'Hot gall bladder service' by emergency general surgeons: Is this safe and feasible?

BACKGROUND: Despite NICE/AUGIS recommendations, the practice of early laparoscopic cholecystectomy (ELC) has been particularly poor in the UK offered only by 11%-20% surgeons as compared to 33%-67% internationally, possibly due to financial constraints, logistical difficulties and shortage of expertise, thus, reflecting the varied provision of emergency general surgical care. To assess whether emergency general surgeons (EGS) could provide a 'Hot Gall Bladder Service' (HGS) with an acceptable outcome. PATIENTS AND METHODS: This was a prospective HGS observational study that was protocol driven with strict inclusion/exclusion criteria and secure online data collection in a district general hospital between July 2018 and June 2019. A weekly dedicated theatre slot was allocated for this list. RESULTS: Of the 143 referred for HGS, 86 (60%) underwent ELC which included 60 (70%) women. Age, ASA and body mass index was 54* (18-85) years, II* (I-III) and 27* (20-54), respectively. 86 included 46 (53%), 19 (22%), 19 (22%) and 2 (3%) patients presenting with acute calculus cholecystitis, gallstone pancreatitis, biliary colic, and acalculus cholecystitis, respectively. 85 (99%) underwent LC with a single conversion. Grade of surgical difficulty, duration of surgery and post-operative stay was 2* (1-4) 68* (30-240) min and 0* (0-13) day, respectively. Eight (9%) required senior surgical input with no intra-operative complications and 2 (2%) 30-day readmissions. One was post-operative subhepatic collection that recovered uneventfully and the second was pancreatitis, imaging was clear requiring no further intervention. CONCLUSION: In the current climate of NHS financial crunch, COVID pandemic and significant pressure on inpatient beds: Safe and cost-effective HGS can be provided by the EGS with input from upper GI/HPB surgeons (when required) with acceptable morbidity and a satisfactory outcome. *Median.

Dynamical analysis of novel COVID-19 epidemic model with non-monotonic incidence function.

In this study, we developed and analyzed a mathematical model for explaining the transmission dynamics of COVID-19 in India. The proposed SI u I k R model is a modified version of the existing SIR model. Our model divides the infected class I of SIR model into two classes: I u (unknown infected class) and I k (known infected class). In addition, we consider R a recovered and reserved class, where susceptible people can hide them due to fear of the COVID-19 infection. Furthermore, a non-monotonic incidence function is deemed to incorporate the psychological effect of the novel coronavirus diseases on India's community. The epidemiological threshold parameter, namely the basic reproduction number, has been formulated and presented graphically. With this threshold parameter, the local and global stability analysis of the disease-free equilibrium and the endemic proportion equilibrium based on disease persistence have been analyzed. Lastly, numerical results of long-run prediction using MATLAB show that the fate of this situation is very harmful if people are not following the guidelines issued by the authority.

Evaluation of a Novel Laparoscopic Cholecystectomy Curriculum With the Use of Animal Models and Live Operating.

BACKGROUND: Despite wide recognition of the benefits of simulation training, there is no established model for the teaching of laparoscopic cholecystectomy. The authors developed a replicable, intensive 2-day proficiency-based curriculum, to include simulation and live operating, designed to be practical to both attend and organize. The primary objective of this study was to evaluate this curriculum for improved procedural confidence, measured by participant self-evaluation. Secondary outcomes were objective improvement in technical skills in accordance with the Objective Structured Assessment of Technical Skills (OSATS) scale and trainee self-assessment scores. METHODS: The course consisted of lectures, operating on a sheep hepatobiliary model through a laparoscopic box trainer, and live operating on female patient volunteers. It was attended by eight junior registrars. Precourse data collated included demographic information, experience, and procedural confidence scores using a visual analog scale. Performance on an animal model and live patient was assessed by experts using the OSATS score. Procedural confidence was re-evaluated after each task, as well as self-assessment of speed, accuracy, and overall performance. RESULTS: Procedural confidence scores improved by a mean of 12% (P < 0.001). All trainees demonstrated sustained objective improvement in technical skills (P < 0.001). The overall mean OSATS score increased by 18%. Significant improvement was observed after performing the procedure on an animal model (P < 0.001); however, no further significant improvement was observed with live operating. No significant difference was found on trainee self-assessment scores, in any category. CONCLUSIONS: The study describes a successful curriculum model for the teaching of laparoscopic cholecystectomy, to include procedural and technical skill acquisition, in addition to the refinement and development of procedural confidence. Importantly, this was carried out in a safe environment with direct transferability to the operating theater.

Quality of Life Using the Carolinas Comfort Scale for Laparoscopic Incisional Hernia Repair: A 12-Year Experience in a Retrospective Observational Study.

