Background and aim COVID-19 pandemic has predisposed patients undergoing surgery to post-operative infection and resultant complications. Appendicitis is frequently managed by appendicectomy. After the onset of the pandemic, selected cases of appendicitis were managed with antibiotics which is a recognised treatment option. Our objective was to compare the management of appendicitis and post-operative outcomes between pre- and post-COVID-19. Methods Ninety-six patients were identified from before the onset of the pandemic (November 2019) to after the onset of the pandemic (May 2020). Data were collected retrospectively from electronic records including demographics, investigations, treatment, duration of inpatient stay, complications, readmissions and compared between pre- and post-COVID-19 groups. Results One hundred percent underwent surgical treatment before the onset of pandemic, compared with 56.3% from the onset of the pandemic. A greater percentage of patients were investigated with imaging post-COVID-19 (100% versus 60.9%; p < 0.00001). There was no significant difference in the outcomes between the two groups. Conclusion CT/MRI scan was preferred to laparoscopy in diagnosing appendicitis and conservative management of uncomplicated appendicitis was common practice after the onset of pandemic. Health boards can adapt their management of surgical conditions during pandemics without adverse short-term consequences. Long term follow-up of this cohort will identify patients suitable for conservative management.

Objective The objective was to assess the interobserver agreement rate, progression rates and malignancy rates in the assessment of complex renal cysts (≥ Bosniak IIF) using a population-based database. Methods A regional database identified 452 complex renal cysts in 415 patients between 2009 and 2019. Each patient was tracked and followed up using a unique identifier and deterministic linkage methodology. The interobserver agreement rate between radiologists was calculated using a weighted kappa statistic. Progression and malignancy rates of cysts (Bosniak ≥IIF) over the 11-year period were calculated. Results The linear-weighted kappa value was 0.69 for all complex cysts. The rate of progression and regression of Bosniak IIF cysts was 4.6% (7/151) and 3.3% (5/151), respectively. All malignant IIF cysts progressed within 16 months of diagnosis. The malignancy rate of surgically resected Bosniak III and IV cysts was 79.3% (23/29) and 84.5% (39/46), respectively. Of all malignant tumours, 73.8% and 93.7% were of low ISUP grade and low stage, respectively. Conclusions This study further confirms that there is a good degree of agreement between radiologists in classifying complex renal masses using the Bosniak classification. The progression rate of Bosniak IIF cysts is low, but the malignancy rates of surgically resected Bosniak IIF, III and IV cysts are high. Benign cysts are frequently resected, and a very high proportion of histopathologically confirmed cancers in complex renal cysts are of low grade and stage. Key Points • There is a good degree of agreement between radiologists in classifying complex renal masses using the Bosniak classification. • The rate of progression of Bosniak IIF cysts is low, and malignant cysts progress early during surveillance. Although the malignancy rates of resected Bosniak IIF, III and IV cysts are high, the rate of benign cyst resection is significant.

Background Subtotal cholecystectomy aims to reduce the likelihood of bile duct injury but risks a multitude of less severe, yet significant complications. The primary aim of the present study was to report peri-operative outcomes of subtotal laparoscopic cholecystectomy (SLC) relative to total laparoscopic cholecystectomy (TLC) to inform the consent process. Method All laparoscopic cholecystectomies between 2015 and 2020 in one health board were included. The peri-operative outcomes of SLC (n = 87) and TLC (n = 2650) were reported. Pre-operative variables were compared between the two groups to identify risk factors for SLC. The outcomes between the SLC and TLC were compared using univariate, multivariate and propensity analysis. Results Risk factors for SLC included higher age, male gender, cholecystitis, increased biliary admissions, ERCP, cholecystostomy and emergency cholecystectomy. Following SLC, rates of post-operative complication (45.9%), imaging (37.9%) intervention (28.7%) and readmission (29.9%) were significant. The risk profile was vastly heightened compared to that of TLC: intra-operative complications (RR 9.0; p < 0.001), post-operative complications [bile leak (RR 58.9; p < 0.001), collection (RR 12.2; p < 0.001), retained stones (RR 7.2; p < 0.001) and pneumonia (RR 5.4; p < 0.001)], post-operative imaging (RR 4.4; p < 0.001), post-operative intervention (RR 12.3; p < 0.001), prolonged PLOS (RR 11.3; p < 0.001) and readmission (RR 4.5; p < 0.001). The findings were consistent using multivariate logistic regression and propensity analysis. Conclusion The relative morbidity associated with SLC is significant and high-risk patients should be counselled for the peri-operative morbidity of subtotal cholecystectomy.

Objectives It is not certain from current evidence which patient groups with non-visible haematuria (NVH) require urgent investigation and which investigations are sufficient. We report referral outcomes data from Scotland to identify patient groups who will benefit from urgent assessment to rule out urological cancer (UC) and whether full set of investigations are necessary in all referred patients. Materials and methods Data were collected from electronic patient records for patients referred with NVH to secondary care urology services between July 2017 and May 2020. The correlations between risk factors and final diagnosis were assessed using categorical variables in a multivariate logistic regression analysis and using chi-squared models. Statistical analysis was performed using IBM SPSS data editor version 25. Results Our study cohort comprised 525 patients (43.4% males; median age 66 years), in which UC was diagnosed in 25 patients (4.8%). Age > 60 years had sensitivity and NPV for UC of 92% and 99%, respectively. Univariate and multivariate analysis showed male sex, age ≥ 60 years and smoking were significant predictors of UC in patients with NVH (p < 0.05). There was no significant difference in UC in patients with history of LUTS, anticoagulation and previous UC. Conclusion The risk of urologic cancer in NVH patients is significant and male gender, age ≥ 60 years and smoking are significant predictors of UC. Patients with risk factors of UC require complete assessment of both the upper and lower urinary tract; however, in the absence of risk factors, patients do not require urgent or complete assessment.

