General 0029 A Diagnostic Accuracy Meta-analysis of Endoanal Ultrasound (EAUS) and Magnetic Resonance Imaging (MRI) for Perianal Fistula Assessment. M. Siddiqui*1, H. Ashrafian2, T. Athanasiou2, A. Hart1, R. Phillips1 1St Marks Hospital, Harrow, UK, 2Imperial College, London, UK Aims: We present a systematic review of published literature comparing endoanal ultrasound with magnetic resonance imaging for the assessment of idiopathic and Crohns perianal fistulas. Methods: Electronic databases were searched from January 1970 to October 2010 for published studies in any language. Results: Six studies comparing endoanal ultrasound and magnetic resonance imaging for perianal fistulas were analysed. There were 293 fistulas in the ultrasound group and 291 in the magnetic resonance group. The combined sensitivity and specificity of magnetic resonance for overall fistulas detected were 0.90 (95% CI: 0.75-0.96) and 0.66 (95% CI: 0.48-0.80). There was significant heterogeneity between studies reporting on MRI (Q=52.39,df=5,p=0.000,I2=90%). This compares to a sensitivity and specificity for endoanal ultrasound of 0.88 (95% CI: 0.77-0.95) and 0.45 (95% CI: 0.24-0.67) respectively. There was significant heterogeneity between studies (Q=49.28,df=5,p=0.000,I2=90%). Conclusions: From the available literature, the summarised performance characteristics for MRI may be interpreted as better than those for EAUS, but the significant between-study heterogeneity precludes any firm conclusions being made for clinical practice. Future trials with improved study design (including prospective data collection and consideration of verification bias) may help to further clarify the role of MRI in the assessment and treatment response monitoring of perianal fistulas (particularly in patients with Crohns disease).

General 0041 Comparing gastric bypass to adjustable gastric banding: a systematic review J. Al Shakarchi* Russells Hall Hospital, Dudley, UK Aims: Although bariatric surgery has become widely popular, there is currently little strong evidence to support one bariatric procedure over another. The two more popular surgical procedures are gastric bypass and gastric banding. We aimed to evaluate which of those treatment is more efficient. Methods: We searched the Cochrane Database of Systematic Reviews and Pubmed for meta-analyses comparing the gastric bypass and gastric banding in the treatment of obesity between 2000 and 2010. Strict inclusion criteria and thorough appraisal of the reviews was required to ensure comparability of the included papers. Results: Our dataset comprised of individual data on 6796 patients from 15 different studies that compared gastric bypass with adjustable gastric banding. The median difference in excess body weight loss across the thirteen studies which reported weight loss was a significant difference of 24.8% (range 16-24). However the mortality rate at 1 year favoured gastric banding (0.12% vs 0.34%) as well as short term complications. Conclusions: From the data we have gathered it may be reasonable to conclude that gastric bypass is a more efficacious procedure than adjustable gastric banding in terms of excess body weight loss. However it is important to be aware that it does carry with it more significant short term morbidity and mortality.

General 0152 Botox treatment for axillary hyperhidrosis should only be offered with adjunct psychological input. D. Baker*, E. Baker Royal Free Hospital, London, UK Aims: Axillary hyperhidrosis affects 2% of people. Treatment focuses on physically reducing sweating, however the precipitating cause is often emotional and psychological therapy may be beneficial. Before considering this, it is necessary to determine the psychological impact of hyperhidrosis and its physical treatment. Methods: 54 axillary hyperhidrosis patients answered questionnaires before and one, six and twelve months after Botox treatment (8:46 M:F; median age 30, range16-56 years) The questionnaire consisting of a general quality of life assessment (SF36) and specific assessment of social anxiety using the Brief Fear of Negative Evaluation Scale (BFNES), Social Phobia Scale (SPS) and Social Interaction Anxiety Scale (SIAS). The former assesses the dread of being evaluated unfavourably and the latter two, the affective reactions to the feared situation. The Hyperhidrosis Disease Severity Scale (HDSS) assessed the physical impact of sweating. Results were compared with 67 controls without hyperhidrosis. Results: Prior to treatment, the SF36 physical component scores were similar to controls (PCS 52.9 v 52.1), but mental component score was lower (MCS 43.0v52.9;p

General 0204 Gallbladder perforation: case series and systematic review R. Date, S. Thrumurthy*, K. Pursnani, J. Ward, M. Mughal Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK Aims: Gallbladder perforation is a serious complication of acute cholecystitis. Its management has evolved considerably since its classification by Niemeier in 1934. This review summarises the evidence surrounding the natural progression of this condition and potential problems with Niemeiers classification, and proposes a management algorithm for the more complex type II perforation. Methods: Data from a retrospective case series and a systematic review were combined. The case series included all patients with gallbladder perforations from 2004 to 2008 at a British teaching hospital. The systematic review searched for gallbladder perforation using the MEDLINE, Embase, Web of Science and Cochrane Library (2011 Issue 4) databases, as well as recent conference abstracts. The outcome data were analysed using SPSS version 15. No adjustments were made for multiple testing. Results: 198 patients (including 19 patients from the present series) with a mean age of 62.1+/-9.7 years and male gender proportion of 55.4% (range 33.3-76.7%) were included. The most common gallbladder perforations were type II (median 46.2%, range 7.4-83.3%), followed by type I (median 40.6%, range 16.7-70.0%) and type III (median 10.1%, range 0-48.1%). Perforation was associated with cholelithiasis in 86.6% (range 78.9-90.6%) of patients, and the overall median mortality rate was 10.8% (range 0-12.5%). Male gender was weakly associated with mortality (p=0.089) but age (p=0.877) and cholelithiasis (p=0.425) were not. Mortality did not vary significantly with perforation type. Conclusions: Gallbladder perforation should be reported according to the original Neimeiers classification to avoid heterogeneity in data (e.g. varying rates of perforation types). The algorithm proposed in this study aims to guide the management of complex type II and III gallbladder perforations to minimise subsequent morbidity and mortality.

