The impact of COVID-19 on emergency general surgery admissions and operative volumes: A single centre experience.

INTRODUCTION: The COVID-19 pandemic has placed a significant strain on healthcare resources and utilisation globally. The appearance of the disease in the Republic of Ireland resulted in a broad postponement of scheduled and routine surgical care. The influence of the novel coronavirus, and the associated imposition of public health measures such as school closures and social distancing, on the burden of emergency surgical disease is less clear. AIM: The aim of this study was to examine the impact of COVID-19 on the number of patients presenting to our institution with emergent surgical illnesses or requiring emergency general surgical procedures. METHODS: All patients attending our service between March 1st 2020 and April 30th 2020 were identified retrospectively by examining electronic handover and electronic discharge summaries, and data were collected relating to demographics, presenting illness, critical care utilisation, length of stay, operative or endoscopic procedure performed, and in-hospital mortality. Similar data were collected March 1st to April 30th 2019, 2018, and 2017 respectively to allow direct comparison. RESULTS: 151 patients were admitted during the study period, compared to a total of 788 during the proceeding three years (mean 2.49 admissions per night versus 4.35 per night, 42.8% reduction, p < 0.001). Median age of admitted patients was 51.8 years, compared to 50.3 years formerly (p = 0.35). 53 emergency procedures were performed, compared to a median of 70 over the same period in the previous years (mean 0.87 per day versus 1.16 per day, 25.4% reduction, p = 0.05). CONCLUSION: A significant overall reduction in the number of patients being admitted to our unit and requiring emergency surgical procedures during March and April 2020 was seen, in line with patterns reported internationally.

Correction to: Laparoscopic-assisted transversus abdominis plane block as an effective analgesic in total extraperitoneal inguinal hernia repair: a double-blind, randomized controlled trial.

In the original publication, one of the co-author 'M. Riaz' details were missed to include in the author group. The complete author group should read as A. Mughal, A. Khan, J. Rehman, H. Naseem, M. Riaz, R. Waldron, M. Duggan, W. Khan, K. Barry, I. Z. Khan.

Laparoscopic-assisted transversus abdominis plane block as an effective analgesic in total extraperitoneal inguinal hernia repair: a double-blind, randomized controlled trial.

PURPOSE: Laparoscopic inguinal hernia repair has facilitated early mobilization. Management of post-operative pain is paramount in these day case procedures. The aim of this study was to compare laparoscopic-assisted transversus abdominis plane (TAP) block with periportal local anaesthetic infiltration in managing post-operative pain. METHODS: A double-blind, randomized controlled trial was conducted with patients undergoing elective laparoscopic inguinal hernia repair (January 2016-October 2017). The intervention group received laparoscopic-assisted TAP block with 30 ml 0.25% Bupivacaine. The control group received 15ml of 0.5% Bupivacaine at the periportal sites. Primary outcome measure was assessment of post-operative pain scores using numerical rating on visual analogue scale (VAS) at rest and on coughing at 3 h. Efficacy of TAP block was assessed as reduction in mean pain scores in the order of 2 points using the VAS. RESULTS: 60 (57 males and 3 females) were enrolled; 30 patients were randomized to each group. Patient demographics, anaesthetic and surgical times were similar in both groups. Mean pain scores were significantly reduced in the intervention group at 3 (3.1 vs 1.1 p < 0.001) and 6 h (4.1 vs 1.7 p < 0.001) at rest and on coughing at 3 (4.8 vs 2.1 p < 0.001) and 6 h (5.4 vs 3.0 p < 0.001). Patient satisfaction was higher (8.0 vs 6.8 p < 0.001) and rescue analgesic requirements (169.4vs 71.3 p < 0.001) lower in the intervention group. CONCLUSIONS: This analysis has demonstrated the therapeutic benefit of laparoscopic-assisted TAP block in initial post-operative pain management for patients undergoing elective laparoscopic inguinal hernia repair.

Prospective validation of neutrophil-to-lymphocyte ratio as a diagnostic and management adjunct in acute appendicitis.

BACKGROUND: No optimal biomarker exists that accurately diagnoses appendicitis or predicts severity, estimates post-operative complications or total length of hospital stay (LOS). AIM: To prospectively validate the utility of neutrophil-to-lymphocyte (NLR) ratio in predicting the severity of appendicitis, LOS, and 30-day complication rates. METHODS: Patients who were admitted with a provisional diagnosis of acute appendicitis over a period of 18 months (Oct 2014-April 2016) were included. Patient demographics and blood results were prospectively collected. Details of imaging, operative intervention, severity of appendicitis, length of stay, and 30-days post admission complications were recorded. Recommended cut-off values of NLR and C-reactive protein for severity of appendicitis were determined using receiver operating characteristic analysis (ROC). These cut-off values were compared with C-reactive protein levels. Mann-Whitney test was performed to assess the correlations between LOS and 30-day complications to NLR. RESULTS: Four hundred fifty-three patients were included in the study; 55.2% (n = 245) were female with mean patient age of 23 years. Two-thirds (n = 281, 62.03%) underwent operative management. Histologically, appendicitis was confirmed in 214 (76%) patients. A NLR of >6.36 or CRP of >28 were statistically associated with complicated acute appendicitis, with a median of one extra hospital day (p < 0.0001). Mean NLR was statistically higher in patients with post-operative complications (14.42 vs. 7.29 for simple appendicitis group, p < 0.001). CONCLUSION: This confirms previous reports that NLR is a simple, readily available adjunct in predicting severity of appendicitis. Additionally, it can aid delineating severe appendicitis that should proceed to surgery without substantial delay.

