimens but were entirely attached to the posterior capsule. Therefore compromise of gastrocnemius muscle function is a potential complication of stripping the posterior capsule in total knee replacement. The average area of the footprint of the medial head of the gastrocnemius muscle was 881±461mm2 and that of the lateral head was 1053±296mm2.

R3. The Use of Bone Adhesive for Fracture Fixation in Long Bones – A Biomechanical Study JW Lim, AC Jariwala, CA Wigderowitz, TS Drew. Department of Orthopaedic and Trauma Surgery, University of Dundee, TORT Centre, Ninewells Hospital and Medical School, Dundee, DD1 9SY, United Kingdom.

Background Kryptonite osteoconductive adhesive (Kryptonite-OA®) is a commercially available, injectable adhesive bone cement that has been proposed as an alternative means of fracture fixation in long bones. However, there is no published evidence to support its sole use for fracture fixation.Aim To test Kryptonite-OA® as novel fracture fixation in long bones. Method Four pig femurs, four Thiel-embalmed human humerii and one dry bone were tested to failure with a three point bending test ptotocol. Bone specimens were then reconstructed with Kryptonite-OA® and re-fractured using the same test protocol. Bone specimens were dried as much as possible to aid adhesion. The rigidity, fracture strength and work to fracture were tested in the original specimens and after fixation with Kryptonite-OA®. Sixteen pig bone specimens with butterfly fragment were loaded at 100N compression and 50N tensile force for 500 cycles at 1Hertz. Kryptonite-OA® was injected onto the fracture site and bone specimens were loaded with the same cyclical protocol for 1000 cycles. The rigidity, total displacement and energy dissipation for initial loading and Kryptonite-OA® fixated were compared. Results All specimens behaved similarly with gross plastic deformation occurring at the site of adhesive application with minimal load. Little resistance to loading was observed in all Kryptonite-OA® fixated specimens. In cyclical loading test, there were no consistencies with wide spread of results between and within each specimen. Conclusion Kryptonite-OA® should not be used as novel fracture fixation in long bones.

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Audits 10.00-11.00am A1. Age and Gender Matched Oxford Unicompartmental Knee Replacement versus Total Knee Replacement JW LIM, Gerard COUSINS, Ben CLIFT. Department of Orthopaedic and Trauma Surgery, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK.

Background There is little evidence comparing unicompartmental kne replacement (UKR) against total knee replacement (TKR) for the orthopaedic practitioner to turn to when a patient of any age with unicompartmental arthritis requires surgical intervention. Aim To compare the medum-term outcomes of age and gender matched patients treated with UKR and TKR. Method We retrospectively reviewed the pain, function, total knee society scores (KSS), reasons for revisions and KSS postrevisions for every UKR and age and gender matched TKR in NHS Tayside. Results There were 602 UKRs implanted between 2001 and 2013. The KSS (function) remained significantly better in UKR from pre-operative until 3 years follow up. Further analysis revealed no statistically significant difference in the change of function scores over time for both UKR and TKR. The total KSS for UKR and TKR were not significantly different at any point of the 5-years study. However, there was a general trend for TKR to perform better than UKR for KSS (pain). Hospital stay was significantly shorter in the UKR group (p = 0.000) with fewer medical complications reported. 6.30% of UKRs were revised compared to 2.99% of TKRs. The pre-revision operative pain, function and total KSS were not significantly different. Conclusion There is a significantly higher rate of implant failure with UKR albeit lower post-operative complications. This has clear implications for patient selection. The theoretical advantages of UKR are not borne out by the findings in this study other than immediate post-operative complications.

A2. Stenting the femoro-popliteal segment: A useful adjunct to primary angioplasty? Brennan C, Hussey K, Chandramohan S, Stuart WP. Department of Vascular Surgery, Glasgow.

Introduction Occlusive disease of the femoro-popliteal segment disease remains challenging. Complex lesions can now be managed endovascularly. Over the past twenty years, stenting the femoro-popliteal segment has become established as both an adjunct to angioplasty and more recently as a primary procedure. The primary aim of this study was to evaluate stenting the femoro-popliteal segment within our institution. Methods The study was a retrospective review of a prospectively maintained radiology database. A minimum dataset was defined and data collected using electronic health records. Results There were 41 cases identified, of which 38 had been correctly coded. There was a male preponderance, with a mean age of 70 years (range 52 to 93 years). The majority of patients had intervention for critical limb ischaemia. The superficial femoral artery was the primary target. Technical success in this case series was 100%. At follow-up patency rates at 3, 6, 9 and 12 months were 84.2%, 81.6%, 76.3% and 73.7% respectively. Limb salvage for patients with critical limb ischaemia was 87.5%. Conclusion The results demonstrated here following femoro-popliteal stenting would seem to be comparable to previous studies, suggesting that it is a useful adjunct to endovascular intervention for femoro-popliteal segment disease.