General 0205 Bacteriological culture and routine outpatient follow-up are ineffective in identifying fistula-in-ano following incision and drainage of primary anorectal sepsis J. Wild*, O. Musa, K. Chapple Colorectal Surgical Unit, Sheffield Teaching Hospitals, Sheffield, South Yorkshire, UK Aims: To determine if microbiological culture or routine outpatient follow-up are able to identify underlying fistula-in-ano following incision and drainage (I&D) of primary anorectal sepsis. Methods: Consecutive patients undergoing I&D of anorectal abscess over a 30 month period were identified. Patients with a previous history of anorectal sepsis, co-existing inflammatory bowel disease or complex anorectal suppuration were excluded. Case notes were retrospectively reviewed and the management, follow-up arrangements and incidence of fistula-in-ano in the two years following I&D recorded. Results: Data were available for 195 of 205 (95%) patients (56 female:139 male; median age 39 [range 16-84] years). 56% of operations were performed or supervised by registrars, 38% by SHOs alone and 6% performed under consultant supervision. Trainees performed an inadequate anorectal examination in 43 (23%) of cases. Overall, 45 of 195 (23%) patients were diagnosed with a fistula-in-ano during the study period. Twenty (10%) patients had a co-existing fistula detected at operation, with seton insertion and fistulotomy performed in 12 and 6 cases respectively. A fistula-in-ano was subsequently identified in the two years following I&D in a further 25/195 (13%) patients. Growth of gut flora from pus taken at I&D (120/170 cases) was associated with a fistula in 41 cases (sensitivity 88%, specificity 35%, PPV 30%, NPV 90%). Planned outpatient follow-up was arranged in 68% (n=132) of patients. Of these patients, 33% (n=43) did not attend their appointment. At out-patient clinic review a fistula-in-ano was identified in 6/89 (7%) patients (median time of out-patient clinic review 6 [range 2-20] weeks). Of those patients (n=106) not seen for routine out-patient clinic review, 19 (18%) subsequently re-presented with a fistula-in-ano (p=0.0158; Fishers exact test) at a median time of 13 (range 2-32) weeks. Conclusions: Fistula-in-ano following acute anorectal abscess I&D occurs in only a minority of patients. Pus culture and routine outpatient follow-up following I&D of primary anorectal sepsis are an ineffective means of detecting a subsequent underlying fistula-in-ano.

General 0224 A Systematic Review and Meta-Analysis of Endovascular versus Open Surgery for Chronic Mesenteric Ischaemia S. Thrumurthy*, S. Markar, A. Karthikesalingam 1St George's Vascular Institute, London, UK, 2Virginia Mason Medical Center, Seattle, Washington, USA Aims: To date, no randomised data exist to support the efficacy of either open or endovascular surgery for chronic mesenteric ischaemia. This study presents the first systematic review and meta-analysis of these operative approaches for this complex condition. Methods: Medline, Embase, trial registries, conference proceedings and reference lists were searched for comparative studies of endovascular against open surgery for chronic mesenteric ischaemia. The primary outcomes were in-hospital mortality and reintervention. Secondary outcome measures were morbidity, technical success, symptomatic relief, symptomatic recurrence, length of hospital stay and length of intensive care. Pooled odds ratios (OR) were calculated for categorical outcomes and weight mean differences (WMD) for continuous outcomes. Results: Ten studies of 535 patients were included in the analysis. Endovascular surgery resulted in lower in-hospital mortality (OR 0.59, p = 0.005), cardiac morbidity (OR 0.32, p < 0.001), gastrointestinal morbidity (OR 0.48, p < 0.001), respiratory morbidity (OR 0.21, p < 0.001), and shorter lengths of intensive care stay (WMD -0.99, p < 0.001) and hospital stay (WMD -0.84, p < 0.001). Open surgery resulted in greater technical success (OR 0.16, p = 0.013), lower reintervention (OR 2.41, p = 0.037), greater symptomatic relief (OR 0.32, p < 0.001) and less symptomatic recurrence (OR 2.65, p = 0.027). There was no significant difference in the incidence of neurological or renal morbidity for both techniques. Significant statistical heterogeneity was present for reintervention and symptomatic recurrence rates; and lengths of hospital and intensive care stays. Significant statistical bias was present for technical success rates. Conclusions: The varying risk-benefit profiles of both operative techniques suggest that patient and physician preferences remain key in the treatment of chronic mesenteric ischaemia. Future prospective studies must aim to reduce selection bias and adhere to reporting standards to minimise data heterogeneity. Randomised trials are needed to provide more definitive evidence to better manage this complex condition.

General 0299 Shifting paradigms in the management of duodenal fistula. B.I. Babu*, J.G. Finch Northampton General Hospital, Northampton, UK Aims: Paradigms in the management of duodenal fistula have evolved over the last half a century. Despite advances, morbidity and mortality still remain high. This paper provides a comprehensive, up to date overview, classifying the various strategies in the management of duodenal fistula. Methods: A systematic review was performed on Medline, Embase and Cochrane library databases using the Cochrane systematic reviews methodology. A final population of 42 studies reported on 349 patients, with a median (range) number of patients per study of two (1-68). The manuscripts were broadly divided in to non-interventional and interventional. The interventional group were subdivided in to minimally invasive and the open surgical approach. Results: A total of 147 patients were treated conservatively (non-interventional group), with a median duration of 28 days (range 13-42days) with 13(9%) deaths recorded in this group. No deaths were reported in the 8 reports on minimally invasive approach.166 patients had open surgical approach with a mortality rate of 30% (50 patients). Conclusion: In the absence of randomised controlled trials, no one interventional modality can be said to be superior to the other. It would seem reasonable, after a period of sepsis control and nutritional augmentation, in those fistulae that fail to close spontaneously, to attempt a low risk minimally invasive intervention where necessary expertise is available. The initial conservative period should be up to 6 weeks. More risky open surgical approaches should clearly be reserved for those that fail and are probably best performed in specialist centres.

