key: cord-0025069-mc2x8wpm
authors: nan
title: Abstracts from the 46th Sir Peter Freyer Memorial Lecture and Surgical Symposium
date: 2021-12-31
journal: Ir J Med Sci
DOI: 10.1007/s11845-021-02859-x
sha: dc63012297712409c6d45593b2dd0ab49af4820b
doc_id: 25069
cord_uid: mc2x8wpm

nan

Department of Trauma & Orthopaedic Surgery, Midlands Regional Hospital Tullamore, Tullamore, Ireland

Background: Distal radius (DR) fractures are common injuries, accounting for up to 17% of all traumatic fractures. Over 60% of DR fractures are displaced and require reduction. Despite classification systems evolving understanding of this injury, controversy remains regarding management. Aims: The aim of this study was to compare the number of patients undergoing delayed surgical intervention following initial closed reduction in ED before and after implementation of a regional management protocol and Trauma Assessment Clinic (TAC). Methods: A retrospective review of patients presenting with wrist injuries to three model-3 hospitals, over a 2 year period. All patients with a radiological diagnosis of a displaced DR fracture were identified.

We compared management outcomes of patients who presented before and after introduction of a regional protocol for the management of DR fractures in conjunction with a TAC. Primary outcomes were the number of patients undergoing delayed surgical intervention following initial reduction in ED, before and after introduction of a regional management protocol and TAC. Results: Of the 262 patients identified, left sided DR fractures were the most common injury (53.4%). Following implementation of a regional protocol and TAC, no significant difference was noted in number of patients undergoing delayed surgical intervention (p = 0.08) however, the mean time to surgery in the delayed surgical cohort reduced significantly (140.2 ± 126.6 vs. 3.67 ± 3.8).

Conclusion: Patients with displaced DR fractures who required operative intervention following initial non-operative management, experienced a significant reduction in time delay to surgery, after the implementation of a regional management protocol and TAC. . Clinical data relating to mechanism of injury, neurovascular status and treatment outcome were obtained. Results: In total 762 children were treated with a supracondylar fracture. The mean age of injury was 5.2 years (range 0.6-16 years). The incidence of documented nerve and/or vascular injury was 8.3% (n = 63). Twenty-six patients had early plastic surgeon involvement and of these 96% (25/26) had an open exploration. The most common reasons for exploration were pre-operative nerve palsy, pulseless hand or ischaemic limb post-reduction. Eight patients required vein grafting for brachial artery reconstruction for intimal tears. There was one nerve rupture requiring repair and 12 children underwent neurolysis for acute tethering at fracture site. There were 17 late referrals to the plastic surgery service, of which three were explored (2 neurolysis, 1 neuroma resection and sural nerve grafting). The rate of initial hypertrophic scarring was 15% (4/26) but all resolved with non-operative measures. In all cases of nerve injury the deficit took 7.9 months (range 1-25) to recover indicating a more significant injury than neurapraxia. Conclusion: Early exploration of supracondylar fractures allows direct visualisation of the extent of neurovascular injury and immediate intervention. Introduction: The preoperative identification of osteoporosis in the spine surgery population is of crucial importance. Limitations associated with dual-energy x-ray absorptiometry (DXA), such as access and reliability, have prompted the search for alternative methods to diagnose osteoporosis. The Hounsfield Unit (HU), a readily available measure on computed tomography (CT), has garnered considerable attention in recent years as a potential diagnostic tool for reduced bone mineral density (BMD). However, the optimal threshold settings for diagnosing osteoporosis have yet to be determined. Methods: We selected studies that included comparison of the HU with DXA evaluation. Studies were characterised into 3 categories, based on the threshold of the index test used with the goal of obtaining a high sensitivity, high specificity or balanced sensitivity-specificity test.

Results: 9 studies were eligible for meta-analysis. In the high specificity group, the pooled sensitivity was 0.652, specificity 0.795 and diagnostic odds ratio was 6.652. In the high sensitivity group, the overall pooled sensitivity was 0.912 (95% CI 0.718 -0.977), specificity was 0.67 and diagnostic odds ratio was 19.424 (5.446 -69.275). In the balanced sensitivity-specificity group, the overall pooled sensitivity was 0.625, specificity was 0.914 and diagnostic odds ratio was 14.880. Considerable heterogeneity existed throughout the analysis. Conclusion: The HU is a clinically useful tool to diagnose osteoporosis. We have demonstrated the impact of differing HU threshold values on the diagnostic ability of this test. We would propose a threshold of 135 HU to diagnose OP. Future work would investigate the optimal HU cut-off to differentiate normal from low BMD. Results: One hundred and fourty four patients with bone metastases were discussed in the local bone metastases meeting over a two-year period. The mean age of the patient discussed was 62. The majority were male (53%) vs female (47%). The most common primary lesion was Breast (24%), followed by Prostate (19%) and Lung (18%). Of the one hundred and fourty four patients, thirty-eight patients were identified to have femoral metastases. Eleven of the thirty-eight patients received arthroplasty for their femoral lesion (7 × THR, 4 × hemiarthroplasty). Thirteen of the remaining twenty-eight patients received prophylactic nailing. Fourteen patients were managed non-operatively. Conclusion: Surgical management of femoral bone metastasis is a complex process that may be best managed as part of a formal interdisciplinary meeting involving subspecialty opinion from arthroplasty specialists. Almost one third of the patients who were discussed at the bone metastases IDT received arthroplasty as their surgical intervention. Results: A total of 6265 studies were identified, with 919 duplicates removed. 5346 studies were screened by two independent reviewers of which, 103 full text articles were screened. 12 full-text articles meeting our eligibility criteria were included for analysis, all of which were prospective observational studies. These included 1,760 elective vascular procedures including open AAA repair (n = 670), carotid endarterectomy (n = 453) and lower limb arterial reconstruction (n = 637). Conclusion: Across all studies, high preoperative serum BNP concentration predicted postoperative cardiac events in the follow-up period. Preoperative BNP is a useful tool to predict cardiovascular events after major vascular surgery.

Introduction: Renal artery aneurysms are a rare phenomenon that are predominantly diagnosed incidentally on imaging. The prevalence is estimated at approximately 0.09% (1) . The rate of renal artery aneurysms diagnosed is rapidly increasing due to the increased use of crosssectional imaging (2) . There is controversy and a paucity of research surrounding the guidelines for surveillance and management of renal artery aneurysms (3). Aim: We aim to create guidelines for the surveillance and management of renal artery aneurysms. Methods: A systematic review of the literature was performed. Proposed guidelines were created based on a review of the literature and in collaboration with the departments of vascular surgery, urology and radiology in Tallaght University Hospital. Results: Our algorithm defines the management and surveillance pathways for patients with a renal artery aneurysm. Patients are assigned to different managment pathways based on initial aneurysm size and increase in aneurysm size over a specified time frame, accounting for the aneurysm features. Conclusion: There is a paucity of guidelines for the surveillance and treatment of renal artery aneurysms in the general population. We have proposed a consensus algorithm for the surveillance and treatment of renal artery aneurysm across the disciplines of vascular surgery, interventional radiology and urology. . These claim to exhibit improved hemodynamic performance in comparison to bioprosthetic valves previously used in surgical aortic valve replacement (AVR). Aim: Our study sought to evaluate the effect of aortic valve type, on both max peak gradient (maxPG), and mean peak gradient (meanPG), taking account of valve size used; through the use of a prospective, non-randomized, study.

Methods: Patients who received a biologic AVR between June 2018 and May 2021 in our centre (n = 106) were studied by echocardiography in the early post-operative period (Avalus = 23, Inspiris = 9, Other = 74). Results: Inspiris valves were associated with lower meanPGs in comparison to the meanPGs for Avalus bioprosthesis' of the same size (p = 0.001). A statistically significant difference was seen in post-operative meanPGs between the Inspiris and the previous generation valves (p = 0.007), taking the contributory effect of valve size on pressure gradient into account.

In contrast, there appeared to be no significant difference in hemodynamics post Avalus versus older generation bioprosthetic aortic valves (p > 0.05).

Conclusions: Limitations of this study include confounding factors such as ejection fraction and body surface area. Despite this, and the small sample size, the results seen from Inspiris bioprosthesis appear promising in this pilot study; showing favourable early flow-gradient patterns in comparison to those seen following implantation of previous generation aortic valves.

C Keogh, W Mirza, R Bryant, D Cavallucci, P Waters, N O'Rourke

Introduction: The adoption of laparoscopy for major hepatectomy has been gaining traction globally. This unit has begun to utilised a dorsal approach for laparoscopic major hepatectomies. Aim: The aim of this study was to analyse patient and oncological outcomes of this approach. Methods: All major liver resections from a prospectively maintained database from July 2017 to December 2020 were analysed. The demographics, indications and outcomes were collated and comparisons made between the previous traditional and dorsal approach. Data was analysed using R with a p < 0.05 considered significant. Results: 397 patients underwent liver resections during the study period of which 112 were major hepatectomy. Of the major hepatectomy 76 patients underwent a laparoscopic major resection, 63 being performed via the dorsal approach. The median patient age was 60 (28-89, m = 39 f = 24). Indications included colorectal cancer (47.6%), intrahepatic cholangiocarcinoma (19%) and HCC (17.5%). For major hepatectomies the percentage which were performed via a minimally invasive technique has increased from 24 to 68% following the induction of the dorsal approach (p = < 0.001), with conversion rate of 8% compared with 29% (p = 0.0068). The average blood loss was 465 ml, with 6.3% of cases requiring intraoperative blood transfusion. The average operating time was 260 min. The R0 resection rate was 92%, major complication rate (Clavien-Dindo > 3) was 8% (n = 5). 5 patients had a liver recurrence. The median hospital stay was 7 days (4-26), and no 30-day mortality. Conclusion: Our results show that a dorsal approach is safe in major hepatectomy. It can help to overcome some of the challenges and extend the indication of laparoscopic major liver resections.

