Management and patient outcomes following admission with acute cholecystitis in Ireland: A national registry-based study.

INTRODUCTION: Acute cholecystitis is a common general surgical emergency, accounting for 3-10 % of all patients attending with acute abdominal pain. International guidelines suggest that emergency cholecystectomy is the treatment of choice for uncomplicated acute cholecystitis where feasible. There is a paucity of published data on the uptake of emergency cholecystectomy in Ireland. AIM: The aim of this study was to evaluate the management of acute cholecystitis in Ireland and to establish the rate of emergency cholecystectomy performed. METHODS: All patients with acute cholecystitis presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics, co-morbidities, length of stay, operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. Propensity score matched analysis and logistic regression were performed to account for selection bias in comparing patients managed with cholecystectomy and those managed conservatively. RESULTS: 20,886 admission episodes were identified involving 17,958 patients. 3585 (20 %) patients underwent emergency cholecystectomy in total. 3436 (96 %) of these were performed laparoscopically, with 140 (4 %) requiring conversion to an open procedure, and common bile duct injuries occurring in 4 (0.1 %) of patients. In comparison to patients treated conservatively, patients who underwent cholecystectomy were younger (median 50 v 60 years, p < 0.001) and more likely to be female (64 % v 55 % p < 0.001). Following propensity score matched analysis, those who had an emergency cholecystectomy had reduced length of stay (LOS) (median 5 days (IQR 3-8) v 6 days (interquartile range (IQR) 3-10), p < 0.001) and fewer readmissions to hospital (282 (8 %) v 492 (14 %), p < 0.001). On logistic regression, age >65 (OR 1.526), CCI >3 (OR 2.281) and non-operative management (OR 1.136) were significant risk factors for adverse outcome. CONCLUSION: Uptake of emergency cholecystectomy in Ireland remains low, and is carried out on a younger, fitter cohort of patients. In those patients, however, it is associated with improved outcomes for cholecystitis compared to conservative management, including shorter LOS and reduced readmission rates for matched cohorts.

Idiopathic jejunal intussusception in an adult.

BACKGROUND: Intussusception is a common surgical diagnosis in the paediatric population and is most commonly idiopathic. In adults a substantial proportion of patients have a malignant leading cause and surgical intervention is mandatory. Intussusception involving the small bowel is thought to be more likely benign in nature and is frequently reduced before the leading cause is excised. AIM: Review of the literature to determine the incidence of malignancy in small bowel intussusceptions and discussion of the optimal operative strategy. METHODS: We describe an unusual case of adult idiopathic jejunal intussusception, which was treated with excision without reduction and present the results of a relevant literature search. RESULTS: A number of reports have confirmed a high incidence of malignancy in small bowel intussusceptions and consequently excision without reduction should be undertaken. CONCLUSION: It is in the authors' view that excision without reduction should be the treatment of choice in small bowel intussusception unless preoperative imaging delineates benign leading pathology and in the rare occasion of a shortened gut.

Occult congenital anomaly of the atlas presenting in the setting of acute trauma.

Congenital absence of the posterior arch of the atlas is rare. Its detection in the setting of acute trauma may be confusing and mimic a fracture. This case serves to highlight the adjunctive use of computed tomography in equivocal cases. Most patients can be managed conservatively, however operative treatment should be reserved for patients in whom atlanto-axial instability has been shown.

Bilateral primary renal lymphoma.

BACKGROUND: Primary renal lymphoma is rare with no well-defined diagnostic criteria. AIM: To describe the first reported case of bilateral and primary renal lymphoma and describe diagnostic criteria. RESULT AND CONCLUSION: If a diagnosis of primary renal lymphoma is to be considered, then specific diagnostic criteria (as outlined) must first be satisfied.

Interspecies variation in axon-myelin relationships.

The primary objective of this paper was to determine the extent and nature of interspecies differences in axon calibre and myelin sheath thickness and in the various relationships between these. Morphometric analysis of the axon perimeter-myelin sheath thickness relationship was performed on an equivalent nerve fibre population in a mammal, the rat, a bird, the chicken, an amphibian, the frog, a bony fish, the trout, and a cartilaginous fish, the dogfish. The abducent nerve was studied. It is especially suitable for this purpose because its fibres are closely similar in type and in peripheral distribution across the species studied. The relationship differed substantially between species. Differences were present in its setting, as described by the positions of the scatterplots, in the g ratio and in the regression and correlation data relating the parameters. Both parameters were markedly larger in the fish species than in all of the others. In addition, in rat, chicken, frog and trout, where large and small fibre classes could be differentiated clearly, the setting of the relationship between the two parameters was different for the two classes. In the main, variation in each of the parameters was greater between than within species. The larger fibres in the fish species were closely similar in axon perimeter and sheath thickness despite their long evolutionary separation. From this study and from others in the series, it may be concluded that there is no fixed or constant relationship between axon calibre and the thickness of the surrounding myelin sheath. Each nerve tends to have its own particular relationship and this differs between species.