A high-volume ERCP service led by surgeons is associated with good outcomes and meets national key performance indicators: results from a British district general hospital.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a common, but technically challenging procedure used in the management of hepatopancreaticobiliary (HPB) disease. It is traditionally performed by medical gastroenterologists. In 2014, the British Society of Gastroenterology (BSG) proposed key performance indicators to evaluate and set standards of ERCP practice. This study aimed to compare our ERCP outcomes against these targets, in a centre where ERCP is exclusively performed by surgeons. METHODS: A retrospective analysis of all ERCPs undertaken over a 38 months in a District General Hospital in the United Kingdom (UK), by three Upper Gastrointestinal Surgeons. Study outcomes were based upon, and compared against, BSG key performance indicators, including number of ERCPs per annum, proportion of successful cannulations of bile duct and stone clearance, ERCP-specific complications and mortality. RESULTS: The unit's caseload over this period was 1324, equating to approximately 418 per annum (BSG minimum 200 per unit). Management of bile duct stones was the commonest indication for ERCP. Overall, 95% (1253/1324) of bile ducts were cannulated and 92% (645/698) for those undergoing their first ERCP. Bile duct clearance was achieved in 80% of patients (BSG recommend > 75%) and the successful stenting of extra-hepatic strictures in 94% (BSG recommend > 80%). The overall complication rate was 4.3% (BSG standard < 6%). Procedure-specific mortality was 0.3% (4/1324) where death was either caused by pancreatitis or sepsis. CONCLUSION: A high-volume ERCP service led and performed exclusively by surgeons meets all BSG performance indicators, with good procedural and patient outcomes. Formal training pathways should be developed to encourage more surgical centres to provide an ERCP service and deal with what are common surgical pathologies.

Quality improvement measures: effects on rectal cancer tissue biopsy process.

PURPOSE: Delay in histologically confirming rectal cancer may lead to late treatment as histological confirmation is required prior to chemo-radiotherapy or surgical intervention. Multidisciplinary colorectal meetings indicate that there are patients who require multiple tissue biopsy episodes prior to histologically confirming rectal cancer. The purpose of this paper is to examine a quality improvement (QI) measure's impact on tissue biopsy process diagnostic yield. DESIGN/METHODOLOGY/APPROACH: The authors performed the study in two phases (pre- and post-QI), between February 2012 and April 2014 in a district general hospital. The QI measures were derived from process mapping a rectal cancer diagnostic pathway. The primary outcome was to assess the tissue biopsy process diagnostic yield. The secondary outcome included total breaches for a 62-day target in the pre- and post-QI study phases. FINDINGS: There was no significant difference in demographics or referral mode in both study phases. There were 81 patients in the pre-QI phase compared to 38 in the post-QI phase, 68 per cent and 74 per cent were referred via the two-week wait urgent pathway, respectively. Diagnostic tissue biopsy process yield improved from 58.1 to 77.6 per cent after implementing the QI measure ( p=0.02). The 62-day target breach was reduced from 14.8 to 3.5 per cent ( p=0.42). PRACTICAL IMPLICATIONS: Simple QI measures can achieve significant improvements in rectal cancer diagnostic tissue biopsy process yields. A multidisciplinary approach, involving process mapping and cause and effect modelling, proved useful tools. ORIGINALITY/VALUE: A process mapping exercise and QI measures resulted in significant improvements in diagnostic yield, reducing the episodes per patient before histological diagnosis was confirmed.

Amyand's hernia managed with open repair and laparoscopic appendicectomy.

We present a rare case of Amyand's hernia that was surgically managed using an open repair of hernia combined with laparoscopic appendicectomy. A 68-year-old man presented with an irreducible recurrent right-sided inguinal hernia and abdominal pain. This gentleman had undergone three previous inguinal hernia repairs on the right, and one on the left using the open mesh technique. Ultrasound suggested the possibility of the appendix within the hernial sac and clinical correlation was advised. An open groin approach was taken to repair the incarcerated hernia. This revealed an indirect inguinal hernia containing the appendix with signs of inflammation. The base of the appendix was not visible due to there being a long appendix with fixed cecum in the abdomen. To safely resect the appendix, a laparoscopy was performed and the appendix was successfully removed. The inguinal hernia was repaired using a sutured technique without mesh. There were no post-operative complications.