Improved outcomes for index cholecystectomy for acute cholecystitis following a dedicated emergency surgery and trauma service (ESAT).

INTRODUCTION: Early laparoscopic cholecystectomy (ELC) has shown to reduce length of stay and improve patients' satisfaction as compared to delayed laparoscopic cholecystectomy (DLC). However, logistics and manpower limitations often preclude ELC. METHODS: A retrospective study was conducted in a single institute to compare outcomes of AC before (August 2013-2014) and after (August 2017-2018) establishment of emergency surgery and trauma (ESAT). RESULTS: There were 82 patients in pre-ESAT period and 172 patients in ESAT period. Mean age was 52.3 ± 11.6 and 55.7 ± 13.8 years, respectively, p = 0.369. There were more patients with moderate-severe grading of cholecystitis based on Tokyo Guidelines (TG 18) in ESAT 143/172 (83.1%) as compared to pre-ESAT 65/82 (79.3%), p = 0.042. Index cholecystectomy was performed in 145/172 (84.3%) of patients in the ESAT vs 34/82 (41.5%) of patients in the pre-ESAT period (p = 0.001). Time interval between booking to surgery was 180 ± 56 min in ESAT vs 197 ± 98 min in pre-ESAT, p = 0.014. Operative duration was shorter in ESAT 121 ± 38.5 min vs 139 ± 53.4, in pre-ESAT period, p = 0.030. Conversion rates were lower in ESAT (4/172, 2.3%) vs (9/72, 11%) in pre-ESAT, p = 0.003. Length of stay was shorter in ESAT (DLC 1.89 ± 1.6 and ELC ± 2.9 days) as compared to pre-ESAT (DLC 4.55 ± 2.2 and ELC 5.03 ± 2.6 days), p = 0.001. 30-day readmissions were lower in ESAT (3/172, 1.7%) vs pre-ESAT (8/72, 9.8%). CONCLUSION: The ESAT model provided more early laparoscopic cholecystectomies with improved efficiency and clinical outcomes.

Evolution of a Dedicated Emergency Surgery and Trauma (ESAT) unit over 3 years: sustained improved outcomes.

INTRODUCTION: The traditional 24-h call model faces pressure from competing needs between emergency and elective services. Recognizing this, a dedicated ESAT service was developed in Khoo Teck Puat Hospital in Singapore, with improved clinical outcomes. It was initially led by a single consultant (SC) in 2014, and subsequently evolved to a weekly consultant rotation (WC) roster in 2017 to achieve sustainability. METHODS: Each consultant led the ESAT WC service for a week and maintained ownership of their patients thereafter. All emergency surgical admissions between two distinct 6-month periods were reviewed, from May to October 2014 (pre-ESAT) and January to June 2017 (ESAT WC). Patient demographics, diagnoses, and operations were compared. Efficiency and clinical outcomes were evaluated. RESULTS: There were 1248 and 1284 patients in the pre-ESAT and ESAT WC group, respectively. Majority were males and in their 50s. Acute appendicitis, gallstone conditions, and soft-tissue infections made up half of the admissions. Trauma workload was comparable (7.8% pre-ESAT vs 9.5% ESAT WC). Cholecystectomies doubled during the ESAT period, 14.2% vs 7.2%, (p = 0.01). More consultants were involved in major cases (95.9% vs 86%), (p = 0.01) and more operations were performed during the day (52.1% vs 47.9%), (p = 0.01). Average time to OT was shorter and there were less major surgical complications (p = 0.02). Mortality (p = 0.08) and length of stay were reduced (4 vs 4.5 days), (p = 0.01). CONCLUSION: The ESAT WC service has sustained improved outcomes in our institution.

Impact of perioperative hypoglycaemia in subjects with diabetes undergoing colorectal surgery.

INTRODUCTION: This study explores the association between perioperative hypoglycaemia and surgical outcomes in subjects with diabetes, undergoing colorectal surgery. METHODS: A retrospective review of 149 subjects with Type 2 Diabetes Mellitus (DM) who underwent colorectal surgery between 2010 and 2015 was performed. Perioperative glucose levels, glycated haemoglobin (HbA1c) measurements within 3 months of surgery and surgical complications based on Clavien-Dindo classification were analysed. RESULTS: The mean age was 67 years (67 ± 11.2). Perioperative hypoglycaemia was found in 7.4% of subjects. The mean HbA1c of subjects with Clavien 2 and above surgical complications were higher than patients with Clavien 1 or no complications, Hba1c 7.6% (7.6 ± 2.5%) and 7.0% (7.0 ± 1.1%, p = 0.008), respectively. Similar findings in subjects with Clavien 3 and above complications, HbA1c of 8.2% (8.2 ± 3.9%) as compared to those with Clavien 2 and below complications, 7.2% (7.2 ± 1.5%, p = 0.001). Adjusted multivariate analysis showed that hypoglycaemia was significantly associated with Clavien 2 and above surgical complications, OR of 19.0 (CI 2.23-162, p = 0.007). Preoperative hypoglycaemia was associated with Clavien 2 and above surgical complications, OR 10.7 (CI 1.22-94.1, p = 0.032). Suboptimal glycaemic control (Hba1c >8.0%) was significantly associated with Clavien 2 and above complications, OR 2.48 (CI 1.04-5.91, p = 0.04), but not with Clavien 3 and above complications, OR 1.50 (CI 0.450-4.98, p = 0.511). CONCLUSION: Perioperative hypoglycaemia is associated with adverse surgical outcomes in diabetic patients undergoing colorectal surgery. Prevention of hypoglycaemia may improve surgical outcomes. HbA1c is an independent predictor for adverse surgical outcomes.