Non-specialist Units Research Articles

Management of acute cervical spinal cord injury in the non-specialist intensive care unit: a narrative review of current evidence.

Each year approximately one million people suffer spinal cord injury, which has significant physical, psychosocial and economic impacts on patients and their families. Spinal cord rehabilitation centres are a well-established part of the care pathway for patients with spinal cord injury and facilitate improvements in functional independence and reductions in healthcare costs. Within the UK, however, there are a limited number of spinal cord injury centres, which delays admission. Patients and their families often perceive that they are not receiving specialist care while being treated in non-specialist units. This review aimed to provide clinicians who work in non-specialist spinal injury centres with a summary of contemporary studies relevant to the critical care management of patients with cervical spinal cord injury. We undertook a targeted literature review including guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials published in English between 1 June 2017 and 1 June 2023. Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also included. We then summarised the key management themes: acute critical care management approaches (including ventilation strategies, blood pressure management and tracheostomy insertion); respiratory weaning techniques; management of pain and autonomic dysreflexia; and rehabilitation.

Implementation of the medical emergencies in eating disorders in adults guidance on non-specialist units

The Royal College of Psychiatrists recently published data showing an 84% increase in UK hospital admissions for eating disorders over the past 5 years, highlighting the importance of the college's new Medical Emergencies in Eating Disorders (MEED) guidance. This includes a 79% increase among adults, many of whom are admitted to general medical wards that do not have input from expert eating disorders services. Consequently, the multidisciplinary nutrition support team, nutrition specialist nurses and dietitians have a potentially vital role in implementing MEED to ensure that the appropriate nutritional, fluid and electrolyte management is in place for safe refeeding and avoidance of the potentially harmful underfeeding syndrome. Furthermore, the guidance includes special recommendations for the use of nasogastric feeding in eating disorder patients, which requires input from experts in this field, including specialist nurses and dietitians. This article focuses on the implementation of MEED on hospital wards that do not have input from specialist eating disorders services.

Caring for patients with substance use disorders: a qualitative investigation of difficulties encountered by hospital-based clinicians

Background: Caring for patients with substance use disorders (SUD) is held in low regard and many clinicians resist treating them. To address this situation, numerous research projects assessed training program gaps and professional attitudes. In contrast, this study explored the actual clinical difficulties that a variety of hospital-based professionals encounter when treating patients with SUD. Methods: Qualitative multiple method design including: (1) individual semi-structured interviews with SUD experts and educators; (2) video-elicited, cross self-confrontation interviews with clinicians working in a specialist addiction unit; (3) paired semi-structured interviews with clinicians working in non-specialist units. Participants were recruited within one university hospital. Data collected at stages (1) and (3) relied on an interview guide and were analyzed using conventional content analyses. Data collected at stage (2) consisted of discussions of video recorded clinical interviews and were analyzed based on a participatory approach. Results: Twenty-three clinicians from seven hospital units participated. Forty-four difficulties were reported that we classified into six categories: knowledge-based; moral; technical; relational; identity-related; institutional. We identified seven cross-category themes as key features of SUD clinical complexity: exacerbation of patient characteristics; multiplication of medical issues; hybridity and specificity of medical discipline; experiences of stalemate, adversity, and role reversal. Conclusions: Our study, providing a comprehensive analysis of the difficulties of caring for patients with SUD, reveals a highly challenging clinical practice for a diversity of healthcare providers. They represent a complementary approach to addressing resistance as an important feature of a complex clinical system, and valuable material to discussing professional preparedness.

