Clinical pathways and outcomes of patients with Barrett's esophagus in tertiary care settings: a prospective longitudinal cohort study in Australia, 2008-2016.

BACKGROUND: Clinical services for Barrett's esophagus have been rising worldwide including Australia, but little is known of the long-term outcomes of such patients. Retrospective studies using data at baseline are prone to both selection and misclassification bias. We investigated the clinical characteristics and outcomes of Barrett's esophagus patients in a prospective cohort. METHODS: We recruited patients diagnosed with Barrett's esophagus in tertiary settings across Australia between 2008 and 2016. We compared baseline and follow-up epidemiological and clinical data between Barrett's patients with and without dysplasia. We calculated age-adjusted incidence rates and estimated minimally and fully adjusted hazard ratios (HR) to identify those clinical factors related to disease progression. RESULTS: The cohort comprised 268 patients with Barrett's esophagus (median follow-up 5 years). At recruitment, 224 (84%) had no dysplasia, 44 (16%) had low-grade or indefinite dysplasia (LGD/IND). The age-adjusted incidence of esophageal adenocarcinoma (EAC) was 0.5% per year in LGD/IND compared with 0.1% per year in those with no dysplasia. Risk of progression to high-grade dysplasia/EAC was associated with prior LGD/IND (fully adjusted HR 6.55, 95% confidence interval [CI] 1.96-21.8) but not long-segment disease (HR 1.03, 95%CI 0.29-3.58). CONCLUSIONS: These prospective data suggest presence of dysplasia is a stronger predictor of progression to cancer than segment length in patients with Barrett's esophagus.

Amoebic Liver Abscesses in Fiji: Epidemiology, Clinical Presentation and Comparison of Percutaneous Aspiration and Percutaneous Catheter Drainage.

BACKGROUND: Amoebic liver abscess (ALA) is a common clinical problem in tropical countries related to poor sanitation. The epidemiology and clinical presentation of ALA in Fiji has not been previously described. It is unclear whether percutaneous aspiration (PA) or percutaneous catheter drainage (PCD) has better outcomes. PURPOSE: The aims were to describe the epidemiology and clinical presentation of ALA in Fiji and to compare the outcomes of PA and PCD for treatment of ALA. METHODS: A retrospective case note review of patients treated with either PA or PCD between 2010 and 2015 was performed. Indications for intervention were ALA > 5 cm, ALA in the left lateral lobe, risk of imminent rupture and failure to respond to medical treatment. RESULTS: There were 262 patients, 90% were male, 92.9% I-Taukei ethnicity and 86.2% regular recreational kava drinkers. Most presented with upper abdominal pain and fevers. The majority (90.3%) had a single abscess with 87.8% being in the right lobe. 174 (66.4%) had LA and 88 (33.6%) had PCD. There was an unintended selection bias for PA in abscess with a volume of <1 litre. PA was associated with a more rapid resolution of fever and shorter hospital stay, more rapid resolution of the cavity and no morbidity. PCD had five complications, one bleed and four bile leaks. There was no mortality in either group. CONCLUSIONS: ALA in Fiji occurs in I-Taukei males who drink kava. PA appears to offer equivalent if not better outcomes for treatment of ALA.

Post-operative Glycaemic Control Using an Insulin Infusion is Associated with Reduced Surgical Site Infections in Colorectal Surgery.

