Laparoscopic Management of Acute Small Bowel Obstruction in Non-Selected Patients: A 10-Year Experience.

The laparoscopic approach to the management of small bowel obstruction (SBO) has been associated with reduced length of hospital stay, complications, and mortality. The laparoscopy-first approach has been limited to highly selective cases to date. In this retrospective observational study, we report our 10-year experience and outcomes within a dedicated Emergency Surgery unit that adopted a non-selective approach in the laparoscopic management of SBO. The surgical approach to all patients that underwent surgery for SBO by an experienced Emergency Surgeon, over a period of 10 years, was divided into two groups of open surgery (OS) or laparoscopy-first (LF). Outcomes included length of stay, complications, mortality, readmission rates and reasons for conversion. Data were reviewed to identify patterns of learning. A total of 189 patients were included in the study. A total of 81.5% were managed with an LF approach. Of these, 25.3% required conversion. LF patients had a similar length of stay, lower 30-day readmission rates and wound complications. Reasons for conversion included need for bowel resection, perforation, and malignancy. Our study had a high intention-to-treat LF population and identified major indications for conversion. As our laparoscopic experience increased, conversion rates substantially reduced. We propose that a LF approach is feasible and can benefit from training within dedicated Emergency Surgery teams.

Requirement of preoperative blood typing for cholecystectomy and appendectomy: a systematic review.

PURPOSE: Blood typing, or group and save (G&S) testing, is commonly performed prior to cholecystectomy and appendectomy in many hospitals. In order to determine whether G&S testing is required prior to these procedures, we set out to evaluate the relevant literature and associated rates of perioperative blood transfusion. METHODS: Studies from January 1990 to June 2021 assessing the requirement of preoperative G&S testing for elective or emergency cholecystectomy and appendectomy were retrieved from MEDLINE, EMBASE and CINAHL databases. The search was performed on 6th July 2021 (PROSPERO registration number CRD42021267967). Number of patients, co-morbidities, operation performed, number of patients that underwent preoperative G&S testing, perioperative transfusion rates and financial costs were extracted. RESULTS: We initially screened 194 studies of which 15 retrospective studies, a total of 477,437 patients, specifically met the inclusion criteria. Ten studies reported on cholecystectomy, two studies on appendectomy and three studies included both procedures. Where reported, a total of 177,539/469,342 (37.8%) patients underwent preoperative G&S testing with a perioperative transfusion rate of 2.1% (range 0.0 to 2.1%). The main preoperative risk factors associated with perioperative blood transfusion identified include cardiovascular co-morbidity, coagulopathy, anaemia and haematological malignancy. All 15 studies concluded that routine G&S is not warranted. CONCLUSION: The current evidence suggests that G&S is not necessarily required for all patients undergoing cholecystectomy or appendectomy. Having a targeted G&S approach would reduce delays in elective and emergency lists, reduce the burden on the blood transfusion service and have financial implications.

Clinical benefits of a combined physician associate and senior specialist-led emergency surgery ambulatory emergency care clinic introduced in response to the COVID-19 pandemic.

