Operative and non-operative management for intestinal emergencies: findings from a single-centre retrospective cohort study.

BACKGROUND: Patients with an intestinal emergency who do not have surgery are poorly characterised. This study used electronic healthcare records to provide a rapid insight into the number of patients admitted with an intestinal emergency and compare short-term outcomes for non-operative and operative management. METHODS: A single-centre retrospective cohort study was conducted at a tertiary NHS hospital (from 1 December 2013 to 31 January 2020). Patients were identified using diagnosis codes for intestinal emergencies, based on the inclusion criteria for the National Emergency Laparotomy Audit. Relevant data were extracted from electronic healthcare records (n=3,997). RESULTS: Nearly half of patients admitted with an intestinal emergency received nonoperative management (43.7%). Of those who underwent surgery, 63.7% were started laparoscopically. The non-operative group had a shorter hospital stay (median: 5.4 days vs 8.2 days [started laparoscopically] or 16.8 days [started open]) and fewer unintended intensive care admissions than the surgical group (2.4% vs 8.7% [started laparoscopically] 21.1% [started open]). However, 30-day mortality for non-operative treatment was double that for surgery (22.4% vs 10.1%). The 30-day mortality rate was found to be even higher for non-operative management (50.3%) compared with surgery (19.5%) in a sub-analysis of patients with admission National Early Warning Score ≥4 (n=683). CONCLUSION: The proportion of patients with intestinal emergencies who do not have surgery is greater than expected, and it appears that many respond well to non-operative treatment. However, 30-day mortality for non-operative management was high, and the low number of admissions to intensive care suggests that major invasive treatment was not appropriate for most in this group.

Novel predictors of mortality in emergency bowel surgery: a single-centre cohort study.

Pre-operative risk stratification is a key part of the care pathway for emergency bowel surgery, as it facilitates the identification of high-risk patients. Several novel risk scores have recently been published that are designed to identify patients who are frail or significantly unwell. They can also be calculated pre-operatively from routinely collected clinical data. This study aimed to investigate the ability of these scores to predict 30-day mortality after emergency bowel surgery. A single centre cohort study was performed using our local data from the National Emergency Laparotomy Audit database. Further data were extracted from electronic hospital records (n = 1508). The National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score were then calculated. The most abnormal National or Laboratory Decision Tree Early Warning Score in the 24 or 72 h before surgery was used in analysis. Individual scores were reasonable predictors of mortality (c-statistic 0.699-0.740) but all were poorly calibrated. A National Early Warning Score ≥ 4 was associated with a high overall mortality rate (> 10%). A logistic regression model was developed using age, National Early Warning Score, Laboratory Decision Tree Early Warning Score and Hospital Frailty Risk Score as predictor variables, and its performance compared with other established risk models. The model demonstrated good discrimination and calibration (c-statistic 0.827) but was marginally outperformed by the National Emergency Laparotomy Audit score (c-statistic 0.861). All other models compared performed less well (c-statistics 0.734-0.808). Pre-operative patient vital signs, blood tests and markers of frailty can be used to accurately predict the risk of 30-day mortality after emergency bowel surgery.

Routine ultrasound for suspected appendicitis in children: a single-centre retrospective cohort study.

INTRODUCTION: Appendicitis continues to be a common surgical emergency in children, but its diagnosis remains challenging. Use of diagnostic imaging to confirm appendicitis has gained popularity in some countries because it is associated with lower negative appendicectomy rates. This study reports our centre's experience of adopting routine ultrasound for the investigation of suspected appendicitis in children. METHODS: A single-centre retrospective cohort study was performed investigating all children aged 5-16 years admitted under surgeons with suspected appendicitis, in January-December 2019. Primary outcomes were the rate of ultrasound use, its accuracy in diagnosing/excluding appendicitis and negative appendicectomy rate. Other outcomes were treatment received, length of stay and complications. RESULTS: The majority of the 193 children with suspected appendicitis underwent a diagnostic ultrasound (87.5%). Ultrasound was highly sensitive (0.90, 95% confidence interval (CI) 0.81-0.96) and specific (1.0, 95% CI 0.96-1.0) for appendicitis in this study. Negative appendicectomy rate was extremely low (1.4%). Laparoscopic appendicectomy was the preferred management (75/86), with one case started open and no conversions to open. A minority of cases of simple appendicitis (10/86) were treated primarily with antibiotics. Rates of complex appendicitis and postoperative complications were similar to other studies. CONCLUSION: Ultrasound can be highly sensitive and specific for appendicitis. Its routine use to confirm appendicitis prior to surgery is associated with a low negative appendicectomy rate. This is a major change in practice for a general surgical unit in the United Kingdom.

The impact of laparoscopy on emergency surgery for adhesional small bowel obstruction: prospective single centre cohort study.

INTRODUCTION: Laparoscopic adhesiolysis is increasingly being used to treat adhesional small bowel obstruction (ASBO) as it has been associated with reduced postoperative length of stay (LOS) and faster recovery. However, concerns regarding limited working space, iatrogenic bowel injury and failure to relieve the obstruction have limited its uptake. This study reports our centre's experience of adopting laparoscopy as the standard operative approach. METHODS: A single-centre prospective cohort study was performed incorporating local data from the National Emergency Laparotomy Audit Database; January 2015 to December 2019. All patients undergoing surgery for ASBO were included. Patient demographic, operative and inhospital outcomes data were compared between different surgical approaches. Linear regression analysis was performed for LOS. RESULTS: A total of 299 cases were identified. Overall, 76.3% of cases were started laparoscopically and 52.2% were completed successfully. Patients treated laparoscopically had lower Portsmouth - Physiological and Operative Severity Score for the enuMeration of Mortality and morbidity (P-POSSUM) predicted mortality (median 2.1 (interquartile range (IQR) 1.3-5.0) vs 5.7 (IQR 2.0-12.4), p=<0.001) and shorter postoperative LOS compared with open (median 4.2 days (IQR 2.5-8.2) vs 11.3 days (IQR 7.3-16.6), p=0.000). Inhospital mortality was lower in the laparoscopic group (2 vs 7 deaths, p=<0.001). In regression analysis, laparoscopic surgery was found to have the strongest association with postoperative LOS (ß -8.51 (-13.87 to -3.16) p=0.002) compared with open surgery. CONCLUSIONS: Laparoscopy is a safe and feasible approach for adhesiolysis in the majority of patients with ASBO. It is associated with reduced LOS with no impact on complications or mortality.