731 MULTICENTRE OBSERVATIONAL REGISTRY OF PATIENTS HOSPITALIZED FOR HEART FAILURE AND REAL-LIFE ADHERENCE TO INTERNATIONAL GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH ACUTE AND CHRONIC HEART FAILURE. THE REAL-HF REGISTRY

Abstract Purpose The Multicentre observational REgistry of patients hospitalized for heart failure and reAL-life adherence to international guidelines for the management of patients with acute and chronic Heart Failure (REAL-HF) aims to provide a comprehensive overview of hospital management of HF patients in Italy. Methods The registry involves 11 cardiology centers from seven Italian regions, including all adult patients hospitalized for HF in the period 2020-2026. Data are derived from hospital discharge letters and electronic records. Patients are included in the registry based on Diagnosis Related Groups codes. Results This preliminary analysis included 1600 patients hospitalized for HF in 2020 in two Italian tertiary university hospitals. Males were 851(53%) with a median age of 81(71-87) years. Less than one-third of the patients (n=461[29%]) was hospitalized in a cardiology unit, while almost half of the patients (n=783[49%]) was admitted to an internal medicine ward. Median hospital length of stay was 9(6-14) days. Readmission rates were 9% and 29% at 30 days and within the same year, respectively. In-hospital mortality was 9%, while 28% of the patients died within the same year. According to HF categories, 501(31%) patients were diagnosed as having HFrEF, 193(12%) mildly reduced ejection fraction (HFmrEF) and 689(43%) preserved ejection fraction (HFpEF). Median left ventricular EF was 49%(35-55%) and was significantly lower in patients with HFrEF (30%[25-35%]) compared to those with HFmrEF (45%[43-45%]) and HFpEF (55%[55-60%]) – p<0.001. Coronary artery disease proved to be the leading cause (n=460[29%]) of HF. Atrial fibrillation was highly prevalent (history -13%; during hospitalization -37%). Arterial hypertension was the most prevalent (71%) cardiovascular risk factor. Chronic kidney disease (51%) and chronic obstructive pulmonary disease (27%) were frequent comorbidities. Apparently, COVID-19 had a low impact, being present in only 3% of patients hospitalized for HF in 2020 at both centers. At discharge, 56% of patients were treated with angiotensin-converting enzyme inhibitors–ACEi (n=490[34%]), angiotensin receptor blockers–ARB (n=221[15%]) or angiotensin-neprilysin inhibitors–ARNi (n=100[7%]), 67%(n=964) with beta-blockers, while mineralocorticoid receptor antagonists–MRAs were prescribed for 56%(n=809) of patients. Loop diuretics were frequently prescribed (89%). When we considered patients with HFrEF, we found that only 69% were treated with ACEi/ARB/ARNi, 82% with a beta-blocker, and 67% with MRAs. Only 48% (n=240) were treated with all three of the above-mentioned classes of drugs. Among patients with HFrEF, only 5% had an implantable cardioverter defibrillator, and only 4% were treated with cardiac resynchronization therapy. Patients hospitalized in wards other than cardiology were older (83vs70 years, p<0.0001), more frequently females (52%vs44%, p<0.001), and with HFpEF (51%vs24%, p<0.0001). In-hospital mortality and death within the same year resulted significantly lower in patients hospitalized in cardiology units (5%vs11% - p<0.001, and 17%vs32% - p<0.001). Overall, drugs indicated in HF were less frequently prescribed in patients hospitalized in non-specialist cardiac units. Conclusions Preliminary data from the multicentre REAL-HF registry confirm that HF constitutes a clinical issue. Adherence to the guidelines is still inadequate and this may impact on patients’ outcomes. Moreover, the significant differences in terms of patients’ profiles might further increase the gap between highly specialized cardiology units and internal medicine departments.

Stickler Syndrome: Airway Complications in a Case Series of 502 Patients.