BACKGROUND: The incidence of surgical site infection (SSI) in colorectal surgery (CRS) is higher than other forms of general surgery. Post-operative hyperglycaemia causes increased SSI in CRS. Post-operative hyperglycaemia control in cardiac surgery reduces SSI. The aim was to evaluate using a cohort comparison the effect of post-operative glycaemic control using an insulin infusion on SSI in CRS. METHODS: Collection of data for the ACS-NSQIP was commenced in 2015. The CRS unit added post-operative glycaemic control to the SSI bundle in late 2016. The intervention was an insulin infusion to titrate blood glucose between 135 and 180 mg/Dl (7.5 and 10 mmol/l). The effect of glycaemic control on SSI was assessed comparing ACS-NSQIP raw data prior and after the intervention was commenced. RESULTS: The NSQIP data from July 2015 to June 2016 revealed the incidence of SSI were 25%. From January 2017 to December 2017, there was a significant reduction in SSI to 6.1% (OR = 517 Cl = 1.92-16.08, p < 0.001). The incidence of organ/space SSI fell significantly from 13% to 1.0% (OR = 11.35, Cl = 1.62-488.7, p < 0.001). There was non-significant reduction in superficial SSI from 11 to 4.0% (OR = 2.93, Cl = 0.68-13.03, p = 0.06). There was no significant difference in other factors associated with SSI in CRS. CONCLUSION: Post-operative glycaemic control in CRS reduces the rate of SSI. Post-operative glycaemic control should be included in SSI bundles for CRS and may be of benefit in other surgical specialties.

Laparoscopic appendicectomy is superior to open surgery for complicated appendicitis.

BACKGROUND: Over the last three decades, laparoscopic appendicectomy (LA) has become the routine treatment for uncomplicated acute appendicitis. The role of laparoscopic surgery for complicated appendicitis (gangrenous and/or perforated) remains controversial due to concerns of an increased incidence of post-operative intra-abdominal abscesses (IAA) in LA compared to open appendicectomy (OA). The aim of this study was to compare the outcomes of LA versus OA for complicated appendicitis. METHODS: A systematic literature search following PRISMA guidelines was conducted using MEDLINE, EMBASE, PubMed and Cochrane Database for randomised controlled trials (RCT) and case-control studies (CCS) that compared LA with OA for complicated appendicitis. RESULTS: Data from three RCT and 30 CCS on 6428 patients (OA 3,254, LA 3,174) were analysed. There was no significant difference in the rate of IAA (LA = 6.1% vs. OA = 4.6%; OR = 1.02, 95% CI = 0.71-1.47, p = 0.91). LA for complicated appendicitis has decreased overall post-operative morbidity (LA = 15.5% vs. OA = 22.7%; OR = 0.43, 95% CI: 0.31-0.59, p < 0.0001), wound infection, (LA = 4.7% vs. OA = 12.8%; OR = 0.26, 95% CI: 0.19-0.36, p < 0.001), respiratory complications (LA = 1.8% vs. OA = 6.4%; OR = 0.25, 95% CI: 0.13-0.49, p < 0.001), post-operative ileus/small bowel obstruction (LA = 3.1% vs. OA = 3.6%; OR = 0.65, 95% CI: 0.42-1.0, p = 0.048) and mortality rate (LA = 0% vs. OA = 0.4%; OR = 0.15, 95% CI: 0.04-0.61, p = 0.008). LA has a significantly shorter hospital stay (6.4 days vs. 8.9 days, p = 0.02) and earlier resumption of solid food (2.7 days vs. 3.7 days, p = 0.03). CONCLUSION: These results clearly demonstrate that LA for complicated appendicitis has the same incidence of IAA but a significantly reduced morbidity, mortality and length of hospital stay compared with OA. The finding of complicated appendicitis at laparoscopy is not an indication for conversion to open surgery. LA should be the preferred treatment for patients with complicated appendicitis.

Laparoscopic versus open surgery for adhesional small bowel obstruction: a systematic review and meta-analysis of case-control studies.

