Keith Seymour

Risk factors in laparoscopic cholecystectomy: A multivariate analysis

BACKGROUND Laparoscopic cholecystectomy (LC) is the operation of choice in the treatment of symptomatic gallstone disease. The aim of this study is to identify risk factors for LC, outcomes include operating time, length of stay, conversion rate, morbidity and mortality. METHODS All patients undergoing LC between 1998 and 2007 in a single district general hospital. Risk factors were examined using uni- and multivariate analysis. RESULTS 2117 patients underwent LC, with 1706 (80.6%) patients operated on electively. Male patients were older, had more co-morbidity and more emergency surgery than females. The median post-operative hospital stay was one day, and was positively correlated with the complexity of surgery. Conversion rates were higher in male patients (OR 1.47, p = 0.047) than in females, and increased with co-morbidity. Emergency surgery (OR 1.75, p = 0.005), male gender (OR 1.68, p = 0.005), increasing co-morbidity and complexity of surgery were all positively associated with the incidence of complications (153/2117 [7.2%]), whereas only male gender was significantly associated with mortality (OR 5.71, p = 0.025). CONCLUSION Adverse outcome from LC is particularly associated with male gender, but also the patients co-morbidity, complexity and urgency of surgery. Risk-adjusted outcome analysis is desirable to ensure an informed consent process.

Nutritional strategies in severe acute pancreatitis: A systematic review of the evidence

Nutrition in severe acute pancreatitis is a critical aspect in the management of this condition. This review aims to systematically review the evidence available to inform the use of nutritional support in severe acute pancreatitis. High quality (level 1) evidence supports naso-jejunal enteral nutrition (NJ-EN) over parenteral nutrition (PN) reducing infectious morbidity and showing a trend towards reduced organ failure although there is no detectable difference in mortality. Trial data may underestimate benefit as patients are often recruited with predicted rather than proven severe disease. NJ-EN is safe when started immediately (level 3 evidence). NJ-EN is often impractical and naso-gastric (NG) feeding seems to be equivalent in terms of safety and outcomes whilst being more practical (level 2 evidence). Regarding feed supplementation, probiotic feed supplementation is not beneficial (level 1 evidence) the and may cause harm with excess mortality (level 2 evidence). No evidence exists to confirm benefit of the addition of prokinetics in severe acute pancreatitis (SAP) although their use is proven in other critically ill patients. Level 2 evidence does not currently support the use of combination immuno-nutrition though further work on individual agents may provide differing results. Level 2 evidence does not support intravenous supplementation of anti-oxidants and has demonstrated that these too may cause harm.

Outcome of patients in laparoscopic training courses compared to standard patients

BACKGROUND & AIM Current Laparoscopic simulators have limited usefulness and patients have been used for training since the dawn of surgery. NUGITS (Northumbrian Upper Gastro Intestinal Team of Surgeons) Laparoscopic Skills courses utilise hands-on experience with simulators moving to live operating on volunteer patients. It is vital to know that the volunteer patient is not disadvantaged by greater surgical risk. METHODS This was a case-controlled prospective comparison of patients undergoing both Laparoscopic Cholecystectomy (LC) [n=51] and Laparoscopic Inguinal Hernia (LIH) [n=62] during NUGITS training courses. They are compared with a matched (age, sex and ASA grade) control group LC (n=51) and LIH (n=62) operated on by consultants. The outcome measures were surgical peri-and post-operative complications, post-operative hospital stay, readmission and early recurrence of inguinal hernia (<6 months). RESULTS In the LC cohort, there was no significant difference in the length of hospital stay (p=0.07) or readmission (p=0.16) in both the groups. The mean operating time was higher in the trainee compared to the control group (p=0.001). There was no difference in the post-operative morbidity or mortality in either group. In LIH cohort, the mean operating time was higher in the trainee compared with the control group. There was no significant difference in post-operative complications (p>0.05) and early post-operative recurrence of hernia (p>0.05). CONCLUSION The post-operative outcomes of patients undergoing laparoscopic surgery during laparoscopic training courses are similar to consultant-operated patients. Thus, it is acceptable and safe to encourage patients to volunteer for laparoscopic training courses.

