Impact of a dedicated emergency surgical unit on early laparoscopic cholecystectomy for acute cholecystitis.

INTRODUCTION: Emergency general surgery (EGS) accounts for 50% of the surgical workload, and yet outcomes are variable and poorly recorded. The management of acute cholecystitis (AC) at a dedicated emergency surgical unit (ESU) was assessed as a performance target for EGS. METHODS: The outcomes for AC admissions were compared one year before and after inception of the ESU. The impact on cost and compliance with national guidance recommending early laparoscopic cholecystectomy (ELC) within seven days of diagnosis was assessed. RESULTS: The overall ELC rate increased from 26% for the 126 patients admitted in the pre-ESU period to 45% for the 152 patients admitted in the post-ESU period (p=0.001). With those unsuitable for ELC excluded, the ELC rate increased from 34% to 82% (p<0.001). The proportion of patients precluded from ELC for avoidable reasons, particularly owing to 'surgeon preference/skill', was reduced from 69% to 18% (p<0.001). The mean total length of stay (LOS) and postoperative LOS fell by 1.7 days (from 8.3 to 6.6 days, p=0.040) and 2 days (from 5.6 to 3.6 days, p=0.020) respectively. The higher ELC rate and the reduction in LOS produced additional tariff income (£111,930) and estimated savings in bed day (£90,440) and readmission (£27,252) costs. CONCLUSIONS: A dedicated ESU incorporating national recommendations for EGS improves alignment of best practice with best evidence and can also result in financial rewards for a busy district general hospital.

Implementation of a novel emergency surgical unit significantly improves the management of gallstone pancreatitis.

INTRODUCTION: Emergency surgery is changing rapidly with a greater workload, early subspecialisation and centralisation of emergency care. We describe the impact of a novel emergency surgical unit (ESU) on the definitive management of patients with gallstone pancreatitis (GSP). METHODS: A comparative audit was undertaken for all admissions with GSP before and after the introduction of the ESU over a six-month period. The impact on compliance with British Society of Gastroenterology (BSG) guidelines was assessed. RESULTS: Thirty-five patients were treated for GSP between December 2013 and May 2014, after the introduction of the ESU. This was twice the nationally reported average for a UK trust over a six-month period. All patients received definitive management for their GSP and 100% of all suitable patients received treatment during the index admission or within two weeks of discharge. This was a significantly greater proportion than that prior to the introduction of the ESU (57%, p=0.0001) as well as the recently reported national average (34%). The mean length of total inpatient stay was reduced significantly after the ESU was introduced from 13.7 ± 4.7 days to 7.8 ± 2.1 days (p=0.03). The mean length of postoperative stay also fell significantly from 6.7 ± 2.6 days to 1.8 ± 0.8 days (p=0.001). CONCLUSIONS: A dedicated ESU following national recommendations for emergency surgery care by way of using dedicated emergency surgeons and a streamlined protocol for common presentations has been shown by audit of current practice to significantly improve the management of patients presenting to a busy district general hospital with GSP.

Failure of fresh frozen plasma infusion and vitamin K to correct elevated international normalised ratio.

An 83-year-old, otherwise well, Caucasian gentleman was admitted with an incarcerated inguinal hernia. Routine preoperative tests revealed a raised international normalised ratio of 7.4, prothrombin time of 72.1 s and activated partial thromboplastin time of 73.1 s with normal liver and renal function tests. Despite fresh frozen plasma 15 ml/kg, and vitamin K, his repeat clotting remained deranged. The patient went on to have his hernia repair, and intraoperative bleeding remained normal despite the deranged clotting. The presence of endogenous clotting inhibitors can cause deranged coagulation studies but not impair bleeding. As in this case, the patient underwent surgery with no abnormal bleeding.