Laparoscopic fundoplication performed in community hospital settings: A protocol for systematic review.

BACKGROUND: Laparoscopic fundoplication (LF) is well-established as the surgical intervention of choice for management of refactory gastro-esophageal reflux disease. Much of its success lies in the reported benefits in symptom control outlined by the postoperative patient. It is unclear whether patient-reported outcomes differ according to the institution type providing care. This review aimed to address this knowledge gap by reviewing the available evidence examining patient-reported outcomes of LF in non-metropolitan centers. OBJECTIVES: To investigate patient-reported outcomes of LF performed in regional or community-based hospitals. DATA SOURCES: Four electronic databases, and citations of relevant articles. STUDY ELIGIBILITY CRITERIA: Only studies that separately reported patient-reported outcomes of LF performed in regional or community hospitals were included; papers deemed to be unclear about the type of facility in which LF surgeries were performed, or in which data from LF surgeries performed in regional/community hospitals was combined with data from major metropolitan hospitals, were excluded. STUDY APPRAISAL: Only studies that were graded as fair or good using Quality Assessment Tool for Observational Cohort and Cross-sectional studies were eligible for inclusion in this review. Seven studies were then eligible for inclusion, all of which were observational cohort studies with 6 of the studies reporting on a single intervention arm. RESULTS: Seven observational cohort studies were included in the review, with a combined total of 1071 patients who underwent LF at non-metropolitan centers. Of these, data was collected for 742 patients, yielding an overall response rate of 69.3%. All 7 studies assessed patients' post-operative outcomes through questionnaires that were based on a modified Likert scale or a similar tool. Overall patient satisfaction was high (86%) and a significant majority of patients stated they would recommend the procedure to others (93.3%). Post-operative prevalence of reflux and dysphagia compared favorably to rates generally reported in the literature (11.9% and 17.6% respectively). Further research is required to ascertain the safety of performing these procedures in non-metropolitan hospitals. CONCLUSION: Current evidence suggests that patient-reported outcomes are favorable for patients undergoing LF in community settings, and are broadly comparable to those undergoing LF in tertiary-level centers.

Loop and drain technique for prevention of surgical site infection in upper gastrointestinal surgery.

INTRODUCTION: Hepatobiliary and pancreatic surgery is frequently complicated by surgical site infections (SSI) with significant postoperative morbidity and mortality rates contributing to the economic burden on healthcare. Advancements in operative techniques to prevent SSI are gaining traction in clinical practice. This study compares the effectiveness of the 'loop and drain technique (LDT)', a combination method utilizing a continuous subcutaneous vessel loop and subcuticular suture for surgical wound closure in patients undergoing upper gastrointestinal surgery at a Metropolitan Hospital in Sydney. METHODS: A retrospective review of patients who underwent an upper gastrointestinal procedure was conducted at Bankstown-Lidcombe hospital between 2017 and 2019. There were 77 patients in the LDT group and 123 patients included in the control group. The primary outcome assessed was the rate of SSI. Secondary outcomes included length of stay (LOS) and drainage of surgical site infections. RESULT: Two hundred adult patients were treated for an upper gastrointestinal procedure. The most common operation was a Whipple procedure (35.0%). The rate of SSI was 12.5% with all these patients receiving intravenous antibiotics. The LDT cohort had a significantly lower rate of SSI compared to their counterparts (3.9% vs. 17.9%, P = 0.004). CONCLUSION: The LDT method is associated with a decreased incidence of SSI and should be considered as a cost-effective operative technique to improve patient outcomes after upper gastrointestinal surgery.

How to perform transcystic stenting in the COVID-19 pandemic: an approach to biliary stenting without specialized endobiliary stenting equipment.

Management options for common bile duct stones found at laparoscopic cholecystectomy (LC) includes concurrent transcystic biliary stenting, effectively providing a conduit for common bile duct drainage and improving the success of subsequent endoscopic retrograde cholangiopancreatography. In the unprecedented COVID-19 pandemic however, potential disruptions to the medical supply chain have been far reaching, including the distribution of specialised biliary stent sets. To overcome this, we devised an innovative method at our centre to substitute traditional procedural stent sets by employing standard, universally accessible open-ended ureteral catheters, jagwires and pancreatic or biliary stents with similar procedural success.

Fast-track ambulatory abscess pathway: an Australian streamlined emergency surgery pathway.

