Background: Acute appendicitis is one of the most common causes of right iliac fossa pain which often warrants surgical management. In many cases, abdominal ultrasonography (USS) is done to confirm the diagnosis however negative appendicectomy is common due to atypical presentations and different visualisation rate. The unnecessary operative intervention can result in complications. The aim of this study was to compare the efficacy between clinical diagnosis and USS in diagnosing acute appendicitis to avoid negative appendicectomy and prevent further complications. Method: A retrospective cohort study was conducted in a district general hospital which 1046 cases of laparoscopic appendicectomy were included and examined for the use of USS or clinical diagnosis. The sensitivity, specificity, negative and positive predictive value in USS and data in clinical evaluation were analysed for their accuracy in the diagnosis of acute appendicitis based on the histology results post appendicectomy. Results: Clinical diagnosis without preoperative imaging was found to have a significantly lower negative appendicectomy rate of 27.20% compared with 42.67% in those who underwent ultrasound. 44.64% of the patients were misdiagnosed with a normal USS result who had a subsequent positive histology of appendicitis. Conclusions: USS has been shown to be less sensitive for diagnosing acute appendicitis which results in high negative appendicectomy and misdiagnosis rate. With an increasing burden of health budget and resources, cautious and appropriate use of USS would avoid the misdiagnosis and prevent further complications. Thorough clinical evaluation remains an important first step and role in the diagnosis of acute appendicitis.
Aim There is a wide variation between National Health Service (NHS) hospitals in the management of patients with acute cholecystitis and biliary pancreatitis. 20–33% of patients will make repeat visits to hospital with gallstone-related symptoms before any surgical intervention performed. We established a ‘Hot Gallbladder Pathway’ with the aim for improving outcome and decreasing complications of these patients. The aim of this quality improvement project was to assess if a district general hospital (DGH) could provide a safe and effective ‘hot gallbladder’ service with a clear pathway. Method Quality improvement methods were used to integrate the ‘hot gallbladder pathway’ to manage patients with acute calculous cholecystitis and biliary pancreatitis. A prospective observational study with strict inclusion/ exclusion criteria and secure online data was conducted during a 13-month period. The data were then compared against existing National Institute for Health and Clinical Excellence (NICE) guidelines and further changes were recommended. Results We achieved almost 70% of the patients undergoing emergency laparoscopic cholecystectomy in both group of patients who met the pathway criteria within the expected time frame, compared with the pre-implementation result of 23% and national average of only 16% in England. None of the patients suffered from intraoperative complications or 30-day mortality. Conclusion A clear ‘hot gall bladder pathway’ is effective at improving care for patients requiring emergency laparoscopic cholecystectomy and potentially useful for other acute Trusts which their standard is below the NICE guideline.
Introduction Gastric banding has become one of the most commonly performed bariatric operations worldwide. Recognised complications are divided into; the laparoscopic approach, the band or the procedure itself. Gastric band misplacement is a rare but recognised early complication. Case description A 58-year-old patient presented to a district general hospital with a 6 day history of epigastric pain, incomplete dysphagia, vomiting, and constipation. Gastric band surgery had been performed 10 years prior in a UK tertiary centre. Diagnostic workup suggested the left gastric artery was trapped in the gastric band with no features of necrosis, perforation or obstruction. The patient was referred to the upper gastrointestinal surgical team and the band was removed laparoscopically and the patient had an uneventful recovery. Discussion Symptoms of gastric band misplacement may include nausea, vomiting, dysphagia, and upper abdominal pain. It is unusual that a malpositioned gastric band resulted in symptoms over 10 years after the procedure. Radiological evidence of gastric band misplacement in the literature is only reported in 0.07% of cases in plain radiograph. Surgical technique and experience are important to prevent band slippage, especially when considering the chosen placement and securing method. Conclusion This case describes an important late rare finding of complication following gastric band surgery. Consideration should be made in management for patients with gastric band presenting with gastrointestinal symptoms and a high level of clinical suspicion is needed to investigate and manage these patients.
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