Epidemiological study of provision of cholecystectomy in England from 2000 to 2009: retrospective analysis of Hospital Episode Statistics.

BACKGROUND: The aim of this study was to report the trends in provision of cholecystectomy in the National Health System in England over the 9 year period from 2000 to 2009 and to determine the major risk factors associated with subsequent poor outcome. METHODS: The Hospital Episode Statistics database was interrogated to identify all cholecystectomy procedures for biliary stone disease in adult patients (>16 years). Multivariate regression analyses were used to identify independent predictors of in-patient death, 1 year death, conversion to open, major bile duct injury (BDI) requiring operative repair, and length of stay. RESULTS: A total of 418,214 cholecystectomy procedures for biliary stone disease were identified. Laparoscopic surgery was used in 348,311 (83.3%) cases and increased by 14.6% over the study period. The in-patient mortality rate (0.2%), 1 year mortality rate (1%), proportion of cases converted to open (5.0%), major BDI rate (0.4%), and mean length of stay (3 days) all decreased over the study period. 52,242 (12.5%) cases were carried out during an emergency admission and uptake has remained stable over the decade. Emergency surgery was more likely to be performed at high-volume centres (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.35-1.44) and specialist units (OR 1.32, 95% CI 1.30-1.35). High-volume centres were more likely to complete emergency cases laparoscopically (OR 1.11, 95% CI 1.05-1.18). Multivariate regression analysis demonstrated that patient- (male gender, increasing age, and comorbidity) and disease-specific (inflammatory pathology and emergency admission) factors rather than hospital institutional characteristics (annual cholecystectomy volume and presence of specialist surgical units) were associated with poorer outcomes. CONCLUSIONS: The provision of laparoscopic cholecystectomy in England has increased. This has been associated with improvements in outcomes such as mortality and length of stay. However, emergency cholecystectomy uptake remains sub-optimal and is more likely to be performed at high-volume or specialist hospitals without adverse outcomes. Further research into the routine provision of emergency cholecystectomy in England is needed in order to optimize patient outcomes.

The clonal origins of dysplasia from intestinal metaplasia in the human stomach.

BACKGROUND & AIMS: Studies of the clonal architecture of gastric glands with intestinal metaplasia are important in our understanding of the progression from metaplasia to dysplasia. It is not clear if dysplasias are derived from intestinal metaplasia or how dysplasias expand. We investigated whether cells within a metaplastic gland share a common origin, whether glands clonally expand by fission, and determine if such metaplastic glands are genetically related to the associated dysplasia. We also examined the clonal architecture of entire dysplastic lesions and the genetic changes associated with progression within dysplasia. METHODS: Cytochrome c oxidase-deficient (CCO⁻) metaplastic glands were identified using a dual enzyme histochemical assay. Clonality was assessed by laser capture of multiple cells throughout CCO⁻ glands and polymerase chain reaction sequencing of the entire mitochondrial DNA (mtDNA) genome. Nuclear DNA abnormalities in individual glands were identified by laser capture microdissection polymerase chain reaction sequencing for mutation hot spots and microsatellite loss of heterozygosity analysis. RESULTS: Metaplastic glands were derived from the same clone-all lineages shared a common mtDNA mutation. Mutated glands were found in patches that had developed through gland fission. Metaplastic and dysplastic glands can be genetically related, indicating the clonal origin of dysplasia from metaplasia. Entire dysplastic fields contained a founder mutation from which multiple, distinct subclones developed. CONCLUSIONS: There is evidence for a distinct clonal evolution from metaplasia to dysplasia in the human stomach. By field cancerization, a single clone can expand to form an entire dysplastic lesion. Over time, this field appears to become genetically diverse, indicating that gastric cancer can arise from a subclone of the founder mutation.

Mechanisms of field cancerization in the human stomach: the expansion and spread of mutated gastric stem cells.