A Kamaludin, N Donlon, C Donohoe

Introduction: Oesophageal cancer has a notably high recurrence rate with a paucity of robust evidence in defining the optimal surveillance strategy. The surveillance protocol at our institution comprises of annual oesophagogastroduodenoscopy (OGD) from year 1 postoperatively up to year 5. Aim: This study aims to evaluate the implementation of the endoscopic surveillance at our institution and to ascertain the value of endoscopy in detecting local recurrence after oesophagectomy. Methods: A retrospective cohort review of all patients who underwent oesophagectomy between 2013 and 2018 was conducted, amounting to 320 patients. The local oesophageal cancer database and corresponding OGD reports were accessed to obtain data on patient demographics, operation details, local recurrence and endoscopy performed. Results: 1083 OGDs were performed between 2014 and 2020, with 521 performed (48.1%) for symptomatic presentation. OGDs secondary to symptom presentation resulted in a higher yield for detection of local recurrence compared to surveillance endoscopy; 5% vs 0.5%, with overall median time-to-recurrence of 12 months (5-32). Surveillance endoscopy detected 3 asymptomatic local recurrences (14.3%) of which only 1 was treated with curative intent. Strictures (36.6%), oesophagitis (9.2%) and Barrett's (6.9%) were the most frequent findings at postoperative endoscopy, while dysphagia was the most common symptom (53.8%). As a result of various factors, a minority of patients (30.9%) received annual scopes as outlined by local protocol. Conclusion: Surveillance endoscopy had a low positive yield rate with subsequent minimal survival benefit. Therefore, it is prudent to consider an alternative protocol that focuses on the period with the highest risk of recurrence, and symptom presentation.

Introduction: Bariatric surgery (BS) is the best treatment for long term management of severe obesity and its complications. Due to the burden on resources in tertiary hospitals, a program was implemented to provide surgery for suitable patients in a low acuity (model 2) hospital. Aims; The aim of this study was to evaluate the feasibility of performing BS in a model 2 hospital. Methods: A retrospective review was performed of all patients undergoing stapled bariatric procedures between March 2017 and June 2020, in both a low and high acuity hospital affiliated with the national bariatric centre. Clinical characteristics and peri-operative data were recorded and compared. Results: A total of 304 bariatric procedures took place. Some 40 patients underwent BS in the model2 Hospital. These patients were younger (46 ± 7.26 vs 49 ± 10.4 years, p < 0.05) and had a lower total bodyweight (129.9 ± 20.6 kg vs 143.4 ± 31.7 kg, p < 0.05) and BMI (46.9 kg/m2 vs 49.8 kg/m2, p < 0.05). The profile of obesity related complications were comparable. All procedures were completed laparoscopically, of which 37 (92.5%) were primary bariatric procedures and 3 (7.5%) were revisional cases. All patients followed a standardised enhanced recovery after bariatric surgery (ERABS) protocol. In the model 2 group, nearly all patients (n = 39, 97.5%) were discharged on post-operative day (POD) 2. There were three early minor complications, all Clavien Dindo I/II. Conclusions: Bariatric surgery is safe and feasible in a low acuity hospital. Careful patient selection and an ERABS program are necessary elements for implementation. 

Introduction: Chronic pancreatitis (CP) is a progressive, fibro-inflammatory disorder of the pancreas that results in under-nutrition. While up to half of patients with chronic pancreatitis are malnourished, their dietary intake is relatively understudied and has not been systematically reviewed. Aim: The objective of this study was to assess energy and macronutrient intake of patients with CP versus controls, and to compare the intakes of patients with alcohol-related CP to those with non-alcoholrelated CP. Methods: Adult subjects with a diagnosis of CP who had undergone dietary assessment were included in the systematic review. Studies comparing the dietary intake of patients with CP to that of healthy controls were included in the meta-analysis. Results: Of 6,715 studies retrieved, 12 were eligible for meta-analysis. The total energy (calorie) intake of patients with CP was similar to that of healthy controls (mean difference (MD):171.3; 95% confidence interval (CI): -226.01, 568.5, P = 0.4). Patients with CP consumed significantly fewer non-alcohol calories than controls (MD: -694.1;95% CI:-1,256.1,-132.1; P = 0.02). CP patients consumed more protein, but carbohydrate and fat intakes did not differ significantly. Those with alcohol-related CP consumed more mean (standard deviation) calories than CP patients with a non-alcohol aetiology (2,642 (1,090) kcal and 1,372 (394) kcal, respectively, P = 0.046), as well as more protein, fat, but not carbohydrate. Conclusion: A high calorie intake, largely comprised of alcohol, may partly contribute to poor nutritional status in CP. Further studies should aim to characterise the diets of patients with CP in detail.

S Cremen, M Robinson, T Gallagher

Introduction: Frailty is characterised by loss of physiologic reserve and increased susceptibility to stressors. Cirrhotic patients of any age have an increased incidence of frailty compared to healthy elderly adults.

Telomere Length (TL) has been identified as an indicator of advanced biological age, and is associated with frailty in healthy elderly adults. Aim: We sought to clarify the relationship, if any, TL had with frailty in cirrhotic patients. Methods: 91 patients were prospectively evaluated while undergoing liver transplant assessment. Assessments included clinical, laboratory-based (LabFI) and CT-based (sarcopenia) scores. Relative TL was measured in 79 patients using qPCR. Outcomes included decompensation-related hospitalisations, time on the waiting-list and post-transplant outcomes. Results: Correlation was high between clinical frailty assessments. When controlled for age, shortened TL was associated with increased LabFi, (rs = -0.331, p = 0.003), increased MELD-Na (rs = -0.266, p = 0.021) and Child-Pugh classification, but was unrelated to clinical frailty scores (LFI rs = -0.172, p = 0.137, FFI rs = -0.144, p = 0.223, RFI rs = -0.084, p = 0.462) and sarcopenia (rs = -0.120, p = 0.55). Clinically frail patients spent significantly shorter time on the waiting list compared to non-frail patients (60 vs 117 days, p = 0.037), but TL in isolation did not impact this. Conclusions: Despite a limited association between clinical frailty scores and TL, shortened TL was associated with worsening MELD-Na and increasing LabFI scores in cirrhotic patients. The mechanisms underlying this association and the implication for practice going forward remain to be elucidated. Results: This review identified nine eligible studies reporting outcomes of 2149 patients treated with PD-1 blockade compared with 1244 patients treated with either a placebo or the standard regimen of chemotherapy for oesophageal and GOJ cancer. Clinically significant improvements in median overall survival have been demonstrated in advanced and metastatic oesophageal and GOJ cancer while maintaining acceptable safety profiles. Promising survival data has also recently emerged from PD-1 blockade in the adjuvant setting. Conclusions: PD-1 blockade in oesophageal and GOJ cancer has delivered impressive survival benefit whilst remaining well tolerated. Its use in the adjuvant setting may further advance our treatment options for this difficult-to-treat tumour, and more advancements in the immunotherapy landscape are highly anticipated. However, further characterization of the PD-1/PD-L1 pathway is required to optimise patient selection. Results: Anti-tumour cytokine production was enhanced following treatment with ACM, however, ACM generated from patients with early stage tumours enhanced T-cell cytotoxicity more substantially than ACM generated from patients with advanced tumours. Markers of T cell activation were decreased, and ICs were increased by ACM generated from patients with more advanced stage tumours. Conclusion: ACM from patients with more advanced stage tumours exerted a more immunosuppressive profile on T-cells. This highlights the role of the tumour in subverting distal organs such as the omentum toward a tumour-promoting milieu which may have detrimental effects on systemic and local anti-tumour immunity. Results: There was a significant (p < 0.05) decrease in effector memory lymphocytes (p < 0.01) with an increase in naïve and CD27 + expressing T-cells peaking on day-7 returning to normal at 6-weeks.The expression of PD-1,PD-L1,CTLA-4 and LAG-3 on CD4 + cells, and TIM-3 and LAG-3 on CD8 + cells, decreased (p < 0.05) 6-weeks post-operatively (P < 0.01).There was a significant (p < 0.01) increase through the study period in pro-inflammatory and tumour promoting cytokines,with a reduction in TH-1 cytokines and an increase in soluble pro-angiogenic factors peaking at day-7.There was an immediate drop in the levels of soluble PD-1, PD-L2, LAG-3, TIGIT, and TIM-3 (P < 0.01) with an increase in PD-L1 & CTLA-4 to day-7,returning to normal by week-6. Conclusion: The perioperative period following an esophagectomy is characterized by a decrease in anti-tumour cytokines and soluble stimulatory and inhibitory ICs.In this immunosuppressive, inflammatory,and pro-angiogenic milieu,the increase in soluble PD-L1,CTLA-4,and tumor-promoting cytokines and chemokines suggest a strong empiric supporting rationale for ICB in the adjuvant setting. Introduction: While HR + positive, HER2-ve, node-negative breast cancer is associated with an excellent overall prognosis, it possesses a unique penchant for late recurrence. Estimating breast cancer recurrence has traditionally relied on clinicopathologic markers, such as those underpinning the Clinical Treatment Score Post 5 years (CTS5) but there is an increasing dependence on multigene molecular signatures such as the Oncotype DX 21-gene recurrence score (ODX-RS). Aim: The purpose of this current study was to examine the relationship between the novel CTS5 and the ODX-RS. Methods The CTS5 and ODX-RS were calculated for 1,358 patients who were diagnosed with HR + , HER2-ve, node-negative, invasive breast cancer. The cohort was split according to menopausal status as defined by age. 381 pre-menopausal (< 52 years) and 977 post-menopausal (≥ 52 years) patients were included in the analysis. Correlation statistics were used to investigate the relationship between the CTS5 and the ODX-RS. Results: Considering the CTS5 and ODX-RS as categorical and continuous variables respectively, there was a significant relationship between the CST5 and the ODX-RS categories (Pearson's chi-squared (× 2) p < 0.001), and a high ODX-RS was weakly associated with a high CTS5 RS (Pearson product moment correlation pre-menopausal r = 0.274, p < 0.05; post-menopausal r = 0.222, p < 0.05).

