Introduction The COVID-19 pandemic has led to drastic measures being implemented for the management of surgical patients across all health services worldwide, including the National Health Service in the United Kingdom. It is suspected that the virus has had a detrimental effect on perioperative morbidity and mortality. Therefore, the aim of this study was to assess the impact of the COVID-19 pandemic on these outcomes in emergency general surgical patients. Methods Emergency general surgical admissions were included in this retrospective cohort study in one of the COVID-19 hotspots in the South East of England. The primary outcome was the 30-day mortality rate. Secondary outcomes included the length of stay in hospital, complication rate and severity grade and admission rates to the ITU. Results Of 123 patients, COVID-19 was detected in 12.2%. Testing was not carried out in 26%. When comparing COVID-positive to COVID-negative patients, the mean age was 71.8 + 8.8 vs. 50.7 + 5.7, respectively, and female patients accounted for 40.0 vs. 52.6%. The 30-day mortality rate was 26.7 vs. 3.9 (OR 6.49, p = 0.02), respectively. The length of stay in hospital was 20.5 + 22.2 vs. 7.7 + 9.8 ( p < 0.01), the rate of complications was 80.0 vs. 23.7 (OR 12.9, p < 0.01), and the rate of admission to the ITU was 33.3 vs. 7.9% (OR 5.83, p = 0.01). Conclusion This study demonstrates the detrimental effect of COVID-19 on emergency general surgery, with significantly worsened surgical outcomes.

Background Colorectal cancer (CRC) is the second most common cancer death in the UK with a 5-year relative survival rate is 57%, which has improved over the last 30 years. Early detection of the cancer has a great impact on its prognosis. In our large district general hospital, we receive GP 2 week pathway referrals for suspected CRC with an average monthly referral of 726. Therefore, the aim of this study is to assess if recently introduced nurses led colorectal rapid access clinic has any impact on early assessment that can facilitate faster diagnosis. Method A retrospective analysis of a prospectively collected data of the patient referred through a 2-week colorectal clinic pathway from outpatient referral system, was carried out from April, 2021 to November, 2021. Patient feedback and clinician advice and guidance were also evaluated in the same period. Result A total of 900 patients were reviewed in our Nurse led clinic with CRC detection rate of 2% approximately. Final diagnosis of cancer been made within the 28th day. Increment of 21% was seen in referrals per month. Optimal slots of 195/week are required but the nurse led clinic capacity is only 40/week. Despite the increased referral, patients are being provided with results within day 13 with positive feedback from the patients. Conclusion Despite of overwhelmed referrals, final diagnosis is provided within 28 days. Nurse Led Colo-rectal Clinic could be the answer to relieving the capacity, financial pressures and providing high quality safe patient care for our already strained NHS.

Case An 85-year-old man underwent elective resection for a large proximal transverse colon tumour. At the time of this open extended right hemicolectomy, a Meckel’s diverticulum was identified in the ileum, but not resected considering the age and character of the diverticulum. However, on the sixth post-operative day, he developed small bowel obstructive symptoms which required a reoperation. It was found that the cause of obstruction was identified as a long pedunculated Meckel’s diverticulum wrapped 15 centimetres proximal to the anastomosis. Considering the general condition of the patient and co-morbidities, resection of the Meckel’s diverticulum and loop ileostomy was performed. The patient has now recovered and is being followed up in the community awaiting stoma reversal. Background Occurring in 2% of the population, Meckel’s diverticulum is the most common congenital gastrointestinal malformation. Complications of a Meckel’s diverticulum include obstruction, haemorrhage, perforation, diverticulitis and intussusception. Most complications manifest in childhood and are less likely to occur in adults. The indication for resection of incidental Meckel’s diverticula in an adults is still debated amongst surgeons. Discussion and Conclusion This case demonstrates an unfortunate scenario of a post-operative complication from an abnormality detected at the time of the index surgery. A recent systematic review has shown that evidence in literature remains controversial for resection in asymptomatic Meckel’s Diverticulum. There are even scoring systems to facilitate decisions in such situations. This case offers an interesting perspective where morbidity may have been reduced if resection was undertaken.

