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Background: Full short-term effects of regional anesthesia in breast surgery is not well known. We aimed to assess any differences in the short-term outcomes of regional block and local anesthetic (LA) wound inltration in breast surgery. Materials and methods: A prospective non-randomized observational study of elective breast surgical procedures between 01/06/2018 and 28/02/3019 was performed at a district general hospital in the North-West England. Data comprised of patientand procedure-specic demographics, relevant health conditions, pain scale, blood pressure, analgesia requirement, Postoperative Nausea and Vomiting (PONV) score and Length of stay (LoS). Operations were classed as minor/ moderate and major. Regional anesthesia (RA) comprised of paravertebral, intercostal, pectoral and serratus blocks. Results: A total of 143 events (regional anesthesia, n=58; LA wound inltration, n=85) were analysed. Reduced pain score and longer anesthetic time were noted in the regional anesthesia group (p

Background: Despite specialisation, a small subset of general surgeons continues to provide breast services in the United Kingdom. We aimed to assess breast cancer i) local recurrence rate against the national benchmarks of

Papillary lesions of breast represent a range of lesions. Intraductal papilloma and its association with nipple discharge are well known. However, multiple papillomatosis has quite distinct characteristics and decision making can be somewhat challenging. We report a case of multiple papillomatosis in association with ductal carcinoma in situ (DCIS). Patient opted for ipsilateral mastectomy and prophylactic mastectomy of contralateral breast. Her decision of having prophylactic mastectomy was vindicated by presence of incidental DCIS in the contralateral breast. To our knowledge, this is the first reported case of multiple papillomatosis with DCIS of breast, along with incidental synchronous papillomatosis of contralateral breast with DCIS. The case illustrates few distinct features of multiple papillomatosis of breast and exemplifies how a patient's choice is so paramount in decision making process. Patients should be fully informed of the treatment options of the condition, and their wishes should be fully taken into account while making the final decision.

Objective: Carcinoid tumour of appendix is an uncommon condition that can potentially give rise to a variation in management. We aimed to assess the occurrence and mode of presentation of carcinoid tumour of appendix, and any variation of its management. Methods: All appendicectomies that took place at North Middlesex University Hospital, London between 1995 and 2005 were considered for study. Results: A total of 1941 appendicectomies took place. Sixteen (0.82%) patients had carcinoid tumours. The mean age of patients with carcinoid tumour (41.8 years) was significantly higher than those with non-carcinoid pathology (27.7 years) (p=0.001). The incidence of female patients was higher than the male amongst the carcinoid tumour group (female/male ratio 2.2). None of the carcinoid tumours were identified at operation. Eight patients as well as their general practitioners (53.3%) were unaware of the diagnosis. Multidisciplinary team involvement or specialty referral took place in three cases (20%). One patient (6.6%) required right hemicolectomy. Three patients (20%) were followed-up in inconsistent manner. Conclusions: Carcinoid tumour of the appendix remains an incidental diagnosis. Patients with carcinoids were significantly older than non-carcinoid conditions. There was a trend of increased occurrence of carcinoids amongst the females. Re-operation rate was low. There was a wide variation in involving the multidisciplinary team, conveying the diagnosis to patients as well as their general practitioners, and follow-ups. This can be perceived as a missed opportunity of selective screening of synchronous and metachronous lesions, raises clinical governance issues and has medicolegal implications.

INTRODUCTIONTriple assessment of a suspicious breast lesion may not always provide a definite diagnosis. We report a case of epidermoid cyst of breast, which caused diagnostic dilemma in spite of a thorough triple assessment and entailed mastectomy.PRESENTATION OF CASEA 69-year-old woman presented with a large painful retroareolar left breast mass. Clinical examination, ultrasound and mammography were highly suspicious of malignancy. However, core biopsy suggested a benign lesion. Due to size of the lesion and diagnostic uncertainty, various options were discussed with the patient. She opted for a simple mastectomy. The histology confirmed a large epidermoid cyst.DISCUSSIONIt is rare for an epidermoid cyst to present as such an advanced lesion, mimicking carcinoma. Excision of such a large retroareolar ‘benign’ lesion, however, may sometime entail mastectomy. This is the first reported case of an epidermoid cyst of breast necessitating mastectomy.CONCLUSIONDiagnostic dilemma while dealing with a suspected breast cancer is not rare. Involvement of multidisciplinary team as well as patient is important in the decision-making. The report illustrates a rare presentation of a deep seated large epidermoid cyst of breast, which mimicked carcinoma, caused diagnostic confusion and entailed mastectomy. We strongly advocate the option of breast reconstruction in such cases.

Background Intravenous cannulation is a very common procedure. Venous aneurysm secondary to peripheral intravenous cannulation is extremely rare. Moreover, venous aneurysm can mimic other conditions and may confuse the issue. Case presentation We describe a case of a 45-year-old woman who was referred with the diagnosis of varicose vein of right arm. A history of intravenous cannulation at the same site was noted that raised suspicion. The swelling was compressible and turned out to be a venous aneurysm. The lesion was completely excised. Postoperative recovery was uneventful. Histology findings were in conformity with the preoperative diagnosis. Conclusion Caution should be exercised in diagnosing varicose vein at a site that bears a history of intravenous cannulation. The case also raises an important issue regarding consent. Should patients undergoing peripheral intravenous cannulation be warned of this rare complication?