Conclusion: The current study demonstrates a weak but statistically significant correlation between the CTS5 and the ODX-RS that is independent of age. This finding mirrors previous research which indicates that the ODX-RS is poorly correlated with traditional clinicopathologic features used to predict recurrence risk. Conclusion: Whilst dense MD was associated with women who had ER positivity and these women were less likely to achieve a pCR, MD did not appear to independently predict pCR post NACT. Introduction: The incidence of Incidental Thyroid Cancers (ITCs) following surgery for benign thyroid disease is not infrequent. Aim: The aim of this study was to assess the incidence of incidental thyroid cancer in patients with benign thyroid disease in our institution over a 10-year period. Method: A retrospective review of all thyroid cases in our institution was performed. Patients included were those that had surgery for benign thyroid disease. Final histology reports and clinical indication for surgery were reviewed. Results: A total of 648 patients attended this institution for benign thyroid disease over a ten-year period (2011-2020). The majority of patients were female (n = 522, 80.5%). The mean age (± SD) at time of surgery was 49 ± 14.9 years. Of those who were initially thought to have benign disease, 10 incidental thyroid cancers were identified. The clinical diagnoses for these patients were goiter (n = 4), cyst (n = 1), nodule (n = 4), Grave's disease (n = 1), primary hyperparathyroidism (n = 2). Nine of these ITCs were papillary thyroid carcinomas (90%), with another patient being diagnosed with diffuse large B-cell Non-Hodgkin's Lymphoma (n = 1). The mean tumour size was 17 mm [Median = 10 mm, Range 3-50]. The majority of ITCs were microcarcinomas (N = 6). The larger tumours (1 cm) were found in enlarging nodules (n = 1) or multinodular goiter (n = 2). Conclusion: The incidence of ITC was small in this patient cohort, however 33% of ITCs were stage T2 or above. The presence of a large goiter or nodule may preclude the detection of these ITCs and should be considered in the pre-operative work up. Tranexamic acid (TXA) reduces blood loss and blood transfusion requirements in a number of surgical procedures. Seroma and haematoma can occur following breast surgery and cause wound infection and dehiscence, delayed wound healing and prolonged hospitalisation. The aim of this study was to perform a meta-analysis to determine the effect of TXA in breast surgery on post-operative haematoma and seroma formation. A comprehensive search was undertaken for all studies assessing post-operative haematoma and seroma rates following TXA administration in breast surgery using PubMed, Embase and Scopus. The search terms used were ["tranexamic acid" or "TXA"] and ["breast surgery" or "mastectomy" or "wide local excision"]. The primary outcomes assessed were haematoma and seroma rate. Rate of infection and thromboembolic events were evaluated as secondary outcomes. Subgroup analyses were undertaken to compare effects of intravenous and topical TXA. Seven studies were included, with a total of 1446 patients. Several breast procedures were performed including modified radical mastectomy, breast conserving surgery, reduction mammoplasty and breast reconstruction. There was a significant reduction in haematoma rate This meta-analysis indicates that perioperative TXA significantly reduces the incidence of haematoma in breast surgery.

T Keating, C Fleming, D Nally, A Brannigan

Introduction: Robotic-assisted surgery (RAS) offers improved visualisation and dexterity compared to laparoscopy. As a result, RAS is considered an attractive option for performing rectopexy, particularly in the confines of the lower-pelvis. Aim: To explore the benefits of RAS in rectopexy by analysing the experience of an International-group of expert-surgeons. Methods: A three-round Delphi process was performed. Combined qualitative and Likert responses were utilised. Particular areas that were studied included: clinical aspects of patient selection, technical aspects of using RAS to perform rectopexy, ergonomic factors and training and consideration of the 'learning-curve'. Potential participants were identified using PubMed and authors of studies reporting outcomes from RAS rectopexy invited. Results: Twenty international-experts consented to taking part from the following countries: France, Germany, Ireland, Italy, Netherlands, Switzerland, UK, and USA. Participants had median operative experience of 165 rectopexies and 66 robotic rectopexies. The majority of the group reported that RAS lead to better visualisation of planes, better exposure of nerves, improved placement of sutures, improved ergonomics, and dexterity. Over 80% reported the 'learning-curve' to be at least greater than 10 cases with familiarity with port placement, dissection and suturing reported as the most important training points. 77.8% of the group felt that RAS had a positive effect on musculoskeletal health. 88.3% of the panel felt that RAS reduced surgeon fatigue that could potentially benefit patient outcomes (72.2%). Conclusion: International-experts with experience in RAS rectopexy report RAS positively impacts rectopexy in terms of technical performance, improved dexterity and visualisation, surgeon comfort and ergonomics.

Introduction: Post-operative surgical adhesions constitute a major health burden internationally. A wide range of materials have been evaluated, but despite constructive efforts and the obvious necessity, there remains no specific barrier widely utilised to prevent post-operative adhesion formation. We aimed to highlight and characterise materials used for prevention of post-operative surgical adhesions in both animal and human studies. Methods: A systematic review was performed of all original research articles presenting data related to the prevention of post-operative adhesions using a barrier agent. All available observational studies and randomised trials using animal models or human participants were included, with no restrictions related to type of surgery or location of adhesions. PUBMED and EMBASE databases were searched using key terms from inception to August 2019. Results: 234 articles were identified for inclusion in the review, with a total of 72 unique adhesion barrier agents (41 natural and 31 synthetic materials). Desirable barrier characteristics of an ideal barrier were identified on review of the literature. Eleven barriers achieved the primary outcome of reducing the incidence of post-operative adhesions in animal followed with positive outputs in human subjects. A further 52 materials had successful results from animal studies, but no human study performed to date. Conclusion: Multiple barriers showed promise in animal studies, with several progressing to success in and fulfilment of desirable qualities in human trials. No barrier is currently utilised commonly worldwide, but potential barriers have been identified to fill the void to reduce the burden and associated sequalae.

A Byrne, M Devine, W Khan, I Khan, K Barry

Introduction: Paediatric head injury is a common presentation with various degrees of trauma and severity of injury. We aimed to evaluate the immediate management of paediatric head injury and to ascertain compliance with NICE Guidelines, length of stay, and overall outcome with assessment of any residual neurological deficit. Methods: All paediatric (age 0-16 years) head injuries which occurred between 01/01/2018 and 31/12/2020 were identified. Medical records, NIMIS radiological reports, and electronic discharges were reviewed. SPSS was used for statistical analysis. Results: 144 paediatric head injuries presented throughout the three year period. A progressive trend with increasing numbers admitted under the paediatricians was seen each year, with 24% (n = 11) admitted under general surgery in 2020. A correlation was observed with decreased imaging performed. Patients admitted surgically were 5.77 times more likely to undergo a CT Brain (odds ratio, p-value < 0.05). 1 patient was transferred to a neurosurgical centre. All patients who met the criteria for CT Brain underwent it in accordance with NICE guidelines. Conclusion: A proportional increase in pathology was seen amongst the CTs carried out during the time period of the study. These results likely have implications for the management of this common pathology for many other Model III hospitals, and have stimulated a quality improvement initiative locally with the development of protocols and education of staff, in addition to organisational alterations to improve the efficiency with which imaging is undertaken where indicated.

Introduction: The prevalence of non-obstetric surgery during pregnancy is estimated to be between 1-2% of all pregnancies. There is a paucity of data on the clinical course and obstetric outcomes related to these relatively common admissions. Aim: To establish the number of pregnant patients admitted under general surgery or undergoing a surgical procedure in our institution over a ten-year period. To quantify the rate of imaging and surgical intervention, as well as determine surgical and obstetric outcomes in this cohort. Methods: The administrative HIPE database was interrogated to identify pregnant patients admitted under general surgery and those who underwent a procedure under the care of general surgery. Patients attending and discharged from ED and those transferred for imaging only were excluded from analysis. The electronic records for these patients were reviewed. Results: 237 patients were identified from 2011-2020. The mean age was 31 (range 18-44). The gestation period ranged from 5 to 2 weeks post-partum. 124 patients were transferred from nearby maternity hospitals. The majority presented with right iliac fossa (n = 74). Imaging was performed on 82%; the majority of patients received ultrasound scans. In total, 100 procedures were performed; the most common procedure was appendicectomy with 17 laparoscopic and 5 open procedures. Adverse obstetric outcomes resulting in miscarriage were reported in 5 patients during their admission. Conclusion: Delivery of surgical care to pregnant patients is nuanced, with imaging and conservative management strategies frequently adapted on account of the pregnancy. Obstetric outcomes must be carefully considered in this patient group.