BACKGROUND: Small bowel obstruction (SBO) due to adhesions is a common acute surgical presentation. Laparoscopic adhesiolysis is being performed more frequently. However, the clear benefits of laparoscopic adhesiolysis (LA) compared with traditional open adhesiolysis (OA) remain uncertain. The aim of this study was to compare the outcomes of LA versus OA for SBO due to adhesions. METHODS: A systemic literature review was conducted using PRISMA guidelines. A search was conducted using MEDLINE, EMBASE, PubMed and Cochrane Databases of all randomised controlled trials (RCT) and case-controlled studies (CCS) that compared LA with OA for SBO. Data were extracted using a standardised form and subsequently analysed. RESULTS: There were no RCT. Data from 18 CCS on 38,927 patients (LA = 5,729 and OA = 33,389) were analysed. A meta-analysis showed that LA for SBO has decreased overall mortality (LA = 1.6% vs. OA = 4.9%, p < 0.001) and morbidity (LA = 11.2% vs. OA = 30.9%, p < 0.001). Similarly, the incidences of specific complications are significantly lower in the LA group. There are significantly lower reoperation rate (LA = 4.5% vs. OA = 6.5%, p = 0.017), shorter average operating time (LA = 89 min vs. OA = 104 min, p < 0.001) and a shorter length of stay (LOS) (LA = 6.7 days vs. OA = 11.6 days, p < 0.001) in the LA group. In the CCS, there is likely to be a selection bias favouring less complex adhesions in the LA group that may contribute to the better outcomes in this group. CONCLUSIONS: Although there is a probable selection bias, these results suggest that LA for SBO in selected patients has a reduced mortality, morbidity, reoperation rate, average operating time and LOS compared with OA. LA should be considered in appropriately selected patients with acute SBO due to adhesions.

The Unacceptable Morbidity of Negative Laparoscopic Appendicectomy.

BACKGROUND: One of the most common acute conditions managed by general surgeons is acute appendicitis. Laparoscopic appendicectomy (LA) is the surgical technique used by many surgeons. The aims of this study were to define our unit's negative appendicectomy rate and compare the outcomes associated with removal of a normal appendix with those for acute appendicitis in patients having LA. METHODS: A single-centre retrospective case note review of patients undergoing LA for suspected acute appendicitis was performed. Patients were divided into positive and negative appendicectomy groups based on histology results. The positive group was subdivided into uncomplicated and complicated (perforated and/or gangrenous) appendicitis. Outcomes were compared between groups. RESULTS: There were 1413 patients who met inclusion criteria, 904 in the positive group and 509 in the negative group, an overall negative appendicectomy rate of 36.0%. Morbidity rates (6.3% vs. 6.9%; P = 0.48) and types of morbidity were the same for negative appendicectomy and uncomplicated appendicitis. There was no significant difference in complication severity (all P > 0.17) or length of stay (2.3 vs. 2.6 days; P = 0.06) between negative appendicectomy and uncomplicated appendicitis groups. Patients with complicated appendicitis had a significantly higher morbidity rate compared to negative and uncomplicated groups (20.1% vs. 6.3% and 20.1% vs. 6.9%; both P < 0.001). CONCLUSION: The morbidity of negative LA is the same as LA for uncomplicated appendicitis. The morbidity of LA for complicated appendicitis is significantly higher. The selection criteria for LA in our unit needs to be reviewed to address the high negative appendicectomy rate and avoid unnecessary surgery and its associated morbidity.

Early Laparoscopic Washout may Resolve Persistent Intra-abdominal Infection Post-appendicectomy.

BACKGROUND: Intra-abdominal abscess (IAA) complicates 2-3% of patients having an appendicectomy. The usual management is prolonged antibiotics and drainage of the IAA. From 2006, our unit chose to use early re-laparoscopy and washout in patients with persistent sepsis following appendicectomy. The aims of this study were to assess the outcomes of early laparoscopic washout in patients with features of persistent intra-abdominal sepsis and compare those with percutaneous drainage and open drainage of post-appendicectomy IAA. METHODS: A retrospective case note review was performed for all patients having a laparoscopic washout, percutaneous drainage or open drainage following appendicectomy between January 2006 and December 2017. RESULTS: During the period, 4901 appendicectomies occurred. Forty-one (0.8%) patients had a laparoscopic washout, 16 (0.3%) had percutaneous drainage, and 6 (0.1%) had an open drainage. The demographics, ASA grade and pathology at initial appendicectomy were similar. The mean time after appendicectomy was significantly shorter for laparoscopic washout (4.1 days vs. 10.1 and 9.0 days, p = <0.003). The mean time for resolution of SIRS was significantly shorter (2.0 days vs. 3.3 and 5.2 days, p <0.02). The morbidity and length of stay were similar. CONCLUSION: Early laparoscopic washout for persistent intra-abdominal sepsis may be an alternative to non-operative management and delayed intervention for IAA and may have better outcomes than either percutaneous drainage or open drainage. A prospective randomised comparison is required to further evaluate the indications and role of early laparoscopic washout post-appendicectomy.

