Optimal antiseptic skin preparation agents for minimizing surgical site infection following surgery: cost and cost-effectiveness analysis.

BACKGROUND: The application of antiseptic skin agents prior to incision minimizes the rate of surgical site infection. Despite their ubiquity, the optimal skin preparation agent remains uncertain. A retrospective economic analysis was conducted to complement the results from the NEWSkin Prep trial which prospectively compared three preparation agents. METHODS: A cost and cost-effectiveness analysis was performed from a healthcare service perspective to compare chlorhexidine with 70% ethanol, and aqueous povidone-iodine, against povidone-iodine with 70% ethanol. Resource use estimates accounted for hospital admissions, readmissions associated with surgical site infection, outpatient and general practitioner attendances, visits from community nurses and therapeutic consumables. The measure of effectiveness comprised the net difference in number of patients with surgical site infections per 1000 patients. Costs were compared using a two-sample Welch's t-test. Deterministic and probabilistic sensitivity analyses were performed to evaluate the incremental cost-effectiveness ratio. RESULTS: The null hypothesis that the mean costs for the trial arms were significantly different was not rejected (Welch's t-test P value: 0.771 for chlorhexidine with 70% ethanol against povidone-iodine with 70% ethanol; and 0.955 for aqueous povidone-iodine against povidone-iodine with 70% ethanol). Based on bootstrap averages, the chlorhexidine with 70% ethanol intervention generated 8.0 fewer surgical site infections per 1000 patients and net cost savings of €151,698 (Euros) per 1000 patients compared with povidone-iodine with 70% ethanol, and aqueous povidone-iodine produced a net cost saving of €37,494 per 1000 patients but generated an additional 11.6 surgical site infections per 1000 patients compared with povidone-iodine with 70% ethanol. The comparison of chlorhexidine with 70% ethanol to povidone-iodine with 70% ethanol was sensitive to the inclusion of cost outliers, while the comparison of aqueous povidone-iodine to povidone-iodine with 70% ethanol was sensitive to the estimated cost per surgical site infection. CONCLUSION: Based on the outcomes from the NEWSkin Prep study, this economic analysis found no definitive evidence in favour of any one of the study comparators. Future model-based economic analyses of alternative skin preparations should critically address the quality of evidence and integrate the results from the NEWSkin Prep study.

Surgeons versus radiologists: do we care what they think?

BACKGROUNDS: Acute surgical care nowadays usually involves access to urgent imaging. There is a paucity of data on how often the images or radiologist reports of these images are used by the surgical team. We aimed to identify the rates and timeliness of radiology images and report viewing for acute surgical admissions in an Australian tertiary university teaching hospital. METHODS: We utilized a data set comprising radiological studies completed at our institute during a one-month period. Investigations were classified by modality and whether images or reports were available 'in-hours' or 'after-hours'. The time taken from imaging to reports available for viewing by the surgical team was calculated using timestamps derived from electronic hospital systems. Spearman's rho test was used to assess correlation between the Study Ascribable Time and time to view an image or report. RESULTS: Of 40 042 investigations, 1156 (3%) satisfied study criteria. Both images and reports were viewed in 82% (n = 950/1156) of cases. CT scans had the shortest median time for image (14 min, IQR 4-47 min) and report (25 min, IQR 8-68 min) viewing. CT (95%, n = 410/430) and MRI (95%, n = 38/40) scans had the highest proportion of both images and reports viewed, regardless of whether the scan was completed 'in-hours' or 'after-hours'. X-ray reports were viewed least often (73%). CONCLUSION: This study demonstrates a high level of viewing of acute surgical radiological imaging and reports by surgical teams. The 'simpler' the study the less likely the radiology report will be viewed.

Antiseptic Skin Agents to Prevent Surgical Site Infection After Clean Implant Surgery: Subgroup Analysis of the NEWSkin Prep Trial.