Introduction: Acute appendicitis is the most common cause of an acute abdomen. The COVID-19 pandemic has affected the management of acute appendicitis. Initial guidelines advised the use of laparoscopy only if benefits substantially exceeded the risk of potential viral transmission. Aim: The aim of this study was to evaluate the trends in surgical management of appendicitis in the first year of COVID-19 in a tertiary referral centre in Ireland. Methods: A retrospective review of all appendicectomies in a tertiary hospital from January to December 2020 was performed. Basic demographic data was collected along with information on operative approach, conversion to open, laboratory and radiological investigations and histopathology. Results: 452 appendicectomies were identified. More males were affected, at 52.5%. The mean age was 25 years (range: 3-85 years). 

Adriana Olaru 1 , Prof Ronan Cahill 2

Introduction: The risk of unknowingly disseminating leiomyosarcoma, by morcellation in women undergoing laparoscopic hysterectomy, has massively impacted practice in this area. Aim: We present user assessment results of a novel protection system currently in development to address this important concern. Methods: The Extracorporeal Manual Morcellation Device (Advanced Surgical Concepts, Wicklow) is an evolved wound protector-specimen extraction bag system compatible with any 12 mm trocar and by adjustment to specimen extraction incisions (range 25-60 mm). The use of this device was assessed by gynaecological and general surgeons on a bench model comprised of biological tissue in a laparoscopic simulator, with camera control after reference to the instructions for use. Results: Twenty surgeons (10 gynaecologists and 10 general surgeons) with median experience of 8 years in practice, and a mean of 150 laparoscopic operations/year, assessed the novel device, providing both expert and inexpert morcellation cohorts. All subjects safely and easily placed the bag through a 12 mm trocar, and bagged the specimen (range 201-1800 g, mean 390 g). After closing the bag through the port, extending the incision allowing insertion of the guard through the mouth of the bag, all subjects, regardless of the prior experience, successfully morcellated the tissue samples within bag, with debris completely contained without spillage (100% bag integrity on water leak testing) despite scalpel contact with the guard being observed in 14/20 cases (70%). Conclusion: Among clinical users, the novel device provided satisfactory, safe containment of debris and aided with specimen removal encouraging onward advance for regulatory approval.

JT Clifford, DJ Hehir.

Department of Surgery, Midlands Regional Hospital, Tullamore, Offaly, Ireland Introduction: Repair of inguinal hernias remain one of the most routinely performed procedures in general surgery. Despite major advances in the repair of inguinal hernias, we continue to employ classification systems dating back to the nineteenth century, which classify inguinal hernias as "direct" or "indirect" based on their location with respect to the inferior epigastric artery. Aims: To review the clinical sensitivity and utility of classifying inguinal hernias as "direct" or "indirect". Methods: The following databases were searched: Pubmed, Cochrane Library, JSTOR, JAMA Network and Google Scholar. Reviews published in English, German and Dutch were analysed. To appreciate the historical element, data from 1762 to 2020 was studied. A total of 43 articles were evaluated.

Results: Several studies have demonstrated poor clinical sensitivity associated with the terms "direct" and "indirect" inguinal hernias at a pre-operative level; with some demonstrating a pre-operative accuracy level as low as 56%. These results are further complicated by variable patient anatomy and disparity amongst textbook definitions of the anatomical location of the deep inguinal ring. Conclusions: Review of the literature would suggest the terms "direct" and "indirect" in relation to the inferior epigastric artery are inaccurate and this vessel is merely a passive anatomical structure in the herniation field. The ongoing utilisation of antiquated anatomical principles is in direct opposition with our enhanced, modern-day understanding of inguinal anatomy. We believe from teaching, practical and comparative research perspectives it is time to revise our classification of inguinal hernias to reflect current anatomical knowledge.

Background: Peritoneal Sarcomatosis is associated with morbidity and high mortality. The emergence of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the successful management of other intraabdominal malignancies has provided a possible alternative for intraperitoneal sarcoma management. This potential role is difficult to establish and its efficacy remains poorly understood. Methods: Data were collected over three months prior to the change in practice (July-September 2019) after this change in 2020. Including source of referral, and management plan. Results: In total there were 625 patients included in the study with 38% (n = 240) presenting in the 2020 study period and 62% (n = 385) in the 2019 study period.The most common referral pathway in 2019 was ED triage accounting for 67% of referrals with GP referrals accounting for the remaining 33%. This compared to 55% and 45% respetively in 2020. In 2019, 16% of patients seen in ASAU were admitted for definitive management, 58% were discharged and the remaining 26% referred for admission under specialities other than surgery. This compared to, 28%, 59%, 13% respectively in 2020. Conclusion: The ED triage alone may lead to increased inappropriate patient referred to ASAU compared to an initial medical assessment. Specific guidelines on patient selection provided to the triage nurse may aid in better patient selection and efficient ASAU working. Cancer was detected in seven (7.9%) patients, three of which were within the EMR specimens (3.4% of EMRs). Post-procedure morbidity occurred in 12 (13.6%) patients; including six perforations (6.8%), three bleeds (3.4%), two admissions for observation, and one post-procedure delirium. Re-intervention was required in two patients; including one laparotomy for a perforation and one repeat scope for bleeding. There were no mortalities.

Conclusion: In this cohort of elderly patients undergoing full colonoscopy with predominantly right sided EMRs, the complication rate was significant at approximately 14%. EMR during colonoscopy in this age group should be considered on a case-by-case basis. Introduction: The COVID-19 pandemic is an evolving healthcare challenge causing secondary disruption of cancer services. Quantitative Faecal Immunochemical Testing (qFIT) has been established as a screening method in asymptomatic patients. Aim: To assess its utility as a triage tool to prioritise investigations in symptomatic patients with suspected colorectal cancer. Method: At the commencement of the COVID-19 pandemic a database was established to include patients awaiting red flag outpatient consultation or colonic investigations and new red flag referrals from March to June 2020. Patients were supplied with qFIT kits and returned results categorised into 3 priority groups according to the qFIT value. Group 1 > 150 µg Hb/g, Group 2 ≥ 10 to ≤ 150 µg Hb/g and Group 3 < 10 µg Hb/g. Subsequent colonic evaluation was offered by colonoscopy or cross-sectional imaging with urgency determined by qFIT priority group. When identified colorectal cancer, inflammatory bowel disease or high-risk polyps were recorded as "significant colorectal pathology." Results: 317 patients were identified with data analysed on 290 patients. Colorectal malignancy was identified in 17 patients; 94% of these were in Group 1. A qFIT result > 150 µg Hb/g a sensitivity and specificity for colorectal cancer of 94.12% (95% CI 71.31% to 99.85%) and 91.21% (95% CI 87.20% to 94.29%) respectively. No malignancy was detected in Priority Group 3; negative predictive value of 100% (95% CI 98.06% to 100%). Conclusion: In symptomatic, suspect lower GI cancer patients qFIT is useful in prioritising patients and can be used to determine the urgency of colorectal investigations. Introduction: Oncological resection remains central to colorectal cancer surgical practice, and this ideally involves reconstitution of bowel continuity by anastomosis of well perfused, tension-free edges. Indocyanine green fluorescence angiography (ICGFA) is an ascendant technology in colonic circulation assessment however its sensing, dosing, display and analysis lack standardisation with inconsistency in AL (Anastomotic leak) rate impact. Importantly, our research collaborative has already demonstrated interuser interpretation variability among inexpert practitioners. Aim: To dissect expert decision consistency by quantitatively deconstructing temporal fluorescence patterns of ICGFA. Method: Intraoperative videos of ICGFA during anterior resections (n = 4) previously assessed via video survey for ideal geographic proximal colonic transection points were interrogated with a bespoke tracker. These quantitative fluorescent plots were flagged for curve milestones and consequently correlated statistically for agreement among a worldwide group of expert surgical users (n = 6). Results: ICGFA intensity-temporal curves (3577 total datapoints/expert over 24 interpretations) were collected from questionnaire-identified ideal transection points on the colon. Within the tagged milestones on these slopes the experts demonstrated excellent ICC (intraclass correlation coefficient, > 0.9 p = < 0.05) for Peak intensity (0.958), Tmax (Time to peak = 0.915),T1/2 (Time to achieve half max intensity = 0.977) and good ICC (0.75-0.9 p = < 0.05) for the previously delineated chronological ratio T1/2overTmax (0.879). Conclusion: Interuser agreement of previously reported ICGFA quantitative curve milestones linked with superior AL outcomes was demonstrated. The ability to convert the unconscious competence of elite users into quantitative criteria may be applied to train inexperienced operators or computationally achieve master level performance using software.

