District General Setting Research Articles

225 The Management of Acute Cholecystitis in a District General setting: An Audit of Practice

Abstract Aim The benefits of laparoscopic cholecystectomy during index admission with acute cholecystitis (AC) are multiple. As such, current NICE guidelines dictate that adults with AC undergo laparoscopic cholecystectomy within 1 week of diagnosis. However, significant variation exists with regards to the management of such patients. Here we present the results of an audit of practice at a UK district general hospital and suggest that this standard can be achieved regardless of hospital. Method Electronic database search at Salisbury District Hospital over a period of 12 months to identify all patients with a coded diagnosis of AC. Electronic Discharge System (EDS) was consulted to assess whether patients underwent laparoscopic cholecystectomy within 7 days of diagnosis. Notes were reviewed for all patients who failed to meet this target to ascertain reasons why. Results Of the 336 patients coded as AC 8 were excluded due to incorrect coding leaving 328. 285 patients (87%) underwent laparoscopic cholecystectomy within 7 days. Of the 43 that did not, 31 (65%) had clinically justified reasons for delay. 285/297 (96%) patients met the NICE standard. Conclusions At Salisbury District Hospital 87% patients presenting with AC underwent laparoscopic cholecystectomy within 7 days. Common reasons for failure included: Awaiting further investigation (i.e., ERCP / MRCP), unfit for operative management, patient choice. Excluding justifiable reasons 96% of patients met NICE standards. Poor documentation was the most common cause for failure. Subsequent education and re-audit showed significant improvement. This audit exemplifies that NICE standards for the management of AC can be achieved in a district general setting.

Management of Metastatic Spinal Cord Compression in Secondary Care: A Practice Reflection from Medway Maritime Hospital, Kent, UK.

Introduction: Malignant spinal cord compression (MSCC) is one of the most devastating complications of cancer. This event requires rapid decision-making on the part of several specialists, given the risk of permanent spinal cord injury or death. The goals of treatment in spinal metastases are pain control and improvement of neurological function. There can be challenges in delivering prompt diagnosis and treatment in a secondary care setting. We have reflected on the experience of managing MSCC in a district general setting. Aim: Our retrospective audit identified 53 patients with suspected MSCC who entered the relevant pathway from April 2017 to March 2018 at Medway, United Kingdom (UK). Our audit standards were set out by Medway Maritime Hospital and Maidstone and Tunbridge Wells NHS Trust MSCC working group members, using a combination of published evidence and best practice. Results: The patients with suspected MSCC were 53 and 29 of them (54.7%) had confirmed MSCC. The most common malignancies within the confirmed MSCC were lung (11 patients, 37.9%), breast (5 patients 17.2%), and renal (3 patients, 10.3%), followed by prostate, myeloma and carcinoma of unknown primary (2 patients (6.9%) each), as well as pancreatic, colorectal, lymphoma and, bladder (1 patient (3.4%) each). A magnetic resonance imaging (MRI) scan was performed in 48 patients (90.5%); the majority (31 patients, 64.6%) underwent the MRI within the first 24 h, whereas 3 patients had the investigation between 24 and 72 h from the admission. Among the 29 patients with confirmed MSCC, 6 (20.6%) were treated with surgical decompression, while 20 (69%) received radiotherapy (RT) and 3 (10.3%) best supportive care, respectively. Median time to surgery was 5 days (ranged between 2 and 8 days), whereas for RT 44.4 h (ranged between 24 and 72 h). Finally, all 3 patients that decided on symptom control were referred to a palliative care team within the first 24 h following the MRI scan. Conclusions: MSCC is frequently presented outside tertiary care. This may cause subsequent delays in investigation, diagnosis, and treatment, which can be improved by following a fast track referral pathway.

Prone cylindrical abdominoperineal resection with subsequent rectus abdominis myocutaneous flap reconstruction performed by a colorectal surgeon

Prone cylindrical abdominoperineal resection (APR) leads to reduced circumferential resection margin (CRM) involvement but is associated with a large perineal deficit. A rectus abdominis myocutaneous (RAM) flap can reduce the morbidity associated with the perineal wound. This is often performed in coordination with a plastic surgeon. We reviewed the outcome of prone APR carried out by a single colorectal surgeon using RAM flap without the involvement of plastic surgeons in a district general hospital. Data were reviewed retrospectively for consecutive patients who have undergone prone cylindrical APR and RAM flap reconstruction between 2008 and 2011. Additional data were reviewed for all patients who have undergone supine APR between 2004 and 2008 for comparison. Twelve patients (seven females, five males) of median age of 69years (range 50-84years) underwent prone APR and RAM flap reconstruction. The CRM was negative in all cases. One patient had complete flap necrosis and subsequent flap removal, and three (25%) patients experienced delayed flap healing. One patient died from bronchopneumonia following a cerebrovascular accident at day 14. In the preceding 4years, nine patients (three females, six males) of median age of 70years (range 32-83years) underwent supine APR alone. The CRM was negative in all cases. Three patients suffered breakdown of the perineal wound requiring prolonged packing, and one developed a methicillin-resistant Staphylococcus aureus wound infection. Prone APR and RAM flap reconstruction can be performed by colorectal surgeons in a district general setting with good outcomes, without the need for a plastic surgeon, thus increasing the feasibility of this treatment modality.