A3. Sorting Swimmers’ Shoulders: An Observational Study on Swimmers that Presented to a Shoulder Surgeon. D Butler and Prof. Funk. Bridgewater Hospital Manchester and University of Manchester. Background It is very common for swimmers to suffer shoulder injuries, with a wealth of research focusing on the causes and types of injury. Despite this, there is a lack of evidence regarding current management techniques for shoulder injuries in swimmers, particularly within an orthopaedic setting. Purpose The study investigates the use of conservative and surgical treatments to provide the best outcomes in swimmers. Methods This study followed 14 swimmers whose injuries were managed by a shoulder surgeon. The clinical tests performed, subsequent management carried out, and the outcome for each swimmer were analysed. Results No significant correlation was identified between swimming stroke and type of injury. The majority of swimmers had good scapula rhythm, with no visible dyskinesis, even in those with chronic impingement. Impingement was not a leading indication for any swimmer that underwent arthroscopy, with these swimmers having a mean return to swimming time of 1.6 months. All labral tears required surgery, with these swimmers having a mean time to return to swimming after arthroscopic labral repair of 2.9 months. Conclusion In summary, the study demonstrated that appropriate use of tests and appropriate choice of conservative and surgical treatments lead to reassuring outcomes for swimmers suffering from shoulder injuries.

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14.00-15.00pm A4. VBG result signing in major trauma cases at the John Radcliffe Hospital Emergency Department” A Abioye, J Day (University of Oxford). Dr Laurence Fitton (John Radcliffe Hospital Emergency Department, Oxford University Hospital Trust). Dr Syed Masud (John Radcliffe Hospital Emergency Department, Oxford University Hospital Trust)

Background John Radcliffe Hospital in Oxford (UK) is one of a few major trauma centres in the country. For all major trauma cases, TTLs (trauma team leaders) are encouraged to review VBG (venous blood gas) results, and to sign and record the time of that review. Objectives To investigate – how often VBG results are reviewed and signed; how often the time of review is recorded; the link between VBG results being signed and the delay in VBGs being performed. Method 50 consecutive cases were selected from 01/12/2013. 43 cases were found however 3 were excluded as the patients were not treated as major trauma cases. Results Of 40 eligible patients, 45% were found to have had VBGs performed. 22% of these had been signed by the TTL. No VBG result had a ‘time of review’ indicated. Analysis of the time elapsed between patients arriving in the Emergency Department (ED) and VBGs being performed showed that the median delay was 11 minutes. The delay was 4 minutes 30 seconds and 23 minutes for records that were signed and unsigned, respectively. Discussion •TTLs are not reviewing and signing enough of the VBGs. •There is a major delay associated with not signing VBGs. •These findings suggest that VBGs are not valued highly enough, and the TTLs that value VBGs are more likely to order them, review, and sign the results. •This audit has led to the implementation of stamps by each blood gas machine to prompt users to review and sign results.

A5. VTE Prophylaxis in Neurosurgical and Neuro-High Dependency Unit Patients

J Phelan with Dr Joe

Sebastian, Consultant Anaesthetist, Salford Royal NHS Foundation Trust.

Introduction Venous Thromboembolism (VTE) prophylaxis presents a dilemma for clinicians following neurosurgery. The importance of prophylaxis in these immobile patients after major surgery has to be balanced against the risks of causing secondary bleeding within the intra-cranial vault, which is a fixed space. The timing of administration of low molecular weight heparin (LMWH) after surgery is crucial. This study audits the prescribing of LMWH in post-op neurosurgical patients and patients upon Neuro High Dependency Unit (NHDU) in Salford Royal NHS Foundation Trust, a specialist neurosurgical centre for the North-West of England. Method Over a two-week period all NHDU admits, neurosurgical and spinal patients were followed up upon electronic records. It was recorded whether VTE prophylaxis was indicated by the HAT assessment and what measures of prophylaxis had been prescribed. Results A total of 139 patients where followed up. Twenty had no HAT assessment. Of the 139 patients, 63 patients where indicated for VTE prohylaxis and 16 who where indicated for VTE prophylaxis did not receive the correct prophylaxis. Further to this, 13 patients who where not indicated or contraindicated where given prophylaxis without a new HAT assessment. Conclusions The essential HAT assessment is not always completed. New HAT assessments are not being completed regularly in high-risk patients or upon changing circumstance when they should be. This is undermining the systems in place and leading to error in the prescribing of VTE prophylaxis.