Postoperative retention of a foreign body is an infrequent but well-recognized complication. A case of a retained swab in the abdominal cavity ("gossypiboma") has been reported. In view of the high morbidity (50%) and mortality (10%) that may result from potential complications, as well as underlying medico-legal implications, it is important to ensure that every effort is made to prevent such occurrences. Presentation of gossypiboma may vary and can be caused by pseudotumoral, occlusive, or septic syndrome. Ultrasonography that shows a "hyper-reflective mass with hypoechoic rim along with a strong posterior shadow" and computed tomography that reveals "a whirl-like spongiform pattern in a hypodense mass with a thick peripheral rim" are considered the mainstay of investigations. These findings, along with a high index of suspicion, can help make a preoperative diagnosis.

Background Telemedicine is a new way of delivering health care to people, particularly in remote areas. The UK has experienced a surge of telematic projects in recent years. However, there is little information available in the literature regarding the past and present of telemedicine in the UK. Objectives To evaluate the state of telemedicine in the UK. Methods All the projects that took place in UK since 1991 were considered for the study and evaluated according to the population and area served. Results A total of 216 projects were identified. The number of projects was highest in England (172). Emergency medicine, medical specialties, and educational projects received most consideration (9.7% each). With the exception of Wales, the number of projects increased steadily with time. The projects, when correlated in accordance with the area (per 10 000 sq km) and population (per million), were found to be highest in England (49.5%) and Northern Ireland (36.2%) respectively. No dedicated educational project took place in Scotland, Northern Ireland, and Wales. Conclusions The UK embraced telemedicine in the early 1990s and the overall growth had been steady. Scotland, in spite of being the most likely beneficiary in UK, has lagged behind in telemedicine schemes and merits more projects. The issue of tele-education needs urgent review. Multisite trials and a combined approach involving the government, health professionals, technologists, and patients’ representatives would facilitate such developments and help widen the application of telemedicine.

Objectives The Department of Health had recently introduced guidelines so that all suspected colorectal cancer patients could be seen by a specialist within two weeks of referral by their general practitioners. The usefulness and practicality of such a decision had been questioned. The aims of this study were to measure the compliance to the guidelines and evaluate the effectiveness of such referrals. Methods All patients who were referred to the rapid access colorectal clinic between August 2000 and July 2001 were included. Settings Darlington Memorial Hospital and Bishop Auckland General Hospital, both under South Durham Health Care Trust, were considered for the study. Measures Date of referral, referring practitioner, time of appointment, reasons for referral, and diagnosis. Results A total of 239 referrals were made; 96.2% of patients were given appointments within two weeks. Rectal bleed was the commonest (32%) cause for referral. Diverticular disease was the most frequent (29%) condition diagnosed. Altogether 97.4% of referrals were incomplete and 37.6% did not comply with the guidelines. Twenty one colorectal cancers (8.9%) were diagnosed. The early cancer detection rate was 4.6%. Conclusions This audit showed that compliance to the guidelines was associated with a higher cancer detection rate. The majority of patients received appointments within two weeks. Contrary to some speculations, the number of referrals was not limitless. However a high number of referrals failed to adhere to the guidelines. The cancer (particularly early cancer) detection rate was disappointingly low. This does not reflect an efficient system of referral and potential benefits to patients remain questionable.

Introduction Involved margins in breast-conserving surgery (BCS) are associated with increased risk of local recurrence. In our institution, it is our practice to remove extra adjacent margins of tissue at the time of primary operation if the surgeon feels that tumour excision is incomplete. The aim of this study was to determine the proportion of necessary versus unnecessary intra-operative extra margin excisions and to determine whether there is any patient or pathological factors associated with making a correct decision. Methods Retrospective study of patient records and pathology reports, for 100 consecutive patients undergoing BCS for primary breast cancer at our institution, from 2011-2012. Statistical analysis was performed using Student’s t-test, chi-squared test and a logistic regression model. Results 66% of all patients had extra tissue removed for suspected involved or close margins. The decision to take extra tissue was correct in 48%. As a result, further surgery was prevented in 53% of these patients. Appropriate extra margin excision was significantly associated with younger patient age (P Conclusions Removing the entire tumour with adequate margins in BCS prevents subjecting a patient to further surgery. Conversely, unnecessarily removing uninvolved extra tissue at primary operation in an attempt to prevent re-operation, may impact negatively on breast cosmesis and increases the workload for the Pathologist. This study suggests that older patients, those with small tumours and invasive as opposed to in situ disease are more likely to have extra margins removed unnecessarily. Larger scale studies may help to clarify how we can select patients more accurately for intra-operative margin excision. Disclosure All authors have declared no conflicts of interest.

