BackgroundTemporary defunctioning ileostomy can reduce the consequences of anastomotic leak following low anterior resection. However, some patients never have their ileostomy reversed and in other cases the time to reversal of ileostomy can be delayed. The aim of this study was to identify the ileostomy closure rate following anterior resection, time to closure of ileostomy, reasons for delay in reversal and whether delay was associated with an increased complication rate.MethodsData were collected retrospectively on consecutive patients undergoing defunctioning ileostomy following anterior resection for rectal cancer, between January 2009 and August 2013. Data were collected on reversal of ileostomy rates, time to reversal, reasons for delayed reversal (defined as > 6 months) and complications following reversal.ResultsOne hundred seventy patients were studied (median age 69 years, range 41 - 90 years), of whom 117 (69%) were male. One hundred twenty-seven (75%) patients had their ileostomies reversed. Median time to reversal was 6 months (range 1 - 42). In 63 patients who had delayed reversal, reasons were adjuvant chemotherapy (22, 35%), medical illness (14, 22%), anastomotic leak (9, 14%), and others (4, 7%). Postoperative complications occurred in 33 patients (26%). There was no postoperative mortality. Univariate analysis showed that delayed reversal was associated with an increased rate of complications and longer length of hospital stay following reversal (P < 0.05).ConclusionsOne in four defunctioning ileostomies are not closed following anterior resection in our unit. Of those that are closed, approximately 50% have delayed closure beyond 6 months which is associated with increased risk of complications following their ileostomy reversal.
This study investigates the effectiveness of preoperative very low-calorie diet (VLCD) in laparoscopic cholecystectomy. A prospective observational study of consecutive patients undergoing laparoscopic cholecystectomy was undertaken. At the preoperative visit, all patients were advised to adhere to VLCD for 2 weeks before surgery (<800 kcal/d). Patients were judged to have complied with the VLCD if weight loss >2 kg. Technical difficulty was assessed using questionnaires. A total of 38 patients met the inclusion criteria. Difficulty of visualization and dissection of Calot's triangle in obese patients was twice that of nonobese patients (P=0.01). In 62% of procedures involving obese VLCD noncompliant patients, the surgeon experienced ≥1 area of technical difficulty, compared with 0% of procedures on obese, compliant patients (P=0.018). Difficulty of dissection of the gallbladder bed was 3 times higher in obese, noncompliant patients, compared with obese, compliant patients (P=0.07). Adherence to a 2-week preoperative VLCD may reduce technical difficulty of laparoscopic cholecystectomy in obese patients.
IntroductionIncreasing pressure and limitations on the NHS necessitate simple and effective ways for maintaining standards of patient care. This quality improvement project aims to design and implement user-friendly and clear ward round stickers as an adjunct to surgical ward rounds to evidence standardised care.Project design and strategyBaseline performance was measured against the recommended standards by the Royal College of Physicians, General Medical Council and a study performed at the Imperial College London. A total of 16 items were studied. All members of staff in surgery department were informed that an audit on ward round entries would be implemented but exact dates and times were not revealed. In the first cycle, ward round sticker was implemented and results collected across three random days for use and non-use of sticker. Feedback was collected through the use of questionnaires. In the second cycle, the ward round sticker was redesigned based on feedback and results collected for use and non-use of sticker.ResultsBaseline performance noted in 109 ward round entries showed that checking of drug chart, intravenous fluid chart, analgesia, antiemetic, enoxaparin, thromboembolic deterrents ranged from 0% to 6%. With the introduction of ward round stickers in both cycles, there was noticeable improvement from baseline in all items; in ward round entries where stickers were not used, performance was similar to baseline.ConclusionThis quality improvement project showed that the use of stickers as an adjunct to surgical ward round is a simple and effective way of evidencing good practice against recommended standards. Constant efforts need to be made to promote compliance and sustainability. Commitment from all levels of staff are paramount in ensuring standardised patient care without overlooking basic aspects.
Introduction Studies show that rates of blood transfusion associated with general surgical laparoscopy are low. Currently, there are no national guidelines in the UK regarding blood group and antibody screening (G&S) for patients undergoing emergency laparoscopy. The aim of this study was to assess whether using G&S before emergency laparoscopic general surgery routinely is worthwhile by identifying rates of perioperative transfusion. Methods Data were collected retrospectively on all emergency laparoscopic procedures at a single district general hospital between January 2014 and 31 December 2016. Emergency laparoscopic general surgical cases were included and gynaecological cases excluded. Records were reviewed to ascertain whether G&S was performed, whether antibodies were detected and whether patients were transfused. Results A total of 562 emergency laparoscopic cases were performed. The median age was 28 years (range: 6-95 years). Laparoscopic appendicectomy (n=446), diagnostic laparoscopy (n=47) and laparoscopic cholecystectomy (n=25) were the most common procedures. Of the total patient cohort, 514 (91.5%) and 349 (70.1%) had a first and second G&S respectively while 30 (5.3%) had no G&S. Four patients (0.71%) had antibodies detected. One patient (0.18%) received a transfusion. This patient had undergone laparoscopic repair of a perforated duodenal ulcer and there was no major intraoperative haemorrhage but he was transfused perioperatively for chronic anaemia. Conclusions These results demonstrate a low rate of blood transfusion in emergency laparoscopic general surgery. The majority of these patients had a low risk of major intraoperative haemorrhage and we therefore argue that G&S was not warranted. We propose a more targeted approach to the requirement for preoperative G&S and the use of O negative blood in the event of acute haemorrhage from major vessel injury.
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