A6. Is biopsy required to aid diagnosis in radiologically diagnosed renal tumours in children? S Prisco Penna with Mr Ross Craigie, RMCH

Wilms’ tumours are the most common renal malignancy in children and commonly arise in children between one and three years of age. It is the most important differential for a child presenting with a renal mass. Through advances in modern medicine and imaging, survival is extremely high for patients diagnosed with Wilms’; however, there are varying approaches to the initial management of renal tumours in children around the world. In the US, primary nephrectomy is the preferred approach compared to Europe, where pre-operative chemotherapy is opted for. In the UK, percutaneous biopsy is used to gain a diagnosis before pre-operative chemotherapy. The aim of this audit is to investigate whether biopsy is indeed required, as it is associated with risks and potential for upstaging the tumour, and whether radiology can be accurately relied upon. 65 patients with renal tumours were found on the clinical trials database at Royal Manchester Children’s Hospital. 50 patients had a Wilms’ tumour and 15 non-Wilms’ tumours (neuroblastoma, rhabdoid tumour, mesoblastic nephroma, angiomyolipoma, metanephric adenoma, oncocytoma and cystic partially differentiated nephroblastoma (CPDN)). The radiology reports for these patients were found. An explicit diagnosis was stated in 54 cases and the radiologist was found to be correct 83% of the time. Sensitivity was calculated as 93%, specificity as 44% and overall accuracy as 85%. In 22% of CT reports, no diagnosis was given. Overall, the accuracy would not be high enough to rely on radiology for diagnosis so biopsy should still be used to aid diagnosis preoperatively.

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Case Reports C1. Primary single stage repair of a rare congenital urogenital abnormality Bethell G, Navroop S. Johal, Great Ormond Street Hospital for Children NHS Trust. Peter M. Cuckow, Great Ormond Street Hospital for Children NHS Trust.

Background Cloacal exstrophy (CEX) is a rare and the most complex congenital ventral wall abnormality with an incidence of 1 in 200,000.(1) It occurs when the cloaca fails to develop into the anorectal canal and the urogenital sinus, by growth of the urorectal septum. The cloacal membrane then ruptures, resulting in exstrophy of the cloaca were the hindgut separates hemisections of the bladder.(2) CEX represents a significant reconstructive surgical challenge with the primary aim of preventing upper renal tract damage and achieving urinary continence. Report A male neonate weighing 2.6 kg, was born vaginally at 39 weeks gestation and diagnosed with CEX. Bladder exstrophy was suspected following an antenatal ultrasound scan at 21 weeks gestation. He was transferred to a tertiary paediatric urology unit on day 1 of life where on day 9 surgical intervention which involved primary complete closure of CEX with bilateral oblique pelvic innominate osteotomies was performed. Discussion This is a novel and innovative approach given that this was a single stage reconstruction as opposed to the traditional multistage approach. The initial stage of surgery involved the osteotomies. The urology team commenced the closure by marking the anatomical structures. The hemi-bladders were dissected free from the epithelium and caecum, and closed dorsally and ventrally. The caecum was closed and an end colostomy created. Stents were placed and the abdominal wall was closed. Each step is described in detail with illustrations.Conclusion The patient made an uneventful post-operative recovery and was discharged home three weeks following surgery.

C2. Cranial non-Hodgkin B-cell lymphoma masquerading as a sebaceous cyst: a case report Abubaker Abioye, Martin Gillies, Jon Westbrook, Timothy Goodacre, Monika Hofer, Elizabeth Soilleux, Richard Kerr. University of Oxford Medical School, John Radcliffe Hospital, Oxford, OX3 9DU.

Background We present a rare case of lymphoma presenting as a rapidly enlarging sebaceous cyst of the scalp. The mass was found to have the radiologic and macroscopic appearance in keeping with a meningioma. However, on histological examination the mass was found to be a low grade follicular non-Hodgkin B-cell lymphoma. Report A 67-year-old woman presented to her GP with a tender spot on her left frontotemporal cranium. The painful spot increased in size as she began to develop a mass in the same region. There were no other symptoms. The initial presentation was consistent with a sebaceous cyst, however she was referred to the Plastic Surgery Department when the mass enlarged excessively over 10 months to measure 10cms in diameter. It was less painful, but it was very disfiguring. CT imaging showed a 7cm mass which extended through the frontal bone and exerted significant mass effect on the brain. The appearance was suggestive of a meningioma. The resection of the tumour was performed by neurosurgeons. A bicoronal flap and left frontal bone flap were made, which allowed the extracranial component and the bony involvement to be removed en-bloc. The intracranial component was removed with the affected dural component. Histological examination of the tumour was consistent with a follicular lymphoma. Conclusion This case presents the second report of primary B-cell lymphoma affecting the cranial vault and dura with intracranial and extracranial extension in an immunocompetent patient who did not have any neurological or systemic manifestations of the disease.

C3. The bearing of an individuals habits and posture as a cause for a rotator cuff tear

Zarafk Khan,

University of Manchester

A case report presentation on a patient who underwent rotator cuff repair relatively young. A novel view on the causes of this persons tear, considering risk factors that combined to cause damage. Highlighting posture and habitual body movements as reasons for damage in a person who’s history would not be considered routine for a tear. Identifying asymmetrical body shape and dominant hand reliance as causative factors. Weight lifting was incorporated into post-surgical physiotherapy, specifically the use of a “no lock out” technique, to strengthen connective tissue and improve body symmetry. Author states that an antalgic gait, caused by a lack of postural symmetry, is present in the vast majority of the populace as well as in the afflicted patient. Examples of modern lifestyle tasks that cause this asymmetry and tax the rotator cuff will be addressed. Speaker will ask the audience to reflect on their own body movements and posture. Finally, a discussion on how to improve the body symmetry of patients suggesting Alexander technique, weight lifting and yoga as stalwarts of rehabilitation and prevention. Outlining the importance of considering the aetiology of tears and hoping for a future where such thoughts can be incorporated into knowledge, that can be communicated to patients. A naïve but passionate view, that is certain to initiate discussion.