General 0325 Conservative management of diverticular abscess: Is it a bridge to definitive therapy? G. Ranganathan*, R. Kochupapy, S. Furtado, D. Shanahan, B. O' Riodan Prince philip hospital, Hywel DDA NHS Trust, Llanelli, Wales, UK Aims: Diverticular abscess is one of the common surgical emergencies which require active surgical intervention. Increasingly we are managing abscess with conservative management using the antibiotics. Our institutional study was to assess the outcome and further complications during the follow up which are equally important factors we need to consider. Methods: Retrospective study of 16 patients who had diverticular abscess and managed with antibiotics alone from 2005 were included in our study. We studied retrospectively their demographic data and past medical history. Their outcome, readmission rate and resection rate along with morbidity and mortality during their admission were also obtained. Results: In our series 16 patients with diverticular abscess without generalized peritonitis were included. Median age was 72 and Male: Female=1:1.5.Patients known to have diverticular disease in 31% cases and 50% patients were grouped ASA 3.Most of the patients were in sepsis syndrome (62.5%) at the time of presentation. The CT Abdomen done during their stay showed ten of the abscesses nested within the sigmoid mesocolon, 3 were pelvic and inter-mesenteric abscess in 3 patients. Abscesses were measuring 2-8.5 in their sizes. Mean size of the abscess was 4cm.Percutaneous drainage was not attempted due to their location and size. 93% responded to conservative management. Median duration of stay was 15 days. Median duration of antibiotic therapy (cefuroxime and metronidazole) was 8 days. One patient died due to chest infection. 80% patients had follow up investigations. Only one had subsequent resection, while the remainder remained asymptomatic (re admission rate 6.25%). Conclusions: Conservative management of diverticular abscess was successful story due to careful selection of patients. Our resection rate and readmission rate were comparable with national average. Good response rate in spite of long duration of stay is acceptable considering their age and morbidity with surgical options. Multidisciplinary surgical approach definitely improved our best practice. Hence, conservative management for diverticular abscess is not a bridge to definitive therapy.

General 0331 Factors predicting significant pathology on ultrasonography in women presenting with non-specific lower abdominal pain D.K. Bilku*, T.C. Hall, A.R. Dennison, M.S. Metcalfe, G. Garcea University Hospitals of Leicester NHS Trust, Leicester, UK Aims: Ultrasound scans (USS) are frequently used to exclude significant pathology in young women presenting with non-specific lower abdominal pain (NSLAP). This study examined parameters which predicted the likelihood of significant findings on USS. These results could be used to select patients for priority scans or identify those who could be managed with no USS. Methods: 65 women with NSLAP were identified from 283 admissions. Group 1 (n=42) were patients with normal scans. Group 2 (n=23) included patients with positive scans requiring treatment. White cell count (WCC), C-reactive protein (CRP), platelets, age, duration of pain and length of stay in hospital were compared between the groups. Results: Median WCC and CRP were greater in Group 2 versus Group 1: 15x109/l and 123 mg/l versus 11x109/l and 72 mg/l respectively (P=0.01 & 0.05). CRP was a weak predictor of positive pathology on USS (AUC=0.66 and P=0.027) and WCC was a strong predictor of abnormal pathology on USS (AUC of 0.7 and P=0.005). A WCC of >12.8x109/l was 65% sensitive and 71% specific in predicting subsequent pathology on USS. Median wait for USS was 24 hours (range of 1 to 96 hours). Conclusions: This study failed to define any criteria which could select patients not requiring USS. Since USS is a relatively cheap and safe investigation, its continued use to screen women with non-specific lower abdominal pain is justified. WCC should be used to prioritise scans.

General 0372 The use of preoperative cardiopulmonary exercise testing (CPET) in upper gastrointestinal resectional surgery: does it predict postoperative morbidity? I. Hamzah*, J. Low, P.C. Leeder Royal Derby Hospital, Derby, Derbyshire, UK Aims: The aim of this study was to assess the value of cardiopulmonary exercise testing (CPET) in predicting postoperative complications in patients undergoing upper GI resectional surgery. Methods: A retrospective review of 41 patients referred by a single centre for upper GI resectional surgery who underwent CPET preoperatively using cycle ergometer was performed. Measured CPET variables included anaerobic threshold (AT) and maximum oxygen uptake (VO2 peak). Outcome measures assessed included length of hospital stay, presence of postoperative cardiopulmonary or non-cardiopulmonary complications and number of patients that received medical intervention after CPET for optimisation prior to surgery. Results: CPET outcomes of 41 patients (35 male, 6 female) referred by the Department of Upper GI Surgery were assessed over a 22-month period (January 2010 October 2011). Mean age was 70.1 years. 32 patients underwent transthoracic oesophagectomy and 9 patients had open gastrectomy. Out of the 41 patients, 58.5% developed postoperative cardiopulmonary complications and 22% had non-cardiopulmonary complications. If focused on the transthoracic oesophagectomy group (32 patients), 62.5% had postoperative cardiopulmonary complications whilst 21.9% had non-cardiopulmonary complications. 22% of patients received medical optimisation prior to surgery. 2 in-hospital deaths occurred postoperatively (4.9%). There were no statistically significant differences in mean AT and VO2 peak measurements between patients with or without cardiopulmonary complications. This was similar in non-cardiopulmonary complications. There was no correlation between AT or VO2 peak with length of hospital stay or mortality. Conclusions: Our study has not identified any value in CPET assessment in the prediction of post-operative morbidity and mortality, or length of hospital stay in upper GI resectional surgery. Larger studies will be needed to determine its value.