Objective To determine the identification and the percentage of the false negative of the sentinel nodes in patients with early breast cancer Hospital La Linea, during the period 2007 to 2010. Methods We collect fifty patients with early breast cancer, without clinical and ultrasonographic involvement of axillary nodes, from November 2007 to September 2010. We use the vital dye in the first twenty patients, and the combined technique with vital dye and albumin labeled with technetium 99 in the other thirty patients. The site of injection for patients who use blue dye was the subdermal near to the tumor, and to the patients who use the technetium was the periareolar technique. The sentinel node biopsy was examined during the surgery. The sentinel node was cut through its long axis and then with fine cuts of 250 microns, with freezing technique. The axillary dissection was completed in the first seventeen patients, and in the remaining patients we performed total axillary dissection if the sentinel node was positive for metastasis. Results Sentinel nodes were identified in 49 of 50 patients (98%), procedures. The only case where we did not identify the sentinel node was a patient in the combined technique. The percentage of nodes identified in the patients with vital dye was one sentinel node, and in the patients who use technetium the percentage was two sentinel nodes. The false negative rate was 8% (4 patients), in three of them we found a micrometastasis in the final examination, in the other one we found a macrometastasis. This cases of false negative in the sentinel node biopsy occurred at the beginning of the study. Pathologists acquired a learning curve for sentinel node examination, and practiced subsequently fine cuts in the intraoperative examination of the sentinel node. Conclusion This experience indicates that intraoperative examination of sentinel node biopsy is crucial for staging of the axilla. The rate of identification of sentinel node is excellent and with the use of the technetium the technique is more accurate. The improvement in the learning curve about the intraoperative examination of the sentinel node biopsy has decreased our rates of false negatives. Disclosure All authors have declared no conflicts of interest.

s / International Journal of Surgery 10 (2012) S1–S52 S15 ABSTRACTS 1127: INTRA-OPERATIVE RE-EXCISION OF MARGINS IN BREASTCONSERVING SURGERY: HOW WELL ARE WE ABLE TO JUDGE TUMOUR PROXIMITY? Lorna Cook, Debasish Debnath, Zoe Lin, Raouf Daoud, Isabella Karat, Ian Laidlaw. Frimley Park Hospital, Frimley, UK Introduction: In breast-conserving surgery (BCS), specimen margin involvement with tumour often necessitates re-operation. For this reason, extra margins are often taken at the time of primary operation. The aim of this study was to determine how often such re-excisions are appropriate. Methods: The records of 100 consecutive patients undergoing BCS for cancer during 2011 were analysed. Data was collected on demographics, tumours characteristics, surgery performed and final histology. Results: All 100 patients were female, median age 56 years (range 33-83 years). 66% had intra-operative re-excision of margins. In 26/66 (40%), re-excision was the correct decision. 25 of the 34 patients who had no extramargins taken at all were managed appropriately with the remaining 9 patients having close/positive margins. Unnecessary re-excisions were performed in 40/66 patients. The correct intraoperative decision was therefore made in 51% of patients. Conclusion: The decision regarding intra-operative margin re-excision was appropriate in just over half of all cases and a second operation was avoided in 26%. However, in order to preserve as much uninvolved breast tissue as possible, further work should be done on methods to improve accuracy and to determine whether there are any patient, radiological or pathological predictors to guide intra-operative re-excision. 1181: FACTORS PREDICTING POSITIVE MARGIN STATUS IN BREAST CANCER PATIENTS UNDERGOING BREAST CONSERVING SURGERY Euan Harris , Andrew Lee . University of Dundee, Dundee, Tayside, UK; Abertawe Bro Morgannwg University Healthboard, Swansea, West

It was another busy admission day. I was working as a surgical senior house officer in CalcuttaMedical College and was part of an eight member team, coping with the usual 30 or so admissions. It was the middle of the night when I saw a 9 year old boy who had just been brought to us by his father. The boy seemed to have developed generalised peritonitis and was not looking good. “Why did you bring him so late?” I asked rather abruptly. The boy's father, a softly spoken man, tried to explain …

Background Blue rubber bleb naevus syndrome (BRBNS), is an uncommon condition characterised by cavernous haemangiomas of skin and gastrointestinal tract. The most common complication of this syndrome is gastrointestinal bleeding. Intussusception of bowel, although a known complication, has rarely been reported. Case presentation We report the case of a 37-year-old man who presented with multiple intussusceptions of small bowel. He required an urgent laparotomy and bowel resections. He suffered from BRBNS. This is the first reported case of multiple synchronous intussusceptions affecting both jejunum and ileum, secondary to haemangiomas occurring in an adult with BRBNS. The underlying conditions of acute abdomen in patients with BRBNS may include intramural haemorrhage, infarction, volvulus or intussusception of bowel. Treatment options include pharmacological manipulation, bowel resection, and interventions such as sclerotherapy, angiographic embolisation, endoscopic ligation, electrocautery and laser photocoagulation for visceral lesions. Conclusion A high index of suspicion is required whilst dealing with acute abdomen in patients with BRBNS. Clinical trials may provide some answers as to the preference of treatment in individual cases, as the current level of evidence does not offer a clear choice of optimal treatment.