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C4. Chance Fractures: Management Options and Assessment of Long-term Disability

Jameson Lua,

University of Manchester

Chance fractures are horizontal fractures of all 3 columns of the spine, with the thoracolumbar junction particularly susceptible to such injury. The treatment options currently available are either non-operative, as in bracing of the spine with orthotics, or surgical, where the spine is stabilised by pedicle-screw instrumentation, which also reduces retropulsed bone fragments. This report focuses on a 29-year old male who obtained a closed Chance fracture of the T10 vertebral body during a sledging accident, and received an instrumented stabilisation of the fracture under fluoroscopic guidance. Despite treatment, there exists a certain degree of functional disability and pain that may still remain even after treatment. Thus, various patient-reported outcome measures have been developed to assess treatment results. Both disease-specific (Oswestry Disability Index, Swiss Spinal Stenosis Score) and general questionnaires (Short-Form 36) have been shown to provide an adequate range of questions to assess the patients’ quality of life. However, due to limitations in question formulation and in having to keep the questionnaires short for practical reasons, there are still areas for these measures to be enhanced, in order to have a true holistic measure of treatment outcomes. As such, further research and analyses are essential, in order to improve the questionnaires and fulfil all the requirements of measuring treatment outcomes.

C5. Amputation as Palliative Management in Secondary Cutaneous Manifestation of nonHodgkin’s Lymphoma – A Case Report Jun Wei LIM, Ben CLIFT. Department of Orthopaedic and Trauma Surgery, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK.

Background Non-Hodgkin Lymphoma (NHL) is the 6th most common cancer in UK. Almost half of all NHL cases diagnosed in UK are diffuse large B-cell lymphoma (DLBCL), accounting for 48% of total NHL diagnosed. Report A 94-year-old male Caucasian, diagnosed with plasmablastic lymphoma (PBL) a year ago presented with pathological fracture of left humerus. The patient was discharged for palliative management. A year later, patient is admitted with a 12 x 10cm fungating tumour on the anterior left arm. Patient was managed with high trans-humeral amputation. Histopathology concluded it was a high-grade EPV-positive B-cell non-Hodgkin’s lymphoma with plasmablastic features. Discussion There are difficulties in clinical laboratory to reproducibly distinguish the specific clinical or pathological features of each subtypes of DLBCL, due to the fact that the vast majority of DLBCL do not have obvious normal counterparts of differentiation pathways. The lack of a distinctive phenotype for aggressive DLBCL explains two different histopathology reports. Primary bone lymphoma is rare, accounting for approximately 5% of extra-nodal lymphoma and less than 1% of all NHL. EBVpositive DLBCL of the elderly is an aggressive disease with a median survival of 2 years in Asian patients. Despite that, major limb amputation should be considered as one of the management options to restore patients’ quality of life, even where elderly patients are concerned. Conclusion This case report revealed a lack of distinctive phenotype for aggressive lymphoma. Palliative major amputation surgery is worth performing in low-performance status cancer patients to restore patients’ quality of life.

C6. FGFR related craniosynostosis syndromes – Pfeiffer Syndrome and Beare Stevenson Syndrome Mina Ip with Mr Partha Vaiude, Mr Christian Duncan. Craniofacial Surgery, Alder Hey Children's Hospital, University of Liverpool.

Pfeiffer and Beare Stevenson Syndromes (BSS) are rare syndromes that result from mutation in the fibroblast growth factor receptor gene (FGFR). There are many clinical similarities between these two syndromes: varying degrees of craniosynostosis and craniofacial abnormalities. The first case is a patient with cloverleaf skull and caudal appendage – clinical phenotype and initial tests suggested a working diagnosis of Pfeiffer Sydrome, however further genetic testing confirmed BSS. The second patient is born with cloverleaf skull, broad thumbs and big toes, and midface hypoplasia, which is clinically consistent with Pfeiffer. Genetic testing reveals a mutation in FGFR-2 gene that has not been previously reported in Pfeiffer syndrome. At 2 months old, both patients had suturectomies to correct craniosynostosis. A series of craniofacial surgeries are expected to follow; the patient with BSS is expected to have a fronto-orbital advancement and remodelling surgery soon. Both patients have no family history of craniosynostosis. Although antenatal scans showed significant abnormalities, both were born at term. Since then they have been receiving varying levels of intensive care, ventricular shunts were inserted to release elevated intracranial pressure. Permanent tracheostomies are in place as they both require long term ventilation; yet still suffer frequent respiratory arrests. These complex craniosynostosis syndromes require long term intensive multi-disciplinary management, however is only available in a few highly specialized centres across the country.