General 0379 The 6Fs of Symptomatic Cholelithiasis: A Clinical Validation of Epidemiologically-derived Historical Predictors G. Bass*, S.N.S. Gilani, T.N. Walsh RCSI Academic Dept of Surgery, Connolly Hospital, Blanchardstown, Dublin, Ireland Introduction: The 5 Fs heuristic Fat, Female, Forty, Fair and Fertile can identify patients with upper abdominal pain that have the highest likelihood of having cholelithiasis. However, in our experience, there is also a missing F, Family History. Aim: To quantify the value of the existing 5Fs and putative sixth, and hence construct a predictive scoring system. Methods: 398 patients admitted for evaluation of upper abdominal pain were grouped for analysis based on the presence or absence of cholelithiasis. Hierarchical multiple linear regression established the independent predictive factors. These significant variables were then weighted to create the scoring system. Results: The gallstone group contained significantly more female (75.8% vs 55%, p

General 0418 Cholecystitis: A positive Predictive Factor for the Presence of Common Bile Duct Stones. N. Charlwood*, D. Flook Pennine Acute Hospital NHS Trust, Manchester, UK Aims: Stone migration into the common bile duct (CBD) is the most dangerous aspect of gallstone disease and should be excluded in all patients with asymptomatic gallstones. Jaundice (75%) and pancreatitis (25%) are positive predictors of the presence of CBD stones at acute laparoscopic cholecystectomy (LC). Calculus cholecystitis is generally believed however to be due to stone impaction in the cystic duct / gallbladder neck and most surgeons do not perform on-table cholangiography (OTC) during LC. We therefore review our experience of routine OTC findings in patients with cholecystitis to test the validity of this approach. Methods: We collected data prospectively between 1.1.09 and 31.12.09 for all patients undergoing LC by a single surgical team. Patients who had clear findings of acute cholecystitis at operation were identified and their pre-operative blood results, ultrasound findings and OTC information were obtained from the computer data base, including electronic letters and discharge summaries, PACS reports, and patients notes. Results: Over this time period 434 LC were performed, 84 of these patients had evidence of cholecystitis at the time of surgery. Female : Male 54:30, age range was 19-87. 54 cases were emergency presentations 30 were elective patients (often admitted acutely from clinic or after emergency admission under other teams). All except one patient had OTC. 34.5% of patients were found to have a stone in the common bile duct. Of the patients with CBD stone at OTC 10 patients had normal liver function tests (LFT) and normal CBD reported on their ultrasound scan (USS). A policy of selective cholangiography would have missed CBD stones in at least 10 of 84 patients (12%). Conclusions: USS and LFTs were not reliable predictors of presence of CBD stone in patients with cholecystitis. This data supports the routine use of OTC in all patients undergoing LC for cholecystitis. This would eliminate the need for pre-operative ERCP/MRCP and therefore prevent delays to surgery, morbidity, financial costs and negative investigations. It would also reduce the risk of retained stones and the associated complications associated with these.

General 0488 The true place of Botulinum toxin in the management of Anal fissures S. Braungart*, G. Kaur Scunthorpe General Hospital, Scunthorpe, UK Introduction: Pain in anal fissures is due to spasm of the internal sphincter muscle. Relief with healing of fissures until very recently has been achieved by surgical procedures aimed at ablation of the sphincter spasm. Because of the risk of incontinence from surgery, medical alternatives have been sought consisting of topical glyceryl trinitrate (GTN) or the topical calcium channel blockers nifedipine or diltiazem. Botulinum toxin injection has also been used with varying rates of success. However, there is no consistency in the dose, site and timing of this therapy, which may explain the variation in the success rates reported with its use in the management of anal fissures. We therefore decided to perform a retrospective audit of a single surgeons result with intrasphincteric Botulinum (Botox) in an attempt to optimize the management of anal fissures in our institution. Methods: All patients who had received Botox injection after failure of medical treatment for anal fissures from 01/01/2009 to 31/12/2011 were included. We observed a very structured approach to the use of Botox, which was only used by a single surgeon and only after lack of symptom relief with at least 8 weeks GTN cream followed by 2 courses of Diltiazem cream for 8 weeks each in addition to laxatives, Instillagel and dietary modifications. 24 patients were found of whom 16 received 1 dose of Botox, 6 patients received 2 doses, 1 patient received 3; 1 patients fissure had healed with diltiazem and instillagel by the time of surgery. Results: The most frequent symptoms prior to treatment were pain (87.5%), bleeding (75%), itching (17%) etc. In 54.2 % patients, the fissure was posterior, in 29 % anterior and posterior and in 17 % it was not documented. Patients were treated with GTN/ Diltiazem PR for an average of 7.5 months prior to botox injections. 70% of patients had 100% symptom relief, 17% of patients had 90% relief, and 4.3% of patients had 80% relief. 1 patient showed no response. Temporary faecal soiling was found in 3 patients and 1 patient had difficulty with urge sensation. In comparison, only one patient underwent a lateral sphincterotomy within the same time frame. Conclusions: Relief of anal spasm has been associated with relief of pain and healing of anal fissures. Historically the most common approach for relieving the spasm is surgical; however morbidity, being principally incontinence, has been substantial in some recent reports, generating enthusiasm for therapies that do not involve sphincter division. Botulinum toxin has been used with wide variation in success rates. We achieved 80% or more symptom relief in 91.3% of our patients in our retrospective study. Our extremely structured approach with its use may explain our good results with Botox in anal fissures.

