30-day Morbidity and Mortality after Cholecystectomy for Benign Gallbladder Disease (AMBROSE): A Prospective, International Collaborative Cohort Study.

OBJECTIVE: This study aimed to assess 30-day morbidity and mortality rates following cholecystectomy for benign gallbladder disease and identify the factors associated with complications. SUMMARY BACKGROUND DATA: Although cholecystectomy is common for benign gallbladder disease, there is a gap in the knowledge of the current practice and variations on a global level. METHODS: A prospective, international, observational collaborative cohort study of consecutive patients undergoing cholecystectomy for benign gallbladder disease from participating hospitals in 57 countries between January 1 and June 30, 2022, was performed. Univariate and multivariate logistic regression models were used to identify preoperative and operative variables associated with 30-day postoperative outcomes. RESULTS: Data of 21,706 surgical patients from 57 countries were included in the analysis. A total of 10,821 (49.9%), 4,263 (19.7%), and 6,622 (30.5%) cholecystectomies were performed in the elective, emergency, and delayed settings, respectively. Thirty-day postoperative complications were observed in 1,738 patients (8.0%), including mortality in 83 patients (0.4%). Bile leaks (Strasberg grade A) were reported in 278 (1.3%) patients and severe bile duct injuries (Strasberg grades B-E) were reported in 48 (0.2%) patients. Patient age, ASA physical status class, surgical setting, operative approach and Nassar operative difficulty grade were identified as the five predictors demonstrating the highest relative importance in predicting postoperative complications. CONCLUSION: This multinational observational collaborative cohort study presents a comprehensive report of the current practices and outcomes of cholecystectomy for benign gallbladder disease. Ongoing global collaborative evaluations and initiatives are needed to promote quality assurance and improvement in cholecystectomy.

Global 30-day morbidity and mortality of surgery for perforated peptic ulcer: GRACE study.

BACKGROUND: There is little international data on morbidity and mortality of surgery for perforated peptic ulcer (PPU). This study aimed to understand the global 30-day morbidity and mortality of patients undergoing surgery for PPU and to identify variables associated with these. METHOD: We performed an international study of adults (≥ 18 years) who underwent surgery for PPU from 1st January 2022 to 30th June 2022. Patients who were treated conservatively or had an underlying gastric cancer were excluded. Patients were divided into subgroups according to age (≤ 50 and > 50 years) and time from onset of symptoms to hospital presentation (≤ 24 and > 24 h). Univariate and Multivariate analyses were carried out to identify factors associated with higher 30-day morbidity and mortality. RESULTS:  1874 patients from 159 centres across 52 countries were included. 78.3% (n = 1467) of the patients were males and the median (IQR) age was 49 years (25). Thirty-day morbidity and mortality were 48.5% (n = 910) and 9.3% (n = 174) respectively. Median (IQR) hospital stay was 7 (5) days. Open surgery was performed in 80% (n = 1505) of the cohort. Age > 50 years [(OR = 1.7, 95% CI 1.4-2), (OR = 4.7, 95% CI 3.1-7.6)], female gender [(OR = 1.8, 95% CI 1.4-2.3), (OR = 1.9, 95% CI 1.3-2.9)], shock on admission [(OR = 2.1, 95% CI 1.7-2.7), (OR = 4.8, 95% CI 3.2-7.1)], and acute kidney injury [(OR = 2.5, 95% CI 1.9-3.2), (OR = 3.9), 95% CI 2.7-5.6)] were associated with both 30-day morbidity and mortality. Delayed presentation was associated with 30-day morbidity [OR = 1.3, 95% CI 1.1-1.6], but not mortality. CONCLUSIONS: This study showed that surgery for PPU was associated with high 30-day morbidity and mortality rate. Age, female gender, and signs of shock at presentation were associated with both 30-day morbidity and mortality.

The First Modified Delphi Consensus-Building Exercise on Surgical Ward Rounds in the United Kingdom National Health Service.