Background:Patients with Stickler syndrome often require emergency surgery and are often anesthetized in nonspecialist units, typically for retinal detachment repair. Despite the occurrence of cleft palate and Pierre-Robin sequence, there is little published literature on airway complications. Our aim was to describe anesthetic practice and complications in a nonselected series of Stickler syndrome cases. To our knowledge, this is the largest such series in the published literature.METHODS:We retrospectively identified patients with genetically confirmed Stickler syndrome who had undergone general anesthesia in a major teaching hospital, seeking to identify factors that predicted patients who would require more than 1 attempt to correctly site an endotracheal tube (ETT) or supraglottic airway device (SAD). Patient demographics, associated factors, and anesthetic complications were collected. Descriptive statistical analysis and logistic regression modeling were performed.RESULTS:Five hundred and twoanesthetic events were analyzed. Three hundred ninety-five (92.7%) type 1 Stickler and 63 (96.9%) type 2 Stickler patients could be managed with a single attempt of passing an ETT or SAD. Advanced airway techniques were required on 4 occasions, and we report no major complications. On logistic regression, modeling receding mandible (P = .0004) and history of cleft palate (P = .0004) were significantly associated with the need for more than 1 attempt at airway manipulation.CONCLUSIONS:The majority of Stickler patients can be anesthetized safely with standard management. If patients have a receding mandible or history of cleft, an experienced anesthetist familiar with Stickler syndrome should manage the patient. We recommend that patients identified to have a difficult airway wear an alert bracelet.

A comparison of patients managed in specialist versus non-specialist inpatient rehabilitation units in Australia

Aim: To compare the rehabilitation of patients with brain and spinal cord injury in specialist rehabilitation units and non-specialist rehabilitation units in Australia over a 10-year period.Method: A retrospective cohort study design was used. Epidemiological descriptive analysis was used to examine inpatient rehabilitation data held in the Australasian Rehabilitation Outcomes Centre Registry Database at four discrete time points: 2007, 2010, 2013 and 2016. Data sets included patient demographics, length of stay and the Functional Independence Measure. Data sets were examined for differences between specialist and non-specialist rehabilitation units.Results: Over the 10-year study period, compared to patients admitted to non-specialist rehabilitation units patients admitted to specialist rehabilitation units: (1) were younger and more likely to be male; (2) had a longer time between onset of illness/injury and rehabilitation admission; (3) had a longer median rehabilitation length of stay; (4) had a higher burden of care on admission to rehabilitation; however (5) had a greater functional gain. Patients in specialist rehabilitation units had a lower relative functional efficiency per day of rehabilitation, but higher percentage of Functional Independence Measure gain. In 2016, 66% of brain injury and 51% of spinal cord injury patients were not rehabilitated in specialist rehabilitation units.Conclusion: There are differences in the characteristics of patients admitted to specialist versus non-specialist rehabilitation units. Patients admitted to specialist rehabilitation units have greater functional gain. A noteworthy proportion of brain and spinal cord injury patients are not being rehabilitated in specialist rehabilitation units, particularly patients with non-traumatic injuries.Implications for rehabilitationPatients with a brain or spinal cord injury rehabilitated in specialist rehabilitation units achieve a greater functional gain than those in non-specialist units.Development of best practice admission guidelines would better enable the right care for the right patient in the right setting at the right time.There is a need for longitudinal examination of patient outcomes to better understand the long-term benefits of being rehabilitated in specialist rehabilitation units compared to non-specialist rehabilitation units.

British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies – penile amputation

Male genital emergencies relating to the penis and scrotum are rare and require prompt investigation and surgical intervention. Clinicians are often unfamiliar with the management of these conditions and may not work in a specialist centre with on-site expertise in genitourethral surgery. A series of consensus statements have been developed by an expert consensus committee comprising members of the British Association of Urological Surgeons (BAUS) Sectionof Andrology and Genitourethral Surgery together with experts from urology units throughout the UK. Penile amputation is a rare genital emergency, which requires prompt intervention and microsurgical reconstruction. The consensus statements will outline the management of these cases for non-specialist units, as well as recommendations for reconstruction for specialists.