General 0505 Assessing Awareness of Colorectal Cancer Symptoms and Screening in a Peripheral Colorectal Surgical Unit T. McVeigh*, A.J. Lowery, M. Akhtar, R. Waldron Mayo General Hospital, Castlebar, Co. Mayo, Ireland Aims: The National Screening Program for Colorectal Cancer (CRC) will commence January 2010. Previous studies on the topic of CRC and screening have highlighted paucity in public awareness of Epidemiology, symptoms and signs of CRC. The aim of this study was to assess understanding of Colorectal Cancer and screening in a representative sample of the local catchment population of Mayo General. Methods: A prospective cohort study was carried out by means of an anonymous survey, which was distributed at all out-patient clinics. Data collected included demographics, presenting complaint type and duration, and general knowledge of CRC facts. Attitudes towards screening were also evaluated. Results: Forty-four of the sixty-two patients sampled were female (71%). 51.6% of the sample were within the screening target age-group (55-74) or older, with mean age 53.37years (+/-17.6). Most respondents recognised bleeding per rectum as a possible symptom of CRC. A significant proportion, however, incorrectly selected less sinister symptoms as concerning, while only 50% correctly cited weight loss. 53% acknowledged family history as a risk factor, with age and gender cited less often (32%, 10%). 42% incorrectly cited Stress as a risk. 87% of respondents associated screening with testing of symptomatic patients or those with a positive family history. Only 13% associated screening with an asymptomatic cohort. Strikingly, 33% of patients would decline screening. Conclusions: There remains poverty of awareness regarding Colorectal Cancer. More public health initiatives are required to help improve understanding of the disease process, and to improve public compliance with the screening initiative.

General 0512 Ischaemic pre-conditioning for elective liver resections performed under vascular occlusion A Cochrane systematic review J. Vaughan*1, K. Gurusamy1, Y. Kumar2, V. Pamecha1, D. Sharma1 1UCL Medical School, London, UK, 2Leeds Teaching Hospital, Leeds, UK Aims: Vascular occlusion is used to reduce blood loss during liver resection surgery. This causes ischaemia to the liver and subsequent damage. When the liver circulation is restored, the damage can be increased (ischaemia reperfusion injury). It is not clear whether brief periods of ischaemia followed by reperfusion (ischaemic preconditioning) prior to vascular occlusion has a protective effect during elective liver resections. Methods: We identified randomised clinical trials by searching The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, meta-register of Controlled Trials and Science Citation Index Expanded until September 2011. Two authors independently identified the trials and extracted the data. We analysed the data with both the fixed-effect and the random-effects models using RevMan software. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat or available case analysis. Results: We identified a total of eight trials (of high bias-risk) involving participants undergoing liver resection comparing ischaemic preconditioning (n = 259) versus no ischaemic preconditioning (n = 260). There was no significant difference in short-term mortality (RR 1.21; 95% CI 0.36 to 4.11) or in the rate of serious adverse events (rate ratio 0.86; 95% CI 0.55 to 1.35). Long term mortality and quality of life was not reported in any of the trials. There was no significant difference between the two groups with regards to blood loss or blood transfusion requirements, hospital stay (MD -0.97 days; 95% CI -2.92 to 0.99) or operating time (MD -9.50 minutes; 95% CI -20.04 to 1.05). Return to work was not reported in any of the studies. Conclusions: Currently, there is no evidence to suggest a protective effect of ischaemic preconditioning in patients undergoing elective liver resection under vascular occlusion.

General 0585 Combined stapled anopexy and posterior vaginal repair: Is there any benefit? P.G. Vaughan-Shaw*1, A. Talwar1, S.A. Pilkington1, A. Monga2, K.P. Nugent1 1Department of Colorecal Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK, 2Department of Urogynaecology, University Hospital Southampton NHS Foundation Trust, Southampton, UK Aims: The underlying anatomical abnormalities in patients with pelvic floor dysfunction are often rectocoele and haemorrhoidal or mucosal prolapse. Traditionally these two conditions have been treated separately by different surgical specialities. A combined approach may be utilised with a urogynaecologist and a colorectal surgeon performing a posterior vaginal repair (PVR) and a stapled anopexy (PPH). The efficiency and morbidity associated with this combined approach is assessed and compared with standard treatment. Methods: Patients undergoing PPH and PVR over a 3 year period were included and three cohorts identified. 1-patients undergoing PPH and PVR combined, 2-PVR only (50 sequential patients included) and 3-PPH alone. Clinical data were collected retrospectively from case-notes and Chi-squared and Mann-Whitney U tests performed to identify significant variation between cohorts. Results: 121 patients were included, 41 undergoing a combined procedure. Mean combined length of stay was greater for patients undergoing separate procedures (1.6 v 1 days, p=0.0004). Median follow-up was 91, 97 and 144.5 days in groups 1, 2 and 3 respectively. Post-operative morbidity was comparable between groups with no significant increase in post-operative infections (n=3), recurrent rectocele (n=1), recurrent haemorrhoids (n=7) or post-operative fistula (n=0) in those undergoing a combined procedure. Conclusions: In patients with symptomatic rectocoele and haemorrhoids, a combined approach with posterior repair and stapled anopexy as a combined operation is associated with a reduced hospital stay and low morbidity.

General 0639 Meta-analysis of Randomised Studies Comparing Infrared Coagulation (IRC) and Rubber Band Ligation (RBL) for the treatment of haemorrhoids. S. Loizides*3, G. Reese1, B. Stubbs2, M.R. Machesney1

1Whipps Cross Hospital, London, UK, 2Chase Farm Hospital, London, UK, 3Royal London Hospital, London, UK Aims: To compare the complications and efficacy of IRC and RBL for the treatment of haemorrhoids. Methods: Randomized trials comparing IRC to RBL for the treatment of haemorrhoids were selected from the standard electronic databases. Outcomes were analysed using RevMan. The primary outcomes were discrete variables and were reported using odds ratios with 95% confidence intervals. The data was analysed using a random-effects model. Results: Seven randomized trials containing 987 patients were included. There was significant heterogeneity among trials. There was no significant difference between the IRC and RBL groups for post-operative bleeding (OR 1.19, 95% CI 0.70-2.03, p=0.52) or tenesmus (OR 0.37, 95% CI 0.13-1.05, p=0.06). RBL was a significantly more painful procedure (OR 0.22, 95% CI 0.10-0.45, p