Amanda Troy 1 , Dr Lata Bhandary 1 , Mr Dara Walsh 1 , Prof John Calvin Coffey 1

Introduction: At present radiologists mainly use 2D images derived from computerised tomographic (CT) imaging of the abdomen when assessing the abdomen. We hypothesised that combining recent advances in knowledge of the mesentery, with digital software capabilities, would enable generation of 3D reconstructions of the abdomen, from CT data sets. Methods: Following ethical approval and informed consent, 2D CT data sets of patients undergoing CT abdomen (n = 20), were imported into Horos. The mesentery and mesenteric domain were outlined (MD and NMD respectively). Both MD and NMD were then imported into Blender in which individual organs (including the mesentery) were reconstructed, then compiled. The final product was a 3D representation of the abdomen. Results: Using the above pipeline, a 3D reconstruction of the abdomen was generated for all data sets used. This was repeated for data sets which were described as normal (i.e. lacking pathology) and which contained evidence of pathology. The resultant reconstructions enabled direct visualisation and assessment of numerous types intra-abdominal pathology, in 3D. Conclusions: It is possible to generate a comprehensive 3D reconstruction of the abdomen from 2D radiological data sets. Direct inspection of 3D reconstructions obviates inferring of anatomical properties from 2D data sets. Introduction: The use of trans-anal surgery for treatment of benign rectal polyps has increased. Neoplastic lesions are being detected at an earlier stage due to increased screening in asymptomatic populations. This has resulted in in more organ and function preservation. However, requirement of multiple procedures is higher. Aim and Methods: A retrospective review of patients who underwent transanal resection between 2005 and 2020 was performed. Specifically, we assessed histopathological outcomes and need for further surgery between those who had trans-anal microsurgery (TEMS) versus trans-anal resection (TART Conclusion: Use of trans-anal surgery is significantly increasing. Patients should be counselled that this is both diagnostic and therapeutic, with over 30% requiring a further procedure depending on lesion morphology, histology and size. Introduction: The optimal treatment strategy for left-sided malignant colonic obstruction (LMCO) is controversial. Emergency colonic resection (ECR) has been the standard of care; however, self-expanding metallic stenting(SEMS) as a bridge-to-surgery may offer short term advantages, although oncologic concerns exist. A decompressing stoma (DS) may provide a valid alternative, but evidence for this strategy is limited. Aim: To compare the advantages and disadvantages of the various techniques in terms of successful minimally invasive surgery (MIS), primary anastomosis and permanent stoma rates, morbidity and oncologic efficacy.

Methods: A systematic review of the literature was conducted from inception to 1st of April 2021. Only randomised control trials (RCT) and propensity score matched (PSM) studies were included in network metaanalysis to account for bias.

Results: A total of 14 articles from 1249 identified met our predefined inclusion criteria ( .54) were also associated with less morbidity. There was no difference in the permanent stoma rates, 90-day mortality, and overall and disease-free survival rates at 3 and 5 years.

Conclusion: This study provides high level evidence that SEMS and DS increases primary anastomosis rates and reduces post-operative morbidity as compared to ECR for the management of LMCO without compromising oncologic outcomes. SEMS also more frequently facilitated MIS than ECR.

Michael Flanagan 1 , Cillian Clancy 1 , Jan Sorensen 2 , Lindsay Introduction: There is no consensus on the use of neoadjuvant radiotherapy for tumours of the upper rectum. Due to conflicting findings in high-quality trials and significant long-term side effects associated with neoadjuvant radiotherapy, the benefit of neoadjuvant radiotherapy for upper rectal tumours is less certain than for lower two third rectal tumors. This metaanalysis compares oncological outcomes with neoadjuvant radiotherapy and surgery versus surgery alone for upper rectal tumours. Methods: PubMed, Embase, and the Cochrane library databases were searched. Randomized controlled trials (RCT) comparing neoadjuvant radiotherapy and surgery versus surgery alone for resectable rectal cancer were included. Individual patient data were sought from the principal investigator of each eligible trial for comparative data on patients with upper rectal tumors. The main outcomes measured were survival outcomes, oncological outcomes, postoperative morbidity, and late toxicity. Results: Individual patient data from two RCTs examining outcomes in 758 patients were obtained. Published data from one further RCT containing comparable data on upper rectal tumors were included in analysis of local recurrence. In patients with curative surgery, there was no significant reduction in local recurrence or significant improvement in overall survival or disease-free survival with neoadjuvant radiotherapy (LR RR: 0.38, 95% CI 0.14-1.04, p = 0.06) (OS RR: 1.10, 95% CI 0.98-1.24, p = 0.11) (DFS RR: 1.11, 95% CI 0.97-1.26, p = 0.13).

Conclusions: The benefit of neoadjuvant radiotherapy for upper rectal tumors is not certain, and surgery alone for patients with potentially curative disease at preoperative staging may be sufficient. Introduction: While minimally-invasive surgery for rectal cancer is now standard, robotic-assisted surgery for this condition is a relatively novel technique. The literature suggests that short-term outcomes such as TME quality, margin status, lymph node retrieval and 30-day morbidity and mortality are equivalent between robotic-assisted and laparoscopic procedures.(1) However, there is little data on the longer-term oncologic safety of robotic-assisted surgery for rectal cancer. Methods: We conducted a retrospective review of all robotic-assisted (n = 31) and laparoscopic (n = 34) rectal cancer cases performed at our institution between January 2015 to December 2018. Inclusion criteria were patients with a histologically confirmed rectal cancer diagnosis scheduled electively for a minimally-invasive (laparoscopic or robotic) resection. Exclusion criteria comprised patients with distant metastases at presentation and those who underwent surgery as an emergency.

Results: A total of 65 (n = 65) cases met the inclusion criteria. The median follow-up was 34 months. Of the 65, 21 patients received neoadjuvant chemoradiotherapy. No significant difference was detected in local recurrence rates (p = 0.5), overall survival (p = 0.7) or disease-free survival (p = 0.8) between the robotic-assisted and laparoscopic cohorts. Conclusion: In this series, robotic-assisted rectal cancer resections demonstrated non-inferiority to laparoscopic procedures with respect to medium-term oncological outcomes. However, given the small numbers in this cohort, larger scale datasets will be required to confirm these results. 

Charles O'Connor 1 , Dr Louise Lyons 1 , Mr Derek Hennessey 1

Introduction: The LithoClast Trilogy Lithotripter is the latest generation lithotripter. It has four modifiable settings for stone fragmentation-Impact (0-100%), frequency (0-12 Hz), ultrasound (0-100%) and suction (0-100%). The configuration for different stone types is unknown. Aim: We aim to determine the optimal settings for four stone types. Methods: Calcium oxalate, calcium phosphate, uric acid and struvite 2cm3 phantoms were created using Begostone. Ultrasound and suction were kept constant at 100% and 40%. Impact and frequency were adjusted for a combination of 9 settings and repeated N = 3. Drill speed and fragment size were calculated using 34 mm and 39 mm probes. Results: One hundred percent impact and frequency of 12 Hz resulted in the fastest clearance times of Struvite phantom stones, mean 85 s. For uric acid stone phantoms, impact of 30% and a frequency of 4 Hz was the fastest setting for stone clearance, mean 77 s. Calcium phosphate phantom stones were treated fastest at an impact of 30% and frequency of 4 Hz (mean 213 s). The fastest clearance rate for calcium oxalate stone phantoms was at an impact of 30% and a frequency of 12 Hz (mean 343 s). Interestingly the slowest rate of calcium oxalate stone phantom clearance was an impact of 100% and 12 Hz (mean 502 s).

Conclusion: Stone clearance rates, drill speeds and average fragment sizes were calculated for the most commonly occurring stones using the Swiss Lithoclast Trilogy lithotripter. The results indicate that the relationship between stone hardness and treatment settings is complex. Introduction: Annually, the HSE receives up to 20,000 complaints from patients. We aimed to assess the reasons for patient dissatisfaction in a Model III hospital, gauge our ability to meet key performance indicators in dealing with complaints, and moreover by using non-consultant hospital doctors (NCHDs) to assess these issues through a structured framework.

Methods: The Risk Register and Patient Liaison, Safety and Quality Improvement departmental records were reviewed for all complaints occurring between 01/01/2020 and 31/12/2020. These and patient records were analysed by two NCHDs qualitatively. Root cause analysis and sigma six principles were used to identify the aetiology of such complaints where appropriate. Remedial action was taken to effect change and an improvement in the organisational structure and provision of care. Results: 238 patient complaints occurred during this period. Provision of care and communication were the two most common complaints at 31.5% (n = 75) and 26.9% (n = 64) respectively. 80 complaints (33%) were against doctors. The peri-operative directorate accounted for 47 complaints (19%). Methods of improving wait times, ameliorating against visiting restrictions, strengthening communication skills and providing better overall care were instituted to shape organisational quality improvement in accordance with these results. Conclusion: Over half of patient complaints are derived from issues regarding care and communication. This is ubiquitous throughout the HSE; however, by examining complaints from a regional rather than national perspective, substantive improvement in the quality of care can be effected. Furthermore, engaging NCHDs in problem analysis can generate unique insights into the cause and solutions of organisational problems. full-text articles were screened for eligibility. Nineteen articles were included in the final review. Students were assessed by a variety of methods -ten written assessments, three OSCEs, five checklist assessments, and one combined OSCE/written assessment. All nineteen articles reported a positive effect of SMBE on medical students knowledge. Three studies reported improved retention of knowledge following SBME. Conclusion: SMBE has been shown to improve knowledge based performance of undergraduate medical students when used as an adjunct to the existing curriculum. More work needs to be done to assess the long term effect of SBME on knowledge retention. Further studies could investigate whether simulation is best employed as an adjunct or replacement to the traditional curriculum.