Background De Garengeot's hernia (DGH) is a Femoral Hernia that contains an appendix and has been named after Rene De Garengeot, a French surgeon in 1731. It is a rare entity that is mostly identified as an incidental finding during exploration of an incarcerated Femoral Hernia and even rarer is the incidence of a gangrenous appendix in these cases. Case An 81 years-old female patient presented to Accident & Emergency complaining of a progressively tender enlarging mass in the right groin region, associated with local inflammation. CT scan of abdomen and pelvis (CTAP) performed showed suspected perforated caecum with large groin abscess. She underwent groin exploration which confirmed femoral hernia sac containing a gangrenous appendix with a surrounding abscess. The abscess cavity extended from the right groin to medial aspect of thigh. Appendectomy was performed, abscess cavity drained and washed with normal saline/ Betadine followed by suture repair of the femoral hernia defect . She made an uneventful recovery following the surgery. Discussion DGH itself is rare surgical pathology with an incidence of about 0.18% to 0.13%, however, the presentation like our case is even rarer. Emergency surgery is the definitive treatment of DGH to avoid any complications. During surgery, appendectomy and femoral hernia repair are performed consecutively. In conclusion, appendicitis within a femoral hernia often lacks a classical presentation. CTAP can be helpful in diagnosis, however there can be limitations. Appendectomy with mesh-free hernia repair is an acceptable treatment for DGH. Keywords De Garengeot hernia, Incarcerated femoral hernia

Background Congenital peritoneal encapsulation (CPE) is a rare, congenital entity in which the small bowel is surrounded by an accessory peritoneal membrane. This condition is usually asymptomatic and rarely causes intestinal obstruction. This report highlights this rare congenital anomaly as a cause of intestinal obstruction. Case A 28-year-old fit man presented to A&E with classical features of intestinal obstruction. Abdominal CT scan showed features of mechanical small bowel with 360-degree rotated mesentery, and a suspicion of closed loop obstruction. An emergency laparotomy was performed. A large congenial peritoneal sac, wrapped the small bowel from D-J flexure to proximal part of ileum, and this sac was rotated 360 degrees with multiple adhesions and a single band to the left lateral wall. Early ischemic changes were noted, along with congested mesentery. The sac was opened, dissected and adhesiolysis was performed. The thick solitary band was released. There was immediate restoration of the blood supply and the bowel was viable. Patient recovered and discharged home on day 3 Discussion and conclusion Worldwide, only 50 cases on CPE have been published till date, with the maximum reported from the UK. The other common conditions that mimic CPE are internal paradodenal hernia, abdominal cocoon and sclerosing encapsulating peritonitis. Young patients with abdominal pain and feature of closed loop high small bowel obstruction on CT scan will need a high index of suspicion, before confirming the diagnosis. At this point, it will remain a rare occurrence and an incidental finding at laparotomy.

Aims Entrapped rectal foreign bodies (FB) are being encountered by acute surgical teams with increasing frequency and can be a challenge to manage. This study aims to highlight typical patient demographics, risk factors for presentation and management options for these patients. Methods Between 2017 and 2021, 29 cases of rectal FB were diagnosed and managed at East Kent Hospital University Foundation trust. Retrospective data taken from theatre directory and electronic notes was used to audit patient demographics, co-morbidities, the type of foreign body and the extraction technique. Results The majority of patients were male (87%). The patient's age ranged from 15 to 78 years, with a median age of 48 years. In the majority of cases, the FB had become entrapped during sexual activity. Nineteen patients (65%) underwent examination under GA for removal, seven patients (24%) were manually evacuated and three required a laparotomy (10.3%). Nine patients (31%) had a history of known mental health problems. The most common FB removed was a roll-on deodorant (n=5). Conclusion Cases of rectal FB's needing surgical management typically involve male patients in their 40's. While a small proportion can have manual evacuation, the majority require examination under anesthetic and in some cases a laparotomy. While a larger study would be required for significance, it appears a history of mental health problems may predispose patients to presenting with this problem. Patients present with a wide range of foreign body type, typically items commonly found in the home, the most common being roll on deodorant.