Brain injury rehabilitation after road trauma in new South Wales, Australia \u2013 insights from a data linkage study

BackgroundPopulation-based patterns of care studies are important for trauma care but conducting them is expensive and resource-intensive. Linkage of routinely collected administrative health data may provide an efficient alternative. The aims of this study are to describe the rehabilitation pathway for trauma survivors and to analyse the brain injury rehabilitation outcomes in the two care settings (specialist brain injury and non-specialist general rehabilitation units).MethodsThis is an observational study using routinely collected registry data (New South Wales Trauma Registry linked with the Australasian Rehabilitation Outcomes Centre Inpatient Dataset). The study cohort includes 268 road trauma patients who were admitted to trauma services between 2009 and 2012 and received inpatient rehabilitation because of a brain injury.ResultsOf those who need inpatient rehabilitation, 62% (n = 166) were admitted to specialist units with the remainder (n = 102) admitted to non-specialist units. Those admitted to a specialist units were younger (p < 0.001), had a lower cognitive FIM score (p = 0.003) on admission than those admitted to non-specialist units. Specialist units achieved better overall FIM score improvements from admission to discharge (43 vs 30 points, p > 0.001) but at a cost of longer length of stay (median 47 vs 24 days, p < 0.001). There were very few discharges to residential aged care facilities from rehabilitation (2% in non-specialist units and none from specialist units). There was a long time lag between trauma and admission to inpatient rehabilitation with only a quarter of the patients admitted to a specialist unit by end of week four. Few older patients (19%) with brain injury were admitted to specialist units.ConclusionsIt is feasible to use routinely collected registry data to monitor inpatient rehabilitation outcomes of trauma care. There were differences in characteristics and outcomes of patients with traumatic brain injury admitted to specialist units compared with non-specialist units.

A Comparison of Hospital Stressors and their Related Factors: From the Perspective of the Cardiac and Internal Wards’ Patients

Background: Stress is one of the human being’s predicaments in the current century which has extended its effects on various aspects of peoples’ lives. These unpleasant effects have indeed afflicted the patients even more and can aggravate their health status. Therefore, this study was conducted to examine the stressors inherent in the cardiac ward and internal ward of hospitals. Methods and materials: This cross-sectional study was carried out in Sistaan-va-Baluchestaan province, Zahedaan city in 2013 and all of the patients hospitalized in the cardiac and internal wards of the Khaatam Hospital and Imam Ali Hospital were taken as the population. Available sampling was used to extract a sample of 368 patients. Data was gathered by handing out a questionnaire produced by the researcher and the descriptive statistics, Chi-square, and ANOVA tests were used to analyze the data. Results: Analyses indicate that the mean of stressors in the internal and cardiac wards are 60.36 and 44.90 respectively which are statistically significant. The mean of stressors’ scores has a significant relationship with background factors such as level of education, hospitalization history, marital status, religion, and sex but did not render any significant relationship with other variables. Conclusion: Since stress may lead to the deterioration of the patients’ illness it is expected that the authorities detect the least stressors in hospitals and take action to moderate them. In this regard non-specialist units are in greater need for attention.

Family carer perspectives of acute hospital care following a diagnosis of motor neuron disease: a qualitative secondary analysis

ObjectivesThe multifaceted nature of the problems faced by someone with motor neuron disease requires a knowledgeable multidisciplinary team approach. Where available, generally, such services are only provided on an outpatient...

Management of late postoperative complications of bariatric surgery

The prevalence of obesity is increasing worldwide and the past decade has witnessed an exponential rise in the number of bariatric operations performed. As a consequence, an increasing number of patients are presenting to non-specialist units with complications following bariatric procedures. This article outlines the management of the most common late postoperative complications that are likely to present to the general surgeon. A search was conducted for late postoperative complications after bariatric surgery using PubMed, Embase, OVID and Google search engines, and combinations of the terms bariatric surgery, gastric bypass, gastric banding or sleeve gastrectomy, and late or delayed complications. Only studies with follow-up longer than 6 months were included. The most common long-term complications after gastric banding include band slippage and erosion. Deflation or removal of the band is often required. Internal hernia, adhesions and anastomotic stenosis are common causes of intestinal obstruction after gastric bypass surgery. Hepatobiliary complications pose a particular challenge because of the altered anatomy. Functional disorders such as reflux and dumping, and nutritional deficiencies are common and should be differentiated from conditions that require urgent investigations and timely surgical intervention. The immediate management of bariatric patients presenting with complications outside the immediate postoperative period requires adherence to basic surgical principles. Accurate diagnosis often relies on high-quality contrast and cross-sectional imaging, and effective surgical intervention necessitates a broad understanding of the altered anatomy, advanced surgical skills and liaison with specialists in the field when necessary.