General 0655 Kidney Transplantation from Donors after Circulatory Death Single Centre Experience K.S. Benaragama*1, T. Tymkewcyz2, B.J. John1, D.L. Nicol1, B.S. Fernando1 1Royal Free Hospital, London, UK, 2South Central Organ Donation Services, London, UK Introduction: The acute shortage of organs for transplantation has led to the increasing use of organs from donors after circulatory death (DCDs). It is well known that short term outcomes are better following transplantation of organs harvested from donors after brain death (DBDs) although, the long term impact is unclear. We present our 8 year experience of DCD kidney transplants. Methods: Retrospective analysis of DCD kidney transplants at the Royal Free Hospital, London from 2002-2010. Information retrieved from the UKT Hot A form, medical databases and patient notes. Data included donor/recipient demographics and co-morbidities, graft and implantation variables, delayed graft function (DGF) and graft survival/death. Results: A total of 78 DCD transplants were performed during this period. 2 patients were lost to follow up. The overall patient survival was 72/76(95%). Overall incidence of graft loss was 11/78(14%). The 1-, 3- and 5- year graft survival was 93%, 90% and 77% respectively. Conclusion: Kidneys from DCDs provide excellent short term outcome in terms of graft survival, equivalent to those from Donors after Brain Death (DBD). Increased utilization of DCD organs will shorten waiting times. Our data supports findings from literature

General 0663 The experts views on Surgical Expertise a historical perspective A. Harris*, N. Matar Imperial College, London, UK Aims: To define the experts views on historical surgical expertise. Methods: Nine individual, semi-structured, interviews were performed with experts in the field of surgery and surgical history (selected by their roles within relevant organisations). Each interviewee was asked for their interpretation of terms relating to expertise and mastery, before discussing their own choice of historical surgeon. Interviews were audio-recorded, transcribed, checked, and Thematic Analysis performed by two independent researchers. Results: Expert opinion on what constitutes expertise and mastery was divergent and frequently contradictory. The historical surgeons discussed ranged from Joseph Lister and John Hunter to Erasmus Wilson and Edgar Parry. Only one interviewee had worked with or met their choice of expert. No female surgeons were championed. All interviewees discussed the background, training, personal characteristics, skills and achievements of their chosen expert. There appear to be no significant commonalities between the surgeons championed, nor what was felt to be important by the historical experts. Conclusions: This study demonstrates the need for a dictionary of terms and the subjectivity of what constitutes surgical expertise, (even amongst experts in the field). Further work will comprise structured analysis of modern day expertise against which historical comparisons will be made.

General 0674 A systematic review of the literature on Surgical Expertise A. Harris*, S. Mavroveli, A. Yeh Imperial College, London, UK Aims: To identify what original research has been performed exploring surgical expertise. Methods: The PRISMA 2009 checklist and flow diagram provided the structure of this review. Medline, Embase and PsycINFO databases were systematically searched using a list of key words and search terms (e.g. surg$, expert$, excellence, master$) created from preliminary work reviewing key texts and the grey literature in this topic area. Two researchers screened 464 abstracts according to pre-determined inclusion and exclusion criteria. The full texts of 49 abstracts were retrieved. After application of criteria only 4 articles remained. For quality control purposes, a third reviewer was invited to review the 49 articles using the same inclusion and exclusion criteria, whilst blinded to the findings of the other researchers, and included the same 4 articles. Data were extracted and analysed using an adapted data extraction form and established quality control measures. Results: The four included articles are diverse, comprising two studies that used mixed methodology, one quantitative study and one qualitative study. All four articles provide low-level evidence, have significant limitations (e.g. small sample size), and score poorly on robust quality control criteria. Conclusions: In the absence of high impact, original, research there is: no universally agreed upon definition of expertise; a lack of operationalisation; and inadequate guidance for developing expertise. Given the current political interest in expertise and excellence, for the current generation of surgical trainees to aspire and train to excellence, further research in this field is required as a matter of urgency.

General 0677 Aetiology and management of spontaneous liver haemorrhage S. Qiu*, E. Vaughan-Huxley, S. Mikhail, M.B. Pai, D.R.C. Spalding Hammersmith Hospital, London, UK Aims: Spontaneous haemorrhage secondary to non-traumatic rupture of the liver has life-threatening consequences. Hepatocellular carcinomas (HCC) are the commonest cause with an incidence of rupture

General 0695 Pre-operative Colonoscopic localization of tumour with tattoo: a re-audit of current practice at a District General Hospital. S. Panteleimonitis*, U. Ihedioha, A. Kansagra, J. Evans, P. Kang Northampton General Hospital, Northampton, UK Aims: Preoperative localisation of tumour is an essential requirement in laparoscopic colorectal surgery. Tattooing guidelines should be simple to follow and consistent for all lesions irrespective of the location of the tumour. Our recommendations were: To place at least two spots of tattoo distal to each lesion, and clearly document site of tattoo with respect to tumour in the endoscopy report. Methods: We conducted a prospective audit of endoscopic tattooing of colorectal tumours resected in our hospital from February 2010 to January 2011. It was felt that the current guidelines were too complicated, leading to higher rates of inaccurate tattooing. Thereafter new guidelines were developed and subsequent practice reaudited. Results: 2010: 37 patients in total were identified. 14 were not tattooed. 3 patients had a tattoo which was inaccurate. 13 had accurate and well documented tattoos. 7 patients had tattoos of unknown accuracy. 2011: 24 patients in total were identified. 6 patients were not tattooed. 4 patients had no tattoos visible at operation. 1 patient had a tattoo which was inaccurate. 11 patients had accurate and well documented tattoos. 2 patients had tattoos of unknown accuracy. Of those patients which were tattooed and seen at surgery, 78.6% were accurate and clearly documented in 2011 compared to 56.5% in 2010 (p=0.2124) Of those patients which were tattooed and seen at surgery, 14.2% had unknown accuracy (not clearly documented) in 2011, compared to 30.4% in 2010 (p=0.3032) Of those patients which were tattooed and seen at surgery 7.14% were deemed inaccurate (tattoo in wrong place) in 2011, compared to 13.04% in 2010 (p=0.6043). Conclusions: The simpler method of tattooing all tumours distally has improved the accuracy of tattooing.