BACKGROUND: Superficial skin abscesses account for a significant burden of emergency surgical admissions. The aim of this study was to evaluate the effectiveness of an ambulatory care pathway for emergently treating abscesses of the body requiring operative drainage. METHOD: A retrospective study of a prospective patient database was performed, using randomized patient selection. Patient demographics, length and cost of stay were compared between patients undergoing operative management for skin abscess before and after the implementation of the fast-track ambulatory abscess pathway (FAAP). RESULTS: In total, 100 patients were analysed with 50 in the pre-ambulatory care pathway group and 50 in the FAAP group. The pre-ambulatory care pathway group had a mean age of 37.7 ± 15.8 years versus FAAP group of 35.3 ± 14.5 years. Total length of stay for the group was 85 versus 17 days with a mean comparison of 1.7 days versus 0.34 days (P < 0.001). This translated into a total cost saving of $74 100 in the FAAP group, with a mean comparison cost between the groups of $2884 versus $1402 (P < 0.001). Both reductions in length of stay and cost of stay were statistically significant after implementation of the pathway. CONCLUSION: This is the first Australian study to report the findings from an ambulatory care pathway for an emergency surgical intervention. We have shown that skin abscesses presenting through emergency can be managed as a day-case procedure, thereby decreasing these patients' overall length and cost of stay.

Surgical ultrasonography at the bedside: a comparison of surgical trainees with trained sonographers for symptomatic cholelithiasis - a first Australian experience.

BACKGROUND: Symptomatic cholelithiasis accounts for a significant burden of emergency general surgical presentations in Australia and the Western population. Access to hepatobiliary ultrasonography to facilitate diagnosis can lead to delays in timely treatment. Surgical ultrasonography at the bedside (SUB) can mitigate this barrier to patient care. This study assessed the diagnostic accuracy of SUB by trainees versus formal ultrasonographer or computed tomography examination for suspected symptomatic cholelithiasis. METHODS: A prospective non-inferiority study of emergency patient admissions with abdominal pain in two tertiary referral hospitals during July 2017 to October 2018 was performed. Results of SUB were compared with accredited radiographer ultrasonography or computed tomography and histopathological assessment. Positive findings at SUB for symptomatic cholelithiasis included: cholelithiasis, gallbladder wall thickness ˃3 mm, pericholecystic fluid or sonographic Murphy's sign. RESULTS: One hundred patients with epigastric or right upper quadrant pain underwent SUB. Mean patient age was 49 years (range 20-90 years), with 61 females and 39 males. Sensitivity and specificity for diagnosis of symptomatic cholelithiasis was 94.9% and 100% for SUB and 98.7% and 100% for accredited radiographers. Diagnostic accuracy was 96% for SUB and 99% for radiographer ultrasonography. Positive predictive value and negative predictive value were 100% and 84.6% for SUB and 100% and 96% for radiographers. The inter-rater reliability for features compatible with the diagnosis of symptomatic cholelithiasis was good with a kappa of 0.758 (95% confidence interval 0.587-0.929, P < 0.001). CONCLUSION: This first Australian experience demonstrates that general surgical trainees can accurately diagnose cholecystitis with SUB and this assessment is not inferior and has substantial agreement with accredited radiographer ultrasonography.

Loop and drain technique for subcutaneous abscess: a safe minimally invasive procedure in an adult population.

BACKGROUND: This study evaluated the safety, efficacy and compliance of an emerging technique for managing complex subcutaneous abscesses in an adult population (≥16 years). METHODS: A retrospective review of prospectively collected data between April and October 2015 at a rural hospital comparing conventional incision drainage (CID) and repetitive packing to the minimal incision, irrigation, loop and drain technique (LDT). LDT method was consistent with previous publications, being ≤5 mm incisions at abscess edges, irrigation and passage of a VessiLoop through the cavity and then secured above the skin. The loop remained in situ until resolution. Both groups had empirical oral antibiotics. RESULTS: Sixty-three patients required intervention for complex subcutaneous abscess: CID group had 27 patients and LDT had 36 patients. The mean age of CID group was 43.9 years (range: 16-86 years), all required intervention in theatre with 10 patients lost to follow-up (37%) and the remaining 17 required a mean of 11.8 (range: 1-17) care visits. The mean age of LDT group was 34.9 years (range: 16-62 years), 11 completed intervention in ED under local anaesthetic (30%) and 27 required general anaesthesia. Compliance to follow-up clinic was 100%: 27 seen once at 10-14 days with loop removal and nine were seen a second time to complete care. There were no re-operations. CONCLUSION: This is the first LDT data in adults and proves it is safe and effective. It saves operating theatre time with 30% of LDT treated in the Emergency Department and ensures excellent follow-up compliance as patients return for VessiLoop removal. Healthcare burden is greatly reduced using LDT; most patients require only one review at 10-14 days.