Evidence before this study: Acute appendicitis is the most common general surgical emergency in children. Its diagnosis remains challenging and children presenting with acute right iliac fossa (RIF) pain may be admitted for clinical observation or undergo normal appendicectomy (removal of a histologically normal appendix). A search for external validation studies of risk prediction models for acute appendicitis in children was performed on MEDLINE and Web of Science on 12 January 2017 using the search terms ["appendicitis" OR "appendectomy" OR "appendicectomy"] AND ["score" OR "model" OR "nomogram" OR "scoring"]. Studies validating prediction models aimed at differentiating acute appendicitis from all other causes of RIF pain were included. No date restrictions were applied. Validation studies were most commonly performed for the Alvarado, Appendicitis Inflammatory Response Score (AIRS), and Paediatric Appendicitis Score (PAS) models. Most validation studies were based on retrospective, single centre, or small cohorts, and findings regarding model performance were inconsistent. There was no high quality evidence to guide selection of the optimum model and threshold cutoff for identification of low-risk children in the UK and Ireland. Added value of this study: Most children admitted to hospital with RIF pain do not undergo surgery. When children do undergo appendicectomy, removal of a normal appendix (normal appendicectomy) is common, occurring in around 1 in 6 children. The Shera score is able to identify a large low-risk group of children who present with acute RIF pain but do not have acute appendicitis (specificity 44%). This low-risk group has an overall 1 in 30 risk of acute appendicitis and a 1 in 270 risk of perforated appendicitis. The Shera score is unable to achieve a sufficiently high positive predictive value to select a high-risk group who should proceed directly to surgery. Current diagnostic performance of ultrasound is also too poor to select children for surgery. Implications of all the available evidence: Routine pre-operative risk scoring could inform shared decision making by doctors, children, and parents by supporting safe selection of lowrisk patients for ambulatory management, reducing unnecessary admissions and normal appendicectomy. Hospitals should ensure seven-day-a-week availability of ultrasound for medium and high-risk patients. Ultrasound should be performed by operators trained to assess for acute appendicitis in children. For children in whom diagnostic uncertainty remains following ultrasound, magnetic resonance imaging (MRI) or low-dose computed tomography (CT) are second-line investigations.
Background Resumption of elective surgery during the current coronavirus disease 2019 pandemic crisis has been debated widely and largely discouraged. The aim of this prospective cohort study was to assess the feasibility of resuming elective operations during the current and possible future peaks of this coronavirus disease 2019 pandemic. Methods We collected data during the peak of the current pandemic in the United Kingdom on adult patients who underwent elective surgery in a “COVID-19-free” hospital from April 8 to May 29, 2020. The study included patients from various surgical specialties. Nonelective and pediatric cases were excluded. The primary outcome was 30-day mortality postoperatively. Secondary outcomes were the rate of coronavirus disease 2019 infections, new onset of pulmonary symptoms after hospitalization, and requirement for admission to the intensive care unit. Results A total of 309 consecutive adult patients were included in this study. No patients died nor required intensive care unit admission. Operations graded “Intermediate” were the most performed procedure representing 91% of the total number. One patient was diagnosed with a coronavirus disease 2019 infection after being transferred to the nearest local emergency hospital for management of postoperative pain secondary to common bile duct stone and was successfully treated conservatively on the ward. No patient developed pulmonary complications. Three patients were admitted for greater than 23 hours. Twenty-seven patients (8.7%) developed complications. Complications graded as 2 and 3 according to the Clavien-Dindo classification occurred in 14 and 2 patients, respectively. Conclusion This prospective study shows that, despite the severity and high transmissibility of novel coronavirus 2 disease, COVID-19-free hospitals can represent a safe setting to resume many types of elective surgery during the peak of a pandemic.
Laparoscopic CME can be performed to the same standard as open surgery by supervised trainees. However, this did not increase the lymph node yield.
Background Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions.
