Three hundred and ten patients having elective cholecystectomy were randomized to either laparoscopic cholecystectomy or mini-cholecystectomy. There were 155 patients in each group. Conversion to open cholecystectomy was significantly more common with laparoscopic cholecystectomy (13 versus 4 per cent) and complications were significantly more frequent with laparoscopic cholecystectomy (9 versus 3 per cent). If laparoscopic cholecystectomy was successful, hospital stay was significantly shorter than for mini-cholecystectomy (2 versus 3 days respectively), but overall the hospital stay was not significantly different. Postoperative analgesia requirements were reduced and return to normal activities and to work were faster after laparoscopic cholecystectomy. There was no significant cost difference between the two procedures.

The presentation, operative management and final diagnosis were reviewed in 28 patients with AIDS (27 men and one woman) who underwent emergency laparotomy. On clinical and radiological examination, six patients showed features of toxic megacolon, five patients had small bowel obstruction, six patients had localized peritonitis and three had perforated viscus with generalized peritonitis. The most common disease processes were acute colitis in seven patients (associated with cytomegalovirus (CMV) infection in six), intra-abdominal lymphoma in five patients, acute appendicitis in five patients (associated with CMV infection in two), and atypical mycobacterial (MAI) infection in four patients. Two perioperative deaths occurred; one in a patient with acute pancreatitis and a second with generalized peritonitis. Later deaths were due to progression of AIDS, and patient survival at 1 month, 3 months and 6 months was 89 per cent, 64 per cent and 48 per cent, respectively. Lower operative mortality than in previously reported series may be due to earlier intervention in CMV toxic megacolon. Surgery, however, conferred less benefit in patients with acute abdominal pain from MAI infection or lymphoma. With careful patient selection, emergency laparotomy may achieve worthwhile palliation in patients with AIDS.

BackgroundStudies suggest that defunctioning stomas reduce the rate of anastomotic leakage and urgent reoperations after anterior resection. Although the magnitude of benefit appears to be limited, there has been a trend in recent years towards routinely creating defunctioning stomas. However, little is known about post-operative complication rates in patients with and without a defunctioning stoma. We compared overall short-term post-operative complications after low anterior resection in patients managed with a defunctioning stoma to those managed without a stoma.MethodsA retrospective cohort study of patients undergoing elective low anterior resection of the rectum for rectal cancer. The primary outcome was overall 90-day post-operative complications.ResultsTwo hundred and three patients met the inclusion criteria for low anterior resection. One hundred and forty (69%) had a primary defunctioning stoma created. 45% received neoadjuvant radiotherapy. Patients with a defunctioning stoma had significantly more complications (57.1 vs 34.9%, p = 0.003), were more likely to suffer multiple complications (17.9 vs 3.2%, p < 0.004) and had longer hospital stays (13.0 vs 6.9 days, p = 0.005) than those without a stoma. 19% experienced a stoma-related complication, 56% still had a stoma 1 year after their surgery, and 26% were left with a stoma at their last follow-up. Anastomotic leak rates were similar but there was a significantly higher reoperation rate among patients managed without a defunctioning stoma.ConclusionPatients selected to have a defunctioning stoma had an absolute increase of 22% in overall post-operative complications compared to those managed without a stoma. These findings support the more selective use of defunctioning stomas.Study registrationRegistered at www.researchregistry.com (UIN: researchregistry3412).

One thousand and ninety human immunodeficiency virus (HIV)-positive homosexual or bisexual males were seen in one hospital for management of HIV disease over a 9-year period. One hundred and fifty-five patients were referred by acquired immunodeficiency syndrome (AIDS) physicians for general surgical management. The most frequent reason for surgical referral (64 patients) was anorectal disease which occurred in 5.9 per cent of all HIV-positive patients. One or more diagnoses were reached in 61 of the 64 patients referred with anorectal disease: warts (38 per cent of diagnoses), anorectal ulceration (26 per cent), perianal sepsis (15 per cent), neoplasia (14 per cent) and haemorrhoidal disease (8 per cent). Anorectal symptoms were relieved in 68 per cent of patients and the median survival of those treated was 17.5 months from the time of surgical referral. Both warts and perianal sepsis were associated with in situ neoplasia, but no case of progression from in situ to invasive anal squamous carcinoma was detected. The aetiology of anorectal ulcers was not clear, but surgical excision of anal ulcers and skin tags can produce healing. Palliation of anorectal symptoms in HIV-positive homosexual patients is possible but some conditions are unusual and surgeons should be familiar with their presentation and management.

Introduction: the NHS Long Term Plan has called for a reduction in the number of outpatient appointments to reduce pressure on hospital services and increase ease of access for patients. This article presents a service evaluation of an innovative, nurse-led telephone follow-up service for a group of elective bowel cancer patients following surgery. Methods: the records of patients who underwent surgery over a 2-year period were accessed to determine the number of telephone follow-ups and other investigations. This was used to model the potential cost saving for commissioners against traditional clinic follow-up. Patient satisfaction was assessed by the European Organisation for Research and Treatment of Cancer questionnaire on Outpatient Satisfaction in 30 patients. Results: feedback on the service was overwhelmingly positive, with patients praising the care received from the specialist nurses, but also commenting on increased continuity of care, ease of access and convenience. The service also potentially creates significant savings for commissioners as the agreed tariff for nurse telephone follow-up is significantly less than the outpatient tariff. Discussion: this innovative follow-up system is well liked by patients and should provide savings for commissioners. The hospital also benefits from an increase in capacity to see new or more unwell patients, and a reduction in carbon emissions. Such a service, however, is dependent on people, and although it has functioned effectively in this department for approximately 20 years, it would only be generalisable to other units if staff had appropriate expertise.