Paul Cashin

Impact of an acute care surgery model on appendicectomy outcomes.

Monash Medical Centre introduced the acute surgical unit (ASU) in July 2011. The ASU is modelled on the concept of acute care surgery (ACS). This study reviews the impact of the ASU on the outcomes in an appendicectomy population.

Randomized clinical trial of intraoperative endoscopic retrograde cholangiopancreatography versus laparoscopic bile duct exploration in patients with choledocholithiasis

Various minimally invasive approaches exist for the management of choledocholithiasis at the time of laparoscopic cholecystectomy. The aim of this study was to compare endoscopic retrograde cholangiopancreatography (ERCP) with laparoscopic bile duct exploration (LBDE) and test the hypothesis that intraoperative ERCP is no different to LBDE in terms of rate of bile duct clearance or retained stones.

Management of choledocholithiasis in an emergency cohort undergoing laparoscopic cholecystectomy: a single‐centre experience

INTRODUCTION Minimally-invasive options for the management of choledocholithiasis in patients undergoing laparoscopic cholecystectomy include laparoscopic and endoscopic approaches. This study reviews the effectiveness of both approaches in an emergency setting. METHODS A retrospective chart review was performed for a cohort of patients who underwent laparoscopic cholecystectomy. Outcomes assessed were duct clearance, the number of procedures performed (NPP), length of stay (LOS) and complication rate. RESULTS A total of 182 patients who underwent emergency laparoscopic cholecystectomies received intervention for choledocholithiasis. The duct clearance rate was lower in the laparoscopic group, 63% versus 86% (P = 0.001). However, the median NPP was also lesser in the laparoscopic group, 1 (interquartile range (IQR) 1-2) versus 2 (IQR 2-2) (P < 0.001), as was the median LOS, 5 days (IQR 3-8) versus 7 days (IQR 6-10) (P = 0.009). Forty-eight laparoscopic endobiliary stents were attempted; stent deployment was successful in 37 patients. A larger proportion of patients with laparoscopic endobiliary stents had duct clearance by endoscopic retrograde cholangiopancreatography (ERCP) compared with those without, although this was not statistically significant (P = 0.208). CONCLUSION Laparoscopic clearance is not as effective as post-operative ERCP in an emergency cohort, but is associated with fewer procedures required and a shorter inpatient stay. Thus, laparoscopic clearance may still be an attractive option for surgeons especially where conditions are favourable during an emergency laparoscopic cholecystectomy.

Management of CBD stones in patients having laparoscopic cholecystectomy in a private setting in Australia.

Laparoscopic bile duct exploration at the time of laparoscopic cholecystectomy has been promoted as being equally successful as endoscopic bile duct clearance. Further, if successful it offers the possibility of reducing the number of interventions required and therefore reducing overall costs. However, there is little in the literature that describe current treatment patterns in the Australian environment.

Acute surgical unit safely reduces unnecessary after-hours cholecystectomy.

INTRODUCTION The acute surgical model has been trialled in several institutions with mixed results. The aim of this study was to determine whether the acute surgical model provides better outcomes for patients with acute biliary presentation, compared with the traditional emergency surgery model of care. METHODS A retrospective review was carried out of patients who were admitted for management of acute biliary presentation, before and after the establishment of an acute surgical unit (ASU). Outcomes measured were time to operation, operating time, after-hours operation (6pm - 8am), length of stay and surgical complications. RESULTS A total of 342 patients presented with acute biliary symptoms and were managed operatively. The median time to operation was significantly reduced in the ASU group (32.4 vs 25.4 hours, p=0.047), as were the proportion of operations performed after hours (19.5% vs 2.5%, p<0.001) and the median length of stay (4 vs 3 days, p<0.001). The median operating time, rate of conversion to open cholecystectomy and wound infection rates remained similar. CONCLUSIONS Implementation of an ASU can lead to objective differences in outcomes for patients who present with acute cholecystitis. In our study, the ASU significantly reduced time to operation, the number of operations performed after hours and length of stay.

Post-operative telephone review is safe and effective: prospective study - Monash outpatient review by phone trial: Monash outpatient review by phone trial

Studies have shown that post‐operative telephone follow‐up is satisfactory and effective. As high quality evidence is scant, we conducted a randomized controlled trial to compare it against outpatient clinic review for emergency laparoscopic appendicectomy or cholecystectomy.

Cholecystitis/cholangitis secondary to drainage of the biliary tree into an obstructed duodenum: a new technique with a novel complication?