Stapled haemorrhoidopexy—Complications and patient satisfaction

Background: Surgical haemorrhoidectomy is recognised as an effective but often painful intervention for haemorrhoids. Performed in a district hospital setting, this survey studied the success rates of stapled haemorrhoidopexy (SH) technique according to reported symptoms and patient satisfaction, post operatively. Methods: A cohort of 108 patients admitted for cir- cular stapled procedure at Inverclyde Royal Hospital between June 2006 and December 2011 gave their consent to be interviewed over the telephone after their procedure. 101 out of the 108 patients responded. Assessment of patient satisfaction was made on the basis of pre operative symptoms, postoperative results and complications. Results: Preoperatively, all patients had Grade lll or lV haemorrhoids complicated by haemorrhage. 33% of patients reported associated pain, and 25% complained of anal leakage. Mean follow up time was 23.8 months (7 - 38 months). Overall reported complication rate was 17%, with 9% reporting short term bleeding, 4% reporting shortlived post-operative pain and 3% with recurrence of prolapsed haemorrhoids. 88% of patients were happy with results, with 87% of patients happy to recommend the procedure to others. Conclusion: Stapled anopexy is a relatively new procedure. It has been found to be a successful and well-tolerated procedure for prolapsing haemorrhoids in this district general setting. It has a low recurrence rate, low incidence of post operative pain and a high level of patient satisfaction. However, there are associated complications and it has a steep training curve.

The Influence of Touch-Imprint Cytology on Further Management for Breast Cancer Patients

The Influence of Touch-Imprint Cytology on Further Management for Breast Cancer Patients

Training Outcomes in Colorectal Cancer Surgery in a District General Hospital

Objectives: The purpose of this study was to quantify the effect of training on outcomes following colorectal cancer resections in a District General Hospital.Patients and methods: Data on 102 consecutive elective colorectal cancer resections performed at a District General Hospital over a three-year period were prospectively collated. The proportion of cases performed by trainees was recorded and the seniority of the operating surgeon was related to pre-operative morbidity, operative time and postoperative outcome.Results: Consultants, staff grades and registrars performed 46, 35 and 21 procedures respectively. Of the cases performed by registrars, consultant supervision was provided in seven cases, with staff grades providing supervision in 14 cases. As compared with consultants, registrars were less likely to undertake anterior resection (p = 0.001). However, the mean operating times of trainees (145 ± 8 mins) and consultants (135 ± 6 mins) were similar. There were no significant differences between the groups with respect to postoperative mortality or morbidity. There was a trend towards more advanced disease in consultant cases, and consultants had a significantly poorer freedom from death or recurrence at two years as compared with trainees (p = 0.03).Conclusions: In our unit, trainees performed 21% of all elective colorectal resections with no detrimental effect on length of hospital stay, overall hospital costs and early and late patient outcomes. Major colorectal procedures can be successfully accomplished in a District General setting by trainees, with the training burden shared between consultants and staff grade surgeons.

Exeter-Ogee total hip replacement using the Hardinge approach; the ten to twelve year results

We reviewed 131 consecutive primary total hip replacements implanted into 127 patients between 1995 and 1997. Surgery was performed through a Hardinge approach using the Exeter universal stem in combination with the Ogee Elite acetabular component.Five of 131 hips have required revision. The ten year survival analysis demonstrates: 95.3% survival with revision for any cause as the end point; 98.9% with revision for aseptic loosening of the stem as the endpoint, 98.1% revision for aseptic loosening of the acetabular component as the endpoint. There were no cases of dislocation.Our findings show that the Exeter universal stem in combination with the Ogee Elite acetabular component can be inserted through a Hardinge approach in a district general setting with results comparable to surgery performed in a specialist unit and through a posterior approach.

Exeter-Ogee total hip replacement using the Hardinge approach; the ten to twelve year results

We reviewed 131 consecutive primary total hip replacements implanted into 127 patients between 1995 and 1997. Surgery was performed through a Hardinge approach using the Exeter universal stem in combination with the Ogee Elite acetabular component.Five of 131 hips have required revision. The ten year survival analysis demonstrates: 95.3% survival with revision for any cause as the end point; 98.9% with revision for aseptic loosening of the stem as the endpoint, 98.1% revision for aseptic loosening of the acetabular component as the endpoint. There were no cases of dislocation.Our findings show that the Exeter universal stem in combination with the Ogee Elite acetabular component can be inserted through a Hardinge approach in a district general setting with results comparable to surgery performed in a specialist unit and through a posterior approach.