Background: There remains debate as to the ideal skin preparation agent to prevent surgical site infection (SSI) after clean implant surgery. This study is a subgroup analysis of all patients undergoing implant surgery in the NEWSkin prep trial. Patients and Methods: The NEWSkin prep trial is a randomized clinical trial (RCT; n = 3300) comparing the three antiseptic skin preparation agents commonly used prior to incisional surgery: chlorhexidine with alcohol (C-Alc), povidone iodine with alcohol (PI-Alc), and aqueous povidone iodine (PI-Aq). All participants who underwent clean incisional surgeries with implants from this trial were selected for analysis. The primary outcome was SSI rate; secondary outcomes were complication rates and re-admission rates. Results: A total of 712 patients in the NEWSkinPrep study underwent clean implant surgery between January 2015 and December 2018. Randomization resulted in the following distribution: C-Alc, 238; PI-Alc, 243; and PI-Aq, 231. Median age of participants was 63 years and 41% were female. Surgical site infection rates were: C-Alc, 10.13%; PI-Alc,11.52%; and PI-Aq, 11.26%. Povidone iodine with alcohol did not appear to be non-inferior to C-Alc (mean difference, 1.39%; 95% confidence interval [CI], -4.17 to 6.95) and PI-Alc was not superior to PI-Aq (mean difference, 0.27%; 95% CI, -5.45 to 5.99; p = 0.9271). There were no differences seen in secondary outcomes between groups. Conclusions: These results indicate a similarity between PI-Alc and C-Alc and that PI-Alc was not superior to PI-Aq. Because this study was not powered to assess these differences in clean cases with implants, additional studies are needed to assess these agents.

Getting back 'home' after emergency laparotomy: how many never make it?

BACKGROUND: Emergency laparotomy (EL) is performed on about 15 500 patients in Australia each year. Aside from mortality there is significant concern about the possibility that previously independent patients discharged after EL will become reliant on long-term dependent care. This study aimed to establish the proportion of patients not returning to their pre-admission residence, a proxy for dependent care, following EL. METHODS: Data were collected on all adult patients who underwent EL across four Australian hospitals over 2 years. A total of 113 data points were collected including pre-hospital residence, discharge destination, mortality and place of residence at 90 and 365 days. RESULTS: A total of 782 patients underwent EL, the mean age was 64 years. Pre-admission, 95.5% of patients were living in their own home. Inpatient mortality was 7.0% and at discharge 72.4% of patients returned directly back to their pre-hospital residence. At 90 days, mortality was 10.5%, and 87% of patients had returned to their pre-hospital residence, including all patients under 70 years of age. By 365 days, overall mortality was 16.8%, and only 1.5% of patients (all aged >70 years) had not returned to their pre-hospital residence. CONCLUSION: Patients who survive 90 and 365 days following EL nearly all return to their pre-hospital residence, with only a very small proportion of previously independent patients entering dependent care. This should help inform shared decision-making regarding emergency laparotomy in the acute setting.

Venous thromboembolic prophylaxis: current practice of surgeons in Australia and New Zealand for major abdominal surgery.

BACKGROUND: Surgical prophylaxis for venous thrombo-embolic disease (VTE) includes risk assessment, chemical prophylaxis and mechanical prophylaxis (graduated compression stockings [GCS] and/or intermittent pneumatic compression devices [IPCD]). Although there is overwhelming evidence for the need and efficacy of VTE prophylaxis in patients at risk, only about a third of those who are at risk of VTE receive appropriate prophylaxis. OBJECTIVE: There is debate as to the best combination of VTE prophylaxis following abdominal surgery due to lack of evidence. The aim of this survey was to understand this gap between knowledge and practice. METHODS: In 2019 and 2020, a survey was conducted to investigate the current practice of venous thromboembolism (VTE) prophylaxis for major abdominal surgery, with a focus on colorectal resections. The study received ethics approval and involved distributing an 11-item questionnaire to members of two professional surgical societies: the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) and the General Surgeons Australia (GSA). RESULTS: From 214 surgeons: 100% use chemical prophylaxis, 68% do not use a risk assessment tool, 27% do not vary practice according to patient risk factors while > 90% use all three forms of VTE prophylaxis at some stage of treatment. Most surgeons do not vary practice between laparoscopic and open colectomy/major abdominal surgery and only 33% prescribe post-discharge chemical prophylaxis. 42% of surgeons surveyed had equipoise for a clinical trial on the use of IPCDs and the vast majority (> 95%) feel that IPCDs should provide at least a 2% improvement in VTE event rate in order to justify their routine use. CONCLUSION: Most surgeons in Australia and New Zealand do not use risk assessment tools and use all three forms of prophylaxis regardless. Therfore there is a gap between practice and VTE prophylaxis for the use of mechanical prophylaxis options. Further research is required to determine whether dual modality mechanical prophylaxis is incrementally efficacious. Trial Registration- Not Applicable.

