Reducing emergency admissions and length of stay by introducing emergency surgical ambulatory service.

BACKGROUND: Emergency surgical ambulatory care provides safe and effective assessment of acute surgical referrals, in addition to reducing the pressures on hospital beds.Our aim was to look at the effect of opening a surgical ambulatory care unit (SACU) and a dedicated surgeon for the unit on length of stay and same day discharge for emergency referrals. METHODS: Data was collected prospectively and updated daily to include all referrals to SACU. Historical data was retrieved to compare the effect of introduction of SACU and dedicated surgeon on same day discharge and length of stay. RESULTS: Three groups of patients were identified: pre-SACU, SACU and SACU with dedicated surgeon. There was 104.5% percentage increase in same day discharge rate for emergency GP referrals (22% pre-SACU to 45% in the dedicated surgeon group). Similarly, same day discharge for all emergency referrals increased from 17% pre-SACU to 29% in the dedicated surgeon group.There was 25.88 h reduction in the mean length of stay for emergency GP admissions (92.95 h pre-SACU to 67.07 h in the dedicated surgeon group). In pre-SACU group mean length of stay for all emergency admissions was 125 h, this dropped to 107.09 h in the dedicated surgeon group. This resulted in 102 hospital bed stays saved every month since the opening of SACU. CONCLUSIONS: Establishing an emergency surgical ambulatory service has reduced length of stay and saved significant hospital bed stays. This effect was enhanced by having a dedicated senior surgeon providing early input and decision making.

Venous thromboembolism following colorectal resection.

AIM: The study investigated the rate of significant venous thromboembolism (VTE) following colorectal resection during the index admission and over 1 year following discharge. It identifies risk factors associated with VTE and considers the length of VTE prophylaxis required. METHOD: All adult patients who underwent colorectal resections in England between April 2007 and March 2008 were identified using Hospital Episode Statistics data. They were studied during the index admission and followed for a year to identify any patients who were readmitted as an emergency with a diagnosis of deep venous thrombosis or pulmonary embolism. RESULTS: In all, 35 997 patients underwent colorectal resection during the period of study. The VTE rate was 2.3%. Two hundred and one (0.56%) patients developed VTE during the index admission and 571 (1.72%) were readmitted with VTE. Following discharge from the index admission, the risk of VTE in patients with cancer remained elevated for 6 months compared with 2 months in patients with benign disease. Age, postoperative stay, cancer, emergency admission and emergency surgery for patients with inflammatory bowel disease (IBD) were all independent risk factors associated with an increased risk of VTE. Patients with ischaemic heart disease and those having elective minimal access surgery appear to have lower levels of VTE. CONCLUSION: This study adds to the benefits of minimal access surgery and demonstrates an additional risk to patients undergoing emergency surgery for IBD. The majority of VTE cases occur following discharge from the index admission. Therefore, surgery for cancer, emergency surgery for IBD and those with an extended hospital stay may benefit from extended VTE prophylaxis. This study demonstrates that a stratified approach may be required to reduce the incidence of VTE.

Bile duct reconstruction following laparoscopic cholecystectomy in England.

OBJECTIVES: To determine the incidence of bile duct reconstruction (BDR) following laparoscopic cholecystectomy (LC) and to identify associated risk factors. BACKGROUND: Major bile duct injury (BDI) requiring reconstruction is a serious complication of cholecystectomy. METHODS: All LC and attempted LC operations in England between April 2001 and March 2013 were identified. Patients with malignancy, a stone in bile duct or those who underwent bile duct exploration were excluded. This cohort of patients was followed for 1 year to identify those who underwent BDR as a surrogate marker for major BDI. Logistic regression was used to identify factors associated with the need for reconstruction. RESULTS: In total, 572,223 LC and attempted LC were performed in England between April 2001 and March 2013. Five hundred (0.09 %) of these patients underwent BDR. The risk of BDR is lower in patient that do not have acute cholecystitis [odds ratio (OR) 0.48 (95 % CI 0.30-0.76)]. The regular use of on-table cholangiography (OTC) [OR 0.69 (0.54-0.88)] and high consultant caseload >80 LC/year [OR 0.56 (0.39-0.54)] reduced the risk of BDR. Patients who underwent BDR were 10 times more likely to die within a year than those who did not require further surgery (6 vs. 0.6 %). CONCLUSIONS: The rate of BDR following laparoscopic cholecystectomy in England is low (0.09 %). The study suggests that OTC should be used more widely and provides further evidence in support of the provision of LC services by specialised teams with an adequate caseload (>80).