A previously well, 73-year-old woman presented with chest pain and was noted to have markedly abnormal cholestatic liver function tests. Magnetic resonance cholangiopancreatography (MRCP) demonstrated a multicystic mass in the pancreatic head with possible extrinsic biliary compression. She underwent endoscopic ultrasound (EUS) with cytological aspiration, which demonstrated dysplastic cellular material. Multidisciplinary review of the imaging and pathology concluded that she had locally advanced pancreatic cancer involving the hepatic artery. An endoscopic retrograde cholangiopancreatography (ERCP) failed to reach the second part of the duodenum because of tumor ingrowth. She then underwent EUS-guided biliary drainage and a 4-cm fully covered metal stent was inserted (▶Video1). After this procedure, her jaundice improved and plateaued. She developed epigastric pain that failed to settle. Computed tomography (CT) scans showed a thick-walled gall bladder suggestive of acute cholecystitis and a grossly distended stomach that suggested duodenal obstruction (▶Fig. 1; ▶Video2). She proceeded to a laparoscopic cholecystectomy, during which the gallbladder was noted to be edematous. Furthermore, the cholangiogram demonstrated a patent cystic duct with free flow of contrast though the stent into the first part of the duodenum but absent flow distally (▶Fig. 2). On-table gastroscopy confirmed that she had complete duodenal obstruction. A self-expanding metal stent (SEMS) was placed across the stricture (▶Fig. 3). The patient subsequently recovered well and was discharged home. EUS-guided biliary drainage is an alternative to percutaneous access in circumstances where ERCP has failed. Indications include unsuccessful biliary cannulation or an inaccessible papilla [1]. Two major approaches have been described, either the transgastric or transduodenal routes [2]. Concomitant duodenal and biliary obstruction is not uncommon in advanced pancreatic cancer and this can further complicate biliary access and drainage. We postulate that, following the EUS-guided choledochoduodenostomy, our patient developed biliary sepsis due to progression of the duodenal obstruction distal to the choledochoenteric stented anastomosis. This caused contamination of the biliary tree with gastric contents and subsequent cholangitis.

Re: Single-stage laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography: is this strategy feasible in Australia?

Bing Mei Teh,*† MBBS, PhD Adnan Safdar,*‡ MBBS, FRCSEd, FRACS *Department of Otolaryngology Head and Neck Surgery, Monash Cancer Centre, Monash Health, Melbourne, Victoria, Australia, †Ear Science Institute Australia and Ear Sciences Centre, School of Surgery, The University of Western Australia, Nedlands, Western Australia, Australia and ‡Department of Surgery, Monash University, Melbourne, Victoria, Australia

Trends in the management of local complications of acute pancreatitis in Australia

It was with relief that I read this paper reviewing the literature on the risk of iatrogenic lymphoedema after mastectomy and concluding that there is no evidence base for banning the use of intravenous (IV) puncture or sphygmomanometers in the arms of patients who have had axillary surgery associated with breast cancer treatment. This and other studies confirm my own 35-year experience of following breast cancer patients in the reconstructive arena, noting no correlation between the development of lymphoedema and IV access in the ipsilateral arm. However, in recent years, those of us seeing these patients for breast reconstruction encounter many who are terrified by the prospect of lymphoedema occurring after IV access for anaesthesia in the arm on the side of their mastectomy. These fears have been magnified, if not generated, by well-meaning paramedicals, including breast-care nurses, some physiotherapists and even some doctors. Many who have had veins in the other arm made inaccessible by chemotherapy are doubly anxious, as further IV access in that arm sometimes becomes impossible. The anxiety caused by the unnecessary ban on the use of the ipsilateral arm for IV access is unhelpful for any patient about to undergo surgery and puts the anaesthetist under needless pressure. There are a number of us in this field, including oncologists, anaesthetists, surgeons, physiotherapists and others (personal correspondence with six senior workers in breast cancer care, including four professors, in Sydney, Melbourne and New Zealand) who feel that provision of more evidence-based material to those caring for patients with breast cancer should help to alleviate some of the lymphoedema anxiety currently being experienced by these patients. If evidence-based practice is to be taken seriously, it is incumbent on us as surgeons, who often are team leaders in caring for these patients with cancer, to encourage a uniform approach to patient education in this and other areas.

Laparoscopic common bile duct exploration, does real life practice mirror the evidence?

Choledocholithiasis is identified in approximately 10–15% of the population with symptomatic cholelithiasis (1,2). Treatment is indicated, particularly when symptomatic, as the consequences may be serious. Ensuing complications from choledocholithiasis include pain, cholangitis, pancreatitis, hepatic abscess and in chronic obstruction, biliary cirrhosis and portal hypertension (1,3).