BACKGROUND: The ward round is an integral part of everyday surgical practice. It is a complex clinical activity that requires both sound clinical management and communication skills. This study reports the results of a consensus-building exercise on the common aspects of the general surgical ward rounds. METHODS: The consensus-building committee involving a range of stakeholders from 16 United Kingdom (UK) National Health Service trusts took part in this consensus exercise. The members discussed and suggested a series of statements concerning surgical ward round. An agreement of ≥ 70% among members was regarded as a consensus. RESULTS: Thirty-two members voted on 60 statements. There was a consensus on fifty-nine statements after the first round of voting, and one statement was modified before it reached consensus in the second round. The statements covered nine sections: a preparation phase, team allocation, multidisciplinary approach to the ward round, structure of the round, teaching considerations, confidentiality and privacy, documentation, post-round arrangements, and weekend round. There was a consensus on spending time to prepare for the round, a consultant-led round, involvement of the nursing staff, an MDT round at the beginning and end of the week, a minimum of 5 min allocated to each patient, utilisation of a round checklist, afternoon virtual round, and a clear handover and plan for the weekend. CONCLUSION: The consensus committee achieved agreement on several aspects concerning the surgical ward rounds in the UK NHS. This should help improve the care of surgical patients in the UK.

Laparoscopic subtotal cholecystectomy; change in practice over a 10-year period.

BACKGROUND: Laparoscopic subtotal cholecystectomy is a recognised safe, alternative strategy when a critical view of safety cannot be obtained. This study audits the change in practice at a District General Hospital following the adoption of subtotal cholecystectomy in 2013. METHODS: Retrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic subtotal and laparoscopic converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay. RESULTS: There were 4217 cases: 1381 in Group A (pre-adoption of subtotal cholecystectomy 2009-2012), and 2836 in Group B (post-adoption of subtotal cholecystectomy 2013-2019). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.4% vs. 92.8%, p < 0.001). In the subtotal group (n = 114, 14 (12.3%) patients had bile leak, 6 (5.3%) underwent re-laparoscopy, and median length of stay was 2 days. CONCLUSION: Laparoscopic subtotal cholecystectomy appears to be an acceptable alternative technique at this centre, reducing the rate of open conversion and length of stay, with a low reintervention rate for bile leak.

Does hiatal repair affect gastroesophageal reflux symptoms in patients undergoing laparoscopic sleeve gastrectomy?

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has gained popularity as a treatment of choice for morbid obesity and associated comorbidities. There has been a concern about new onset or worsening of gastroesophageal reflux (GERD) following LSG. OBJECTIVE: The objective of the study was to evaluate the effect of surgically treating hiatal weakness on GERD symptoms in patients undergoing LSG. SETTING: Single tertiary referral institution, Sydney, Australia. METHODS: A prospective observational cohort study was conducted with consecutive patients undergoing LSG. Hiatal findings, patient demographics, medications and reflux score were recorded prospectively. Patients were followed up post-operatively for a minimum of 12 months and assessed using GERD-HRQL score to quantify reflux symptoms. RESULTS: Data from 100 patients with a minimum of 1-year follow-up were analysed. Mean follow-up was 18.9 months. Overall, GERD-HRQL improved from mean 4.5 ± 5.8 pre-operatively to 0.76 ± 1.5 after 18.9 months (p = 0.0001). For those with pre-operative reflux, GERD-HRQL improved from mean (SD) 8.43 ± 6.26 pre-operatively to 0.94 ± 1.55 (p = 0.0001). All the nine patients with troublesome daily reflux significantly improved. For those without pre-operative reflux, GERD-HRQL improved from 0.88 ± 1.37 to 0.47 ± 1.25 (p-ns) post-operatively. On multivariate analysis, higher pre-operative reflux and dysphagia/bloat scores, younger age and lower percentage excess weight loss after 18.9 months were associated with GERD-HRQL improvement. CONCLUSION: In the medium term, GERD-HRQL improves following sleeve gastrectomy with meticulous hiatal assessment and repair of hiatal laxity and herniation.

Surgery for faecal incontinence in adults.