Background: Incisional hernias are a common complication of abdominal surgery (10%-35%) and are notorious for recurrence. Laparoscopic incisional hernia repair (LIHR) was first performed in 1991 and is reported to have lower recurrence rates. Few studies to date have assessed quality of life (QoL) resulting from a repair. The purpose of this observational study was to present a 12-year experience performing LIHR, with a focus on the impact on QoL. Methods: All adult patients undergoing elective LIHR performed by a single surgeon, whether primary or recurrent, were included in the study. The data collection was performed prospectively between 2007 and 2019 to include demographic details, intraoperative findings and postoperative short- and longterm outcomes. We used the Carolinas Comfort Scale (CCS) to assess QoL following surgery. Results: Ninety-seven patients were included in the study. Patients had a median age of 57 years, body mass index of 32 kg/m2, 35% were male and 88% were American Society of Anesthesiologists (ASA) class I or II. The duration of surgery was 90 minutes*. Nineteen percent of patients had complications during or after surgery; 1 (1%) had recurrence. length of stay in hospital was 1* (0-12) days and long-term follow-up period was 42* (2-140) months after surgery. Time of return to daily activities was 14* (1-365) days. Eighty-six percent of patients rated their experience undergoing LIHR as "Excellent" or "Good". Regarding QoL after surgery, scores on the CCS indicated that 82% of patients had minimal or no discomfort following surgery, and only 1% had significant discomfort. *Presented as median. Conclusions: The technique for LIHR displayed in this study is safe and effective. There was an acceptable rate of complications, with a low recurrence rate. Patients were highly satisfied and had a good QoL after the procedure. Research Registry ID Number: researchregistry6056.

Laparoscopic modified subtotal cholecystectomy for difficult gall bladders: A single-centre experience.

AIM: Laparoscopic cholecystectomy (LC) is considered the 'gold standard' intervention for gall bladder (GB) diseases. However, to avoid serious biliovascular injury, conversion is advocated for distorted anatomy at the Calot's triangle. The aim is to find out whether our technique of laparoscopic modified subtotal cholecystectomy (LMSC) is suitable, with an acceptable morbidity and outcome. PATIENTS AND METHODS: A retrospective analysis of prospectively collected data of 993 consecutive patients who underwent cholecystectomy was done at a large District General Hospital (DGH) between August 2007 and January 2015. The data are as follows: Patient's demographics, operative details including intra- and postoperative complications, postoperative stay including follow-up that was recorded and analysed. RESULTS: A total of 993 patients (263 males and 730 female) were included. The median age was 52*(18-89) years. Out of the 993 patients, 979 (98.5%) and 14 (1.5%) were listed for laparoscopic and open cholecystectomy, respectively. Of the 979 patients, 902 (92%) and 64 (6.5%) patients underwent LC ± on-table cholangiography (OTC) and LMSC ± OTC, respectively, with a median stay of 1* (0-15) days. Of the 64 patients, 55 (86%) had dense adhesions, 22 (34%) had acute inflammation, 19 (30%) had severe contraction, 12 (19%) had empyema, 7 (11%) had Mirizzi's syndrome and 2 (3%) had gangrenous GB. The mean operative time was 120 × (50-180) min [Table 1]. Six (12%) patients required endoscopic retrograde cholangiopancreatography (ERCP) postoperatively, and there were four (6%) readmissions in a follow-up of 30 × (8-76) months. The remaining 13 (1.3%) patients underwent laparoscopic cholecystectomy converted to an open cholecystectomy. The median stay for open/laparoscopic cholecystectomy converted to open cholecystectomy was 5 × (1-12) days. CONCLUSION: Our technique of LMSC avoided conversion in 6.5% patients and believe that it is feasible and safe for difficult GBs with a positive outcome.

Black necrotic oesophagus following the use of biodegradable stent for benign oesophageal stricture.

Biodegradable stents are increasingly being used for benign oesophageal conditions that include refractory strictures and perforations. Acute oesophageal necrosis has been reported with various other conditions but none due to the insertion of biodegradable stents. A 58-year-old male presented as an acute emergency in severe haemodynamic shock. Investigations confirmed an oesophageal perforation. He underwent an emergency surgical intervention that identified extensive necrosis of the oesophagus requiring thoracic oesophagectomy, cervical oesophagostomy and a feeding jejunostomy as a damage control procedure. This was followed a month later, by successful reconstruction using a gastric conduit. This is the first reported case of a necrosis of the oesophagus following insertion of two biodegradable stents for a benign oesophageal stricture and highlights this rare but very serious life-threatening complication.

The general surgical care practitioner improves surgical outpatient streamlining and the delivery of elective surgical care.

The feasibility of implementing a surgical care practitioner (SCP) role for the delivery of secondary care within the general surgery department of a district general hospital was evaluated. Streamlining patients into an SCP-led 'one-stop' gallbladder clinic for symptomatic uncomplicated cholelithiasis led to a reduction in follow-up clinic workload for major elective laparoscopic work and more appropriate triaging of primary care referrals. Each of these improvements contributed to an efficient service model.

One-stop cholecystectomy clinic: an application of lean thinking--can it improve the outcomes?

Lean thinking principles were utilised to set up 'One-stop cholecystectomy clinics' at which patients underwent the surgical and the preoperative assessment during the same visit. The main aims were to reduce the number of patient hospital visits, preoperative admissions and the waiting time to surgery. The results showed a significant reduction in the number of patient visits as well as the waiting time to surgery thus highlighting that patientcare can be improved by good team working and lean management.