Rapunzel syndrome resulting in gastric perforation.

We report the case of an 18-year-old female patient with no past medical history who presented to the emergency department with acute abdominal pain and vomiting on the background of a long history of ingesting hair (trichophagia). Computed tomography revealed pneumoperitoneum and free fluid in keeping with visceral perforation. In addition, a large hair bolus was seen extending in contiguity from the stomach to the jejunum. A laparotomy was performed, revealing an anterior gastric perforation secondary to a 120cm long trichobezoar, which had formed a cast of the entire stomach, duodenum and proximal jejunum. The bezoar was removed and an omental patch repair to the anterior ulcer was performed. The patient made an excellent postoperative recovery and was discharged home with psychiatric follow-up review.

Definitive management of gallstone pancreatitis in England.

INTRODUCTION: The aim of this study was to investigate whether definitive treatment of gallstone pancreatitis (GSP) by either cholecystectomy or endoscopic sphincterotomy in England conforms with British Society of Gastroenterology (BSG) guidelines and to validate these guidelines. METHODS: Hospital Episode Statistics data were used to identify patients admitted for the first time with GSP between April 2007 and April 2008. These patients were followed until April 2009 to identify any who underwent definitive treatment or were readmitted with a further bout of GSP as an emergency. RESULTS: A total of 5,454 patients were admitted with GSP between April 2007 and April 2008, of whom 1,866 (34.2%) underwent definitive treatment according to BSG guidelines, 1,471 on the index admission. Patients who underwent a cholecystectomy during the index admission were less likely to be readmitted with a further bout of GSP (1.7%) than those who underwent endoscopic sphincterotomy alone (5.3%) or those who did not undergo any form of definitive treatment (13.2%). Of those patients who did not undergo definitive treatment before discharge, 2,239 received definitive treatment following discharge but only 395 (17.6%) of these had this within 2 weeks. Of the 505 patients who did not undergo definitive treatment on the index admission and who were readmitted as an emergency with GSP, 154 (30.5%) were admitted during the 2 weeks immediately following discharge. CONCLUSIONS: Following an attack of mild GSP, cholecystectomy should be offered to all patients prior to discharge. If patients are not fit for surgery, an endoscopic sphincterotomy should be performed as definitive treatment.

Loop ileostomy following anterior resection: is it really temporary?

INTRODUCTION: A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis if anastomotic dehiscence occurs following low colorectal anastomosis. Although it has been suggested that a loop ileostomy should be reversed within 12 weeks of formation, this is often not the case. We set out to analyse the use of loop ileostomy following elective anterior resection in England and to identify factors associated with non and delayed reversal. METHOD: Hospital episode statistics for the years 2001-2006 were obtained from the Department of Health. Patients undergoing elective anterior resection with a loop ileostomy for a primary diagnosis of rectal or recto-sigmoid cancer between April 2001 and March 2003 were identified as the study cohort. This cohort was followed until March 2006 to identify patients undergoing reversal of an ileostomy in an English NHS Hospital. RESULTS: A total of 6582 patients had an elective anterior resection between April 2001 and March 2003, of which 964 (14.6%) also had an ileostomy. Seven hundred and two (75.1%) patients were reversed before March 2006. Advancing age and comorbidity were statistically related to nonreversal. Median time to reversal was 207 days (Interquartile range 119-321.5 days). Postoperative chemotherapy and comorbidity significantly delayed reversal. CONCLUSIONS: One in four loop ileostomies performed to defunction an elective anterior resection is not reversed, and in the presence of significant comorbidity one in three is not reversed. Only 12% is reversed within 12 weeks.

Conversion after laparoscopic cholecystectomy in England.

BACKGROUND: Laparoscopic cholecystectomy is the procedure of choice for the treatment of symptomatic gallstones. Conversion to open surgery is reported to be necessary in 5-10% of cases. This study aimed to define those factors associated in English hospitals with the need to convert a laparoscopic cholecystectomy to an open procedure. These included patient-related and particularly nonpatient-related factors. METHODS: Using data derived from a national administrative database, Hospital Episode Statistics, patients undergoing cholecystectomy in acute National Health Service (NHS) hospitals in England during the financial years 2004-2006 were studied. The individual surgeon caseload and the hospital conversion rate were calculated using data from the first (baseline) year. Factors affecting the need for conversion were analyzed using data from the second (index) year. RESULTS: The study included 43,821 laparoscopic cholecystectomies undertaken from 2005 to 2006 in English hospitals. The overall conversion rate was 5.2%: 4.6% for elective procedures and 9.4% for emergency procedures. Patient-related factors that were good predictors of conversion included male sex, emergency admission, old age, and complicated gallstone disease (p < 0.001). Nonpatient-related factors that were good predictors of conversion included the laparoscopic cholecystectomy caseload of individual consultant surgeons and the overall hospital conversion rate in the previous year (all p < 0.001). CONCLUSIONS: Conversion after laparoscopic cholecystectomy is less common as consultant caseload increases. This suggests that operation should be undertaken only by surgeons with an adequate caseload. There is a wide variation in conversion rates among hospitals. This has important implications for training as well as for the organization and accreditation of cholecystectomy services on a national basis.

