✓ A case of delayed paraplegia due to a traumatic arachnoid diverticulum from a traction injury of the brachial plexus is reported. The authors emphasize the necessity of carrying out proper radiological studies for evaluation of delayed weakness of the legs following trauma to the brachial plexus; by this means, a surgically correctable lesion can be identified.

Ann R Coll Surg Engl 2009; 91: 39-42 39One-fifth of Western adults will develop gallstones, with women three times more commonly affected than men; approximately 20% will become symptomatic.1 The treatment of choice for symptomatic cholelithiasis remains cholecystectomy. The traditional open approach has now largely been replaced by laparoscopic cholecystectomy which was first introduced into the UK in 1990. Whilst waiting for elective cholecystectomy, approximately 70% of patients will suffer on-going biliary symptoms 2 and up to 50% will require admission.3 Repeated hospital admissions increase costs and utilise beds unnecessarily. Traditionally, patients admitted with biliary symptoms have been treated conservatively with intravenous fluids, analgesia and antibiotics in cholecystitis to allow the inflammation to settle followed by delayed cholecystectomy. 4 In the early years of laparoscopic cholecystectomy, surgery for acute cholecystitis was eschewed because of increased rates of bile duct injury; 5 however, as it has entered routine practice, it has become clear that there is no increase in complications associated with surgery in the acute setting.6 Acute laparoscopic cholecystectomy during the index hospital admission is associated with decreased overall hospital stay. 7,8 Seven of the nine general surgeons in our hospital performed elective laparoscopic cholecystectomy during the study period, but none performed acute laparoscopic cholecystectomy. Patients admitted with acute biliary symptoms were managed conservatively and cholecystectomy scheduled for a second admission. This study was designed to identify the number of patients admitted with acute biliary symptoms once the decision to perform cholecystectomy had been made; the cost of additional or repeated investigations during these admissions and the cost implications for the trust in terms of tariff income were estimated. Immediate cholecystectomy during the first admission is safe and effective, even when performed laparoscopically, but acute laparoscopic cholecystectomy has only recently become increasingly commonplace in the UK. This study was designed to quantify this problem in our hospital and its cost implications. PATIENTS AND METHODS The case notes of all patients undergoing laparoscopic cholecystectomy in our hospital between January 2004 and June 2005 were examined for details of hospital admissions with biliary symptoms or complications whilst waiting for elective cholecystectomy. Additional bed occupancy and radiological investigations were recorded and these costs to the trust calculated. We compared the potential tariff income to the hospital trust for the actual management of these patients and if a policy of acute laparoscopic cholecystectomy on first admission were in place. RESULTS In the 18-month study period, 259 patients (202 females) underwent laparoscopic cholecystectomy. Of these, 147 presented as out-patients and only 11% required hospital admission because of biliary symptoms whilst waiting for elective surgery. There ...

Aim To identify trends in management of patients with post operative complications following appendicectomy in a district general hospital. Method The coding department identified patients who were admitted with appendicitis in the previous year and those who developed post operative complications. Data was gathered retrospectively from these patients using their online records. Results Coding identified 270 patients that were admitted between 22/10/20–29/10/21 with appendicitis. 19 patients had post operative complications. 9 had intra-abdominal collections, 5 had wound infections/collections, 3 had an ileus. 15/19 patients with complications underwent imaging, 8 had CT scans and 7 had US scans. Patients waited a mean of 0.4 days between presentation and imaging. Patients waited a mean of 2.2 and median of 0 days between imaging and appendicectomy. 12 patients had complicated appendicitis, 6 had simple appendicitis and 1 had a normal appendix. 16 patients had antibiotics pre and post operatively, 3 did not. The mean length of stay was 5.6 days for patients with complications, compared to a mean length of stay of 3.9 days for all patients with appendicitis. Conclusions Early identification and management of appendicitis reduces morbidity, and our centre appears to have lower than average complication rates. The patients who did develop complications, were generally imaged and operated on efficiently An area of improvement is ensuring all patients undergoing appendicectomies are given at least one preoperative dose of antibiotics and up to 3–5 days post operatively if complicated as per WSES guidelines. We aim to re-audit this after an education drive within our department.

Aim The aim of this audit was to investigate how patients referred by the Emergency Department (ED) with biliary disease were managed. Also, to identify a cohort of patients which could be safely discharged from ED with an outpatient US and follow up with the Surgical Assessment Unit. Method Data was collected from 23/11/20 to 11/12/20. The inclusion criteria were patients referred by ED with abdominal pain and a diagnosis of biliary disease. Data collected included blood results, US results and if they underwent a laparoscopic cholecystectomy (LC). Results There were 22 patients identified; 5 had biliary colic, 4 had cholangitis and 13 had cholecystitis. The 5 patients with biliary colic had almost completely normal bloods on admission. While 16/17 patients with cholecystitis/cholangitis had elevated FBC, CRP or LFTs. US was performed on 3 patients with biliary colic within 3 days of ED attendance. US was performed on 16/17 patients with cholecystitis/cholangitis, mainly within 2 days. None of the patients with biliary colic received antibiotics and 2 had an inpatient LC. All patients with cholecystitis and cholangitis were admitted and treated with antibiotics. 1 patient with cholecystitis had a LC and 7 were on the waiting list. Conclusions This has shown that patients are being imaged with US efficiently and are treated appropriately with antibiotics. It has demonstrated that a blood test in ED is effective at differentiating between biliary colic and other diseases that require admission. However, improvements need to be made to increase access for patients to undergo timely LCs.