Acute Chest Presentation following a Laparoscopic Nissen Fundoplication.

We describe a case of an acute paraoesophageal hernia in the early post-operative period following a laparoscopic Nissen fundoplication. Patient developed intraoperative tension pneumothorax requiring an immediate chest drain and subsequently needed respiratory support of a continuous positive airway pressure (CPAP) ventilation. A short discussion of this rare but deleterious complication and the difficulty of making a prompt diagnosis are included as delayed revision surgery can be technically challenging with a poor outcome.

Giant mesenteric lymphangioma: a rare cause of a life-threatening complication in an adult.

Mesenteric cyst lymphangiomas (MCLs) are rare benign tumours of unknown aetiology seen mostly in children. Clinical presentation can be diverse ranging from incidental abdominal cysts to an acute abdomen. A 24-year-old previously fit and healthy young man presented with a 2-week history of cramping, central abdominal pain and vomiting requiring acute hospital admission. He was a diagnostic conundrum despite extensive preoperative investigations. Recurring symptoms required urgent surgical exploration, resection and histological confirmation with a successful outcome. We review the literature and present here this rare case in an adult of MCL that has the potential to grow, invade and develop major life-threatening complications.

An unusual presentation of a Gastrointestinal stromal tumour (GIST).

BACKGROUND: Gastrointestinal stromal tumours (GIST) are rare tumours, now more frequently identified with the new imaging modalities like computerised tomography (CT) and magnetic resonance imaging (MRI). We report a rare presentation of a GIST with an unusual diagnostic workup in a multidisciplinary setting leading to a definitive diagnosis and treatment. CASE PRESENTATION: A 55-year-old lady was admitted under the general surgeons, with 3-day history of abdominal pain, three-week history of loss of appetite and weight. The patient was sequentially investigated with ultrasonography, computerised tomography and finally selective angiogram in a multidisciplinary setting. The selective angiogram showed a GIST with intratumour bleed, leading to successful surgical excision and being recurrence free at 22 month follow up. CONCLUSION: Clinical presentation of these tumours can be varied and gastrointestinal bleeding is the commonest mode described in the literature. The clinician needs to be aware of much more rare presentations of the GIST including an intra tumour bleed. A structured multidisciplinary approach would lead to successful diagnosis and treatment.

Gastrointestinal stromal tumors (GIST) and laparoscopic resection.

AIM: To review management, outcome and the lessons learnt from a laparoscopic approach to GISTs. METHOD: All cases of GIST presenting to the upper GI MDT between 2000 and 2006 were reviewed. Presentation, preoperative investigations, management and follow-up were recorded. Surgical resection using a laparoscopic approach, where feasible was the preferred management. RESULTS: 25 consecutive patients that included one oesophageal, three oesophago-gastric, 19 gastric and two smallbowel GISTs were treated between 2000 and 2006. There were 11 male and 14 females with a median age of 68 (25-90) years. Clinical presentation was: gastrointestinal bleed 15, pain 6, dysphagia 2, anaemia 3, weight loss 1, and asymptomatic 2. Out of 25, four were inoperable and treated with imatinib. 17 laparoscopic (including 2 conversions) and four open procedures were performed. Two (both GISTs close to the oesophago-gastric junction) required reoperation due to surgical-related morbidity. Of the 25, five were high-, 11 intermediate- and nine low-risk GISTs. No recurrences in follow-up (median 24, range 6-75) months was observed. CONCLUSION: GISTs can safely and effectively be treated laparoscopically although larger GISTs in difficult anatomical locations may require open surgery.

Value of fentanyl in flexible sigmoidoscopy.

Studies have recorded significant patient discomfort during flexible sigmoidoscopy when it is performed without sedation/analgesia. This study observed whether a single dose of 50 mcg intravenous fentanyl reduces pain, improving compliance, acceptability, and completion rates. In a prospective study, 109 consecutive patients were offered the option of 50 mcg intravenous fentanyl or no analgesia. Patient's pre-procedure expectations, objective pain scores, and willingness to undergo a subsequent procedure using the same technique were recorded. Endoscopist recorded the success, complications, and objective pain scores for each patient. Of the 46 patients (42%) choosing fentanyl, 9 (20%) experienced moderate/severe pain as against 26 (41%) of the 63 patients (58%) opting for no analgesia (p < 0.05). Further, 52% receiving fentanyl had a significantly better experience compared to their pre-procedure expectations as against 33% who received no analgesia (p < 0.05). No patient receiving fentanyl expressed unwillingness to undergo the procedure again using the same technique, whereas 16 (25%) of those receiving no analgesia indicated they would not (p < 0.01). Endoscopists recorded moderate/severe pain in 13 patients (12%), whereas 35 patients (32%) recorded moderate/severe pain (p < 0.001). Analgesia for endoscopy should involve patient choice. However, a single dose of 50 mcg fentanyl reduced patient discomfort and improved satisfaction. It appeared safe and likely to improve patient compliance and acceptability for flexible sigmoidoscopy.