Use of Hartmann's procedure in England.

INTRODUCTION: Hartmann's procedure is widely used in the management of complicated diverticular disease and for colorectal cancer. Very little national data are available about the reasons for performing this procedure and the reversal rate. METHOD: Hospital episode statistics data were obtained from The Department of Health and exported to an Access database for analysis. A cohort of patients who underwent a Hartmann's procedure between April 2001 and March 2002 were identified and followed until April 2006 to identify patients undergoing reversal of Hartmann's. RESULTS: Approximately 3950 Hartmann's procedures were performed between April 2001 and March 2002, 2853 as an emergency and 1097 as an elective procedure. Most emergency Hartmann's were performed for benign disease (2067, 72.5%) whereas a majority of the elective Hartmann's were performed for cancer (756, 68.9%). Seven hundred and thirty six (23.3%) of these patients underwent reversal during the study period. The median time interval between a Hartmann's procedure and reversal was 284.5 days (interquartile range 181-468.25). CONCLUSION: This study represents the single largest cohort in whom outcome after Hartmann's procedure has been studied. A majority of Hartmann's are performed as an emergency for benign diseases and most of them are not reversed.

Management of acute gallbladder disease in England.

BACKGROUND: Recent literature suggests that early laparoscopic cholecystectomy for acute gallbladder disease is safe and efficacious, but few data are available on the management of acute gallbladder disease in England. METHODS: Hospital Episode Statistics data for the years 2003-2005 were obtained from the Department of Health. All patients admitted as an emergency with acute gallbladder disease during the period from April 2003 to March 2004 were included as a cohort. Repeat emergency admissions for acute gallbladder disease, and cholecystectomies performed during the first admission, an emergency readmission or an elective admission were followed up until March 2005. RESULTS: Some 25,743 patients were admitted as an emergency with acute gallbladder disease, of whom 3791 had an emergency cholecystectomy during the first admission (open cholecystectomy (OC) 29.8 per cent, laparoscopic conversion rate (LCR) 10.7 per cent) and 9806 patients had an elective cholecystectomy (OC 11.3 per cent, LCR 8.3 per cent) during the study period. CONCLUSION: Early cholecystectomy for acute gallbladder disease is not widely practised by surgeons in England. Open cholecystectomy is more commonly used in the emergency than in the elective setting. Early laparoscopic cholecystectomy following an emergency admission carries a higher conversion rate than elective cholecystectomy.

Oesophagectomy practice and outcomes in England.

BACKGROUND: The 2001 UK National Health Service guidance on improving outcomes recommended centralization of oesophageal resection. The aim of this study was to analyse national trends in oesophageal resection in England to determine whether centralization has occurred and its impact on outcomes. METHODS: The study used data from Hospital Episode Statistics for 1997-1998 to 2003-2004 and included patients who had resection for oesophageal cancer. The annual hospital volume was grouped into five categories based on the recommendation for annual volume for a designated centre. RESULTS: A total of 11 838 oesophageal resections were performed. The total number of hospitals performing resections decreased, mainly owing to a fall in the number of very low-volume hospitals (117 in 1997 to 45 in 2003). The proportion of resections performed in very high-volume hospitals increased from 17.8 per cent during 1997-1999 to 21.9 per cent during 2002-2003 (P < 0.001). The overall in-hospital mortality rate was 10.1 per cent, with a significant reduction over time (from 11.7 to 7.6 per cent; P < 0.001). The decline in mortality rate may be due to increased numbers of patients undergoing surgery in higher-volume hospitals. There was an increase in the annual number of new patients from 5672 to 6230 during the study, although a fall in the proportion of resections from 31.5 to 26.0 per cent (P < 0.001). CONCLUSION: Centralization and multidisciplinary team expertise partly explain the improvement in mortality rate, but changes in preoperative selection also play a part.