Conor were analysed. Reliability analyses for laparoscopic appendicectomy assessments were compared to those across all general surgery procedures and all procedure assessments regardless of sub-specialty. Variance component analysis was used to determine the variance in scores attributable to trainee performance, assessor stringency and inter-case variability. Generalizability and decision studies determined the number of assessments and observers needed to achieve a reliability coefficient (G) of ≥ 0.7 and ≥ 0.8 (appropriate for low-and high-stakes assessment respectively).

Results: A total of 2,294 SSAOP assessments were analyzed. G ≥ 0.80 is achieved for laparoscopic appendicectomy assessments using 2 assessors and 4 cases. This cannot be achieved using a single assessor, though reliability of ≥ 0.7 can be reached after 3 cases. G ≥ 0.8 across general surgery procedures or all procedures could only be achieved with large numbers of assessors and cases (7 assessors, 57 cases and 7 assessors, 80 cases respectively). Conclusion: Operative competence should be assessed on a procedurespecific basis. At least two observers are required to achieve reliable procedure-specific assessments. Single-assessor ratings can achieve a reliability coefficient appropriate for low-stakes assessment after a modest number of cases, supporting the SSAOP's role in multi-modality assessment of trainee competence. Factors positively influencing career choice were academic interest, flexibility in working schedule and opportunity for career progression respectively. Respondents were least likely to choose a career in Surgery (33%). Factors influencing these decisions were a lack of interest in the area, perceived workload of specialty, training scheme length and a lack of control over working hours, respectively. 70% of respondents reported that having a subspecialty mentor would make them more likely to choose a career in that specialty. Conclusion: Uncertainty of future career choice in this cohort is common, however a prospective career in surgery is least popular. Positive experiences in clinical attachments and mentorship are important factors to ultimate career choice which should be considered by educational stakeholders in attracting future generations of surgeons. Introduction: Craniosynostosis is the premature fusion of one or more of the cranial sutures, with Sagittal Cranioynostosis (SCS) the most common presentation. The aetiology is multifactorial, though androgen exposure in utero has been suggested as a factor. The second-to-fourth digit ratio (2D:4D) is a sexually dimorphic trait, describing the relative length of the index finger to the ring finger. It is reflective of levels of androgen and oestrogen exposure in utero, with a lower 2D:4D ratio associated with higher androgen exposure. Aims: We hypothesise that alterations in androgen exposure will also affect patients' 2D:4D ratio. Therefore, this study aims to examine the difference in 2D:4D ratio between SCS patients and controls. Methods: Patients with non-syndromic SCS, and gender-matched controls, were prospectively recruited from the Craniofacial and Plastic Surgery Outpatients Clinic. Photographs were taken of the right hand, and three independent researchers measured the length of the fingers and 2D:4D ratio, with the mean ratios then calculated. Results: Fifty-six patients were recruited to both groups, 35 males and 21 females in each. The mean age of the study and control groups were 5.6 and 6.3 years respectively. There was no difference in the 2D:4D ratio between groups overall (p = 0.126). However, males with SCS had a significantly higher 2D:4D ratio in comparison to male controls (0.969 ± 0.379 vs. 0.950 ± 0.354, p = 0.038). Conclusion: It is unlikely that one single hormonal pathway is responsible for suture fusion as our results suggest an imbalance between Conclusion: Whilst a wide range of information is available to patients on this topic, it appears to be of low qualibility and high readability levels for the average Irish reader. We have developed an online information resource pitched appropriately for prospective body contouring patients.

R Milling, S Potter, C Quinlan

Introduction: Microsurgery is a highly technically skilled area of surgery which is rapidly becoming integral to many specialties. Microsurgery is often required in the midst of high-risk surgery where time is limited and pressure is high. There is increasing demand for skills acquisition ahead of time. To ensure success there must be tools to assess development of these skills. Aim: To systematically review the literature on validated microsurgical assessment tools and examine their objectivity, complexity and fidelity of the model used.

Methods: Covidence was used to screen papers for inclusion. Keywords included 'microsurgery', 'simulation','assessment', 'end-product assessment', and 'competence'. Of the 90 papers identified, 40 were suitable for inclusion. Inclusion criteria were robotic, animal, non-living and synthetic models. Each tool was evaluated for validity, reliability, complexity and fidelity of the model. Results: Of 40 articles reviewed, 12 distinct assessment tools specifically validated for use in microsurgery were identified. Two were motion tracking devices, three involved image analysis and 7 were modified global rating scales. The tools presented consistently achieved content, construct and face validity with 10 demonstrating interrater reliability. UWOMSA and GRS achieve criterion validity, these are the only tools assessed for intrarater reliability. Conclusion: 12 assessment tools are validated for microsurgical use. Reliability and validity are demonstrated for 11 of 12 tools. The ISSLA requires further study. The EPIA tool and the ICSAD device provided objective assessment of microsurgical skill. There are numerous validated, reliable tools which can be used to assess microsurgical ability accurately across skill levels.

Dr We believe this is figure may be incorrect. This could have important implications for health care professionals and the public for early detection of melanomas, especially amelanotic melanomas. Aims:

• Determine the true incidence of amelanotic melanoma in an Irish population.

• Determine if amelanotic melanoma presents at a later stage and subsequently has worse outcomes in an Irish context. Methods: Quantitative data collection will be carried out using histopathology reports examined in cork university hospital. Results: The results demonstrated that out of 152 invasive melanoma diagnoses made at Cork University Hospital in 2019, 46 (15.9%) were diagnosed as amelanotic melanoma. This percentage suggests a greater incidence of amelanotic melanoma in the Irish population that previously estimated. 59% of amelanotic melanoma patients were female and 41% were male. The lesions were distributed between the head and neck (16), upper limb (6), torso (9) and lower limb (15). The average Breslow Thickness of an amelanotic melanoma was increased in comparison to a pigmented melanoma, demonstrating a further advanced melanoma and poorer prognosis with an amelanotic lesion (2.9 mm and 1.4 mm respectively. Conclusion: It is known that amelanotic melanoma is associated with worse outcomes. These patients are not benefitting from rapid access to pigmented lesion clinics and therefore likely have a worse outcome due to going undetected for a longer time.

AS Bhreathnach, M Stokes, JM Barry, SM Walsh, MR Kell

Introduction: In recent years there has been a resurgence in the use of the pre-pectoral implant breast reconstruction (IBR) with favourable reported outcomes. Most studies have reported the use of biological mesh. TIGR® mesh is a synthetic cheaper alternative. Aim: To establish the outcome of an Irish cohort of patients who underwent pre-pectoral immediate implant reconstruction using TIGR® mesh. Method: We performed a review of a prospectively maintained database of all patients that underwent pre-pectoral implant reconstruction using TIGR® mesh from January-December 2020 at The Mater Misericordiae University Hospital. We included all patients who underwent immediate pre-pectoral implant based breast reconstruction using synthetic mesh. Patient and tumour characteristics, oncological management, surgical data and complications were collated and analysed. Results: 62 immediate pre-pectoral implant reconstructions were performed on 49 patients. Majority were unilateral, 73%, with 27% bilateral. The mean age at time of surgery was 46.79 years (range29-63). The mean length of stay was 2.5 days (range1-4). The average BMI was 24.28, only two patients had a BMI >30. Majority of patients were non-smokers 79% with 18% of patient reporting an ex-smoker status. 59% of patients proceeded with radiation therapy and 51% underwent chemotherapy. Majority of patients had skin-sparing mastectomies (77%), 23% were nipple-sparing. The complication rate was 18 %, 2% had implant loss, 2% haematoma rate, 6% infection, 4% skin necrosis and capsular contraction rate was 4%. Conclusion: Pre-pectoral breast reconstruction is a novel method of breast reconstruction, with acceptable early outcomes

Prospective evaluation of a virtual urology outpatient clinic

Fertility Treatment and Breast Cancer Incidence: A Meta-Analysis and Systematic Review (1) Department of Surgery, Trinity Centre for Health Sciences

Methods: ENSURE was an international multicentre study of consecutive patients undergoing surgery for oesophageal cancer (2009-2015) across 20 European and North American cancer centers (NCT03461341). IS was defined as annual CT/PET-CT for three years postoperatively, and compared with investigation as clinically indicated. The primary outcome measure was overall survival (OS), secondary outcomes included treatment, disease-specific survival, disease-free survival, recurrence pattern, and HRQL. Multivariable linear, logistic and Cox proportional hazards regression analyses were performed to determine the independent impact of surveillance on oncologic outcomes and HRQL. Results: 4,682 patients were studied (72.6% adenocarcinoma, 69.1% neoadjuvant therapy, 45.5% IS)

Discriminating Colorectal Tissue Pathology Using Indocyanine Green Perfusion Quantification and Simple Machine Learning Methods NP Hardy 1

UCD Centre for Precision Surgery

As colorectal cancer distinguishes from healthy colonic tissue by its perfusion patterns, pattern analysis, using fluorescence imaging and computer vision, may facilitate tissue characterisaspecimens, along with specialist colorectal clinician input, facilitated retrospective annotation of tissue regions within each video ("cancer"/ "benign"/ "healthy"), resulting in 5 patients with cancerous lesion, and 11 patients with benign lesions. Quantitative fluorescence plots over time for each region of interest, based on video annotations, were subsequently created, and analysed using a bespoke tracker. Features including "time to peak", "upslope" and "downslope" were extracted from the fluorescence plots and classified using several different machine learning algorithms. Results: Sixteen lesions were successfully tracked. A naïve Bayes classifier achieved the highest sensitivity and specificity of 0.950 and 0.958, respectively. Conclusion Colorectal tissue can be characterised by its dynamic perfusion pattern using ICG and easily explainable machine learning methods