Transabdominal Pre-Peritoneal Versus Open Repair for Primary Unilateral Inguinal Hernia: A Meta-analysis.

BACKGROUND: Recent NICE guidelines recommend open surgical approaches for the treatment of primary unilateral inguinal hernias. However, many surgeons perform a laparoscopic approach based on the advantages of less post-operative pain and faster recovery. Our aim was to examine current evidence comparing transabdominal pre-peritoneal (TAPP) laparoscopic repair and open surgical repair for primary inguinal hernias. METHODS: A systematic search of six electronic databases was conducted for randomised controlled trials (RCTs) comparing TAPP and open repair for primary unilateral inguinal hernia. A random-effects model was used to combine the data. RESULTS: A total of 13 RCTs were identified, with 1310 patients receiving TAPP repair and 1331 patients receiving open repair. There was no significant difference between the two groups for rates of haematoma (RR 0.92; 95% CI 0.49-1.71; P = 0.78), seroma (RR 1.90; 95% CI 0.87-4.14; P = 0.10), urinary retention (RR 0.99; 95% CI 0.36-2.76; P = 0.99), infection (RR 0.61; 95% CI 0.29-1.28; P = 0.19), and hernia recurrence (RR 0.67; 95% CI 0.42-1.07; P = 0.10). TAPP repair had a significantly lower rate of paraesthesia (RR 0.20; 95% CI 0.08-0.50; P = 0.0005), shorter bed stay (2.4 ± 1.4 vs 3.1 ± 1.6 days, P = 0.0006), and shorter return to normal activities (9.5 ± 7.9 vs 17.3 ± 8.4 days, P < 0.00001). CONCLUSIONS: Our findings demonstrated that TAPP repair did not have higher rate of morbidity or hernia recurrence and is an equivalent approach to open repair, with the advantages of faster recovery and reduced paraesthesia.

Laparoscopic versus open cholecystectomy in pregnancy: a systematic review and meta-analysis.

BACKGROUND: The operative management of symptomatic cholelithiasis during pregnancy is either laparoscopic cholecystectomy (LC) or open cholecystectomy (OC). The aim of this systematic review and meta-analysis is to compare the outcomes of the laparoscopic and open approach for cholecystectomy during pregnancy. METHOD: A literature search was conducted using MEDLINE, PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL and Current Contents Connect using appropriate search terms. All comparative studies reporting maternal, fetal, and/or surgical complications were included. RESULTS: Eleven comparative studies, with a total of 10,632 patients, were included. The laparoscopic approach was performed at mean 18-week gestation and the open approach at mean 24-week gestation. LC was associated with decreased risks for fetal (OR 0.42; 95 % CI 0.28-0.63; p < 0.001), maternal (OR 0.42; 95 % CI 0.33-0.53; p < 0.001) and surgical (OR 0.45; 95 % CI 0.25-0.82, p = 0.01) complications. The average length of hospital stay (LOS) was: LC 3.2 days and OC 6.0 days (p = 0.02). The conversion rate from LC to OC was 3.8 %. CONCLUSION: The results of this first meta-analysis suggest that LC is associated with fewer maternal and fetal complications than OC during pregnancy. However, 91 % of included patients were in the first or second trimester at the time of surgery. These findings do not account for gestational age during pregnancy, which may be a significant confounding factor. The results support intervention for symptomatic gallstones in the first and second trimester with a laparoscopic approach.

Early laparoscopic cholecystectomy is superior to delayed acute cholecystitis: a meta-analysis of case-control studies.