Aim To improve discussions between microbiology and surgical juniors. Method As a group we identified that discussions with microbiology were documented in notes, but not easily found when further discussions were required. We also found that some discussions were more difficult if the junior did not have all of the appropriate information to hand. We created a separate form to document microbiology discussions, bring together the essential information that they required for the conversations and enable quick reference for future discussions. We sent out a questionnaire to assess the level of the difficulties, introduced the form and documented any additional information that was asked for during discussions. We then repeated the questionnaire to assess if there were any improvements. Results The original version was insufficient, in that it was not distinct from other paper notes so could be difficult to find, and some questions were asked frequently that we did not have answers for. The discussions however were improved, and the recording of reasoning for decisions enabled more consistent recommendations. Conclusions By creating the form we helped juniors prepare for more constructive calls to microbiology, were able to answer some of their questions regarding why prior decisions were made and at the end have the most sensible suggestions and plans from microbiology for surgical patients. While we still use paper notes, the concept and format are suitable for transfer to other specialities and electronic records where available.
Aims The open abdomen following emergency laparotomy for peritoneal contamination is becoming an increasingly popular method of managing severe intra-abdominal sepsis. However, this approach has been associated with increased morbidity and mortality. The aim of this study is to compare patient populations and post-operative outcomes from patients undergoing primary closure or those managed with an open abdomen after emergency laparotomy. Methods A retrospective case note review was undertaken of all patients recorded on the NELA database over a five-year period at a district general hospital. Patients with no intra-abdominal contamination or who were palliated peri-operatively were excluded. Data collected included P-possum morbidity and mortality, post-operative complications (Clavien-Dindo), length of stay and in-hospital mortality. Results 811 NELA entries were reviewed; 313 were included with 79% (n = 248) undergoing primary closure. Cohorts were similar in age and sex. P-possum morbidity and mortality scores were significantly higher in the open abdomen group (89% vs 79%, p = 0.0003; 38% vs 24%, p = 0.0003, respectively). Of the outcome variables, significant complications (34% vs 11%, p = 0.001), length of stay (31 vs 18 days, p = 0.0001) and mortality (11% vs 4%, p = 0.001) were significantly higher in the open compared to closed abdomen group. Only 10% of patients undergoing primary closure required further surgery. Conclusions This study highlights that the open abdomen is used in higher risk patients, with significantly poorer outcomes. This approach, which confers a significant physiological burden requiring further intervention should be used with caution in selected cases.
Background Resumption of elective surgery during the current coronavirus disease 2019 (COVID-19) pandemic crisis has been debated widely and largely discouraged. This prospective cohort study aimed to assess the feasibility of resuming elective operations during the current and possible future peaks of COVID-19 pandemic. Method Data were collected during the peak of the first pandemic in the United Kingdom on adult patients who underwent elective surgery in a “COVID-19-free” hospital from April 8 to May 29, 2020. The study included patients from various surgical specialities. Non-elective and pediatric cases were excluded. The primary outcome was 30-day mortality postoperatively. Secondary outcomes were the rate of COVID-19 infections, new onset of pulmonary symptoms after hospitalization and requirement for admission to the intensive care unit. Results 309 consecutive adult patients were included in this study. No patients died nor required intensive care unit admission. Operations graded “Intermediate” were the most performed procedures. One patient was diagnosed with COVID-19 infection after being transferred to the nearest local emergency hospital for management of postoperative pain and was successfully treated conservatively on the ward. No patient developed pulmonary complications. Three patients were admitted for greater than 23 hours. Twenty-seven patients (8.7%) developed complications. Complications graded as 2 and 3 according to the Clavien-Dindo classification occurred in 14 and 2 patients, respectively. Conclusions This prospective study shows that, despite the severity and high transmissibility of novel coronavirus 2 diseases, “COVID-19-free” hospitals can represent a safe setting to resume many types of elective surgery during the peak of a pandemic.
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