Comparison of patients managed in specialised spinal rehabilitation units with those managed in non-specialised rehabilitation units

Prospective open cohort study. Compare the demographic characteristics and rehabilitation outcomes for both non-traumatic SCI (NT-SCI) and traumatic SCI (T-SCI) patients admitted into either specialist spinal cord injury rehabilitation units (SCIRUs) or non-specialist rehabilitation units (NSRUs). Rehabilitation units in Australia. The Australasian Rehabilitation Outcomes Centre maintains a national database on inpatients admitted to most (130/145) public and private rehabilitation units in Australia. Patients were included if they had a diagnosis of spinal cord injury (SCI) and were discharged between 1 January 2006 and 31 December 2006. Patients were excluded if admitted for <7 days, only for assessment, or were a readmission following a previous SCI. There were 668 patients with confirmed SCI admitted (NT-SCI n=361, 54.0%; T-SCI n=307, 46.0%). NT-SCI patients were much less likely to be admitted into a specialist SCIRU (30.5%) compared with T-SCI patients (70.4%). For both NT-SCI and T-SCI patients, those admitted to a specialist SCIRU tended to be younger (P=0.000), have a longer length of stay in rehabilitation (P=0.000), and lower Functional Independence Measure (FIM) motor subscale score on admission (P=0.000) than those admitted to a NSRU. For NT-SCI patients, after adjusting for covariates, those admitted into specialist SCIRU had greater improvement in their FIM motor score during rehabilitation. This finding was not demonstrated in T-SCI patients. There are differences in the characteristics of SCI patients admitted to SCIRU compared with NSRU. NT-SCI patients admitted to SCIRU have greater functional gain.

‘Listening to Patients’: what is the value of age-appropriate care to teenagers and young adults with cancer?

Current healthcare policy increasingly recognises the importance of patient experience in determining care. The 2005 UK National Institute for Health and Clinical Excellence Improving Outcomes Guidance encompasses caring for young people with cancer in an age-appropriate model of care developing regional principal treatment centres for this purpose. When published this was based upon limited outcomes evidence, and only a small amount of teenage and young adult patient and parent opinion. We have systematically reviewed the literature between 1996 and 2008, examining how far the experiences of this patient group support or refute the current policy. The recent literature describes with increasing consistency that teenage and young adult cancer patients have specific care needs, and gain benefits from an age-appropriate environment of care, including peer group support, age-appropriate information, recreational and vocational support, and staff expert in both the cancer and care of their age group. Many patients are prepared to travel to receive such care, if services are not in place to deliver excellent shared care between principal treatment centres and services nearer home. Some of these needs are unmet in non-specialist units. There remains, however, a paucity of rigorous comparative studies quantifying the value of specialist cancer care for this patient group.

Diagnosis and management of pancreatic trauma

BACKGROUND: Pancreatic injury is uncommon and often presents with subtle clinical and radiological signs. For this reason, diagnosis may be delayed, or inappropriate surgery may be attempted, leading to significant morbidity and mortality. METHODS: We performed a thorough investigation of the literature between 1963 and 2008 in order to review the diagnosis and management of pancreatic trauma. RESULTS: In unstable patients and in cases of penetrating injury, immediate surgical exploration is usually essential. In these cases damage control surgery should be performed and major pancreatic resections with primary anastamoses should not be attempted, particularly in non-specialist units. In stable patients, imaging modalities are vital to grade the degree of injury and crucially identify signs of major pancreatic duct disruption, which is a key indicator of prognosis. Management may then be tailored to the degree of injury identified. CONCLUSIONS: Pancreatic injury is uncommon but must be suspected following trauma to the epigastrium. In stable patients urgent radiological investigations should be performed prior to planning treatment. Early consultation with specialist units is essential.