BACKGROUND: Since the advent of laparoscopic cholecystectomy (LC) there has been continued debate regarding the management of acute cholecystitis with either early or delayed LC. Nearly all studies have demonstrated that early LC has a significantly shorter total length of hospital stay compared with delayed LC. Although previous randomized controlled trials and meta-analysis have shown clinical outcomes to favour early surgery, clinical practice continues to vary significantly worldwide. In addition, there is much confusion in the optimal timing for early LC with definitions of early varying from 72 h to 7 days. There have been numerous case-control studies investigating the timing of LC in acute cholecystitis. The aim of this paper is to pool the results from all case-control studies to investigate outcomes including mortality rates, complication rates, length of hospital stay and conversion rates to open procedures. METHODS: A search of electronic databases was performed for case-control studies published between 1985-February 2015. RESULTS: Results from 77 case-control studies showed statistically significant reductions in mortality, complications, bile duct leaks, bile duct injuries, wound infections, conversion rates, length of hospital stay and blood loss associated with early LC. Although LC within the 72-h window is optimal, patients operated after this window still benefit from early surgery compared to delayed surgery. The duration of symptoms in acute cholecystitis should not influence the surgeons' willingness to operate acutely. CONCLUSIONS: Early LC is clearly superior to delayed LC in acute cholecystitis. The most recent evidence-based practice strongly suggests that early LC should be standard of care in the management of acute cholecystitis.

Acute pancreatitis: update on management.

Acute pancreatitis is a common acute surgical condition associated with high morbidity and mortality in severe cases. New guidelines for management have recently been published by the American College of Gastroenterology and by the International Association of Pancreatology in collaboration with the American Pancreatic Association. The main differences between the new and previous versions of the guidelines relate to the use of endoscopic retrograde cholangiopancreatography (ERCP) and the addition of the new severity category of 'moderately severe acute pancreatitis' All patients with pancreatitis should have its cause determined by features of the history, results of laboratory tests (liver function tests, serum calcium triglyceride levels) and findings on transabdominal ultrasound. Those with idiopathic pancreatitis should have endoscopic ultrasound as a first-line investigation. Acute pancreatitis should be managed with aggressive hydration with intravenous fluids and fasting. Oral feeding can be recommenced in mild pancreatitis once pain and nausea and vomiting have resolved. Patients with mild biliary pancreatitis should have a laparoscopic cholecystectomy during their index admission. In addition to aggressive intravenous fluid resuscitation and fasting, patients with severe pancreatitis should have enteral feeding (nasoenteric or nasogastric feeds) commenced 48 hours after presentation. Total parenteral nutrition should be avoided where possible. All patients with organ failure or severe pancreatitis as defined by the revised version of the Atlanta classification should be managed in an intensive care setting. Patients with biliary pancreatitis and concurrent cholangitis should have endoscopic retrograde cholangiopancreatography within 24 hours of presentation.

Timing and nature of presentation of unsuspected retained common bile duct stones after laparoscopic cholecystectomy: a retrospective study.

BACKGROUND: Common bile duct (CBD) stones may be over looked at the time of laparoscopic cholecystectomy (LC), particularly when intra-operative cholangiography (IOC) is not performed. Currently, there is no data available about the time course and pattern of presentation for stones retained in the CBD at the time of LC. The aim of this study was to establish the time course and pattern of presentation of unsuspected retained CBD stones post LC. METHODS: Patients presenting with symptomatic CBD stones from 1994 until 2010, having previously undergone LC were studied in this retrospective, case note review. CBD stones were confirmed at ERCP. Data collected included LC date, mode of presentation, imaging results including CBD diameter, stone appearance, length of stay and post ERCP complications. Patients having an ERCP for stones found on IOC at LC were excluded. RESULTS: Sixty-one patients met the inclusion criteria. The most common mode of presentation was abdominal pain (n = 38, 62%) with (17) or without (21) deranged liver function tests. Nineteen (31%) patients presented with clinical complications of the CBD stones: cholangitis (10), acute biliary pancreatitis (6) or obstructive jaundice (3). The CBD was usually mild-to-moderately dilated (8-15 mm) on ultrasound. The median time span from LC to presentation with CBD stones was 4 years (range: 6 days-18 years). Five (8.2%) patients had a complication from their ERCP; mild pancreatitis (3), bleed (1) and cholangitis (1). Nineteen (31.1%) patients required more than one ERCP to complete stone/stent removal. CONCLUSIONS: The median time for patients to present with symptomatic CBD stones after LC is 4 years. Patients with retrained stones may remain asymptomatic for many years. A third of the patients presented with potentially serious complications of the retained CBD stone. Future studies for CBD stones after LC need to follow patients for at least 10 years.