Protocol paper for SMART OPS: Shared decision-making Multidisciplinary Approach - a Randomised controlled Trial in the Older adult Population considering Surgery.

INTRODUCTION: The Australian population presenting with surgical pathology is becoming older, frailer and more comorbid. Shared decision-making is rapidly becoming the gold standard of care for patients considering high-risk surgery to ensure that appropriate, value-based healthcare decisions are made. Positive benefits around patient perception of decision-making in the immediacy of the decision are described in the literature. However, short-term and long-term holistic patient-centred outcomes and cost implications for the health service require further examination to better understand the full impact of shared decision-making in this population. METHODS: We propose a novel multidisciplinary shared decision-making model of care in the perioperative period for patients considering high-risk surgery in the fields of general, vascular and head and neck surgery. We assess it in a two arm prospective randomised controlled trial. Patients are randomised to either 'standard' perioperative care, or to a multidisciplinary (surgeon, anaesthetist and end-of-life care nurse practitioner or social worker) shared decision-making consultation. The primary outcome is decisional conflict prior to any surgical procedure occurring. Secondary outcomes include the patient's treatment choice, how decisional conflict changes longitudinally over the subsequent year, patient-centred outcomes including life impact and quality of life metrics, as well as morbidity and mortality. Additionally, we will report on healthcare resource use including subsequent admissions or representations to a healthcare facility up to 1 year. ETHICS AND DISSEMINATION: This study has been approved by the Hunter New England Human Research Ethics Committee (2019/ETH13349). Study findings will be presented at local and national conferences and within scientific research journals. TRIAL REGISTRATION NUMBER: ACTRN12619001543178.

Combining sarcopenia and ASA status to inform emergency laparotomy outcomes: could it be that simple?

BACKGROUND: Risk assessment for emergency laparotomy (EL) is important for guiding decision-making and anticipating the level of perioperative care in acute clinical settings. While established tools such as the American College of Surgeons National Surgical Quality Improvement Program calculator (ACS-NSQIP), the National Emergency Laparotomy Audit Risk Prediction Calculator (NELA) and the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity calculation (P-POSSUM) are accurate predictors for mortality, there has been increasing recognition of the benefits from including measurements for frailty in a simple and quantifiable manner. Psoas muscle to 3rd lumbar vertebra area ratio (PM:L3) measured on CT scans was proven to have a significant inverse association with 30-, 90- and 365-day mortality in EL patients. METHODS: A retrospective analysis was conducted of 500 patients admitted to four Australian hospitals who underwent EL during 2016-2017, and had contemporaneous abdomino-pelvic CT scans. Radiological sarcopenia was measured as PM:L3 ratios. ASC-NSQIP, NELA and P-POSSUM were retrospectively calculated. Univariate and multivariate logistic regression modelling was used to assess these ratios and scores, as well as American Society of Anaesthesiologists (ASA) classification separated into ASA I-III and IV/V (simplified ASA), as potential predictors of 30-, 90- and 365-day mortality. RESULTS: PM:L3, simplified ASA, ACS-NSQIP, NELA and P-POSSUM were each statistically significant predictors of 30-day, 90-day and 365-day mortality (P < 0.001). Logistic regression models of 30-, 90- and 365-day mortality combining PM:L3 (P = 0.001) and simplified ASA (P < 0.001) exhibited AUCs of 0.838 (0.780, 0.896), 0.805 (0.751, 0.860) and 0.775 (0.729, 0.822), respectively, which were comparable to that of ACS-NSQIP and NELA. CONCLUSION: Combining the semi-physiological parameter ASA classification with PM:L3 provides a quick and simple alternative to the more complex established risk assessment scores and is superior to PM:L3 alone.

