Specialist-led urgent cholecystectomy for acute gallstone disease.

BACKGROUND: Despite overwhelming evidence of the clinical and financial benefit of urgent cholecystectomy, there is variable enthusiasm and uptake across the UK. In 2014, following the First National Emergency Laparotomy Audit Organisational Report, we implemented a specialist-led urgent surgery service, whereby all patients with gallstone-related pathologies were admitted under the direct care of specialist upper gastrointestinal surgeons. We have analysed 5 years of data to investigate the results of this service model. METHODS: Computerised operating theatre records were interrogated to identify all patients within a 5-year period undergoing cholecystectomy. Patient demographics, admission details, length of stay, duration of surgery, and complications were analysed. RESULTS: Between 01/01/2016 and 31/12/2020, a total of 4870 cholecystectomies were performed; 1793 (36.8%) were urgent cases and 3077 (63.2%) were elective cases. All cases were started laparoscopically; 25 (0.5%) were converted to open surgery-14 of 1793 (0.78%) urgent cases and 11 of 3077 (0.36%) elective cases. Urgent cholecystectomy took 20 min longer than elective surgery (median 74 versus 52 min). No relevant difference in conversion rate was observed when urgent cholecystectomy was performed within 2 days, between 2 and 4 days, or greater than 4 days from admission (P = 0.197). Median total hospital stay was 4 days. CONCLUSION: Urgent laparoscopic cholecystectomy is safe and feasible in most patients with acute gall bladder disease. Surgery under the direct care of upper gastrointestinal specialist surgeons is associated with a low conversion rate, low complication rate, and short hospital stay. Timing of surgery has no effect on conversion rate or complication rate.

Sarcopenia and Myosteatosis Predict Adverse Outcomes After Emergency Laparotomy: A Multi-center Observational Cohort Study.

OBJECTIVE: To determine the relationship between BC, specifically low skeletal muscle mass (sarcopenia) and poor muscle quality (myosteatosis) and outcomes in emergency laparotomy patients. BACKGROUND: Emergency laparotomy has one of the highest morbidity and mortality rates of all surgical interventions. BC objectively identifies patients at risk of adverse outcomes in elective cancer cohorts, however, evidence is lacking in emergency surgery. METHODS: An observational cohort study of patients undergoing emergency laparotomy at ten English hospitals was performed. BC analyses were performed at the third lumbar vertebrae level using preoperative computed tomography images to quantify skeletal muscle index (SMI) and skeletal muscle radiation attenuation (SM-RA). Sex-specific SMI and SM-RA were determined, with the lower tertile splits defining sarcopenia (low SMI) and myosteatosis (low SM-RA). Accuracy of mortality risk prediction, incorporating SMI and SM-RA variables into risk models was assessed with regression modeling. RESULTS: Six hundred ten patients were included. Sarcopenia and myosteatosis were both associated with increased risk of morbidity (52.1% vs 45.1%, P = 0.028; 57.5% vs 42.6%, P = 0.014), 30-day (9.5% vs 3.6%, P = 0.010; 14.9% vs 3.4%, P < 0.001), and 1-year mortality (27.4% vs 11.5%, P < 0.001; 29.7% vs 12.5%, P < 0.001). Risk-adjusted 30-day mortality was significantly increased by sarcopenia [OR 2.56 (95% CI 1.12-5.84), P = 0.026] and myosteatosis [OR 4.26 (2.01-9.06), P < 0.001], similarly at 1-year [OR 2.66 (95% CI 1.57-4.52), P < 0.001; OR2.08 (95%CI 1.26-3.41), P = 0.004]. BC data increased discrimination of an existing mortality risk-prediction model (AUC 0.838, 95% CI 0.835-0.84). CONCLUSION: Sarcopenia and myosteatosis are associated with increased adverse outcomes in emergency laparotomy patients.

The Supracondylar Process: A Rare Case of Ulnar Nerve Entrapment and Literature Review.

A fit and well 33-year-old male mechanic was referred to the clinic complaining of locking of right elbow and paraesthesia and pain affecting the forearm and hand. Radiographs demonstrated a right-sided supracondylar process. The patient had locking of his right elbow, which caused shooting pains both distally and proximally. The ulnar nerve was irritable proximal to the cubital tunnel, and there was some weakness of the ulnar nerve supplied muscles of the hand and forearm. The patient had a subjective feeling of altered sensation over the medial one and a half digits. The magnetic resonance imaging (MRI) suggested that there was anomalous anatomy around the elbow and that compression of the ulnar and or the median nerve by a fibrous band appeared to be the cause of his symptoms. A surgical exploration was arranged. The incision was posterior to the medial epicondyle. A fascial/muscular band was identified from the tip of the supratrochlear spur to the olecranon and was seen to kink the ulnar nerve. This was corrected upon its release. The supratrochlear spur was excised with an osteotome, and bone wax applied to the humerus. On review 6 weeks postoperatively, his function had returned to normal.