BACKGROUND & AIMS: How mutations are established and spread through the human stomach is unclear because the clonal structure of gastric mucosal units is unknown. Here we investigate, using mitochondrial DNA (mtDNA) mutations as a marker of clonal expansion, the clonality of the gastric unit and show how mutations expand in normal mucosa and gastric mucosa showing intestinal metaplasia. This has important implications in gastric carcinogenesis. METHODS: Mutated units were identified by a histochemical method to detect activity of cytochrome c oxidase. Negative units were laser-capture microdissected, and mutations were identified by polymerase chain reaction sequencing. Differentiated epithelial cells were identified by immunohistochemistry for lineage markers. RESULTS: We show that mtDNA mutations establish themselves in stem cells within normal human gastric body units, and are passed on to all their differentiated progeny, thereby providing evidence for clonal conversion to a new stem cell-derived unit-monoclonal conversion, encompassing all gastric epithelial lineages. The presence of partially mutated units indicates that more than one stem cell is present in each unit. Mutated units can divide by fission to form patches, with each unit sharing an indentical, mutant mtDNA genotype. Furthermore, we show that intestinal metaplastic crypts are clonal, possess multiple stem cells, and that fission is a mechanism by which intestinal metaplasia spreads. CONCLUSIONS: These data show that human gastric body units are clonal, contain multiple multipotential stem cells, and provide definitive evidence for how mutations spread within the human stomach, and show how field cancerization develops.

Consenting practice for laparoscopic cholecystectomy - are we doing enough to warn patients about their operation?

INTRODUCTION: Provision of informed consent prior to surgery is fundamental in allowing patients to make balanced choices about their care. This study compares consenting practice amongst different grade of surgeons for Laparoscopic Cholecystectomy (LC) with specific reference to the documentation of the complications of surgery. Timing and delivery of source of information is also evaluated. METHODS: Retrospective review of medical notes of all patients undergoing LC at London district general hospital between September 2006 to April 2009. RESULTS: Records were successfully retrieved for 163 patients. The five most commonly mentioned complications were bleeding (99%), infection (95%), conversion to open (93%), bile duct injury (82%) and visceral injury (65%). There were 27 documented complications in 23 patients and in 9 of these patients (39%) the specific complication was not discussed during the written consent process. Consultant surgeons tended to focus on important operation-specific risks such as bile duct injury whereas junior surgeons tend to focus on a broad range of general complications. CONCLUSION: Consenting practice for LC remains variable and is resulting in failure to warn patients of significant complications. This can lead to potential medico-legal implications. Having a structured consent form detailing all significant and common risk is one way of improving the consent process.

Malignant gastro-colic fistula presenting with upper extremity deep vein thrombosis.

Locally invasive colonic carcinomas are seldom complicated by the formation of gastro-colic fistula. The authors present a case of a 52-year-old man with malignant gastro-colic fistula presenting with upper extremity deep vein thrombosis posing operative challenges.

Conservative management of pneumatosis intestinalis and massive pneumoperitoneum in the acute abdomen: a case report.

We present a case of massive pneumoperitoneum in association with pneumatosis intestinalis that was successfully managed without surgery despite a clinical picture of an acute abdomen and biochemical evidence of inflammation and systemic upset. Recognition of non-surgical pneumoperitoneum is important to avoid unnecessary laparotomy, and clinical examination for the presence of peritonitis is the most important determinant of the need for emergency surgery.

Consenting practice for open inguinal hernia repairs - are we failing to warn patients of serious complications?

INTRODUCTION: Open inguinal hernia repairs are one of the most commonly performed procedures in the UK. The procedure can sometimes result in considerable morbidity. It is imperative that the consenting process for this procedure is meticulous. This allows the patient to make a fully informed decision as they are aware of potential complications. In turn, this reduces the risk of future litigation. The aim of this study was to examine the adequacy of consenting for open inguinal hernia repairs, in particular, focusing on serious risks associated with the procedure. PATIENTS AND METHODS: The notes of male patients who had undergone open inguinal hernia repair over a 6-month period were identified by the IT department. Inclusion and exclusion criteria were defined, giving a total of 97 male patients. Their consent forms were examined, focusing on: (i) the complications mentioned; and (ii) the grade of the consentor. A proforma was filled in for each of these patients and the data collated. RESULTS: Of the 97 patients in the study, 25.7% of patients were consented by a consultant, 54.6% by a specialist registrar, and 19.6% by a senior house officer/FY2. The most commonly recorded risks included infection (100%) and bleeding (100%). Serious complications such as chronic pain (consented for at an average of 14%), testicular complications (45.3%) and visceral injury (52.1%) were poorly accounted for at all levels. CONCLUSIONS: Consultants and juniors alike are not adequately consenting patients for inguinal hernia repairs, omitting serious complications such as chronic pain, recurrence and testicular complications. This leaves surgical teams vulnerable to claims for negligence. Good consenting practice may ultimately benefit both patient and surgeon.