Efficacy of intermittent compression devices for thromboembolic prophylaxis in major abdominal surgery: a systematic review and meta-analysis.

BACKGROUND: The benefits of mechanical prophylaxis for the prevention of venous thromboembolism (VTE) in abdominal and pelvic surgery are uncertain, with different guidelines stating that graduated compression stockings (GCS) and intermittent pneumatic compression devices (IPCDs) can be used either alone or in combination. To review the efficacy of IPCDs in preventing VTE following abdominal and pelvic surgery. METHODS: A systematic review was conducted, identifying relevant literature reporting clinical trials conducted in abdominopelvic surgery, comparing the effect of IPCDs alone or in combination with no prophylaxis, GCS and chemical prophylaxis. The review identified studies reported from 1966 to 2022 in Medline, Embase, PubMed and Cochrane databases for randomized controlled trials. RESULTS: Thirteen RCTs involving 1914 participants were identified. IPCDs were superior to placebo (OR VTE 0.39; 95% CI 0.20-0.76) but not superior to other forms of prophylaxis (OR 0.83; 95% CI 0.30-2.27) or to GCS alone (OR 0.9; 95% CI 0.24-3.36). The addition of IPCDs to GCS compared with GCS alone was beneficial (OR 0.45; 95% CI 0.23-0.91) as was the addition of IPCDs to standard perioperative chemoprophylaxis (OR 0.25; 95% CI 0.09-0.74). The overall quality and reliability of trials were low, with high risk of bias. CONCLUSIONS: IPCDs are more effective than placebo in reducing VTE rates but are not more effective than other forms of thrombo-prophylaxis (chemical or mechanical) following abdominal and pelvic surgery. There is poor quality evidence to suggest that they might have a role as additional prophylaxis when combined with GCS and chemical prophylaxis.

Sarcopenia 'made simple' and outcomes from emergency laparotomy.

BACKGROUND: Emergency Laparotomy (EL) is recognized as high-risk surgery with high mortality. Established surgical risk assessment tools (NELA Risk Prediction Calculator, P-POSSUM, ACS-NSQIP) are accurate predictors of morbidity and mortality. However, their multicomponent complexity limits their use in practice. Sarcopenia is associated with poorer surgical outcomes. This study tests for an association between a simple measure of radiological sarcopenia and mortality in EL patients in an Australian cohort. METHODS: A retrospective analysis was conducted of 500 patients admitted to four Australian hospitals who underwent EL during 2016-2017. All patients had a contemporaneous abdomino-pelvic CT scan. Radiological sarcopenia was measured as the ratio of total psoas muscle area (PM) to L3 vertebral body cross sectional area (PM:L3). Patients were followed up to 12 months. Primary outcomes were 30-, 90- and 365-day mortality. RESULTS: The mean 30-day mortality predictions for NELA, P-POSSUM and ACS-NSQIP were 11.36%, 17.28% and 11.30% respectively. PM:L3 ratio was associated with 30-, 90- and 365-day mortality (P < 0.001) and sex (P < 0.001) and negatively correlated with age (r = -0.4612; P < 0.001). Radiological sarcopenia had a weak negative correlation with NELA (r = -0.2737; P < 0.001), P-POSSUM (r = -0.1880; P < 0.001) and ACS-NSQIP (r = -0.2351; P < 0.001). The latter three metrics were significantly correlated (r > 0.5696; P < 0.001). CONCLUSION: Radiological sarcopenia (CT-assessed PM:L3) is a significant predictor of mortality in EL patients in Australia. The results of this study suggest that radiological sarcopenia is equivalent to established risk assessment tools. The more timely and easily accessible CT-assessed PM:L3 metric is potentially automatable and may have significant utility in clinical practice.