Folate intake and the risk of upper gastrointestinal cancers: a systematic review and meta-analysis.

BACKGROUND AND AIM: There is conflicting evidence on the association between folate intake and the risk of upper gastrointestinal tract cancers. In order to further elucidate this relationship, we performed a systematic review and quantitative meta-analysis of folate intake and the risk of esophageal, gastric, and pancreatic cancer. METHODS: Four electronic databases (Medline, PubMed, Embase, and Current Contents Connect) were searched to July 26, 2013, with no language restrictions for observational studies that measured folate intake and the risk of esophageal cancer, gastric cancer, or pancreatic cancer. Pooled odds ratios and 95% confidence intervals were calculated using a random effects model. RESULTS: The meta-analysis of dietary folate and esophageal cancer risk comprising of nine retrospective studies showed a decreased risk of esophageal cancer (odds ratio [OR] 0.59; 95% confidence interval [95% CI] 0.51-0.69). The meta-analysis of dietary folate and gastric cancer risk comprising of 16 studies showed no association (OR 0.94; 95% CI 0.78-1.14). The meta-analysis of dietary folate and pancreatic cancer risk comprising of eight studies showed a decreased risk of pancreatic cancer (OR 0.66; 95% CI 0.49-0.89). CONCLUSION: Dietary folate intake is associated with a decreased risk of esophageal and pancreatic cancer, but not gastric cancer. Interpretation of these relationships is complicated by significant heterogeneity between studies when pooled, and by small numbers of studies available to analyze when stratification is performed to reduce heterogeneity.

The acute surgical unit model verses the traditional "on call" model: a systematic review and meta-analysis.

BACKGROUND: The acute surgical unit (ASU) is a novel model for the provision of emergency general surgery care. The ASU model was initially developed in New South Wales hospitals during 2005 and 2006. Several studies have analysed the effects on patient outcomes and timeliness of care for nontrauma patients presenting with acute general surgical conditions. The purpose of this study was to perform a meta-analysis to determine the efficacy of the ASU model compared with the traditional on-call model for specific conditions. METHODS: A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Original data were extracted from each study and used to calculate a pooled odd ratio (OR) and 95 % confidence interval (CI). RESULTS: The search identified 18 studies; appendectomy (n = 9), acute cholecystitis (n = 7), and small-bowel obstruction (SBO) (n = 2). In the appendectomy cohort, the proportion of appendicular perforation were similar in pre-ASU and ASU period (OR 1.02, 95 % CI 0.77-1.37, p = 0.13). The incidence of complications in the appendectomy cohort was significantly lower in the ASU group; 14.5 % pre-ASU and 10.9 % post-ASU (OR 1.649, 95 % CI 0.732-3.714, p = 0.009). The negative appendectomy rate was similar for the pre- and post-ASU groups (OR 1.07, 95 % CI 0.88-1.31, p = 0.83). Likewise the conversion rate to open surgery and total hospital stay were similar between the two groups. The proportion of night time operations reduced significantly in the ASU period (OR 1.9, 95 % CI 1.32-2.74, p = 0.001). In the acute cholecystitis cohort, the conversion rate to open surgery was significantly higher in the pre-ASU group (15.1 %) compared with the post-ASU group (7.5 %) (OR 1.879, 95 % CI 1.072-3.293, p = 0.04) The incidence of complications was higher in the pre-ASU (14 %) compared with the post-ASU (6.8 %) group (OR 2.231, 95 % CI 1.372-3.236, p = 0.03). The mean hospital stay was significantly lower in the ASU period (5.3 vs. 3.7 days, p = 0.0063). There was insufficient data available to analyse outcomes for SBO. CONCLUSIONS: The ASU model provides a safe surgical environment for patients and is associated with a reduced complication rate for appendectomy and laparoscopic cholecystectomy for acute cholecystitis. There is a reduced conversion rate and a shorter length of stay for patients with acute cholecystitis. Overall, the ASU model has translated to better outcomes for patients presenting with acute general surgical conditions.

