Table Sugar as a Bridge from Emergency to Elective Perineal Proctosigmoidectomy for Incarcerated Rectal Prolapse

Incarcerated rectal prolapse is a rare pathology and is considered an emergency, using table sugar can shift the emergency surgery to an elective one. If left untreated, rectal prolapse may present as an emergency, be it incarceration or strangulation. In an emergency presentation for incarcerated rectal prolapse every attempt should be taken to reduce the prolapsed rectum, if not successful, emergency surgery is indicated, with perineal approach being the first choice in elderly with multiple comorbidities.

Diffuse large B cell lymphoma (DLBCL) in patients older than 65 years: analysis of 3 year Real World data of practice patterns and outcomes in England

Background We wished to examine treatment and outcome patterns in older diffuse large B-cell lymphoma (DLBCL) patients, with a focus on the effect of route-to-diagnosis to outcome. Methods Data were extracted from Public Health England’s National Cancer Registration and Analysis Service between 2013 and 2015 included route-to-diagnosis, disease characteristics and survival for 9186 patients ≥65 years. Systemic Anti-Cancer Therapy data identified front-line regimens, cycles and doses. Results Route-to-diagnosis were emergency (34%), NHS urgent cancer pathway (rapid haemato-oncologist review <2 weeks), (29%) and standard GP referral (25%). The most common regimen was R-CHOP (n = 4392). 313 patients received R-miniCHOP (7% of R-CHOP). For all patients, 3-year overall survival (OS) for 65–79 years was 57% and for ≥80 years was 32%. Three-year OS for R-CHOP-treated patients diagnosed via emergency presentation was 54% (adjusted hazard ratio (HR) 1.63, p < 0.01) and 75% (adjusted HR 0.81, p < 0.01) on the NHS urgent cancer pathway (reference HR:1.00: GP referrals). 3-year OS was 54% for both R-miniCHOP and R-CHOP in ≥80 years. Conclusions Our comprehensive population analysis is the first to show that the NHS urgent cancer pathway is associated with a superior survival after adjusting for multiple confounders. Equivalent survival for R-CHOP and R-mini-CHOP was demonstrated in those ≥80 years.

SP1.1.5Association between prior screening involvement and presentation and outcomes in patients with colorectal cancer

Aims Population bowel cancer screening (BCS) is well established, however many patients still present acutely or with advanced disease. Within a cohort of patients with colorectal cancer (CRC), this study aimed to analyse the relationship between prior engagement with the screening programme and mode of presentation, disease stage and survival. Methods All patients diagnosed with CRC from 2011-2014 in West of Scotland were identified from a regional database and linked into the Bowel Screening dataset for screening participation within two years preceding diagnosis. Results 6551 patients were diagnosed with CRC, 19% (n = 1217) through screening. 39% of patients were not invited for screening and 29% of patients did not respond to invite. Non-response to invite was associated with male sex, increasing age, socioeconomic deprivation, co-morbidity and smoking (all p &lt; 0.001). 13% had previously returned negative screening tests. Negative screening was associated with female sex, anaemia, right sided, poorly differentiated and EMVI positive tumours, and screening with gFOBT versus FIT (all p ≤ 0.001). 2% did not undergo further investigation of a positive test, and &lt;1% had a negative colonoscopy. Participation in screening was associated with reduced emergency presentations (8%vs22%), lower TNM Stage, and improved 3-year CSS (88%vs74%) and OS (85%vs69%) (all p &lt; 0.001). Conclusion Most new cases of CRC are diagnosed outwith the screening programme, predominantly due to non-invite/failure to respond to invite. This has a significant association with adverse outcomes including emergency presentation, advanced TNM stage and poorer survival. Further work is required to increase screening uptake and widen access to BCS.