BACKGROUND: Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (for example pelvic floor muscle training, biofeedback, drugs) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex. OBJECTIVES: To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques. SEARCH METHODS: Electronic searches of the Cochrane Incontinence Group Specialised Register (searched 6 March 2013), the Cochrane Colorectal Cancer Group Specialised Register (searched 6 March 2013), CENTRAL (2013, issue 1) and EMBASE (1 January 1998 to 6 March 2013) were undertaken. The British Journal of Surgery (1 January 1995 to 6 March 2013), Colorectal Diseases (1 January 2000 to 6 March 2013) and the Diseases of the Colon and Rectum (1 January 1995 to 6 March 2013) were specifically handsearched. The proceedings of the Association of Coloproctology of Great Britain and Ireland annual meetings held from 1999 to 2012 were perused. Reference lists of all relevant articles were searched for further trials. SELECTION CRITERIA: All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse). DATA COLLECTION AND ANALYSIS: Three review authors independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency. MAIN RESULTS: Nine trials were included with a total sample size of 264 participants. Two trials included a group managed non-surgically. One trial compared levatorplasty with anal plug electrostimulation and one compared an artificial bowel sphincter with best supportive care. The artificial bowel sphincter resulted in significant improvements in at least one primary outcome but the numbers were small. The other trial showed no difference in the primary outcome measures.Seven trials compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, and total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Sacral nerve stimulation and injectables are considered in separate Cochrane reviews. Only one comparison had more than one trial (total pelvic floor versus postanal repair, 44 participants) and no trial showed any difference in primary outcome measures. AUTHORS' CONCLUSIONS: The review is striking for the lack of high quality randomised controlled trials on faecal incontinence surgery that have been carried out in the last 10 years. Those trials that have been carried out have focused on sacral neuromodulation and injectable bulking agents, both reported in separate reviews. The continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.

Surgery for faecal incontinence in adults.

BACKGROUND: Faecal incontinence is a debilitating problem with significant medical, social and economic implications. Treatment options include conservative, non-operative interventions (e.g. pelvic floor muscle training, biofeedback, drugs) and surgical procedures. A surgical procedure may be aimed at correcting an obvious mechanical defect, or augmenting a functionally deficient but structurally intact sphincter complex. OBJECTIVES: To assess the effects of surgical techniques for the treatment of faecal incontinence in adults who do not have rectal prolapse. Our aim was firstly to compare surgical management with non-surgical management and secondly, to compare the various surgical techniques. SEARCH STRATEGY: Electronic searches of the Cochrane Incontinence Group Specialised Register (searched 26 November 2009), the Cochrane Colorectal Cancer Group Specialised Register (searched 26 November 2009), CENTRAL (The Cochrane Library 2009) and EMBASE (1 January 1998 to 30 June 2009) were undertaken. The British Journal of Surgery (1 January 1995 to 30 June 2009) Colorectal Diseases (1 January 2000 to 30 June 2009) and the Diseases of the Colon and Rectum (1 January 1995 to 30 June 2009) were specifically handsearched. The proceedings of the UK Association of Coloproctology meeting held from 1999 to 2009 were perused. Reference lists of all relevant articles were searched for further trials. SELECTION CRITERIA: All randomised or quasi-randomised trials of surgery in the management of adult faecal incontinence (other than surgery for rectal prolapse). DATA COLLECTION AND ANALYSIS: Three reviewers independently selected studies from the literature, assessed the methodological quality of eligible trials and extracted data. The three primary outcome measures were: change or deterioration in incontinence, failure to achieve full continence, and the presence of faecal urgency. MAIN RESULTS: Thirteen trials were included with a total sample size of 440 participants. Two trials included a group managed non-surgically. One trial compared levator with anal plug electrostimulation and one compared artificial bowel sphincter with best supportive care. The artificial bowel sphincter resulted in significant improvements in at least one primary outcome but numbers were small. The other trial showed no difference in primary outcome measures.Eleven trials compared different surgical interventions. These included anterior levatorplasty versus postanal repair, anterior levatorplasty versus total pelvic floor repair, total pelvic floor versus postanal repair, end to end versus overlap sphincter repair, overlap repair with or without a defunctioning stoma or with or without biofeedback, injection of silicone, hydrogel, physiological saline, carbon beads or collagen bulking agents, total pelvic floor repair versus repair plus internal sphincter plication and neosphincter formation versus total pelvic floor repair. Sacral nerve stimulation and injectables are also considered in separate Cochrane reviews. Only one comparison had more than one trial (total pelvic floor versus postanal repair, 44 participants) and no trial showed any difference in primary outcome measures. AUTHORS' CONCLUSIONS: Despite more studies being included in this update, the continued small number of relevant trials identified together with their small sample sizes and other methodological weaknesses continue to limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical procedures. Larger rigorous trials are still needed. However, it should be recognised that the optimal treatment regime may be a complex combination of various surgical and non-surgical therapies.