Development of a novel rapid response event review process for quality improvement.

INTRODUCTION: Rapid response team (RRT) and code activation events occur relatively commonly in inpatient settings. RRT systems have been the subject of a significant amount of analysis, although this has been largely focused on the impact of RRT system implementation and RRT events on patient outcomes. There is reason to believe that the structured assessment of RRT and code events may be an effective way to identify opportunities for system improvement, although no standardised approach to event analysis is widely accepted. We developed and refined a protocolised system of RRT and code event review, focused on sustainable, timely and high value event analysis meant to inform ongoing improvement activities. METHODS: A group of clinicians with expertise in process and quality improvement created a protocolised analytic plan for rapid response event review, piloted and then iteratively optimised a systematic process which was applied to all subsequent cases to be reviewed. RESULTS: Hospitalist reviewers were recruited and trained in a methodical approach. Each reviewer performed a chart review to summarise RRT events, and collect specific variables for each case (coding). Coding was then reviewed for concordance, at monthly interdisciplinary group meetings and 'Action Items' were identified and considered for implementation. In any 12-month period starting in 2021, approximately 12-15 distinct cases per month were reviewed and coded, offering ample opportunities to identify trends and patterns. CONCLUSION: We have developed an innovative process for ongoing review of RRT-Code events. The review process is easy to implement and has allowed for the timely identification of high value improvement opportunities.

Cigarette smoking and the risk of Barrett's esophagus: a systematic review and meta-analysis.

BACKGROUND AND AIM: Barrett's esophagus (BE) is a premalignant condition to esophageal adenocarcinoma. It is currently not clear whether cigarette smoking increases the risk of developing BE, and no meta-analysis has been performed on the topic. We conducted a systematic review and meta-analysis, providing a quantitative estimate of the increased risk of BE associated with cigarette smoking, to help clarify whether a relationship exists between smoking and BE. METHODS: Four electronic databases (Medline, PubMed, Embase, and Current Contents Connect) were searched to May 17, 2013, for observational studies of BE patients. We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using a random effects model for the association of smoking with BE. BE patients were compared with non-gastroesophageal reflux disease (GERD) controls as well as with population-based and GERD controls. RESULTS: Thirty-nine studies comprising 7069 BE patients were included in the meta-analysis. Having ever-smoked was associated with an increased risk of BE compared with non-GERD controls (OR 1.44; 95% CI 1.20-1.74), population-based controls (OR 1.42; 95% CI 1.15-1.76), but not GERD controls (OR 1.18; 95% CI 0.75-1.86). The meta-analyses of the studies reporting the lowest and highest number of pack-years smoked showed an increased risk of BE (OR 1.41; 95% CI 1.22-1.63) and (OR 1.53; 95% CI 1.27-1.84), respectively. CONCLUSION: Cigarette smoking was associated with an increased risk of BE. Being an ever-smoker was associated with an increased risk of BE in all control groups. A greater number of pack-years smoked was associated with a greater risk of BE.

Hiatal hernia and the risk of Barrett's esophagus.