Technique and outcome of day case laparoscopic hiatus hernia surgery for small and large hernias: a five-year retrospective review from a high-volume UK centre.

INTRODUCTION: Laparoscopic anti-reflux surgery is the standard surgical treatment for gastro-oesophageal reflux disease in patients for who long-term pharmacotherapy is intolerable or ineffective. Advances in anaesthesia and minimally invasive surgery have led to day case treatment being adopted by some centres. The objective of this study is to describe our day case pathway and peri- and postoperative outcomes. MATERIALS AND METHODS: This is a single centre, retrospective case series review of a prospectively collected database from October 2014 to August 2019 performed in a tertiary centre for upper gastrointestinal surgery. Data collected included demographics, comorbidities, indications, complications, length of stay and readmission. RESULTS: A total of 362 patients underwent laparoscopic anti-reflux surgery with or without hiatus hernia repair of up to 10cm, with day case rates of 59%. Unplanned admission following day surgery was 5.1% (13/225) and 30-day readmission was 2.2% (8/362); 90.6% of patients remained in hospital for less than 24 hours. There was one intraoperative complication and one patient required revisional surgery within 30 days. The rate of all postoperative complications was 1.38% (5/362) with one postoperative mortality. DISCUSSION: The inclusion of larger hernias is unusual, as most studies limit size to 5cm or less. Our results show the safety and feasibility of the procedure even when applied to hiatus hernias up to 10cm. Success was multifactorial and based on standardisation of procedures and support from dedicated specialist nursing staff. CONCLUSION: Laparoscopic anti-reflux surgery can be performed safely as a day case procedure even in larger hiatus hernias, with a dedicated care pathway and specialist nurse practitioners to support it.

Ewing's sarcoma: only patients with 100% of necrosis after chemotherapy should be classified as having a good response.

AIMS: The purpose of this study was to review a large cohort of patients and further assess the correlation between the histological response to chemotherapy in patients with Ewing's sarcoma with the overall (OS) and event-free survival (EFS). PATIENTS AND METHODS: All patients treated for Ewing's sarcoma between 1980 and 2012 were reviewed. Of these, 293 patients without metastases at the time of diagnosis and treated with chemotherapy and surgery were included. Patients were grouped according to the percentage of necrosis after chemotherapy: Group I: 0% to 50%, Group II: 51% to 99% and Group III: 100%. RESULTS: The mean age at diagnosis was 16 years (1 to 62) and the mean follow-up was 9.1 years (six months to 32.6 years). The OS and EFS for the series were 75% and 65% at five years. There were significant differences in survival between the groups of necrosis: 0% to 50% (OS: 49% and EFS: 45% at five years, respectively) compared with 51% to 99% (OS: 72% and EFS: 59% at five years, respectively) and 100% (OS: 94% and EFS: 81% at five years, respectively) (p < 0.001). There were no significant differences in survival between patients treated between 1980 and 1989 compared with those treated between 1990 and 1999, and those treated between 2000 and 2012 (p = 0.55). CONCLUSION: Only patients with 100% necrosis after chemotherapy should be classified as having a good response to chemotherapy because they have significantly better rates of survival compared with those with any viable tumour in the surgical specimen. Cite this article: Bone Joint J 2016;98-B:1138-44.

Electrohydrodynamic jetting behaviour of polyhedral oligomeric silsesquioxane nanocomposite.

In this paper, we investigate in detail the electrohydrodynamic spraying of a nonbiodegradable nanocomposite polyhedral oligomeric silsesquioxane polymer developed in our laboratories and currently being explored for coating metallic stent materials. Different concentrations of the polymer have been dissolved to prepare, characterise, and electrohydrodynamically deposit the polymer on stainless steel. From the experiments, the solution containing 15 wt% polymer was selected for further investigation. The variation of film/coating thickness as a function of spraying time was studied and the structural features of the film were assessed using microscopy. Films were also tensile tested. This study has identified a process and conditions which can be used in our stent coating research.

Endotracheal suctioning causes right upper lobe collapse in intubated children.

OBJECTIVE: Right upper lobe collapse is a common radiographic finding in intubated children. We hypothesized that deep suctioning and uncontrolled negative pressures during endotracheal tube suctioning were significant contributory factors. METHODS: The incidence of right upper lobe (RUL) collapse in intubated, ventilated children on a paediatric cardiac intensive care unit was determined over a 3-month period (n = 102). Graduated suction catheters and suction vacuums of < 165 cm H2O were then introduced. Another prospective audit was carried out 3 months later (n = 60). RESULTS: We found that 24% developed RUL collapse and 4 developed an apical pneumothorax. Following the introduction of graduated catheters and controlled vacuums pressures; a significant reduction in the incidence of RUL collapse, to 7%, was observed (p < 0.05). CONCLUSIONS: We conclude that high negative pressure and deep-suctioning causes RUL collapse in children. Any lobar collapse not only prolongs the child's stay in intensive care, but can be associated with further morbidity which may have a serious implication. By improving suctioning technique this morbidity can be significantly reduced.