General 0730 Diverticular disease: Are we recognizing the full extent of the problem? M. Alfa-Wali*, G. Zhou, Q. Iqbal, A. Prabhudesai Hillingdon Hospital NHS Foundation Trust, London, UK Aims: Diverticular disease is a common health problem in the UK population. It accounts for one of the commonest general surgical admissions. We report the financial implications of acute admissions for diverticular disease in a district general hospital over a 5-year period Methods: The electronic hospital database was used to identify patients that were admitted with diverticular disease between 2006 and 2011. Demographic, investigations and treatment were analysed using descriptive statistics. The modified Hinchey classification was used to describe complicated versus uncomplicated diverticular disease Results: The prospective database identified 1, 932 patients. Investigations in the form of colonoscopy or flexible sigmoidoscopy were carried out in 1,525 patients (92%) and urgent CT scans of the abdomen and pelvis was performed in 122 patients (7%), out of 380 emergency admissions. Three percent of patients (n=65) had complicated diverticular disease in the form of an abscess or perforation. Four percent (n=74) required surgical management (n=67) or radiological intervention (n=7). This accounted for 3205 days of hospital stay, with a median stay of 5 days. This equates to over 1 million for hospital stay alone at an average cost of 350/day. The additional costs of investigations accounting to approximately 2000/day. Conclusions: With emphasis laid on cancer targets, the extent of this benign of this benign condition is being underestimated. The extent of the problem should be realised and funds allocated appropriately, particularly as this involves the increasing elderly population with comorbidities.

General 0808 Colorectal cancer surgery: are we really obtaining informed consent from patients? L.S. Gall*, N. Stephens, A. Macdonald, T. Sharma Department of General Surgery, Monklands District General Hospital, Airdrie, North Lanarkshire, UK Aims: ACPGBI guidelines state that valid consent to treatment for colorectal cancer is essential and reflects patients fundamental legal and ethical right to determine what happens to their own body. Complication rates following colorectal cancer surgery have been published and outcomes vary widely between surgeons and institutions. This study examines the basis on which surgical trainees and consultants obtain informed consent, questioning whether their knowledge of complication rates is based upon their own experience, local practice or nationally published figures. Methods: An online questionnaire was circulated to consultants and trainees interrogating the origins of the knowledge base which underpinned their consent process. Specifically, was information conveyed to patients based on personal experience, local figures (unit/trust), nationally published figures or on a trainers figures in the case of trainees? Participants were asked about mortality rates (elective and emergency surgery), wound infection and anastomotic leak rates; in addition to whether or not thromboembolism, splenectomy and nerve injury (pelvic surgery) were discussed. Results: 118 completed responses were received (90 consultants and 28 trainees). All trainees had been involved in obtaining consent. Complication rates quoted by trainees were based on published data - 32%; figures quoted by a current or previous trainer - 14%; personal experience - 25%; local unit/trust figures - 7%; do not know - 11%; other 11%. Consultants quoted rates based on published data - 21%; personal experience - 44%; local unit/trust data - 23%; other -12%. Average complication rates quoted by both trainees and consultants were either similar or below ACPGBI guidelines. Of the consultants surveyed, 93% discuss nerve injury in pelvic surgery compared with only 64% of trainees. Conclusions: Informed consent for colorectal cancer surgery was based on information that was not consultant specific in at least 50% of cases.

General 0820 Do hospital staff understand the importance of common risk factors for colorectal and breast cancer? S. Harris*, S. Ghosh Nevill Hall Hospital, Abergavenny, UK Aims: Risk factors for some of the common malignancies are well known. This study aims to assess understanding of the importance of modifiable and non modifiable risk factors for colorectal and breast cancer amongst hospital employees, including medically trained staff in a DGH. Methods: A written questionnaire was given out to a wide variety of hospital employees and requested them to rank eight risk factors for colorectal and breast cancer separately. One being the most important and eight being the least important. It also asked if any of their family members had had colorectal cancer and or breast cancer. Results: 167 employees completed questionnaires. An average was taken for each risk factor from the responses. It is well established that family history contributes to only 8% of breast and 15-20% of colorectal cancer. The employees however ranked having two close relatives with the specific cancer as the most important with an average of 1.71 for breast cancer and 1.98 for colorectal cancer. Well known important risk factors such as excess alcohol intake, nulliparity and age for breast cancer risk were ranked low, while diet rich in red meat, history of polyps in the bowel and age as risk factor for colorectal cancer was also ranked unimportant by most. The employee data was split into four groups: doctors, nurses, allied health professionals, administration and domestic. The results showed no significant difference in the understanding across the groups. 34 employees had a family history of breast cancer and 39 had a family history of colorectal cancer. This history however did not comparatively affect the understanding of the risk factors. Conclusions: Breast and colon cancers are common and some of their risk factors are modifiable. However even amongst the hospital employees, including those medically trained, understanding of common risk factors for these cancers is lacking. Education is required to improve their understanding, so those modifiable risk factors can be addressed and their knowledge communicated to the wider public.