Pelvic vein reflux in female patients with varicose veins: comparison of incidence between a specialist private vein clinic and the vascular department of a National Health Service district general hospital

Mounting evidence suggests that pelvic vein reflux is an important contributing factor to recurrent varicose veins. We compared the incidence in our specialist private unit (Unit A) with that of a District General Hospital (Unit B). Results of all female patient lower limb duplex ultrasound (LLDUS) and transvaginal pelvic ultrasound (TVUS) scans performed over a one-year period were retrospectively reviewed. Patients with refluxing veins emanating from the abdomen or pelvis on LLDUS (non-saphenous reflux) routinely proceeded to TVUS in Unit A. In Unit A, non-saphenous reflux on LLDUS was present in 90-462 female patients (19.5%). In 81.1% of these, TVUS confirmed reflux in truncal pelvic veins (incidence 15.8%). In Unit B, non-saphenous reflux was present in 60-279 female patients (21.5%). One in five women presenting with varicose veins have reflux of non-saphenous origin. This is the case in specialist and non-specialist units. One in six has associated pelvic vein reflux.

Services for liver disease in district general hospitals in the UK: a national questionnaire-based survey

The burden of liver disease in the UK is increasing and much of this is managed in district general hospitals (DGHs). Previous studies of liver services have focused on specialist units. This study assessed the provision of liver services in non-specialist units. A questionnaire-based survey was conducted to assess resources, staffing and clinical management of liver disease. Replies were received from 61 consultant gastroenterologists working in DGHs across the UK. The data show inadequate consultant numbers and limited availability of nurse specialists, hepatobiliary pathologists and radiologists. There is marked variability in the management of hepatitis C, variceal bleeding and hepatorenal syndrome. Liver databases and outcomes are rarely kept. There are significant shortfalls in the provision of liver services across DGHs. This supports the need for managed clinical networks and data collection as proposed in the National Plan for Liver Services.

An audit of nurses' conduct and recording of observations using the Glasgow Coma Scale

Objectives: The Glasgow Coma Scale (GCS) is routinely used to assess patients following head injury or other acute neurological events. The aims of this project were: to assess and evaluate registered nurses' baseline knowledge of the three behavioural responses that make up the assessment tool; to review the recording of GCS in neuroscience areas compared with non-specialist units; and to ascertain when the GCS is taught during nurse training and the background experience of the lecturers who teach it. Methods: Sixty questionnaires were used across six clinical areas: neurosurgery, neuro-intensive care, neuromedicine, general medicine, accident and emergency, and general intensive care. Observational studies compared nurses' performance, recording and documentation of GCS observations in each of these units. The unpublished standards for making GCS observations, written by the Neuroscience Nursing Benchmarking Group, were used to identify questions for examination in the audit. Results: Several areas for improvement were identified; including the use and application of painful stimulus. The use of sternal rubbing and nail bed compression continues to be common practice. Data collected also suggested a lack of knowledge of the patho-physiology underpinning the three components that make up the scale. Problems were evident in the record keeping, with very few examples of documentation within nursing records of the separate components of the GCS. Finally, the questionnaires returned from the universities revealed that students were introduced to the assessment tool during the first year of training, normally by lecturers with a critical care or accident and emergency clinical background. Conclusions: The data demonstrated wide variation in GCS scoring across all specialties. While the benchmarking standards are applied in neuroscience wards, the guidelines are not widely available for use in other units. It is pertinent to consider whether access to a clear and comprehensive protocol would help remove some of the ambiguities and ensure a more consistent approach to assessment. Novel approaches to education are required to maintain knowledge and skills in this area of practice. Documentation needs to improve and include the results from component parts of the scale. Instruction on the performance of GCS observations, if taught in the first year of training, should be re-examined, linking theory to practice prior to qualifying. The findings from this study will provide a useful basis for future research using more precise methods.

