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Background: Patients who are haemodynamically unstable from surgical emergencies require prompt surgical intervention, and delay to surgery may lead to poorer clinical outcomes. The Red Blanket Protocol (RBP) is a communication algorithm intended to facilitate surgery as expediently and safely as possible. By developing a protocol for these channels of communication, RBP may reduce the time to surgical intervention and improve patient outcomes. Our aim was to identify whether patient outcomes, including time to surgery, blood product use and survival were improved by the Red Blanket protocol. Methods: Haemodynamically unstable adults in Middlemore Hospital, Aotearoa New Zealand from 1/1/2014 to 31/12/2015 were compared with RBP patients from 1/4/2017 to 1/4/2020. Time from emergency department (ED) to knife-to-skin (KTS) was compared between the groups. The number of blood products used, LOS and 30-and 90-day survival were also compared between the pre-protocol and RBP groups. Results: Thirty-two patients were identified in the pre-protocol group, and 25 in the RBP group. The median time from ED to KTS reduced from 84 to 70.5 min after the implementation of RBP (P = 0.044). The median number of blood products was 21 pre-protocol and 11.5 in the RBP group (P = 0.102). The median LOS was 8 versus 4 days in the RBP group (P = 0.204). 30-day survival rate was comparable in the two groups (65% versus 60% (P 0.71)). Conclusion: RBP was associated with a shorter time to knife-to-skin for haemodynamically unstable patients. There was no significant difference in clinical outcomes between the two groups. Larger studies are required to assess clinical outcomes of the RBP.

Background: Phyllodes tumour (PT) is a rare breast neoplasm and little is known about its epidemiological risk factors. The literature suggests a higher incidence of PT in Asian patients and other minority ethnic groups. The purpose of this study was to identify whether there was a difference in incidence, grade and age at presentation for patients with PT among minority ethnic groups when compared with European patients in Aotearoa New Zealand (AoNZ). Methods: A retrospective review was conducted across the three District Health Boards (DHBs) in Auckland, Aotearoa New Zealand (AoNZ), from 2008 to 2018 to investigate the relationship between ethnicity and clinical characteristics of PT. Demographic information and histology reports were reviewed to obtain relevant data. The primary outcome measure was ethnicity and the secondary outcome measures were age at presentation, tumour volume and grade. Results: One hundred and fifty-nine patients were included. The total number of non-European patients were 108 (68%). Minority ethnic groups including Pasifika, M aori and MELAA were overrepresented in the patient cohort. Larger tumour volume was significantly correlated with higher tumour grade (p < 0.001). Pasifika patients presented with larger tumours (p 0.05) and at a younger age (p 0.027) when compared with European patients. Conclusion: This study found that patients with PT in AoNZ were significantly overrepresented in Asian, Pasifika and MELAA ethnic groups. Pasifika patients may be at an increased risk of presenting at a younger age with larger, higher grade tumours when compared with European patients. Further research is required to investigate the reasons behind these findings in minority ethnic groups.

Introduction Duodenal web is a rare pathology presenting infrequently in adults. Diagnosis is challenging and definitive management is commonly delayed. We present a case of a patient with a late diagnosis of duodenal web, who underwent laparotomy, intraoperative gastroscopy and surgical removal of the web performed by two general surgeons. Case presentation A 32-year-old woman with a previous diagnosis of irritable bowel syndrome presented with a three day history of abdominal pain, nausea and anorexia, and a one day history of melaena and haematemesis. Investigations including a magnetic resonance enterography, barium swallow study and gastroscopy revealed the diagnosis. The patient underwent laparotomy and excision of duodenal web. Intraoperative gastroscopy assisted with identification of the web's anatomical location. A longitudinal duodenotomy was performed and this was closed in a transverse fashion using the Heineke-Mikulicz technique. Discussion This case reports successful application of intraoperative gastroscopy during laparotomy and duodenotomy. Longitudinal duodenotomy with excision of the web and transverse closure of the duodenum appears to be the best approach. There are no previous publications detailing gastroscopy at the time of laparotomy with duodenal web. This technique may be utilised in appropriate situations to improve operative accuracy. Conclusion Duodenal web is a rare entity in adults, and delayed diagnosis may lead to significant patient morbidity. Incorporating intraoperative endoscopy ensures accurate anatomical visualisation. This technique avoids duodenectomy, organ damage, bypass, or an unnecessarily large incision.

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