General 0912 Management of Colovesical fistulae in the modern era a single institutions 12 year experience N. Ladwa*, M.S. Sajid, T. Liston, M. McFall, M.K. Baig Worthing Hospital, Worthing, UK Aims: This aim of this study is to review how investigations and management of colovesical fistulae (CVF) has progressed in our institution over a 12 year period and to propose a protocol to ensure prompt diagnosis and treatment in the future. Methods: A retrospective case note review was conducted of all patients with (CVF) who underwent definitive surgery over a 12 year period. Variables collected include patient demographics, symptoms, investigations, operative data, histology, complications and length of stay. Results: 56 patients (38 male) underwent operative intervention for (CVF). The most common symptoms were pneumaturia (69%), faecaluria (32%) and symptoms associated with recurrent UTIs (68%). Cystoscopy was the most accurate investigation to make the definitive diagnosis of CVFidentify fistulae (91%) followed by CT (60%) and barium enema (31%).Two patients were unfit for surgery and underwent palliative loop colostomy.. The most common aetiology was diverticular disease (% cases). Of the 54 remaining patients, 45% underwent laparoscopic resection with a conversion rate of 33% (due to adhesions or multiple abscesses). Sigmoid colectomy (52%) anterior resection (30%) and Hartmanns (9%) were the most common procedures performed. Cystoplasty was required in 25% of cases with a further 16% requiring partial cystectomy..All patients received a postoperative cystogram to outrule bladder leak.70% of patients had defnctioning loop ileostomy There was no mortality reported peri-operatively; the anastomotic leak rate was 5% and recurrence rate was 5%. Median postoperative stay was 12.5 days (range 4-91) in the laparoscopic group and 16 days (range 6-62) in the open group. Conclusions: Laparoscopic and open surgical management for CVF is very effective with a high success rate. A large multi-centre randomized, controlled trial is required to validate its potential benefits over open surgery.

General 0935 The effects of double gloving on knot tying: double gloving may impair knot tying when using monofilament suture material. C. Battersby*2, N. Battersby3, J. Hunt1 1University of Liverpool, Liverpool, UK, 2Mersey School of Surgery, Liverpool, UK, 3West Midlands School of Surgery, Birmingham, UK Aims: Double gloving is recommended by a number of authorities, as it is believed to enhance both patient and surgeon safety. However, it is not known whether double gloving affects the surgical skill of knot tying. Our aim was to establish whether wearing two pairs of surgical gloves impairs the surgical skill of knot tying. Methods: 106 delegates (31% consultants, 50% registrars, 18% SHO) at the ASGBI International Congress 2010 tied surgical knots onto pseudotissue using 2.0 & 4.0 vicryl, and 2.0 & 4.0 prolene. 3 knots were tied with each material, under standardised double-gloved and single-gloved conditions. The order of material used was randomised, half of the participants double gloved first, half single gloved first. The knots were removed from the pseudotissue, intact, and suspended between hooks on a tensile tester. Displacement between hooks was measured as a marker of how well the material was bedded down onto the pseudotissue. Each knot was then subjected to tensile stress to breaking point, to test knot integrity. Results: 2544 knots were analysed. Data was analysed using paired Students T-test. Knots tied with monofilament suture, under double-gloved conditions, were less well bedded down onto the pseudotissue (p=0.000 for 2.0 prolene, p=0.005 for 4.0 prolene,). This effect was not seen with braided suture. The tensile stress required to disrupt the knot is not significantly affected by double gloving, for either monofilament or braided suture. Conclusions: With this novel study we have shown that double gloving may compromise knot tying when using monofilament suture, as the material is not as well bedded down onto the tissue under double gloved conditions. We have also shown that double gloving does not appear to affect the integrity of the knot, as assessed by tensile stress. The finding of compromised knot tying with monofilament has important implications for all surgeons who use monofilament suture. An awareness of this risk may help surgeons to modify practice.

General 0955 Appendicectomy: Provision and Clinical Outcome at a University Teaching Hospital J. Tadros, I. Khattak*, S. Bruce, I. Khan University Hospital Aintree, Merseyside, UK Aims: We aimed to audit the clinical provision and outcome for appendicectomies undertaken at University Hospital Aintree during 2008-9. Methods: Following Audit Department approval, appendicectomies were identified from theatre logs. Data were gathered retrospectively from case-notes, and included type of surgery (open/laparoscopic/lap to open), timing and length of procedure, grade of operating surgeon, length of postoperative stay (LOS), complications, and histology. Theatre logs from 1999 provided a benchmark for number of cases undertaken and grade of operating surgeon prior to national changes in working patterns and surgical training. Results: In 2009 186 appendicectomies were undertaken, and 106 case notes were available for review. Male to female ratio was 1 (52 male : 54 female) and median age was 26 (range 16-82) years and 29.5 (range 16-66) years respectively. Laparoscopic procedures were carried out on 66 (62%) cases of which 9 (14%) were converted to open. Primary operating surgeon was Consultant in 6 (6%) cases, Registrar for 91 (86%), and SHO in 9 (8%). Fifty-two (49%) cases were carried out between 09:00 and 17:00 (day) with a further 39 (37%) between 17:00 and 00:00 (evening) with only 15 (14%) after 00:00. Median operating time was 104 (range 51-238) minutes for open procedure and 106 (range 64-250) minutes for laparoscopic with a median LOS of 2 (range 1-47)days and 1 (range 1-39) day respectively. Immediate post-operative complications occurred in 8 (8%) cases and 14 (13%) required re-admission. Five (5%) returned to theatre. No significant difference in complication rate or return to theatre was observed between open and laparoscopic cases. Histology revealed a normal appendix in 16 (15%) cases and appendicitis in 83 (78%). The remaining 7 cases were cancer (1), Crohns (2), endometriosis (2) and infection (2). In 1999, 200 appendicectomies were carried out. Male to Female ratio was 1.2 (109M:91F) with a median age of 30 (range 16-85) and 34 (range 16-88) years respectively. Cases stratified by grade were: Consultant 31 (16%), Registrar 82 (41%), SHO 80 (40%) HO 7 (3%). Conclusions: Appendicectomy continues to from the staple diet of surgical trainees although the majority of cases were laparoscopic. These were associated with a shorter LOS and similar complication rates to open procedures. Most operating occurred before midnight, and although half were carried out within working hours, a marked reduction in SHO led appendicectomies has occurred within a decade. This is likely to be related to changes in working patterns and training structure, with the requirement for more advanced skills of laparoscopy favouring senior trainees.