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C7. Shoulder injuries in 16 to 18 year old rugby players

Ghazal Hodhody with Prof Lennard Funk- Wrightington

Hospital, University of Manchester

Background Rugby is a high intensity contact sport, frequently causing shoulder injuries. During the ages of 16 to 18 years of age, academy and county level players are being selected for professional contracts, a critical stage in their careers. There are currently a limited number of studies on this important group of athletes. Objectives This study aimed to describe the injury patterns, management and outcomes of serious shoulder injuries in 16 to 18 year old rugby players. Method All academy and county level rugby players in the target age group were included in this study. All sustained injuries playing rugby. Data collected included the mechanism of injury, clinical findings, radiology, surgical findings and recurrence rates post reconstruction. Results 142 cases fitted the inclusion criteria and were available for follow-up. Most cases had two or more pathologies in the shoulder (52%), mainly occurring during a tackle. The commonest pathology was a Bankart tear (44%), followed by reverse Bankart tears (27%), Bony Bankart (23%) and SLAP tears (16%). There was a 5% incidence of HAGL tears, 1% ALPSA lesions, 2% rotator cuff tears and 6% ACJ dislocations. Forwards sustained more shoulder injuries than backs. The mechanism of injury frequently correlated with player positions. All repairs were arthroscopic, except for 12 open Latarjet procedures. Overall, there was a 17% recurrence rate. Conclusion This study highlights the significance of complex shoulder injury patterns in this important group of athletes, but, the majority can be managed with arthroscopic techniques. With recurrence rates higher than older athletes, this may affect the management options.

C8. Anterolateral Leg: A Single Cadaveric Study on Duplicate Veins & Variant Nerves

JOJI Nikita, KEWADA Drashti, HUNTER Alistair. Department of Anatomy and Human Sciences King’s College London, University of Birmingham.

Background The neurovascular structures of the lower limb vary considerably in their. Few studies delineate the clinical consequences of these anatomical variations; most significantly the role of these variations as a possible source of recurrent varicose veins. Report The purpose of this cadaveric case study was to observe the gross anatomy of the great saphenous vein (GSV), small saphenous (SSV) and their accompanying sural and saphenous nerves respectively, delineating their anatomical relationships and variations. Discussion In this study, the SSV arose from two independent trunks. These trunks ran parallel on the posterior aspect of the calf merging at the level of the tendoachilles to form a unique ‘butterfly’ or ‘bifid’ pattern. A missed duplication can be a partial explanation for recurrent varicose veins after corrective surgery; this has been reported to result in a re-operation rate of up to 66% at 5 years, suggesting an indication for pre-operative vein assessment. The saphenous nerve and GSV are closely approximated as they transcend the medial border of the tibia towards the medial malleolus of the leg. Studies on saphenous nerve injury after GSV stripping reveal a 6-7% sensory neurologic deficit of the nerve due to its close anatomical relationship with the vein. Conclusion Both the SSV and GSV can be duplicated and this can lead to recurrence after varicose vein surgery. The close relationship and certain anatomical variations of the saphenous nerve & GSV can lead to its damage during varicose vein stripping.

C9. A Case Report: Locally advanced colorectal cancer with direct invasion into the liver

Catherine Chan with Mr Derek O’Reilly, Senior Consultant General and HPB Surgeon at North Manchester General Hospital, University of Manchester

Colorectal cancer is the second most common cause of cancer death in the UK. Colorectal cancers infiltrate adjacent organs in 5.5-16.7% of cases. Carcinoma of the hepatic flexure, transverse colon, and splenic flexure generally involves the gallbladder, pancreas, duodenum, stomach and spleen. Direct invasion of colonic cancer into the liver, as described in this case report, is very rare. Surgical treatment is recommended where possible as this gives the patient the best outlook at long term survival. This case report describes a 51 year old female diagnosed with a locally invasive adenocarcinoma of the colon involving the hepatic flexure and 6th segment of the liver. CT scan showed a large irregular mass measuring 88.27mm along the widest diameter. Interestingly, no abnormal masses were seen on the previous CT scan taken 11 months ago (taken as part of her annual review for Type 4A Choldedochal Cyst disease), suggesting that this cancer has grown at a very rapid rate. An en bloc right hemi colectomy and liver resection was performed with curative intent. Histology confirmed a T4B N0 M0 R0 tumour. Resection margins were tumour free by 30mm and we hope she will make a full recovery. An en block resection of any locally invasive tumour is highly advocated because removal of the tumour and any other invaded organs as a single entity can avoid spillage and dissemination of cancer cells into other organs. This not only leaves behind cancer but worsens the prognosis considerably.

C10. Catastrophic Lower Limb Injury in a Child Daniel Lazenby with Mr Chris Duff UHSM, University of Manchester. The management of open lower limb fractures has been debated for well over a decade and a set of criteria predicting the need for amputation is yet to be established. This report explores the path of treatment for a child involved in a road traffic accident causing a severe lower limb injury and discusses the correct operative and medicinal steps that may lead to a successful recovery. The psychological effect of such a traumatic injury is also discussed. Treatment by a multidisciplinary team in a specialist centre, prompt antibiotic therapy and thorough debridement have all been shown to improve prognosis.