Antiseptic Skin Agents to Prevent Surgical Site Infection After Incisional Surgery: A Randomized, Three-armed Combined Non-inferiority and Superiority Clinical Trial (NEWSkin Prep Study).

OBJECTIVE: To compare SSI rates between the skin preparation agents: PI-Aq, povidone-iodine with alcohol (PI-Alc), and chlorhexidine with alcohol (C-Alc). BACKGROUND: Guidelines suggest that alcohol-containing chlorhexidine solutions are the gold standard for skin preparation before surgery. It remains difficult to determine whether it is the chlorhexidine component or the addition of alcohol that confers the most benefit. METHODS: We conducted a multicenter, prospective, combined non-inferiority (PI-Alc vs C-Alc) and superiority (PI-Alc vs PI-Aq) randomized clinical trial. Participants were randomized 1:1:1 to receive either C-Alc, PI-Alc, or PI-Aq. The primary outcome was SSI rate as defined by the Centers for Disease Control. Secondary outcomes were complication rates, length of hospital stay, readmissions, and skin reactions. RESULTS: Between January 2015 and December 2018, 3213 patients were randomized (C-Alc: 1076, PI-Alc: 1075, and PI-Aq: 1062). Mean age of participants was 57% and 55% were female. SSI rates were: C-Alc 11.09%, PI-Alc 10.88%, and PI-Aq 12.56%. PI-Alc was found to be non-inferior to C-Alc (mean difference, -0.21%; 95% confidence interval, -2.85 to 2.44; P = 0.0009 non-inferiority), whereas PI-Alc was not superior to PI-Aq (mean difference, -1.68%; 95% confidence interval, -4.40 to 1.05; P = 0.2302). There were no differences seen in secondary outcomes between groups and no treatment related adverse events or deaths occurred. CONCLUSIONS: PI-Alc is non-inferior to C-Alc and not superior to PI-Aq. This is at odds with current guidelines that suggest alcohol-based chlorhexidine solutions should routinely be used for surgical skin preparation. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry: ANZCTRN12615000021571. www.anzctr.org.au.

Incidence and Management of Hypertriglyceridemia-Associated Acute Pancreatitis: A Prospective Case Series in a Single Australian Tertiary Centre.

BACKGROUND: Hypertriglyceridemia-associated acute pancreatitis (HTGAP) has been linked with increased severity and morbidity. In this study, triglyceride levels were measured in all patients admitted with acute pancreatitis (AP) to establish the incidence of HTGAP in an Australian center. METHODS: A prospective cohort with AP was collated over an 18-month period in a single tertiary referral hospital. HTGAP was defined as AP with triglycerides ≥ 11.2 mmol/L (1000 mg/dL). Incidence, clinical co-morbidities, severity and management strategies were recorded. RESULTS: Of the 292 episodes of AP, 248 (85%) had triglycerides measured and were included. HTGAP was diagnosed in 10 of 248 (4%) AP cases. Type 2 diabetes, obesity, alcohol misuse and gallstones were common cofactors. The HTGAP group demonstrated severe hypertriglyceridemia compared to the non-HTGAP group (median 51 mmol/L vs. 1.3 mmol/L). Intensive care unit (ICU) admissions were significantly increased (odds ratio (OR) 16; 95% CI 4-62) in the HTGAP group (5/10 vs. 14/238 admissions, p < 0.001) and constituted 26% (5/19) of total ICU admissions for AP. Four patients received intravenous insulin with fasting and had a rapid reduction in triglyceride levels by 65-77% within 24 h; one patient had mild hypoglycemia secondary to therapy. CONCLUSION: HTGAP occurred in 4% of AP cases and was associated with higher risk of ICU admission. Intravenous insulin and fasting appear safe and efficacious for acutely lowering triglyceride levels in HTGAP.