Adherence to clinical guidelines and the potential economic benefits of admission avoidance for acute uncomplicated diverticulitis.

BACKGROUND: The treatment paradigm for acute diverticulitis is changing. There is an increasing trend towards managing patients with uncomplicated diverticulitis in the community. AIMS: The aim of this study was to analyse how acute diverticulitis is managed in our institution and also to analyse national data pertaining to treatment of acute diverticulitis. METHODS: A prospective database of all patients admitted to our institution over a 2-year period (2014-2016) with acute diverticulitis was maintained. Severity of disease, treatment received and average length of stay (LOS) were analysed for all patients. Contemporaneous hospital inpatient enquiry (HIPE) data was interrogated to analyse current management for acute diverticulitis at a national level. RESULTS: One hundred twenty-six patients were admitted to our institution with acute diverticulitis during the study period (inpatient stay = €1277/night). Of patients, 59.5% had uncomplicated diverticulitis while 40.5% had complicated disease. The median LOS was 4 (range 1-34) days and 8 (range 2-51) days in the uncomplicated and complicated group, respectively. Based on HIPE data, there were 11,357 patients with uncomplicated diverticulitis and 526 patients with complicated diverticulitis admitted to Irish hospitals in the year 2015. Nationally, the median LOS for those with uncomplicated diverticulitis was 3 (range 1-142) days and for those with complicated diverticulitis the median LOS was 7 (range 1-308) days. Projected total cost for hospital stay nationally for uncomplicated diverticulitis amounted to €43.5 million for the year 2015. CONCLUSIONS: At present, uncomplicated diverticulitis in Ireland is not being managed as per evidence-based guidelines. Changing practice could result in significant cost savings for surgical departments.

A national evaluation of the management practices of acute diverticulitis.

INTRODUCTION: Diverticulitis is a common surgical admission that presents with a wide range of symptoms and severity. Overall there has been a shift to conservative management practices, including the consideration of non-antibiotic treatment approaches in select cases. METHODS: A national survey of all consultant surgeons evaluating their practices was performed. Reasons for changes in management, use of radiological imaging, role of non-antibiotic treatment approaches and indications for elective surgical management were evaluated. RESULTS: Response rate for this survey was 67.7% (n = 67/99). An overwhelming 92.5% stated that computed tomography imaging was routinely used to investigate acute presentations. Interestingly, 22.4% stated they would consider a non-antibiotic treatment approach in uncomplicated diverticulitis. Main reasons for adopting this approach was low inflammatory markers with short duration of symptoms. Co-amoxiclav was the most common antibiotic used for acute diverticulitis, with considerable variability in duration of treatment. Additionally, there was considerable heterogeneity regarding how many recurrences were necessary before surgical management was required. CONCLUSION: This review highlights substantial variation in the management of diverticulitis across Ireland. Shifts to non-antibiotic treatment approaches for uncomplicated cases are observed, but less so than in Northern Europe. National guidelines are required to establish uniform treatment protocols including indications for surgical resection.

Sedation for gastroscopy: Is it an adequately understood and informed choice?

INTRODUCTION: Sedation uptake rates for oesophagogastroduodenoscopy (OGD) vary greatly. Issues concerning adequate information and consent have been raised. Additionally, patient comprehension of sedation options is inconsistent. METHODS: A closed ended questionnaire was created and delivered to assess patient understanding regarding sedation prior to OGD. The questionnaire was based on British Society of Gastroenterology guidelines. RESULTS: One hundred and eleven patients were recruited. 90 % of the sedated and 73 % of the unsedated patients were satisfied with their respective decisions (OR 0.283, *p = 0.01). 65 % were unaware of basic differences between conscious sedation and general anesthesia, and 37 % were unaware that driving is permitted after having throat spray alone. The most informed of the age groups had the lowest uptake of sedation and the least informed had the highest uptake. CONCLUSION: The decision to undergo gastroscopy with or without sedation is not a sufficiently informed one. This study highlights the need for the widespread dissemination of good quality information to inform patients better regarding sedation prior to OGD.

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Splenic cysts are rare lesions with around 800 cases reported in the world literature. Traditionally splenectomy was the treatment of choice. However, with the recognition of the important immunological function of the spleen, new techniques to preserve splenic function have been developed. This case emphasizes that in selected cases splenic preservation is appropriate.