Aim Caecal volvulus (CV) is an uncommon cause of large bowel obstruction with potential for complications such as ischaemia, and perforation. Prompt diagnosis and treatment only will ensure better outcomes. We aim to describe our experience in the largest series of CV reported in the United Kingdom. Methodology This was a retrospective study of 16 consecutive patients diagnosed with CV between March 2017 and March 2020. Results Out of 16 patients, 11 were female, with a median age of 64 (range 33–80) years. All patients presented with abdominal pain and vomiting. An initial diagnosis of bowel obstruction was made only in 8 patients (50%). Computed tomography (CT) scan of the abdomen and pelvis correctly diagnosed CV in fourteen (87.5%). Fifteen patients (94%) underwent surgical intervention. All but one (n=14,93.4%) underwent laparotomy, and one patient (6.6%) underwent successful laparoscopic intervention. Right hemicolectomy was performed in all operated patients, and fourteen patients (93.4%) had primary anastomosis. Twelve patients (80%) had one or other form of morbidity. Seven patients (47%) and three patients (20%) had grade II and III (Clavien-Dindo Classification) complications respectively with a median hospital stay of 10 (range 1–49) days. One patient (6.7%) managed conservatively was deemed to be futile. There was no postoperative mortality. Conclusion CV can present with non-specific symptoms, and a definite preoperative diagnosis is only possible with the aid of CT. Open resectional procedures with primary anastomosis is the most favoured approach in management, though laparoscopic access is also feasible in fit patients.

BackgroundEntrapped rectal foreign bodies can be a challenge to manage and are being encountered by acute surgical teams with increasing frequency. The aims of our study were to (a) ascertain the population demographics of patients presenting with this problem in our local area of East Kent, (b) see if an association could be drawn between this presentation and proposed risk factors such as a psychiatric illness or socioeconomic deprivation, and (c) to review how foreign bodies are being removed in the East Kent Hospital University Foundation NHS Trust, United Kingdom and to highlight best practice with regards to this in line with the latest guidelines. MethodologyBetween 2017 and 2021, 32 cases of entrapped rectal foreign bodies were diagnosed and managed at our NHS Trust. Retrospective data taken from the theatre directory and electronic patient records were used to audit patient demographics, co-morbidities, the type of foreign body, and the extraction technique. ResultsThe majority of patients (90%) were male (n = 29). The patients' age ranged from 15 to 95 years, with a median age of 48 years. In total, 12 (37.5%) patients had a medical history of a psychiatric illness. The most common foreign bodies removed were sex toys or vibrators (n = 8) and roll-on deodorant bottles (n = 7). Kent Area B (n = 10) and Kent Area A (n = 9) were the areas with the highest number of cases. Twenty-two (68.8%) patients underwent examination under a general anaesthetic for removal, seven (21.8%) patients had the object manually removed without sedation, and three (9.4%) required a laparotomy with or without bowel resection. ConclusionsCases of an entrapped rectal foreign body in this local region typically involved male patients between 40 and 50 years old. A high proportion of this group had a history of a psychiatric illness supporting an association between this presentation and mental health. We have proposed some explanations for this association including the anal canal nervous system interplay with the "brain-gut axis." Lower socioeconomic status and unemployment may also be risk factors for this surgical problem. A trans-anal approach for management is successful in the majority of cases; however, almost 10% of patients required emergency surgical management. We have highlighted best practice guidelines for the investigation and management of the entrapped rectal foreign body as part of our discussion.