Short- and long-term outcomes of percutaneous cholecystostomy in an Australian population.

BACKGROUND: Percutaneous cholecystostomy (PC) is a well-recognized management option for the treatment of acute cholecystitis (AC) in high-risk patients. Patient characteristics, efficacy and particularly the longer-term outcomes for patients having PC across the Hunter New England Local Health District were analysed. METHODS: A retrospective audit from January 2013 to September 2017 was undertaken. Patients were followed up until September 2019. All were retrospectively risk assessed using the P-POSSUM risk assessment tool, complications and mortality were recorded. In addition to short-term data, longer-term outcomes including patient's living situation at 6 and 12 months were analysed. RESULTS: A total of 82 patients were assessed at ≥12 months post procedure or until death. Successful initial gallbladder drainage was achieved in 99% of cases. The mean P-POSSUM score for mortality was 11%, confirming that this is a high-risk group; 17% had inpatient complications recorded; 10% of these were major (Clavien-Dindo ≥III). Outpatient complications were seen in 45%, 59% underwent further biliary tree intervention and 24% had recurrent AC. Thirty-day mortality was 12% and 1-year mortality was 22%. Functional capacity changed significantly for 41% of patients at 1 year, with 12% requiring a new admission to high-level nursing home care. CONCLUSION: Our series represents the largest reported Australasian series of PC for AC published to date. It confirms that PC is well-established and safe in high-risk patients. However, further intervention rates and recurrence rates of AC are high and escalation of dependency of care affects almost half of patients.

Direct access colonoscopy service for bowel cancer screening produces a positive financial benefit for patients and local health districts.

BACKGROUND: A direct access colonoscopy service (DACS) for the National Bowel Cancer Screening Program has become standard of care in Newcastle public hospitals because of the effect it has on time to colonoscopy. Cost-effectiveness has not been studied to date. AIM: The aim of this retrospective study was to analyse the cost-effectiveness of a DACS. METHODS: Data were collected for patients referred to DACS between January 2014 and June 2016, and patients who were treated on the normal service pathway in 2013 prior to the introduction of the process. A cost-benefit analysis from the patient's and local health district's perspective was undertaken. RESULTS: Introduction of the DACS produces a direct financial gain to patients in the form of reduced direct costs. It produces an indirect financial gain in terms of increased productivity if the patient is in work, and of increased leisure time if not in work. The DACS is modest income generating for the local health district, an evaluation which is sensitive to internal policies for distribution of government funding within a district. The DACS increases the availability of outpatient consultations to other patients, which is not a quantifiable economic benefit, but is likely to be an overall health benefit. CONCLUSION: The introduction of DACS in the public system in Australia is of financial benefit to patients and to the local health service provider. It is likely to produce health benefits to non-screening patients, by means of freeing consultations to be used for other indications.

Time to colonoscopy for patients accessing the direct access colonoscopy service compared to the normal service in Newcastle, Australia.

BACKGROUND: The 2017 National Bowel Cancer Screening Program report records a median time from positive faecal occult blood test to colonoscopy of 53 days. There is some intrinsic delay in accessing specialist medical opinion prior to colonoscopy. AIM: To examine the effect of the introduction of a Direct Access Colonoscopy Service (DACS). METHODS: Using prospectively maintained databases, patients undergoing normal service (NS) colonoscopy and those referred to DACS were compared. The primary outcome measure was the time from general practitioner (GP) referral to colonoscopy. Secondary outcome measures included the proportion of patients who met the current recommended 30 days from GP referral to colonoscopy, and the proportion of patients who waited longer than 90 days. RESULTS: There were 289 patients in the NS group, and 601 patients who progressed on the DACS pathway. The demographics of both groups were comparable. DACS patients had a median waiting time of 49 days, significantly shorter than NS patients whose median wait was 79 days (P < 0.0001). Approximately 15.1% patients in the DACS group had their colonoscopy within 30 days from GP referral, significantly better than in the NS group (4.5%, P < 0.001). In the NS group, 41.2% patients waited longer than 90 days from GP referral to colonoscopy, compared with 16.3% in the DACS group (P < 0.001). CONCLUSION: DACS reduces waiting times to colonoscopy and is associated with an increased proportion of patients undergoing colonoscopy in a timely manner.