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Posters P1. Surgical vs. Radiological Intervention, Functional Outcome Following Oral Cancer Elliot Heward with Mr Akhtar, Lancashire Teaching Hospitals, University of Manchester.

Oral cancer is the 16th most common cancer in the UK. Over 90% of malignancies are squamous cell carcinoma, with the vast majority occurring on the tongue. Compared with other head and neck cancers, the prognosis of oral cancers is poor. With this in mind the focus of treatment now has more emphasis on Quality of Life (QoL). Injury sustained to the oral cavity following treatment can significantly affect the patient’s physical and psychological well-being. Whilst the mainstay of treatment is surgical, radiotherapy or surgery with postoperative radiotherapy are applicable dependent on the disease presentation and pathology. Excision of cancers especially concerning the tongue base causes significant tongue movement loss. However, radiation causes more general damage to both oral and surrounding tissue. Speech and swallowing are vital human functions. With the ability to treat oral cancers more effectively the question is how to reduce the incidence of potentially functional and aesthetic complications. There are a range of factors including tumour stage and location which dictate the functional outcome of the oral cavity following treatment. Evidence demonstrates that the highest rate of locoregional control is achieved through surgical excision followed by post-operative radiotherapy. With regards to locoregional control and functional outcome, direct comparison shows that surgery has a much more favourable outcome. Is it justifiable to use both therapies to achieve higher locoregional control at the risk of increasing the functional deficit of the patient’s oral cavity? Furthermore, are we able to achieve the balance of locoregional control whilst preserving QoL?

P2. Current Outcomes of Emergency Large Bowel Surgery

Mark Twoon with Hwei J Ng*, Michael Yule*, N R Binnie** & E H Aly**.*Medical student, University of Aberdeen **Laparoscopic Colorectal Surgery & Training Unit, Aberdeen Royal Infirmary Aberdeen, University of Manchester.

Background Emergency large bowel surgery (ELBS) is known to carry increased risk of morbidity and mortality. Previous studies have documented morbidity and mortality rates of up to 14.3%. However, there has not been a recent study to document the outcomes of ELBS following greater involvement of consultants in out of hours emergency surgery. Aim To explore the current outcomes of ELBS. Methods Retrospective review of prospectively maintained database of the clinical records of all patients who had emergency large bowel surgery between 2006 and 2013 was done. Data pertaining to patients’ demographic, American Society Of Anesthesiologists (ASA) grade, diagnosis, surgical procedure, grade of surgeon, postsurgery complications and in-hospital mortality were extracted and analysed. Results A total of 203 patients underwent ELBS during this period. The mean age was 62 years and the most common cause was colonic carcinoma (n=61). There were 19.7% (n= 40) presented with obstruction and 30.5% (n= 62) had bowel perforation. One week post-operation mortality rate was 10.8% (n= 22) despite consultants operating in 74.9% and assisting in 15.8% of cases. Conclusion ELBS continues to carry high risk despite greater consultant’s involvement in both office and out of hours surgery. Further developments are needed in the attempt to improve post-operative outcomes in these patients.

P3. Primary Cutaneous Osteosarcoma: a lesion arising de novo in the posterior triangle of the neck Mark Twoon with SE Thomson**, D Boddie**, A Tadros**, L Smith***, S Dundas***.**Plastics & Reconstructive Unit, Aberdeen Royal Infirmary Aberdeen Scotland,***Department Of Pathology, University Of Aberdeen Scotland

Background Extraskeletal osteosarcoma is a rare high-grade soft tissue sarcoma arising outwith the bone or periosteum. It is a malignant neoplasm that produces osseous elements but is located in the soft tissues. Primary extraskeletal osteosarcoma represents 1-2% of all soft tissue sarcomas and accounts for approximately 2-4% of all osteosarcomas. It commonly arises from the deep tissues and primary cutaneous lesions are very rare. Report We describe the first case of primary cutaneous extraskeletal osteosarcoma arising as an exophytic cutaneous lesion, de novo, in the posterior triangle of the neck of a 70-year-old Caucasian male. The rational for surgical excision, reconstruction and post-operative management following Multi Disciplinary Team (MDT) discussion will be deliberated. Conclusively, the lesion was completely excised and the patient was discharged and is currently well with no recurrence. (10 months post-operatively). Discussion The cause of this tumour is unknown and to date there are less than ten cases of primary cutaneous osteosarcoma arising in the scalp or face, each arising at the site of previous trauma. Primary cutaneous osteosarcomatous lesions are a rare entity and to date only a handful of cases have been put forth. Conclusion This case offers a rare differential in patients presenting with head and neck lesions. It is therefore important to learn identifying clinical features and the appropriate referral and management options if clinical suspicion arises. N.B: Intraoperative & histopathological images will be presented.

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P4. Is Radiofrequency Ablation of Paroxysmal and Persistent Atrial Fibrillation Effective at the Bristol Heart Institute and the Spire? Harpreet Sekhom with Dr Glyn Thomas- Bristol Royal Infirmary, University of Bristol.