Nutritional deficiency post esophageal and gastric cancer surgery: A quality improvement study.

BACKGROUND: Esophagectomy or gastrectomy for malignant tumors can have a profound effect on nutritional status of patients undergoing the procedure. Hence, postoperative nutritional status is an important prognostic factor to consider in ensuring optimal recovery. In this study, we looked at assessing the prevalence of micronutrient deficiencies post esophagectomy or gastrectomies and the efficiency of Allied Health Professionals (AHP) led clinics in identifying and appropriately managing the deficiencies. METHOD: Between February 2017 and February 2018, all patients who attended the AHP clinic, had micronutrient screening, which includes ferritin, folate, vitamin B12 and vitamin D. Patients were screened for exocrine pancreatic insufficiency (EPI) through series of questions related to symptoms of EPI including steatorrhea, flatulence and urgency to defecate. All patients included in the study were started on A-Z multivitamin tablets from their first visit. Patients reporting symptoms indicative of EPI were started on Creon. Patients found deficient in any micronutrients were invited for a follow-up measurement of the respective deficiency. RESULTS: A total of 63 patients were included in the study period with a median follow-up of 18 months (range: 2-60 months) post esophagectomy and/or subtotal/total gastrectomy for malignant tumors. Proportion of patients with deficiency in ferritin, folate, vitamin B12 and vitamin D were 42.86%, 9.52%, 6.35% and 36.67% respectively. The proportion of patients identified with symptoms indicative of EPI was 31.75%. At re-test follow-up, 66.67% patient noticed settlement of symptoms of EPI. Ferritin, Folate, Vitamin B12 and D levels significantly improved post initial AHP follow-up (significance level p < 0.05). CONCLUSION: This study highlights that nutritional deficiencies post esophagectomy and/or subtotal/total gastrectomy for malignant tumors are prevalent. AHP run follow-up clinics in our unit helps identify these deficiencies and manage them accordingly. This study shows statistically significant improvement in deficiencies thereby making AHP led follow-up clinics to be cost effective and improve patient outcome.

Ruptured abdominal aortic aneurysm masquerading as isolated hip pain: an unusual presentation.

The rupture of an abdominal aortic aneurysm (AAA) is a catastrophic event. Misdiagnosis by first-contact emergency physicians remains a serious concern. Varied and frequently nonspecific presentations lead to erroneous diagnostic impressions and cause significant delays in definitive intervention. We report the case of a 73-year-old man with a ruptured AAA presenting with isolated acute right hip pain without any classical features such as truncal pain or hypotension. Despite major advances in imaging and definitive treatment, a heightened awareness among emergency physicians remains the only effective means of improving detection and thereby survival.

Acute Anterior Thigh Compartment Syndrome Revisited: A Case Report and Review of Literature.

We present a rare case of acute anterior compartment syndrome of the thigh in a rugby player with no history of trauma during the game. Decompressive fasciotomy with subsequent closure of the wound resulted in good outcome. Acute compartment syndrome of the thigh should be suspected following vigorous exercise and fasciotomy is to be performed on urgent basis.