Pathological Complete Response as a Biomarker of Survival in Human Epidermal Growth Factor Receptor-2 Breast Cancer -A Systematic Review and Meta-Analysis MG Davey 1,2 , F Browne 1

Methods: A systematic review was performed in accordance to PRISMA guidelines. Studies that compared survival in patients with pCR and residual disease (RD) were identified. Log hazard ratios (lnHR) for disease-free (DFS), breast cancer specific (BCSS) and overall survival (OS) and their standard errors were calculated from Kaplan-Meier curves or cox-regression analyses and pooled using the inverse variance method

A Novel Perfusion Solution for Use In Ex Vivo Lung Perfusion For Lung Transplant

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J Dalli 1 , N Quirke 2 , NP Hardy 1 , RA Cahill 1 , S Potter 2 .(1) UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland;(2) UCD School of Medicine, University College Dublin, Dublin, Ireland Introduction: Novel handheld surgical cameras have facilitated the application of indocyanine green fluorescence angiography(ICGFA) to reconstructive surgery, however large-scale trials and objective quantitative interpretation are lacking. Microvascular free flap surgery has cemented its place as a robustly reliable reconstructive technique with success rates exceeding 95%, however re-exploration rates of up to 20% are still reported in the literature. Utilising a state-of-the-art near infra-red camera and bespoke software we sought to quantitatively interrogate ICGFA signals to assess free flap perfusion. Aim: Quantitatively assessing flap perfusion via ICGFA. Method: A head and neck free flap reconstruction (n = 1) was assessed intra-operatively with the Elevision IR Platform following administration of intravenous (0.25 mg/kg) ICG. Perfusion angiograms were computationally quantitatively dissected and converted into fluorescence intensity plots. Metadata milestones extracted from these curves were scrutinised (Mann-Whitney U test) for perfusion discriminatory features. Flap viability was recorded on postoperatively (days 1 and 7). Results: Recordings were tracked and converted to chronologicalintensity plots at 30fps with the flap displaying delayed (53.35 ± 4.03 vs 17.36 ± 2.10 s p < 0.001) but higher zeniths of intensity (66.13 ± 8.59 vs 45.73 ± 16.90 grey units p = 0.001) when compared to the surrounding native tissue, while post apex flap intensity normalised to the surroundings (32.63 ± 2.55 vs 32.11 ± 10.89 p = 0.533) at a hundred seconds. These findings offer quantitative analysis of arterial inflow and venous outflow. Conclusion: ICGFA signals were successfully quantified, and with further work will offer the reconstructive surgeon a methodology to standardise use of commercially available infrared systems. However, capitalisation of this emergent practice may require computational enhancement so as to surpass the shortcomings of oculocognitive interpretation. Introduction: There has been a sevenfold increase in demand for gender affirmation surgery in Ireland over the past decade. Brexit, limitations in availability of Treatment Abroad Scheme and the Covid-19 pandemic, has led to increased demand for treatment in Ireland. Since no reconstructive service currently exists, the Internet remains a key source of information for these patients. We aimed to assess the quality and readability of online information available to patients. Patients & Methods: The first 200 websites on the search engine Google when the term 'gender affirmation surgery' were identified. Websites were then sorted into eight categories. Website quality was assessed using the JAMA Benchmarks, a series of 4 core standards to evaluate websites: authorship, date specification, appropriate references and ownership. Inter-rater reliability was quantified using Cohen's kappa. The median JAMA score for each of the 8 categories was established. High quality equated to a JAMA score of 3 + . Results: There was a critical lack of information regarding indications, suitability, pre-operative assessments, risks and potential complications, and expected quality of life outcomes. Quality of information was often less than satisfactory as evidenced by a median JAMA score of less than 3. The highest score achieved by any website was 3. Of concern, fifty percent of these websites were categorised as professional with a paucity of scientific journal publications. Discussion: The increased demand for gender affirmation surgery should be married with accurate, high quality information available to both prospective patients and their treating physicians. Introduction: As a result of the drive to tackle the obesity pandemic, investment in bariatric services has created exponential demand for body contouring procedures. This reconstruction is a core element of patient's multi-disciplinary management. Being enthusiastic users of online platforms (Instagram, Facebook, Twitter), this study aims to assess the quality and readability of online information relating to postbariatric body contouring surgery, available to prospective patients. Aim: The first 200 search results under "plastic surgery after bariatric surgery" were classified and analysed using qualibility and readability scoring systems. The JAMA Benchmark Scoring system and DISCERN score were used to evaluate the quality of the websites. The readability was determined by the Flesch-Kincaid grade and Coleman-Liau Score. Exclusion criteria included websites containing ≤ 1 sentences, inaccessible websites, websites not in English, websites ≥ 15 years old and duplicates. Results: 166 websites were eligible for inclusion. The average JAMA Benchmark was 2 and the average DISCERN was 28.3. The median JAMA score was 2.0 (range, 0-4), and the median DISCERN was 23 (range, 16-70). The average Flesch-Kincaid Readability scores and Coleman-Liau Index scores for all websites was 53.3 and 14 respectively. There was a median Flesch-Kincaid score of 52.4 (leaving certificate/university grade level), and median Coleman-Liau score of 14.4 (university-grade level). Introduction: The significance of exogenous hormone manipulation as part of fertility treatment and its relationship to the development of breast cancer remains uncertain. Several historical reviews have been performed with conflicting results. This study is an updated metaanalysis to determine whether there is a causal relationship between different fertility treatments and breast cancer. Methods: The primary outcome of the study was to determine whether there is an increased incidence of breast cancer in women treated with fertility treatment. The secondary outcomes were to determine whether fertility treatments such as Clomiphene, HcG, Human Gonadotropins and Progesterone were individually associated with excess breast cancer risk.The study report is based on the PRISMA guidelines and Meta-Analysis of Observational Studies in Epidemiology. Results: Twenty-five studies, including 617,479 participants, were eligible for inclusion. There was no significant breast cancer risk association with fertility treatment (OR 0.97,95 per cent c.i 0.90-1.04). Women who received >6 cycles did not have an increased risk of breast cancer. Similarly, there was no excess breast cancer risk associated with Clomiphene, HcG, Human Gonadotropins and Progesterone when examined individually. Comparably, there was no significant association between fertility treatment and breast cancer risk in patients with >10 years follow up (OR 0.97,95 per cent c.i 0.85-1.12). Conclusion: This meta-analyses did not find a significant association with fertility treatments and excess breast cancer risk. The same remained constant when fertility treatment options such as clomiphene, gonadotropins, HcG and progesterone were examined individually. Women considering IVF should be informed that IVF does not appear to increase breast cancer risk. Introduction: Advanced breast cancer is characterised by enhanced tumour adaptability to therapeutic pressure and the metastatic microenvironment. Emerging evidence supports a role for dynamic epigenetic changes in tumour adaptability and endocrine resistance, with limited knowledge on the role of RNA-methylation in advanced breast cancer Aim: We aimed to investigate the role of RNA epi-transcriptomic events in ER-positive breast cancer and to elucidate its therapeutic potential. Methods: Models of advanced breast cancer were subjected to functional and multi-omic analysis including RNA sequencing and m6A-RIP-seq to identify aberrant RNA methylation. Clinicopathological data was assessed to determine the prognostic implications of altered RNA methylation. ER+ endocrine-resistant tumours were treated with FTO inhibitor as monotherapy and in combination with a kinase inhibitor. Results: To understand the role of the epi-transcriptome we mapped dynamic global RNA epi-transcriptomic events with advancing ERpositive disease. MeRIP-seq analysis displayed global gains in RNA methylation with progression to metastasis. Integration of the methylome and proteome revealed a strong correlation in stem cell differentiation pathways. Specifically, RNA demethylator FTO-mediated expression of KLF4, SOX2 and SOX4 was observed. In single-cell transcriptomics FTO was preferentially expressed in luminal B clusters relative to luminal A or basal-like. FTO associated with poor recurrence-free-survival in ER-positive breast cancer patients and pharmacological FTO inhibition reduced stem cell gene expression and tumour cell growth in patient brain metastatic ex-vivo models. Conclusion: This study defines aberrant RNA methylation with disease progression in breast cancer. Targeting FTO may reverse cellular adaptability, offering new therapeutic strategies to treat advanced disease. Background: Patients diagnosed with colorectal cancer (CRC) have an 8% incidence of developing peritoneal metastases (PM) and 26% incidence of developing liver metastases (LM), in either a synchronous or metachronous fashion. Little is known about how the immune microenvironment of CRC evolves during disease progression. Despite advances in chemo-and immunotherapy, many patients with metastatic CRC do not respond to standard of care therapy. Understanding the role of the tumour microenvironment in establishing distant metastases is essential for developing new immunological agents. In this study, we aimed to characterize the immune microenvironment of metastatic colorectal lesions, specifically LM and PM, and to compare these with the corresponding primary CRC. Methods: We compared tumour-infiltrating lymphocyte (TIL) count, both programmed death protein 1 (PD-1) and programmed deathligand 1 (PD-L1) protein expression by multiplex immunohistochemistry (mIHC), and mRNA levels of 780 immune-related genes using Nanostring barcode technology in matched, synchronously resected primary and metastatic CRC samples. Results: Sixteen patients had synchronous resections of colorectal primaries, LM and PM in various combinations. TIL counts and PD-L1 positivity were significantly lower in metastases, particularly in the liver. Immune cell metagene expression corresponding to angiogenesis, stromal factors, NK cell activity and matrix remodelling were significantly higher in PM. LM displayed differentially expressed genes responsible for the myeloid cell compartment of the immune system and for myeloid cell activity. Conclusion: Metastatic colorectal cancers are immunologically more inert than their corresponding primary tumours. Some immune-oncology targets show preserved expression, suggesting possible therapeutic combinations for clinical testing.