There is emerging evidence to suggest that con-current medical conditions influence the outcome of cancers, irrespective of therapy offered. The prevalence and impact of co-morbidities on the survival outcome of complex renal cystic masses in not known. The objective was to study complex renal cysts (Bosniak ≥IIF ) and assess the overall and renal cancer-specific survival in a population-based database including impact of con-current morbidities. The Tayside Urological Cancer Network (TUCAN) database covering a stable population of more than 416,090 inhabitants in a defined geographical area identified 452 complex renal cysts in 415 patients between 2009 and 2019. Each patient was tracked and followed up using a unique identifier and deterministic linkage methodology. The last date of follow-up including cause of death was determined. Co-morbidities were recorded from primary care referrals. Renal cancer-specific mortality was 1.7% at a median follow-up of 76.0 months; however, overall survival was poor, particularly in patients ≥ 70 years of age and with ≥ 2 significant co-morbid conditions (p < 0.0001). A total of 38.3% of the cohort showed con-current morbidities. Age and co-morbidities were significant risk factors for overall survival in patients with complex renal cystic disease and a careful assessment should be made to recommend surgical intervention in the elderly population, in particular in those with other health-related conditions.

ImportanceA textbook outcome (TO) is a composite quality measure that incorporates multiple perioperative events to reflect the most desirable outcome. The use of TO increases the event rate, captures more outcomes to reflect patient experience, and can be used as a benchmark for quality improvement.ObjectivesTo introduce the concept of TO to elective laparoscopic cholecystectomy (LC), propose the TO criteria, and identify characteristics associated with TO failure.Design, Setting, and ParticipantsThis retrospective cohort study was performed at 3 surgical units in a single health board in the United Kingdom. Participants included all patients undergoing elective LC between January 1, 2015, and January 1, 2020. Data were analyzed from January 1, 2015, to January 1, 2020.Main Outcomes and MeasuresThe TO criteria were defined based on review of existing TO metrics in the literature for other surgical procedures. A TO was defined as an unremarkable elective LC without conversion to open cholecystectomy, subtotal cholecystectomy, intraoperative complication, postoperative complications (Clavien-Dindo classification ≥2), postoperative imaging, postoperative intervention, prolonged length of stay (&gt;2 days), readmission within 100 days, or mortality. The rate of TOs was reported. Reasons for TO failure were reported, and preoperative characteristics were compared between TO and TO failure groups using both univariate analysis and multivariable logistic regressions.ResultsA total of 2166 patients underwent elective LC (median age, 54 [range, 13-92] years; 1579 [72.9%] female). One thousand eight hundred fifty-one patients (85.5%) achieved a TO with an unremarkable perioperative course. Reasons for TO failure (315 patients [14.5%]) included conversion to open procedure (25 [7.9%]), subtotal cholecystectomy (59 [18.7%]), intraoperative complications (40 [12.7%]), postoperative complications (Clavien-Dindo classification ≥2; 92 [29.2%]), postoperative imaging (182 [57.8%]), postoperative intervention (57 [18.1%]), prolonged length of stay (&gt;2 days; 142 [45.1%]), readmission (130 [41.3%]), and mortality (1 [0.3%]). Variables associated with TO failure included increasing American Society of Anesthesiologists score (odds ratio [OR], 2.55 [95 CI, 1.69-3.85]; P &lt; .001), increasing number of prior biliary-related admissions (OR, 2.68 [95% CI, 1.36-5.27]; P = .004), acute cholecystitis (OR, 1.42 [95% CI, 1.08-1.85]; P = .01), preoperative endoscopic retrograde cholangiopancreatography (OR, 2.07 [95% CI, 1.46-2.92]; P &lt; .001), and preoperative cholecystostomy (OR, 3.22 [95% CI, 1.54-6.76]; P = .002).Conclusions and RelevanceThese findings suggest that applying the concept of TO to elective LC provides a benchmark to identify suboptimal patterns of care and enables institutions to identify strategies for quality improvement.

Introduction Patients undergoing elective laparoscopic cholecystectomy (ELLC) represent a heterogeneous group making it challenging to stratify risk. The aim of this paper is to identify pre-operative factors associated with adverse peri- and post-operative outcomes in patients undergoing ELLC. This knowledge will help stratify risk, guide surgical decision making and better inform the consent process. Methods All patients who underwent ELLC between January 2015 and December 2019 were included in the study. Pre-operative data and both peri- and post-operative outcomes were collected retrospectively from multiple databases using a deterministic records-linkage methodology. Patients were divided into groups based on clinical indication (i.e. biliary colic versus cholecystitis) and adverse outcomes were compared. Multivariate regression models were generated for each adverse outcome using pre-operative independent variables. Results Two-thousand one hundred and sixty-six ELLC were identified. Rates of peri- and post-operative adverse outcomes were significantly higher in the cholecystitis versus biliary colic group and increased with number of admissions of cholecystitis (p < 0.05). Rates of subtotal (29.5%), intra-operative complication (9.8%), post-operative complications (19.6%), prolonged post-operative stay (45.9%) and re-admission (16.4%) were significant in the group of patients with ≥ 2 admissions with cholecystitis. Conclusion Our data demonstrate that patients with repeated biliary admission (particularly cholecystitis) ultimately face an increased risk of a difficult ELLC with associated complications, prolonged post-operative stay and readmissions. These data provide robust evidence that individualised risk assessment and consent are necessary before ELLC. Strategies to minimise recurrent biliary admissions prior to LC should be implemented.

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