Background Approximately 100,000 hernia repairs are performed in the UK annually, the vast majority in hospital usually under general anaesthetic. Due to increased pressure on hospital facilities especially after the COVID-19 pandemic the waiting times for non-emergency surgery for benign conditions has increased. This study outlines the development and feasibility of a dedicated ambulatory primary care hernia service and examines the outcomes achieved between November 2018 and November 2021. Methods We prospectively analysed of records of 212 patients who underwent hernia repair in a primary care centre during the above period. Inclusion criteria were a) BMI<35 b) uncomplicated inguinal or umbilical hernia c) non recurrent hernia. The techniques used were Lichtenstein mesh repair for inguinal hernias and a primary sutured repair for ventral hernias. All procedures were performed as day-cases under local anaesthesia without sedation. All patients were telephoned by a healthcare professional a day after their operation. The primary outcomes of the study were length of stay, immediate complications and the secondary outcome was cost effectiveness. Results The median length of post-operative stay was 26 minutes. Complications were low and seen only in 5 patients and managed conservatively. The cost of hernia repair in primary care in UK is only £1012 when compared to £1800 in an NHS hospital. Conclusion Routine elective abdominal wall hernia repairs can be performed in a primary care setting, safely, with good clinical outcomes and clear economic benefits. However, this depends on the availability of surgeons and adequate funds to establish the service.
Background Gallstone disease is one of the most common gastrointestinal conditions in the UK. It is estimated that 10–15% of adults in the UK have gallstones. Most gallstones are found in the gallbladder but sometimes they can pass through the cystic duct into the common bile duct (CBD) causing choledocholithiasis. CBD stones may present with symptoms of jaundice, cholangitis, pancreatitis or be asymptomatic. Endoscopic sphincterotomy (ES), first reported in 1974, is considered a safe and effective method for managing choledocholithiasis. A significant proportion of patients who undergo ES for symptomatic CBD stones are subsequently referred for cholecystectomy. However, it is unclear whether cholecystectomy itself is necessary after endoscopic CBD stone removal. Some studies recently have indicated that cholecystectomy may not always be needed following endoscopic duct clearance (expectant management), especially for patients that remain asymptomatic or decline surgery (due to frailty, significant comorbidities or patient choice). The primary aim of this study was to assess the outcomes of patients who had expectant management (EM) after endoscopic CBD stone removal. Methods We retrospectively analysed the records of patients who underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) in a UK District General Hospital between 01 January 2019 and 31 December 2019. Inclusion criteria were a) presence of CBD stones, and b) patients who underwent ERCP without prior cholecystectomy. The following patients were excluded: a) previous cholecystectomy, b) patients who underwent ERCP for other biliary pathologies, including malignancy. The original data set was obtained from the clinical coding department. ERCP reports, clinic letters, discharge summaries and the hospital results reporting systems were reviewed to extract patient data including demographics, comorbidities, management decision following ERCP, need for repeat ERCP and readmission rate. Results A total of 220 patients underwent ERCP in 2019. After excluding patients who did not fit the inclusion criteria,106 patients were included in this study. The median age was 75 years (22–97). 60 patients were women and 46 were men. Median follow up period was 36 months (30–42), excluding patients who died within the follow up period. 63 (59%) patients had a course of expectant management following ERCP for choledocholithiasis while 43 (41%) had a planned cholecystectomy (CS). Of the sixty-three patients who had EM, 40 were considered unfit for surgery, 18 were asymptomatic following ERCP, 3 did not wish to have surgery and the reason is unknown in 2. The median age for EM patients was 80 years (22–91), whereas the CS group had a median age of 62 years (25–82). In the EM group, 11 patients passed away within the follow-up period, none related to biliary pathology. Of the remaining 52 patients, only 1 proceeded to have cholecystectomy during the 3 year follow-up period due to multiple episodes of cholangitis. 2 out of 52 (4%) were readmitted with biliary complications but they continued to be managed conservatively due to frailty. Conclusions Endoscopic sphincterotomy and clearance of ductal stones followed by cholecystectomy is the most common treatment for choledocholithiasis. Recent NICE guidelines recommend CS for all patients with symptomatic or asymptomatic CBD stones. However, there is minimal evidence regarding the safety of leaving the gallbladder in situ after ES and thus the issue remains debatable. The majority of studies that have evaluated the complication rates of EM have focused only on elderly patients (age>80years), whereas our study has evaluated all patients after ERCP regardless of age and comorbidities. Pancreatitis did not occur during follow-up in any patients without cholecystectomy. This is in keeping with previous evidence as ES may in itself be definitive in prophylaxis against pancreatitis as it decreases the risk of pancreatic duct obstruction. The majority of patients (95%) with choledocholithiasis who did not undergo cholecystectomy after ERCP remained asymptomatic, indicating that expectant management is safe. However, we recognise this was a single centre study with limited patient numbers and medium-term follow-up. We suggest that future randomized controlled trials be multicentre and should include an assessment of patients’ quality of life and non-hospital managed symptoms.