Can CRP velocity in right iliac fossa pain identify patients for intervention? A prospective observational cohort study.

INTRODUCTION: Previous studies have shown single CRP measurements at time of presentation to have limited predictive benefit for appendicitis. Our objective was to determine the diagnostic utility of serial CRP measurements (to determine CRP velocity [CRPv]) in patients with right iliac fossa (RIF) pain. METHODS: A single-centre prospective observational study was conducted on adult patients admitted with RIF pain. CRP was measured on admission, at midnight, and the following morning. Appendicitis was diagnosed on histopathology, or diagnostic imaging in non-operatively managed patients. Therapeutic interventions included all appropriate operative procedures and effective non-operative treatment with antibiotics. Logistic regression was used to generate predictors of therapeutic intervention, and then used to create a new risk score incorporating CRPv. RESULTS: 98 of 112 (87.5%) participants had complete CRP data. 58 patients met the criteria for appendicitis (59.2%). Most patients presented with intermediate Modified Alvarado Scores (MAS) 5-6 (40.8%) or Appendicitis Inflammatory Response Scores (AIRS) 5-8 (49%). Our risk score had an AUROC of 0.88 (95% CI 0.81-0.96) in predicting therapeutic intervention. This score was superior to MAS, AIRS, and single admission biomarker measurements. Patients with an increasing CRPv had 14 times the odds (OR 14.07, 95% CI 0.63-315.2) of complicated appendicitis, and no cases of complicated appendicitis were observed in patients with a flat CRPv. CONCLUSIONS: CRP velocity is superior to single CRP at predicting intervention. Our v-Score shows promise as a decision making-aide by predicting the need for surgical intervention in RIF pain. A flat CRPv identifies a group of patients with a very low risk of complicated appendicitis.

Single-stage laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography: is this strategy feasible in Australia?

Currently in Australasia, concomitant cholecystolithiasis and choledocholithiasis are usually managed with two procedures: laparoscopic cholecystectomy (LC) and pre or postoperative endoscopic retrograde cholangiopancreatography (ERCP). This approach exposes the patient to the risk of complications from the common bile duct stone(s) while awaiting ERCP, the risks of the ERCP itself (particularly pancreatitis) and the need for a second anaesthetic. This article explores the evidence for a newer hybrid approach, single stage LC and intraoperative ERCP (SSLCE) and compares this approach with the commonly used alternatives. SSLCE offers reduced rates of pancreatitis, reduced length of hospital stay and reduced cost compared with the two-stage approach and requires only one anaesthetic. There is a reduced risk of bile leak compared with procedures that involve a choledochotomy, and ductal clearance rates are superior to trans-cystic exploration and equivalent to the standard two-stage approach. Barriers to widespread implementation relate largely to operating theatre logistics and availability of appropriate endoscopic expertise, although when bile duct stones are anticipated these issues are manageable. There is compelling justification in the literature to gather prospective evidence surrounding SSLCE in the Australian Healthcare system.

Laparoscopic drainage of an intramural duodenal haematoma: a novel technique and review of the literature.

Intramural Duodenal Haematoma (IDH) is an uncommon complication of blunt abdominal trauma. IDH's are most often treated non-operatively. We describe laparoscopic treatment of an IDH after failed conservative management. To our knowledge, successful laparoscopic drainage of an IDH in an adult has not been described previously in the literature.