Uterine transplantation, abdominal trachelectomy, and other reproductive options for cancer patients.

More and more women with cancer issues are now raising fertility concerns as survival improves and childbearing is delayed. Pregnancy is no longer contraindicated in cancer patients including breast and endometrial cancer survivors. In fact, survival in patients treated for breast cancer who subsequently become pregnant is actually higher than that in patients who do not become pregnant. "Therapeutic" abortions are no longer recommended. Assisted reproductive technology (ART) have been associated with ovarian neoplasms, but the association is probably not causal. Neither ART nor hormone replacement is contraindicated in cancer patients. Our institution is very supportive of patients and the difficult decisions cancer survivors face. Using a program of counseling and close collaboration between oncologists, perinatologists, and reproductive endocrinologists, informed patients are offered every possible option, including ART and uterine transplantation, to achieve their family planning objectives.

Effect of CD4(+) and CD8(+) cell depletion on wound healing.

BACKGROUND: Depression of the immune system can result in poor or delayed wound healing. METHODS: Thymectomized rats were depleted of CD4(+) and CD8(+) lymphocytes by intraperitoneal injection of Medical Research Council Oxford (MRC OX)38 antibodies and MRC OX8. Significant depletion was demonstrated throughout the wound healing process by immunofluorescence studies of peripheral blood. Following depletion the rats underwent laparotomy incisions which were allowed to heal for 10 weeks. Differences in healing were demonstrated by analysing the wounds biomechanically by tensiometry to obtain values of ultimate strength, resilience, toughness, maximum extension and elastic constant. RESULTS: Wounds of animals depleted of CD4+ lymphocytes showed a significant decrease in ultimate strength, resilience and toughness. Wounds of animals depleted of CD8(+) lymphocytes showed a significant increase in ultimate strength, resilience and toughness. CONCLUSION: Wounds healed in the absence of T lymphocytes. However, the subsets have an opposing regulatory role, with CD4(+) lymphocytes upregulating and CD8(+) lymphocytes downregulating wound healing. Presented to the Surgical Research Society in Nottingham, UK, 11 July 1997 and published in abstract form as Br J Surg 1997; 84: 1618

Increased risk of wound complications and poor healing following laparotomy in HIV-seropositive and AIDS patients.

The number of individuals in the UK who are HIV seropositive is increasing as is their presentation with abdominal complications. Poor wound healing following anorectal surgery in HIV-positive patients has been well reported. This study reviews the incidence of wound complications following laparotomy. The hospital records of all HIV-positive patients who underwent laparotomy at a London teaching hospital over a 10-year period were reviewed and compared to an equal number of matched non-HIV patients. Between April 1986 and April 1996, 64 laparotomies were carried out on 53 patients. There was a significantly greater incidence of wound complications (chi2 = 12.75, 1 d.f., p = 0.0003) and wound breakdown (chi2 = 10.45, 1 d.f., p = 0.012) in the HIV group following laparotomy than in the non-HIV control group.

Abdominal radical trachelectomy: a new surgical technique for the conservative management of cervical carcinoma.

Traditionally radical hysterectomy has formed the mainstay of treatment for early stage cervical carcinoma. More recently radical trachelectomy and laparoscopic lymphadenectomy have been introduced to allow preservation of fertility. We present a new approach to fertility-sparing surgery, namely abdominal radical trachelectomy. The technique is similar to a standard radical hysterectomy and lymphadenectomy. In our technique the ovarian vessels are not ligated and, following lymphadenectomy and skeletonisation of the uterine arteries, the cervix, parametrium and vaginal cuff are excised. The residuum of the cervix is then sutured to the vagina and the uterine ateries re-anastomosed.

Effect of starch-containing glove powder on wound healing in the rat.

The effect of the starch-containing powder BioSorb on wound healing was examined in an immunocompetent and a T cell-deficient animal model. Wounds were tested by tensionometry to give values of resilience, ultimate strength, toughness and extension. Starch significantly decreased the resilience (P < 0.03), ultimate strength (P < 0.004), and toughness (P < 0.006) of wounds in the immunocompetent model but was not shown to affect the healing of wounds in T cell-depleted animals. When the uncontaminated wounds of the two groups were compared, those from T cell-depleted animals were tougher (P < 0.04) and less extensile (P < 0.0002). These results suggest that starch impairs wound healing by its effect on the T cell-mediated immune system, and that this system may also be involved in regulation of the reparative process because its absence leads to tougher wounds.