Aims Surgery for colorectal cancer is associated with risks of complications and death. These are associated with higher mortality and morbidity rates, lower quality of life and increased expenditure in healthcare. We aimed to determine the impact of prehabilitation on patient outcomes with regards to length of hospital stay and postoperative complications. Methods The prehabilitation programme was introduced to our unit in March 2021. We compared outcomes of all patients undergoing elective colorectal cancer surgery before and after introduction of the programme from a prospectively maintained database. Records of patients in the non prehabilitation group (NP) between January to June 2019 and those in the prehabiltation group (PhP) between April to October 2021 were analysed. Our primary aim was to compare the length of stay between the groups with a secondary aim to compare postoperative complications. Results A total of 151 elective colorectal cancer patients were included. There were 64 patients in the NP group and 87 patients in the PhP group. The median length of stay in the NP group was 7 days and in the PhP group was 5 days. 30% of patients in the NP group developed post-operative complications while only 19% of patients in the PhP group developed post-operative complications. Conclusion Prehabilitation is a vital component in a patient's treatment journey. Results from our study have shown an improvement in postoperative outcomes. It should therefore be an element of all enhanced recovery programmes. Further research in this domain could include individualised programs to obtain more benefits
Background Adhesive small bowel obstruction (aSBO) is a common surgical emergency causing high morbidity and even some mortality. The adhesions causing such small bowel obstructions (SBO) are typically the footprints of previous abdominal surgeries. The National Audit of Small bowel Obstruction (NASBO) recommended that in patients not needing emergency surgery for aSBO, gastrografin should be embedded in clinical management. An audit was undertaken to see our adherence to best practice in the management of aSBO. Methods Data of all patients who were admitted with SBO between April and October 2020 were obtained. This list was filtered carefully to extract patients who had aSBO. Data was collected on signs of intestinal ischaemia, administration of gastrografin and progression, need for surgery and length of stay. Results 26 patients were admitted with aSBO in the above period. Half of all patients needed an emergency operation. Only 30% (8) received gastrografin. Conservative management was successful in 62% (5/8) of patients who received gastrografin. 38% (3/8) needed surgery as they either had signs of intestinal ischaemia or gastrografin failed to pass through. More than half of all patients (55%) who did not receive gastrografin (10/18) required surgery. The average length of stay was significantly higher in patients who did not receive gastrografin. Conclusion From the limited data it is evident that the use of gastrografin in patients with aSBO reduces the duration of stay and need for surgery. We have now developed and implemented a local protocol for managing such patients and we aim to re-audit in 6 months.
Aim Annually 9.9 million people undergo elective surgery in the NHS. The National Institute of Health and Care Excellence (NICE) published guidelines on ‘Routine pre-operative tests in elective surgery’ in 2016. It aimed to reduce unnecessary testing by taking into account patient comorbidities and the complexity of surgery. Excessive testing can cause significant anxiety in patients, delays in treatment and exposure to COVID caused by unnecessary hospital visits. Additionally, unnecessary blood tests can exacerbate blood bottle shortages. We are auditing the compliance of NICE guidelines when requesting blood tests for elective general surgical patients in pre-operative assessment clinics at Northampton General Hospital (NGH) Method The audit team at NGH provided details of the first 64 patients undergoing elective general surgery (categorised into 22 Minor, 23 Intermediate, 19 Major procedures), from May to July 2021. Electronic records were used to determine patient ASA grades and blood tests requested at pre-operative assessment clinics. These were checked against NICE (2016) guidelines. Results Conclusion There is poor compliance with NICE guidelines. NGH Anaesthetic team have implemented changes in November 2021, as part of MyPreOP online app, to ensure these guidelines are followed. We will re-audit in February 2022 and consider implementing changes across all surgical specialties.
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