The morbidity of negative LA is the same as LA for uncomplicated appendicitis. The morbidity of LA for complicated appendicitis is significantly higher. The selection criteria for LA in our unit needs to be reviewed to address the high negative appendicectomy rate and avoid unnecessary surgery and its associated morbidity.

IIb.

Background Boerhaave syndrome is a rare and life‐threatening condition characterized by a spontaneous transmural tear of the oesophagus. There remains wide variation in the condition's management with non‐operative management (NOM) and surgery being the two main treatment strategies. The aim was to review the presentation, management and outcomes for patients treated for Boerhaave syndrome at our institution and to compare these data with that previously reported within the Australasian literature. Methods A retrospective case series was performed for consecutive patients diagnosed with Boerhaave syndrome at our institution between January 2000 and January 2020. A systematic review of the Australasian literature was also performed. Results In case series, 15 patients were included (n = 2 NOM, n = 13 operative). The most common operative technique was primary repair with intercostal drainage via thoracotomy. Major complications occurred in 11 (73%) patients. Median Comprehensive Complication Index was 53.4 (interquartile range: 50). There was a significantly lower Comprehensive Complication Index associated with primary repair when compared to oesophageal resection (P = 0.01). There was one death, in the operative management group. Median length of hospital stay was 33 days (interquartile range: 58). In systematic review, 11 articles were included; four case series and seven case reports. From these, 23 patients met inclusion criteria. The majority of patients (83%) were managed operatively, with only four undergoing NOM. Seven patients died, representing an overall mortality rate of 30%. Conclusions We provide an updated overview of the management of Boerhaave syndrome within Australasia. Aggressive operative management is associated with reasonable outcomes.

A 79-year-old woman presented with postprandial epigastric pain. She had normal vital signs, inflammatory markers and liver function tests. Ultrasound and CT of the abdomen demonstrated features consistent with acute cholecystitis. Her medical comorbidities and extensive abdominal surgical history prompted the decision to treat non-operatively. Despite optimal medical management, worsening abdominal pain and uptrending inflammatory markers developed. She underwent an emergency laparoscopy which revealed a necrotic gallbladder secondary to an anticlockwise complete gallbladder torsion; a rare condition associated with significant morbidity and mortality if managed non-operatively. Laparoscopic cholecystectomy was achieved without complication and the patient had an uneventful recovery. Preoperative diagnosis of torsion of the gallbladder is difficult. However, there are certain patient demographics and imaging characteristics that can help surgeons differentiate it from acute cholecystitis; a condition which can be safely managed non-operatively in selected patients. The differentiating features are elaborated on in this case report.

Background: Intra-abdominal abscess (IAA) post-appendicectomy occurs in 1.4-4.4% of cases. Non-operative management of small (<4 cm) post-appendicectomy IAA in children is well established, but minimal evidence exists in adults. Percutaneous catheter drainage is considered standard treatment for IAA, yet outcome data for post-appendicectomy IAA are sparse. The aims of this study were to assess the effectiveness of non-operative management of small (<4 cm diameter) IAA and the outcomes of percutaneous drainage for larger (>4 cm) IAA post-appendicectomy. Methods: A retrospective case note review of a series of patients with a postappendicectomy IAA between 2006 and 2017 was conducted. IAAs were treated selectively; small (<4 cm) IAAs were managed non-operatively and larger IAAs were managed with percutaneous drainage. Results: A total of 4901 patients had an appendicectomy. Forty-two (0.9%) developed a post-operative IAA. Sixteen (38%) had a percutaneous drainage and 26 (62%) had non-operative management. The percutaneous drainage group had a higher proportion of complicated appendicitis (75%) compared to the non-operative group (42%, P = 0.04). The percutaneous drainage group had a significantly higher leucocytosis (P = 0.01) and C-reactive protein (P = 0.02). All patients managed non-operatively resolved without the need for invasive procedures. In the percutaneous drainage group, six had aspiration alone, nine had a percutaneous drain and one was abandoned. Three required repeat percutaneous drainage and four (25%) required operative drainage. Seven patients (34%) of the percutaneous drainage group had grade II or III complications. Conclusion: This case series study provides support that small (<4 cm) IAA postappendicectomy can be safely and effectively managed non-operatively.

Objectives: Venous thromboembolism (VTE) prophylaxis regimes frequently have a wide variation in application. Nepean acute surgical unit was established in 2006 as a novel model for emergency surgical care. As part of the model's rollout, there were several areas of clinical management targeted for improvement, one being VTE prophylaxis compliance. It was decided all patients older than 18 years treated for a variety of acute surgical conditions within the acute surgical unit should be administered routine VTE prophylaxis with heparin and compression stockings. A novel multifaceted intervention was implemented at the time to achieve this goal. The primary aim of this study was to determine VTE prophylaxis administration rates before and after this intervention.Methods: A before-after study conducted as a retrospective review of medical records of all patients 18 years or older, having an appendicectomy in 3 periods: Before acute surgical unit (ASU)

Acute ischaemia of the glans penis is a rare and serious complication following circumcision. We report the case of a teenage boy with glanular ischaemia shortly after circumcision with dorsal penile nerve block. This was successfully treated with total 11 days of topical 2% nitroglycerin ointment, 14 days of oral pentoxifylline 400 mg three times a day and 3 days of epidural (0.2% ropivocaine). There was marked clinical improvement at 4 days with a few patches of cyanosis remaining. Surgical intervention was not required, and the patient was discharged with follow-up review. At 12 days, there was complete resolution of ischaemia and the glans penis appeared normal. We suggest that oral, topical and epidural regimen of vasodilators and anti-sympathomimetic agents can be used in combination for acute ischaemia of the glans penis.

Background Intra-abdominal abscess (IAA) complicates 2-3% of patients having an appendicectomy. The usual management is prolonged antibiotics and drainage of the IAA. From 2006, our unit chose to use early re-laparoscopy and washout in patients with persistent sepsis following appendicectomy. The aims of this study were to assess the outcomes of early laparoscopic washout in patients with features of persistent intra-abdominal sepsis and compare those with percutaneous drainage and open drainage of post-appendicectomy IAA. Methods A retrospective case note review was performed for all patients having a laparoscopic washout, percutaneous drainage or open drainage following appendicectomy between January 2006 and December 2017. Results During the period, 4901 appendicectomies occurred. Forty-one (0.8%) patients had a laparoscopic washout, 16 (0.3%) had percutaneous drainage, and 6 (0.1%) had an open drainage. The demographics, ASA grade and pathology at initial appendicectomy were similar. The mean time after appendicectomy was significantly shorter for laparoscopic washout (4.1 days vs. 10.1 and 9.0 days, p = \0.003). The mean time for resolution of SIRS was significantly shorter (2.0 days vs. 3.3 and 5.2 days, p \0.02). The morbidity and length of stay were similar. Conclusion Early laparoscopic washout for persistent intra-abdominal sepsis may be an alternative to non-operative management and delayed intervention for IAA and may have better outcomes than either percutaneous drainage or open drainage. A prospective randomised comparison is required to further evaluate the indications and role of early laparoscopic washout post-appendicectomy.