SP3.2.15 Patient demographics and outcomes following emergency presentation with a groin hernia; a 15-year retrospective cohort study from the North of England

Aims Over 70,000 groin hernia repairs are performed in the UK annually. While most are performed in day-case settings, emergency presentation remains common and has a high associated morbidity and mortality. This study aims to report on patient demographics and outcomes following emergency presentation with a groin hernia. Methods Data was collected for all patients &gt;18 years admitted acutely with an inguinal or femoral hernia to NHS trusts between 2002-2016 in the North of England. This included patient demographics and operative interventions. Outcomes of interest were thirty-day inpatient mortality and length of stay (LoS). Results Overall, 6165 patients presented as an emergency with a groin hernia (76.2% inguinal) over the 15-year study period. There was a male preponderance (n = 4469, 72.5%) with a median age of 73 years (IQR: 58,82). No changes in the distribution of age or gender were noted over the study period. Comorbidity, as measured by Charlson score, increased over time (p &lt; 0.001). Median LoS was 2 days (IQR: 1,5), increasing with age and comorbidity (both p &lt; 0.001). Emergency surgery was performed for 3904 patients (63.3%). The thirty-day mortality rate of 3.1% rose to 3.7% in the subgroup of patients undergoing operative repair and 5.6% in those with associated bowel obstruction. Greater comorbidity and advanced age were again associated with increased mortality (both p &lt; 0.001). Conclusions This study highlights changing patient demographics more comorbid patients presenting acutely with groin hernias. These patients must be counselled regarding their increased mortality risk as part of the shared decision-making process.

EP.FRI.248 The bezoar, the bowel, and the blockage: A rare case of a spontaneously passed phytobezoar

Background Bezoar, from the Persian meaning antidote, denotes a trapped mass in the gastrointestinal system. There are several types, but here we present a case of phytobezoar. A phytobezoar is one which is composed of undigestible plant material. While all bezoars account for less than 4% of intestinal obstruction, most occur within the stomach or small intestine. Phytobezoars causing large bowel obstruction appear to be extremely rare. Case report We present a case of a phytobezoar causing large bowel obstruction in a 29-year-old man. He presented with a four-day history of abdominal pain and distension with associated vomiting and no bowel opening. An abdominal X-ray demonstrated significant dilatation of transverse colon. Subsequent CT revealed large bowel obstruction with transition point in the distal sigmoid. An intraluminal lesion, with mottled appearance, containing locules of gas – a phytobezoar – was noted as the cause. The Patient was clinically well with no peritonism and planned for a flexible sigmoidoscopy in the first instance. However, the patient went on to pass two large, hard bowel motions leading to significant resolution of symptoms. A flexible sigmoidoscopy was carried out to exclude other pathology and demonstrated that the obstruction had been relieved. Conclusion While it seems phytobezoar is an incredibly rare cause for large bowel obstruction, most of the literature suggests operative management of the problem by means of laparotomy and enterotomy. This case demonstrates the potential for conservative management and possibility for spontaneous resolution, despite emergency presentation.

A comparative analysis of urine trypsinogen-2 test strip with serum lipase and serum amylase in diagnosis of acute pancreatitis

Background: Acute pancreatitis possess difficulty in diagnosis in its emergency presentation. Hence segregation of this disease from other specific or non-specific causes of acute abdomen is important. In majority of the suspected cases, the urinary trypsinogen-2 test strip can be used to detect this disease, especially in emergency set-up. The aim and objective of the study was to evaluate the sensitivity and specificity of urinary trypsinogen-2 and to compare it with that of the standard biochemical markers of acute pancreatitis serum amylase and serum lipase.Methods: All patients who presented to the surgical emergency with symptoms and signs suspicious of acute pancreatitis were included in the study, rapid urinary trypsinogen-2 test was done immediately at the bed side, serum amylase and lipase was send for all cases along with routine investigations.Results: The urinary trypsinogen-2 test was sensitive in 96.1% cases and specific in 82.6% cases. The sensitivity is superior to that of serum lipase (sensitivity-90.2%) and serum amylase (sensitivity-84.3%). The high sensitivity of the urinary trypsinogen-2 test resulted in very high negative predictive value of 90.5%, hence a negative test almost rules out the diagnosis of acute pancreatitis.Conclusions: In patients with acute abdominal pain with suspicion of acute pancreatitis seen in emergency department, a negative dipstick for urinary trypsinogen-2 rules out acute pancreatitis with high degree of probability and therefore appears to be more suitable for screening of acute pancreatitis.