A manager's guide to dementia care

Older people are the largest group of patients in acute settings, and the risk of dementia rises with age. People with dementia do not function to capacity outside their normal environment, and illness and injury can place further strains on them. Staff working in non-specialist units may have difficulty coping with the person with dementia. They may inadvertently make it more difficult for the person to cope in a bewildering and difficult situation. This article aims to provide managers with a brief overview of dementia, the problems people with dementia face in acute settings and how to enable staff to provide high quality care to meet patient needs.

Large Hepatocellular Carcinoma: Time to Stop Preoperative Biopsy

In Western countries, hepatocellular carcinoma (HCC) often presents at a large size, which is seen as a contraindication to transplantation and often resection. Although diagnosis by imaging and alpha-fetoprotein is usually straightforward, nonspecialist units continue to use biopsy to prove the diagnosis before transfer for specialist surgical opinion. We have looked at the impact of this on our practice. We retrospectively analyzed all large HCCs resected in our unit during the last 12 years. Survival data were calculated according to size and univariate and multivariate analyses were carried out to determine impact of preoperative, operative, and histologic factors affecting outcomes. We identified 85 large HCCs (> 3 cm) and classified 42 as giant (> 10 cm). Overall survival at 1, 3, and 5 years was 76%, 54%, and 51%. Size did not influence survival, although more complex surgical techniques were required for giant tumors. Predictors of poorer disease-free survival were positive resection margin (p < 0.001), multiple tumors (p = 0.003), macroscopic vascular invasion (p = 0.015), and preoperative lesion biopsy (p = 0.027). Our data shows excellent outcomes after resection for large HCC. This supports the management of such patients in large-volume units that are fully equipped and experienced in the management of these patients. Preoperative biopsy should be avoided, as this unnecessary maneuver appears to have worsened our longterm results.

LAPAROSCOPIC BILE DUCT EXPLORATION: RESULTS OF 160 CONSECUTIVE CASES WITH 2‐YEAR FOLLOW UP

Despite numerous reports showing the advantages of laparoscopic common bile duct exploration (LCBDE), many general surgeons, particularly those working outside of nonspecialist units, continue to rely heavily on endoscopic retrograde cholangiography with sphincterotomy (ERCP) to manage bile duct stones (BDS). This article investigates the performance of LCBDE when adopted as the preferred first-line management of both suspected and incidental BDS by general surgeons in a regional setting. A retrospective review was conducted of all patients in whom LCBDE was attempted by a regional general surgical unit. The unit policy was to preferentially treat all incidental and suspected BDS (except in ascending cholangitis or severe pancreatitis) by LCBDE, with ERCP used only if unsuccessful. In addition to chart review, formal prospective follow up by telephone interview was carried out. A total of 160 consecutive patients with BDS (mean age 66.9 years, 65% suspected and 35% incidental) underwent attempted LCBDE between January 2000 and July 2005. Successful clearance was achieved in 84.3% according to chart review. However, four additional cases of retained choledocholithiasis shown by late telephone interview (median interval 2.5 years) yielded a more accurate clearance rate of 81.8%. Major morbidity occurred in 13.8%, including biliary leak in 7.5% and one late biliary stricture (0.6%). Median length of hospital stay was 4.8 days. In-hospital mortality was 0.6%. Laparoscopic common bile duct exploration remains an effective, efficient and safe first-line treatment of BDS even when carried out in regional nonspecialist units. In spite of the wide availability of ERCP, general surgeons should be encouraged to continue performing LCBDE in order to optimise patient care and maintain important surgical skills.