Changes in physical activity after bariatric surgery: using objective and self-reported measures

BACKGROUND Many studies using self-reported physical activity (PA) assessment tools have suggested there is an increase in PA after bariatric surgery. OBJECTIVES Our aim was to assess PA and sedentary behavior before bariatric surgery and at 6 months after, using subjective and objective tools. SETTING Bariatric surgery candidates were recruited from a single center. METHODS Demographic data, medical history, current medications, and anthropometric measurements were recorded. Participants were asked to complete a PA and lifestyle questionnaire and to wear an accelerometer on their nondominant wrist. Data were collected before and at 6 months after surgery. RESULTS Twenty-two participants were included (17 gastric bypass; 4 sleeve gastrectomy; 1 intragastric balloon). Mean age was 46 years and the majority were female (72%). At a median of 6.3 months follow-up, there were significant reductions in measures of body fatness with a mean reduction of 27 kg in weight. The majority of daytime (12.5±1.1 out of 16 h) was spent in sedentary behavior presurgery with little change postsurgery (12.2±1.2; P = .186). Objectively measured mean moderate-vigorous PA did not change significantly from pre- to postsurgery (mean 11.5±13.9 and 11.6±13.1 min/d, respectively; P = .971). Self-reported total nonoccupational PA did not change significantly (P = .390). CONCLUSIONS The majority of bariatric surgery candidates were physically inactive presurgery, and there was no significant change in either subjectively or objectively measured PA at follow-up. This patient group may benefit from objective PA assessment and interventions aimed at increasing PA.

Impact of a care pathway in acute pancreatitis

Background Previous studies have shown that accurate process of care predicts quality of care. Few examples currently exist for process of care for the acute surgical patient. A recent region wide audit had identified good outcomes for patients with acute pancreatitis at our institution but aspects of care that could be improved. Methods For this re-audit, a simple written care pathway for the management of those presenting with acute pancreatitis was introduced in our institution from February to July 2009. The audit standards were set against the British Society of Gastroenterology (BSG) guidelines for management of acute pancreatitis and were compared with the previous region wide audit. Results Marked improvements were noted in the rates of abdominal imaging achieved within 24 h of diagnosis (35.2% vs 47.7%), severity stratification within 48 h of diagnosis (28.7% vs 75%), critical care admission for those classified as severe (39.3% vs 63.6%) and definitive treatment during index admission (22.2% vs 38.5%). Survival rates were 100% for this audit cycle and 95% for all patients within the region wide audit. Despite these improvements, care still does not reach the standards set out by BSG. Conclusion Predefined processes of care may help to recognise those developing or likely to develop severe pancreatitis, ensure accurate documentation of severity, expedite critical care review and/or admission, and help to encourage the timely management of those with a treatable underlying cause of their pancreatitis.

Referral pathways of patients with gallstones

Purpose – Gallstone‐related illnesses are one of the most common reasons for emergency hospital admissions, often with serious complications. Standard treatment of uncomplicated gallstone‐disease is by laparoscopic cholecystectomy, which can be safely and cost‐effectively performed during a short hospital stay or as day‐case. This paper aims to evaluate the referral pattern of patients with gallstones, which treatment is given and whether patients admitted as emergency could have benefited from earlier elective referral. The management of these patients is examined in the context of payment by results to determine cost and potential savings.Design/methodology/approach – The approach takens was prospective clinical audit and patient questionnaire in a district general hospital. Cost comparisons were made using secondary care income (NHS tariff) and estimated cost of hospitalisation, investigations and treatment.Findings – Between May and July 2007, 114 patients were admitted with symptomatic gallstones, 62...