Surgeon-Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland最新文献

Introduction: Acute cholecystitis is a common general surgical emergency, accounting for 3-10 % of all patients attending with acute abdominal pain. International guidelines suggest that emergency cholecystectomy is the treatment of choice for uncomplicated acute cholecystitis where feasible. There is a paucity of published data on the uptake of emergency cholecystectomy in Ireland.

Aim: The aim of this study was to evaluate the management of acute cholecystitis in Ireland and to establish the rate of emergency cholecystectomy performed.

Methods: All patients with acute cholecystitis presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics, co-morbidities, length of stay, operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. Propensity score matched analysis and logistic regression were performed to account for selection bias in comparing patients managed with cholecystectomy and those managed conservatively.

Results: 20,886 admission episodes were identified involving 17,958 patients. 3585 (20 %) patients underwent emergency cholecystectomy in total. 3436 (96 %) of these were performed laparoscopically, with 140 (4 %) requiring conversion to an open procedure, and common bile duct injuries occurring in 4 (0.1 %) of patients. In comparison to patients treated conservatively, patients who underwent cholecystectomy were younger (median 50 v 60 years, p < 0.001) and more likely to be female (64 % v 55 % p < 0.001). Following propensity score matched analysis, those who had an emergency cholecystectomy had reduced length of stay (LOS) (median 5 days (IQR 3-8) v 6 days (interquartile range (IQR) 3-10), p < 0.001) and fewer readmissions to hospital (282 (8 %) v 492 (14 %), p < 0.001). On logistic regression, age >65 (OR 1.526), CCI >3 (OR 2.281) and non-operative management (OR 1.136) were significant risk factors for adverse outcome.

Conclusion: Uptake of emergency cholecystectomy in Ireland remains low, and is carried out on a younger, fitter cohort of patients. In those patients, however, it is associated with improved outcomes for cholecystitis compared to conservative management, including shorter LOS and reduced readmission rates for matched cohorts.

Introduction: Perforation of the gallbladder during cholecystectomy can lead to spillage of gallstones. The aim of this study was to examine if patients with gallstones left in the abdomen after cholecystectomy suffer persisting symptoms.

Method: This study was based on data from the Swedish Register for Gallstone Surgery. Patients with intraoperative gallbladder perforation where it is suspected that gallstones remain in the abdomen were matched with patients that had undergone a cholecystectomy with no suspicion of spilled gallstones. All patients were sent a validated questionnaire including 21 items concerning abdominal pain and inflammatory symptoms. Items were divided into four groups: abdominal pain, consequences of pain, gastrointestinal symptoms, and repeated operation. Mean scores were compared between the study group and the control group using a linear regression model.

Results: The questionnaire was sent to 4269 subjects, and the response rate was 66 %. No significant differences were seen between the study and control groups in the four domains. In the repeated operation domain, 7.1 % in the study group and 5.3 % in the control group underwent a repeated operation (p = 0.057).

Conclusion: Gallstones left in the abdomen are not associated with long-term symptoms. There was a tendency towards a repeat operation in the group that suffered perforation of the gallbladder, although this finding was not significant.

Introduction: Emergency general surgery is typically delivered in addition to routine elective care. Models such as acute surgical assessment units and reduced elective working have been explored to reduce the conflict between these competing demands. We aim to identify the models used, the cohorts of patients seen, and the staffing levels in each system.

Methods: Data on general surgery activities were obtained from the National Quality Assurance and Improvement System (NQAIS) and previously published data. The mode of delivery of acute services in other countries was collated from national surgical bodies and published position statements.

Results: National on-call services are supra-elective or parallel to elective streams with little dedicated on-call. Internationally, many similar countries are moving to separate acute and elective care to ensure both are performing optimally. Staff in Model 3 hospitals are frequently on call with variable but small operative numbers but represent a combination of high and low acuity. These consultants need a wider breadth of surgical skills than Model 4 hospitals due to a lack of local specialists.

Conclusion: The majority of national hospitals still work a traditional on-call model, with limited adoption of separate on-call and elective workstreams. Preserving the elective workload is likely to require separation of these priorities, which is difficult with current staffing levels. The use of Acute Surgical Assessment Units (ASAUs) within emergency surgical networks may improve patient outcomes by regionalising the delivery of higher acuity care.

Background: Surgical site infection (SSI) remains a critical postoperative complication after total hip and knee arthroplasty (THA and TKA). Frailty, a condition characterized by decreased physiological reserve and increased vulnerability to stressors, may influence the risk of SSI in these patients. This meta-analysis aims to evaluate the association between frailty and the incidence of SSI following THA or TKA.

Methods: A systematic search of databases including PubMed, EMBASE, Web of Science, Wanfang, and CNKI was conducted to identify relevant studies. Data were extracted and pooled using a random-effects model to calculate the overall risk ratio (RR) and 95 % confidence intervals (CIs).

Results: A total of ten studies comprising 1,036,787 patients met the inclusion criteria. The meta-analysis revealed that frail patients undergoing THA or TKA had a significantly higher risk of developing SSI compared to non-frail patients (RR = 1.64, 95 % CI: 1.39-1.93, p < 0.001, I² = 66 %). Subgroup analyses indicated that the type of arthroplasty (hip vs. knee) and the method of frailty assessment did not significantly alter the association. Further subgroup analysis suggested that frailty was significantly associated with a higher incidence of deep SSI including joint infection (RR = 1.77, 95 % CI: 1.27-1.48, p < 0.001), but not the incidence of superficial SSI (RR = 1.57, 95 % CI: 0.45-5.42, p = 0.48). The association between frailty and SSI remains in subgroup of multivariate studies only (RR = 1.56, 95 % CI: 1.34 to 1.80, p < 0.001).

Conclusions: Frailty is a potential predictor of SSI following TKA/THA.