Background Atrial fibrillation (AF) is associated with a significantly high risk of morbidity and mortality, which is predicted to increase with the increasing incidence of AF. Radiofrequency catheter ablation (RFCA) is increasingly being used to treat individuals with paroxysmal (PAF) and persistent (PsAF) AF. Purpose The objectives were to determine the a) Rate of success after de novo and redo PAF and PsAF ablation and b) Rate of minor and major complications. Methods A total of 157 RFCA for AF procedures in 139 patients performed at the BHI and Spire between January 2012 and March 2013 were identified. 87 of these were de novo procedures. 17 of these were redo procedures performed in 15 patients. Data required for BHI patients were obtained from two electronic data sources and patient files. Simple mean, proportion and percentage analysis were performed.Results De novo RFCA at the BHI and Spire resulted in a 71.15% success rate in PAF patients. PAF success rates increased further to 76.92% and 78.85% after second and third redo procedures respectively. De novo RFCA had a 31.43% success rate in PsAF patients. This increased to 54.29% and 57.14% when patients underwent a second and third procedure respectively. •Complications occurred in 12 procedures (7.6%), which is below expected rates. Conclusion De novo and redo success rates in PAF patients are acceptable but are lower than expected for PsAF patients. Improvements need to be made. Complication rates were lower than expected and hence RFCA is a safe treatment.

P5. Poor wound healing and increased morbidity in a surgical patient- a multifactorial issue Kalliste Oh, Imperial College London.

Introduction This report details the complexities surrounding surgical wound healing in elderly patients with extensive comorbidities, and emphasises the importance of a multi-disciplinary approach to managing their post-surgical care. Case summary This is the case of an 81-year-old male patient recovering from an elective abdominoperineal resection for an anal squamous cell carcinoma involving the internal sphincter. He was previously treated with a course of neoadjuvant chemoradiotherapy. He was admitted following a collapse and sustained a right fibular fracture. Post-surgery he had a perineal drain in situ, and required admission to intensive care as he was haemodynamically unstable. He then developed a urethral fistula requiring bilateral nephrostomies. A vacuum-assisted closure dressing was discussed but was rejected at the cost of prolonging his admission. Discussion This patient had significant comorbidities, with known insulin-dependent diabetes, atrial fibrillation, hypertension and poor eyesight. He suffered from restricted mobility due to his leg fracture and advanced age. Poor perineal wound healing and urinary tract infections delayed his recovery and discharge from the ward. Due to increasing frailty compounded by visual disability, the patient was deemed unfit for rehabilitation and was eventually discharged home with a hoist package of care, to the distress of both patient and family. Conclusion This case highlights the increased complexity of wound care and rehabilitation in the elderly surgical population. The additive effect of numerous medical issues leads to longer hospital stays, and these issues should be anticipated and managed effectively to avoid poorer overall outcomes and increased long-term mortality.

P6. Clostridium difficile colitis which developed after ileostomy closure requiring subtotal colectomy Shi Sum Poon with Mr S Ahmed, Consultant Colorectal Surgeon, Royal Liverpool and Broadgreen Hospital, University of Liverpool. Background Clostridium difficile is a nosocomial pathogen associated with high mortality in surgical patients. It is wellrecognised as an infection associated with antibiotics use. We present a case of pseudomembranous colitis after the restoration of intestinal continuity, an unusual complication of the procedure which is underreported in the English literature. Report A 78-year-old male was admitted to the hospital to have his loop ileostomy reversed. Day 3 postoperative he presented with the chief complain of diarrhea 8-9 times a day and reduced urine output. He had nothing similar in the past. He has a background of hypertension, Stage 3-CKD, renal oncosytoma requiring left nephrectomy in 2011 and rectal adenocarcinoma, which is managed with TEMS and loop ileostomy in July 2013. Discussion Faecal CD EIA and GDH was tested positive and he had undergone a CT scan and colonoscopy to evaluate the severity of the disease. As his condition continued to deteriorate with oliguria AKI, a decision was made to have a subtotal colectomy on day 8 after the reversal of ileostomy. He spent 9 days in ICU and was discharged 5 later with an uneventful recovery. Conclusion This case report highlights the importance managing CD colitis aggressively to prevent the development of full-blown fulminant colitis. CT scan and colonoscopy represent a reliable modality to decide the necessity of surgical intervention. Also, regular review on patients with prolonged antibiotics exposure is essential, especially in this context.

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P7. Inter- and intra- observer reliability of the anterior and posterior fat pad signs in elbow injury

S.

Bell, Ms. V. Sinclair, Dr. J. Harris and Mr. L. Muir, University of Manchester.