BACKGROUND AND AIM: Barrett's esophagus has been associated with the presence of hiatal hernia; however, to date no meta-analysis of the relationship has been performed. We aimed to conduct a systematic review and meta-analysis, providing a quantitative estimate of the increased risk of Barrett's esophagus associated with hiatal hernia. METHODS: A search was conducted through four electronic databases (Medline, PubMed, Embase, and Current Contents Connect) to 4 April 2012, for observational studies of Barrett's esophagus patients. We calculated pooled odds ratios and 95% confidence intervals using a random effects model for the association of hiatal hernia with any length Barrett's esophagus, as well as with short segment Barrett's esophagus and long segment Barrett's esophagus. 33 studies comprising 4390 Barrett's esophagus patients were eligible for the meta-analysis. RESULTS: Hiatal hernia was associated with an increased risk of Barrett's esophagus of any length (odds ratio 3.94; 95% confidence interval 3.02-5.13). Heterogeneity was present (I2 = 82.03%, P < 0.001), and the Egger test for publication bias was significant (P = 0.0005). The short segment Barrett's esophagus subgroup analysis likewise showed an increased risk (odds ratio 2.87; 95% confidence interval 1.75-4.70). The strongest association was between hiatal hernia and long segment Barrett's esophagus (odds ratio 12.67; 95% confidence interval 8.33-19.25). The increased risk was present even after adjusting for reflux and body mass index. CONCLUSIONS: The presence of hiatal hernia was associated with an increased risk of Barrett's esophagus, even after adjusting for clinically significant confounders. The strongest association was found between hiatal hernia and long segment Barrett's esophagus.

Gallstone disease is associated with rectal cancer: a meta-analysis.

BACKGROUND: Increased levels of secondary bile acids after cholecystectomy and cholelithiasis are believed to increase the risk of colorectal cancer, and several studies have suggested that the risk of colorectal cancer may be the greatest proximally. Numerous conflicting studies have been published and it remains unclear whether the risk is apparent in the rectum. This meta-analysis aims to determine the risk of developing rectal cancer following gallstone disease or cholecystectomy. METHODS: The prospective protocol included a literature search of PubMed, MEDLINE, EMBASE, and Current Contents (1950-2011). Selection criteria were developed to sort for studies exploring the relationship between cholelithiasis, cholecystectomy, and rectal cancer in an adult population. A random-effects model was used to generate pooled odds ratios (OR) and 95% confidence intervals (CI). Publication bias and heterogeneity were assessed. RESULTS: Of the 2358 studies identified, 42 were suitable for final analysis. There were 1,547,506 subjects in total, 14,226 diagnosed with rectal cancer, and 496,552 with gallstones or cholecystectomy. There was a statistically significant risk of rectal cancer following cholelithiasis (OR = 1.33; 95% CI = 1.02-1.73), though no risk was apparent following cholecystectomy (OR = 1.14; 95% CI = 0.92-1.41). CONCLUSIONS: Cholelithiasis increases the risk of rectal cancer. No association exists between cholecystectomy and rectal cancer.

The acute surgical unit as a novel model of care for patients presenting with acute cholecystitis.

OBJECTIVE: To determine whether the introduction of an acute surgical unit (ASU) resulted in a greater proportion of patients with acute cholecystitis receiving definitive surgery on index admission with no adverse change in surgical outcomes. DESIGN, SETTING AND PARTICIPANTS: A retrospective study of medical records for patients presenting to Nepean Hospital with acute cholecystitis during the 2 years before and 2 years after introduction of an ASU in November 2006. MAIN OUTCOME MEASURES: Time to diagnosis, timing of surgical intervention, surgical outcomes, duration of total admission and complication rates. RESULTS: A total 271 patients were included in the study (114 pre-ASU, 157 post-ASU). After introduction of the ASU, a higher proportion of patients had surgery on index admission (89.8% v 55.3%; P < 0.001) and there were decreases in median time to diagnosis (14.9 h v 10.8 h; P = 0.008), median time to definitive procedure (5.6 days v 2.1 days; P < 0.001), median duration of total admission (4.9 days v 4.0 days; P = 0.002), rate of intraoperative conversion to open surgery (14.9% v 4.5%; P = 0.003) and rate of postoperative infection (3.5% v 2.5%; P = 0.40). CONCLUSION: Introduction of the ASU at Nepean Hospital resulted in significant improvements in care and outcomes for patients with acute cholecystitis.