Abstract T3: Type 2 Myocardial Infarction Predicts Outcome In Hypertensive Crisis Patients: Nationwide Analysis

Background: Type 2 Myocardial infarction (T2MI) can occur in hypertensive crisis patients. The impact of T2MI in this population is poorly understood due to limited available data. Objective: To assess the impact of T2MI on patients admitted to the hospital with hypertensive crisis. Methods: We queried National Readmission Database (NRD) of year 2018 for adult patients admitted with a primary diagnosis of hypertensive crisis. Patients were excluded if they had type 1 myocardial infarction (T1MI), septic shock, or bleeding in the index admission. Primary outcome was 90-day readmission due to T1MI. Secondary outcome was in-hospital mortality. Subgroup analysis was done according to urgency and emergency presentation. Multivariate regression was done to account for confounders. Results: A total of 101211 patients were included in our cohort of whom 3644 (3.6%) were diagnosed with T2MI and 24471 (24.2%) were readmitted within 90 days of discharge. Of those, 912 (3.7%) were diagnosed with T1MI on readmission. T2MI was independently associated with increased odds of 90-day readmission with T1MI (Adjusted odds ratio (aOR): 2.67, 95% CI [1.91-3.75], P=0.000). T2MI effect was observed in hypertensive urgency, and in hypertensive emergency. T2MI was associated with increased in-hospital mortality in hypertensive urgency population (aOR: 4.21, 95% [1.58-11.25], P=0.004) but not in hypertensive emergency (table 1). Conclusion: In hypertensive crisis patients, T2MI was associated with increased 90-day readmission with T1MI. Aggressive management of cardiovascular risk factors and risk stratification should be considered at the time of diagnosis.

1609 Patient Demographics and Outcomes Following Acute Presentation with An Inguinal Hernia; A 15-Year Retrospective Cohort Study from The North of England

Aim Although inguinal hernia repair is one of the most common elective procedures performed, emergency repair carries a far greater risk to patients. This study aimed to report on patient demographics and outcomes following emergency presentation with an inguinal hernia. Method Patients ≥18 years admitted acutely with an inguinal hernia across NHS trusts in the North of England between 2002-2016 were identified. Data were collected on demographics, investigations, and operative interventions. Outcomes including length of stay (LoS) and 30-day mortality were analysed. Results A total of 4698 patients presented over the 15-year study period. The cohort were predominantly male (n = 4133, 88.0%) with median age of 71 years (IQR: 56-81). Whilst no significant difference in age or gender were found across the study period, comorbidities, as measured by Charlson score, increased over time (p &lt; 0.001). In those who underwent operative intervention (n = 2580), median length of stay was 3 days (IQR: 2-5) and 30-day inpatient mortality rate was 2.5%. Advanced age and comorbidity were associated with higher overall 30-day mortality and post-operative 30-day mortality (both p &lt; 0.001). Conclusions This study highlights the frailty of patients presenting as emergency with complications secondary to inguinal hernia. Given the increased risk observed in this patient group, it is vital that perioperative care is optimised, and patients are counselled appropriately.

833 An Interesting Association Between Recurrent Acute Pancreatitis and Myotonic Dystrophy, A Case Report

Myotonic Dystrophy(MD) is an autosomal dominant genetic condition affecting the musculoskeletal system. Recurrent acute pancreatitis(RAP) is a frequent presentation in the emergency surgical scenario with two or more episodes of established acute pancreatitis separated by a minimum of 3 month periods. We report here a case of a patient presenting with a background of Myotonic Dystrophy with a third episode of RAP. Diagnostic work up led to the discovery of microlithiasis as a possible cause of pancreatitis in our patient. Literature review reports two other case reports detailing a potential association between MD and pancreatitis at the time of writing. This could be due to disturbances of the pancreatobiliary system, resulting from the sphincter of Oddi dysfunction (SOD) and gallbladder myotonia as MD affects the smooth and striated muscle of the gastrointestinal tract. In our case report, we highlight the importance of understanding how MD is a rare cause for a common surgical emergency presentation clinicians should be aware of.