Background An effusion produced by trauma can displace the fat pads either more anteriorly in the anterior pad or dorsally in the posterior fat pad producing fat pad ‘signs’. Purpose This study evaluates inter- and intra- observer reliability of the fat pad sign in elbow injury. The study included 12 participants viewing 38 elbow x-ray films. During a literature search no similar studies were found. Methods Inter- observer reliability was measured by comparing the participants individually with a control (consultant radiologist, intra-observer error measured independently).The intra-observer reliability was measured by showing participants 38 images twice; the second time in a random order. The participants stated the presence/absence of an anterior/ posterior fat pad for each image. Cohen’s Kappa coefficient was used to evaluate the data. Results Anterior fat pad sign interobserver gained a‘fair’ kappa score of 0.36562, 95% (CI 0.17-0.56) and a P value of 0.124208, showing that agreements between participants could be due to chance. The anterior sign gained a intra- observer kappa score of 0.538991 ‘moderate’. However, the P value is less than 0.05 showing the agreements are not by chance. The results for inter- and intra- reliability of the posterior fat pad sign have been shown to be reliable. The kappa scores are 0.772797 ‘good’ and 0.809458 ‘very good’ respectively. Conclusion The results show that the anterior fat pad sign is not inter- observer reliably seen. The anterior sign could also be said to be unreliable. The posterior fat pad sign is inter- and intra- observer reliable.

P8. Clinical audit: availability of water for patients on Urology ward Abubakar Abioye, University of Oxford. Background Ensuring that patients are well-hydrated is an important part of patient care and can prevent acute kidney injury. This audit and re-audit looked at the proximity of water to each patient as an indicator of availability. Aims • Assess the availability of water to patients by measuring how far water jugs and glasses were from each patient on the ward • Ensure that appropriate staff were informed about the importance of patient hydration • Assess the effect of staff education on water availability Methods This local audit was performed on the Urology ward in the Great Western Hospital, Swindon. The distance between every patient’s shoulder and their water jug/glass was measured. The results were presented to ward staff and recommendations made to improve water availability to patients. The ward was re-audited the next day to evaluate the effectiveness of the intervention. Results 33 cases were identified for inclusion in this audit of water proximity. Standard: No patient should have a water jug or glass Out of Reach (70 cm away or more away). Compliance: water jug – 36% (12/33); glass – 38% (16/33); both – 33% (11/33). Standard: All patients (N=33) should have a water jug and glass that is easily Within Reach (less than 50 cm away). Compliance: water jug – 6% (2/33); glass – 12% (4/33); both – 3% (1/33). Difficult to Reach (50 - 69cm away). Water jug – 30% (10/33); glass – 36% (12/33); both – 21% (7/33). Re-audit results The intervention led to an increase in the availability of water to patients.

P9. Spitz Naevi in Children: 5 year audit in a paediatric hospital and proposed management guidelines Sara Beattie, Jessica Fielding, Rakhee Chawla, Jo McPartland, Sian Falder, University of Liverpool. Introduction Spitz naevi have uncertain malignant potential and present diagnostic and management challenges. There is little guidance for managing this condition in childhood. Method A literature search of Spitz naevi identified 226 articles for review. Management guidelines were developed based on best-available evidence. A retrospective audit of Spitz naevi in children, diagnosed between 2008 – 2013 was performed. Surgery, histology, follow-up and recurrence were analysed. Results 90 patients were included. Mean age was 9.0 years (range 1 to 17). 83 were benign Spitz naevi/variants; 7 atypical Spitz tumours (AST); none was malignant. Plastic surgeons managed 53, dermatologists 31, general surgeons 6. Initial biopsy was excision (79%), punch (10%), shave (7%), curettage (4%). Of Spitz naevi/variants, 64% were completely excised; 78% were followed-up (mean 5 months). All ASTs were completely excised; 57% were re-excised; all were followed-up. No cases recurred. Histological reporting was inconsistent with 31 different descriptive terms employed and few documented excision margins. Discussion We found variable management of Spitz lesions, not always meeting our guidelines. We added amendments, including uniform histology reporting and MDT discussion of atypical lesions. Conclusions We have produced guidelines for management of Spitz lesions in children based on written evidence and our own experience.

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Notes

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Notes cont.

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Clinical Tutors Mazen Soufi Ioannis Sarantitis James Bedford Kartic Rajaram Geoff Chiu Chris Sweet Matt Kennedy Zainab Sherazi Frances Wood Kiran Majid Man Ho Kwok Natasha Ng Jonathan Lim Issac Kim Blair Graham Jung Tsang Christine Mitoko Elizabeth Kilcourse Erin Meenan Miloš Brkljac 18


Scalpel Committee 2013 Hasan Mohammad Joshua Burke Natasha Westbrook

President Vice-President Conference Director

Andy Minhas

Secretary

Zainab Jawad

Treasurer

Audrey Le Bihan Haider Ali Lauren Bolton Rachael Morley Andrew Kennedy-Dalby Wallaa Ali Anna Avrova Rayko Kalenderov

Communications & Publicity Membership & IT Officer Lecture Events Director Skills Day Lead & MRI Representative Salford Royal Representative Wythenshawe Representative 2nd Year Representative 1st Year Representative 19


Booklet design by Rachael Morley

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SUSC 2013 Conference booklet