Day case laparoscopic cholecystectomy, room for improvement: A United Kingdom District General Hospital experience

Background: Laparoscopic cholecystectomy (LC) is the surgical treatment of choice for symptomatic gallstones. The current NHS innovation drive is to perform 60 % of all elective laparoscopic cholecystectomies as day cases. Methods: A retrospective data analysis was performed for all day case laparoscopic cholecystectomies in a single institution between January 2009 and December 2011. Causes of failed discharges, post-operative complications and readmission rates were recorded. Results: A total of 476 patients were listed as day-cases. 348 patients (73 %) were discharged the same day. 128 patients (27 %) were admitted, of these 89 (69.5 %) were discharged within 24 hours and 21 (16 %) were discharged within 2 days. 39 patients who failed discharge were due to pain only (30 %), 6 due to nausea & vomiting (5 °A)), 55 due to other reasons (43 %) and the remaining 28 due to a combination of symptoms. All 15 patients who had a drain inserted, stayed overnight (P < 0.001). All those patients who had a procedure lasting longer than two hours, failed same day discharge (P < 0.001). Our overall rates for complications, conversions to open and readmission were 2.5 %, 1.5 % and 1.7 % respectively. Our day case rate doubled from 22 % in 2009 to 50 °A) in 2010 and then plateaued at 48 °A) in 2011 as more emergency cases were being performed over this period. Conclusion: Day case laparoscopic Cholecystectomy is a feasible and a safe treatment for symptomatic gallstones. Patients should be listed on a morning list and drain insertion avoided whenever possible, with robust protocols for management of post-operative pain and vomiting (AU)

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Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia.

BACKGROUND: Hypocalcaemia is common after thyroidectomy. Accurate prediction and appropriate management may help reduce morbidity and hospital stay. The aim of this study was to perform a systematic literature review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia. METHODS: A systematic search of PubMed, EMBASE and the Cochrane Library databases was undertaken, and the quality of manuscripts assessed using a modified Newcastle-Ottawa Scale. RESULTS: Some 115 observational studies were included. The median (i.q.r.) incidence of transient and permanent hypocalcaemia was 27 (19-38) and 1 (0-3) per cent respectively. Independent predictors of transient hypocalcaemia included levels of preoperative calcium, perioperative parathyroid hormone (PTH), preoperative 25-hydroxyvitamin D and postoperative magnesium. Clinical predictors included surgery for recurrent goitre and reoperation for bleeding. A calcium level lower than 1·88 mmol/l at 24 h after surgery, identification of fewer than two parathyroid glands (PTGs) at surgery, reoperation for bleeding, Graves' disease and heavier thyroid specimens were identified as independent predictors of permanent hypocalcaemia in multivariable analysis. Factors associated with transient hypocalcaemia in meta-analyses were inadvertent PTG excision (odds ratio (OR) 1·90, 95 per cent confidence interval 1·31 to 2·74), PTG autotransplantation (OR 2·03, 1·44 to 2·86), Graves' disease (OR 1·75, 1·34 to 2·28) and female sex (OR 2·28, 1·53 to 3·40). CONCLUSION: Perioperative PTH, preoperative vitamin D and postoperative changes in calcium are biochemical predictors of post-thyroidectomy hypocalcaemia. Clinical predictors include female sex, Graves' disease, need for parathyroid autotransplantation and inadvertent excision of PTGs.

Combined modality treatment for complex fistulating perianal Crohn's disease.

AIM: Perianal disease affects 33% (range 8-90%) of patients with Crohn's disease. Fistulae are often complex and their management is often difficult and unsatisfactory. This study was a retrospective assessment of a combination of surgical treatment with a standardized protocol of infliximab (IFX) therapy. METHOD: A consecutive series of patients with complex perianal Crohn's disease, presenting between January 2003 and June 2008, were included. Acute sepsis was initially treated with antibiotics and/or surgical drainage (MRI guided when appropriate) and loose seton insertion. IFX was given at 5 mg/kg, at 0, 2 and 6 weeks. End-points were complete, partial or no response. Setons were empirically removed after the second cycle of IFX. RESULTS: Forty-eight patients, average age 46 (range 24-82)years, with perianal Crohn's disease were identified. Three patients stopped IFX after the second infusion, either because of allergy (two patients) or for failure to respond (one patient). Fourteen patients were given maintenance IFX at 8-weekly intervals. Results were recorded for 48 patients, of whom 14 (29%) had a complete response, 20 (42%) had a partial response and 14 (29%) had no response to treatment. Outpatient follow-up was for a median of 20 months. CONCLUSION: Combining surgical procedures with IFX resulted in complete and partial remission in 29% and 42% of patients, respectively. No serious side effects occurred. Using a combined, intensive medico-surgical approach, good initial control of perianal disease was achieved safely.

Percutaneous cholecystostomy as an alternative to cholecystectomy in high risk patients with biliary sepsis: a district general hospital experience.

INTRODUCTION: Cholecystectomy is the standard treatment for patients with acute cholecystitis. However, percutaneous cholecystostomy (PC) is an alternative for patients at high risk for surgery. We present our five-year clinical experience with the aim of evaluating the efficacy of PC in high risk patients. METHODS: A retrospective review was performed on 30 consecutive patients who underwent PC at our institution. The indications for cholecystostomy, route of insertion, technical success, clinical improvement, length of hospitalisation, in-hospital or 30-day mortality, complications, subsequent admissions and performance of interval cholecystectomy were recorded. The median follow-up period was 25 months (range: 1-52 months). RESULTS: Thirty-two PCs were performed in thirty patients (mean age: 76.1 years; range: 52-90 years). The indications for PC were acute calculous cholecystitis (29/32), acalculous cholecystitis (1/32) and emphysematous cholecystitis (2/32). The route of insertion was transperitoneal for 22/32 PCs (68.8%) and transhepatic for 10/32 (31.2%). The procedure was technically successful in all patients although 2/22 transperitoneal drains (9.1%) were dislodged subsequently. Twenty-seven PCs (84.4%) resulted in clinical improvement within five days. The in-hospital or 30-day mortality rate was 16.7% (5/30). Eleven patients (36.7%) had a subsequent cholecystectomy: 6 were laparoscopic and 5 converted to open procedures at a median interval of 58 days (range: 1-124 days). CONCLUSIONS: PCs are straightforward with few complications. Most patients improve clinically and the procedure can therefore be used as a definitive treatment in unfit patients or as a bridge to surgery in those who might subsequently prove fit for a definitive operation.