Introduction: Visceral obesity is a known risk factor for the development of colorectal cancer (CRC) and weight loss can attenuate risk. In obesity, adipose tissue function is dysregulated and could result in CRC through chronic inflammation and adipocytokine release. Orphan nuclear receptors play a role in modulating inflammatory pathways. Aim: To examine the inflammatory profile of mesenteric and omental fat from patients with colorectal cancer. Method: Mesenteric and omental fat samples were obtained from consenting patients undergoing surgery with curative intent for CRC. Omental control tissue was obtained from operations where there was no inflammatory or malignant process. Cytokine levels were measured by enzyme-linked immunosorbent assay (ELISA) and expressed as median (pg/ml). Results: Omental fat had higher levels of interleukin 8 (IL-8) in patients with CRC than healthy controls (11,870 to 2,230 pg/ml; p < 0.05). Similarly, omental fat demonstrated higher interleukin 1 Beta (IL-1β) levels than controls (2,590 to 769 pg/ml; p < 0.05). Patients with CRC had higher IL-8 (11,870 to 4,569 pg/ml; p < 0.05) and IL-1β (2,590 to 1,080 pg/ml; p < 0.05) in the omental fat than mesenteric fat. An orphan nuclear receptor agonist (100μM Cytosporone B) attenuated IL-1β levels in both mesenteric (1,080 to 298 pg/ml; p < 0.05) and omental fat (2,590 to 661 pg/ml; p < 0.05) from patients with CRC. This effect was not observed for IL-8. Conclusion: Visceral intra-abdominal fat inflammasome is dysregulated in CRC and the effect of orphan nuclear receptors appear to be cytokine and adipose site specific. Background: Inferior responses to chemotherapy are reported in mucinous colorectal cancer (CRC). Immune checkpoint inhibitors are indicated in microsatellite instability (MSI) CRC, but tumour response is variable. We hypothesized that outcomes in mucinous CRC may be influenced by expression of genes responsible for chemotherapy and immunotherapy activity. Aims: To compare gene expression between mucinous and non-mucinous tumours. Methods: Gene expression data was extracted from The Cancer Genome Atlas. Clinical, pathological and gene expression variables were compared between 74 mucinous and 521 non-mucinous CRCs. Predictors of overall survival (OS) were assessed by multivariate analysis and Kaplan Meier curves used to compare survival according to gene expression. Results: The expression of 5-fluorouracil pathway genes TYMS, TYMP and DYPD was higher in mucinous CRC (p < 0.001, p = 0.003, p < 0.001 respectively). Expression of oxaliplatin-pathway genes ATP7B and SRPK1 was reduced in mucinous CRC (p = 0.004, p = 0.007 respectively). High SRPK1 expression was associated with significantly longer OS in rectal cancers (p = 0.011). Higher expression of genes for immune checkpoints PD-L1 and TIM-3 was observed in mucinous CRC (p = 0.004, p < 0.001 respectively). Mucinous status was a significant contributor to prediction of TIM-3 expression in a multiple regression model (B = 0.591, p < 0.01). Conclusion: Molecular differences in mucinous and non-mucinous CRC include genes responsible for chemotherapy and immunotherapy activity. Identification of SRPK1 as a potential biomarker is an important finding given the paucity of prognostic factors available in rectal cancer. The role for immunotherapy in mucinous CRC requires investigation given the frequency of MSI and increased expression of immune checkpoints in this subtype.

Introduction: This study investigated the effect of features of the hostile tumour microenvironment (TME) including acidosis, glucose-deprivation and hypoxia on T-cell anti-tumour immunity in the context of oesophageal adenocarcinoma (OAC) and whether immune checkpoint blockade (ICB) might attenuate these immune-inhibitory effects. Methods: PBMCs isolated from treatment-naïve OAC patients were activated for 7-days with anti-CD3/28 and subsequently cultured for 24h under hypoxia(0.5% O2), glucose-deprivation, dual hypoxia and glucose-deprivation or acidosis (pH6.6 and pH5.5) (n = 6). Immunophenotyping was conducted by flow cytometry and included assess- ICB increased T-cell production of IFN-γ under moderately acidic conditions (pH 6.6) but not severe acidic conditions (pH 5.5) and decreased IL-10 production by T-cells under severe acidic conditions. Conclusion: ICB skewed T-cell cytokine profiles toward an anti-tumour phenotype under conditions reflective of a hostile TME, highlighting the ability of ICB to help T-cells overcome the immunosuppressive effects of the TME and their promising potential to combine with standards of care in OAC, to boost cancer-immune surveillance and subsequent clinical outcomes. Introduction: Sphincter preservation and avoidance of permanent stomas in low rectal cancer is increasingly viewed as gold standard. Functional outcomes may be variable. A permanent colostomy is considered to adversely affect quality of life but poor function from a coloanal anastomosis (CAA) may be intolerable. The aim of this study is to examine quality of life outcomes in patients undergoing restorative and non-restorative resection for low rectal cancer. Methods: Meta-analysis was performed using PRISMA guidelines. Databases were searched for studies comparing quality of life outcomes between CAA versus abdominoperineal resection (APR) for low rectal cancer. Scores assessed were the EORTC QoL QLQ-C30, and the QLQ-CR38 which is specific to colorectal cancer. Random effects models were used to combine data. Results: 145 studies were reviewed. 12 studies with 1,293 patients were included. Patients who had an APR reported higher physical function scores compared to those who had a CAA (mean difference 7.06, 95% CI 2.34-11.78, P = 0.003). Patients who had a CAA reported lower pain scores (mean difference -5.33, CI -9.29 --1.36, P = 0.008), less fatigue (mean difference -8.25, 95% CI -15.18 --1.33, P = 0.02) and less appetite loss (mean difference -5.11, 95% CI -9.26 --0.95, P = 0.02). Male sexual function was markedly reduced in patients following CAA compared to APR (mean difference -18.89, 95% CI -26.03 --11.76, P < 0.0001). Conclusions: There are significant differences in specific symptoms reported between patients undergoing CAA vs APR which could be used pre-operatively to counsel patients regarding optimal treatment options. Introduction: Defining molecular mechanisms of allograft injury may help identify therapeutic targets and salvage a proportion of discarded organs. The transcription factor NRF2 has antioxidant and anti-inflammatory functions, playing a key role in cellular defence. Aim: To determine the functional expression and clinical relevance of the NRF2 axis in discarded human livers. Methods: Protein expression in discarded human livers (n = 40) was determined on immunoblotting and donors were stratified into a high NRF2 and low NRF2 group. Hepatic injury was characterized using histological grading scores and immunofluorescent staining. Select allografts (n = 8) were exposed to 6-hours of ex-vivo normothermic machine perfusion. Liver function testing (LFTs) and lactate clearance determined organ viability post-perfusion. Results: NRF2 expression varied widely across all 40 discarded allografts. Livers with higher NRF2 expression levels demonstrated significantly lower LFTs before procurement (ALT 53 IU/L vs 152 IU/L; AST 58 IU/L vs 220 IU/L, p < 0.05). Additionally, livers with higher NRF2 levels had decreased vascular inflammation, peri-portal inflammatory cell infiltration and less evidence of glycogen oversaturation. When livers were exposed to machine perfusion, higher hepatic NRF2 was associated with lower LFTs (ALT 5,919 IU/L vs 12,000 IU/L; AST Unfortunately the use of current acellular perfusion solutions is limited to four hours in standard clinical environments. We have developed a perfusion solution with the potential to extend these times. Methods:Large animal model Lungs from 20 pigs, the gold standard preclinical lung transplant model, were harvested and randomised into 4 groups (n = 5) across two series. Series one compared our solution to the most popular marketed solution for four hours. Series 2 was a prolonged perfusion time of 6 hours designed to stress the lungs. Physiological parameters, gas exchange and lung weight were all measured. Data are expressed as mean (SD). Results: Series one results showed similar efficacy at four hours of our solution to the clinical standard. In series 2 the high viscosity solution (HVS) performed significantly better than a standard viscosity solution (SVS). SVS weight gain was 147% (81%) and HVS 44% (32%) (p = 0.029). SVS p02 at 6 hours 13.81kA (13.4kPa), HVS 37kPa (16.8kPa) (p = 0.042). Conclusion: An elevated viscosity solution can protect against oedema formation in EVLP and preserve lung function until at least six hours. This solution could be used to extend the length of time lungs are perfused in the clinical setting and allow other adjuvant therapies time to take effect. This could increase the number of donor lungs available for transplant and ultimately improve patient outcomes.