Index admission vs elective laparoscopic common bile duct exploration: a district general hospital experience over 6 years.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is relatively a new approach for clearing choledocholithiasis. The aim of this study is to assess the safety of this approach to clearing common bile duct (CBD) stones on an index admission including emergency setting. METHODS: Retrospective data collection and analysis were carried out for 207 consecutive cases of LCBDE performed in Royal Cornwall Hospital over 6 years (2015-2020). Patients were divided into two groups (Index admission vs elective) then both groups compared. RESULTS: A total of 207 cases of LCBDE were performed in our unit during the time period. One hundred twenty-two operations were performed on the index admission and 85 on a subsequent elective list. Mean operative time was 146 ± 64 min in the index admission group and 145 ± 65 min in the elective group (p = 0.913). Length of stay post-operatively was 3.3 ± 6.3 days in the index admission cases and 3.5 ± 4.6 days after elective cases. Successful clearance was achieved at the end of the operation in 116 patients in the index admission group, clearance failed in one case and negative exploration in 5 patients. In the elective group 83 patients had a successful clearance at the end of the operation, and 2 patients has had a negative exploration. Twelve patients (index admission group) and 8 patients of the elective cases required post-operative Endoscopic Retrograde Cholangiopancreatography (ERCP) to manage retained stones, recurrent stones and bile leak (p = 0.921). Three patients required re-operation for post-operative complications in each group. CONCLUSION: Common bile duct exploration in index admission is safe with high success rate if performed by well-trained surgeons with advanced laparoscopic skills.

Idiopathic omental infarction: One for conservative or surgical management?

Idiopathic omental infarction (IOI) is a rare cause of right-sided abdominal pain, mimicking serious surgical pathology. It occurs in <4 in 1000 cases of appendicitis. IOI can be a challenge to diagnose, as features may mimic appendicitis, and therefore in young patients, may only be discovered on laparoscopy. CT features can be diagnostic, but due to its rarity the diagnosis may be unclear. The literature supports both conservative management and surgical management (to expedite symptom resolution). We present a case of IOI and discuss our management and learning from the case. We discuss the utility of CT radiology, conservative management and the benefits of non-resection management, even at laparoscopy.

A randomised trial of post-discharge enteral feeding following surgical resection of an upper gastrointestinal malignancy.

BACKGROUND: Patients undergoing upper gastrointestinal surgery often eat poorly post-operatively, despite dietetic input. A pilot study was conducted to examine the benefit of a 6 week nutritional supplementation via a feeding jejunostomy on fatigue, quality of life and independent living. METHODS: A feeding jejunostomy was placed routinely at oesophagectomy or total gastrectomy for cancer. At discharge, patients were randomised to nutritional supplementation (600 kcal/day) via their feeding jejunostomies or no jejunal supplement. Patients were assessed at discharge and 3, 6, 12 and 24 weeks following discharge for fatigue (MFI-20), quality of life (QLQ-OES18), health economic analysis (EQ5D) as well as completing a two-day dietary diary. RESULTS: 44 patients (M:F, 29:15) were randomised, 23 received jejunal supplements. There were no differences between the groups. Percentage of calculated energy requirement received was greater in the supplemented group at weeks 3 and 6 (p < 0.0001). Oral energy intake was not different between the groups at any time period. After hospital discharge, there were no differences in MFI-20, EQ5D and QLQ-OES18 scores at any time point. From hospital discharge fatigue improved and plateaued at 6 weeks (p < 0.05 for both groups), independence at 12 weeks (p < 0.05 for both groups). No improvement was seen in quality of life until 24 weeks in the active group alone (p < 0.02) and not at all in the control group. CONCLUSIONS: Addition of jejunal feeding is effective in providing patients with an adequate energy intake. Increased energy intake however, produced no obvious improvement in measures of fatigue, quality of life or health economics.