INTRODUCTION: A well-designed ambulatory emergency care (AEC) can alleviate demand for inpatient beds by reducing admissions or supporting early discharges. Increasing service demands and workforce gaps present major challenges to surgical departments. Physician's associates (PAs) have been suggested as one way to address this, but previous barriers include lack of job role clarity, and inability to prescribe or request ionising radiation. An AEC clinic using PAs supported by senior decision-makers could improve patient care and provide workforce stability alongside a new capacity for successful PA positions. METHODS: An emergency surgery AEC pathway was introduced to a single centre in anticipation of a second COVID-19 wave. All emergency surgical referrals were prospectively collected over 3 months (November 2020 to February 2021) with minimum 30-day follow-up. The primary aims were to evaluate clinical outcomes and success of a new AEC PA role. RESULTS: A total of 175 patients were entered into the study. The median time from request for senior review to treatment decision was 26 min (IQR 9-62 min). The primary discharge rate was 38.3% (n=67), while the overall discharge rate without needing admission was 84% (n=147). Of the total 28 (16.0%) patients requiring admission, 18 (10.3%) were clinically appropriate. Four patients represented with Clavien-Dindo Grade II complications and above: two grade II (1.1%) and two grade IIIb respectively (1.1%). The role of the PA was well defined with no team discord. No patient complaints were received. CONCLUSION: During the COVID-19 pandemic, an emergency surgery AEC pathway was implemented by combining a PA with a senior decision-maker, enabling fewer emergency admissions and significantly reduced time-to-reach-treatment decisions. This in turn facilitates bed-flow and minimises delays in patient treatment. The use of a well-defined PA role in this setting shows initial success and should be considered as a long-term role.

Adult necrotising enterocolitis-pig-bel disease: a Pacific disease in London.

Adult necrotising enterocolitis secondary Clostridium perfringens type C-pig-bel disease-is rarely seen outside of Pacific populations, with the highest incidence being in Papau New Guinea. We present the first reported case of pig-bel disease in a previously well patient without diabetes following food poisoning since 1996. In this case, the enterotoxin-induced disease necessitated emergency laparotomy and bowel resection following the failure of medical treatment and worsening septic shock. We hypothesise that obstruction secondary to a sigmoid diverticular stricture complicated by infection-related oedema led to colonic stasis and rapid progression of disease and bowel loss. Following bowel resection, several parenteral antibiotic agents and prolonged intensive care, this patient survived this severe infective process and was discharged home.

A Model Example: Coexisting Superior Mesenteric Artery Syndrome and the Nutcracker Phenomenon.

Superior mesenteric artery (SMA) syndrome is a rare cause of gastrointestinal obstruction, caused by external compression of the third part of the duodenum by the SMA. It may be associated with the Nutcracker phenomenon: external compression of the left renal vein. To our knowledge, there are few reports in the literature describing the coexistence of these two conditions and so we take this opportunity to highlight a rare cause of the acute abdomen that might otherwise be overlooked in cases of nonspecific abdominal findings and potentially unremarkable initial investigations. We report a case of SMA syndrome and Nutcracker phenomenon in a 19-year-old female who presented to our emergency department with a short history of epigastric pain and emesis. The SMA syndrome is thought to develop as the result of an abnormally narrow angle between the proximal SMA and the aorta, for which a number of predisposing factors have been described. Surgical options exist; however, the SMA syndrome is typically managed conservatively in the first instance, consistent with the approach described in this case. The Nutcracker phenomenon may give rise to the Nutcracker syndrome in the presence of typical clinical manifestations; however, these did not feature in this case.

Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams.

BACKGROUND: Outdated communication technologies in healthcare can place patient safety at risk. This study aimed to evaluate implementation of the WhatsApp messaging service within emergency surgical teams. METHODS: A prospective mixed-methods study was conducted in a London hospital. All emergency surgery team members (n = 40) used WhatsApp for communication for 19 weeks. The initiator and receiver of communication were compared for response times and communication types. Safety events were reported using direct quotations. RESULTS: More than 1,100 hours of communication pertaining to 636 patients were recorded, generating 1,495 communication events. The attending initiated the most instruction-giving communication, whereas interns asked the most clinical questions (P < .001). The resident was the speediest responder to communication compared to the intern and attending (P < .001). The participants felt that WhatsApp helped flatten the hierarchy within the team. CONCLUSIONS: WhatsApp represents a safe, efficient communication technology. This study lays the foundations for quality improvement innovations delivered over smartphones.

Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients.

OBJECTIVE: To systematically risk assess and analyze the escalation of care process in surgery so as to identify problems and provide recommendations for intervention. BACKGROUND: The ability to escalate care appropriately when managing deteriorating patients is a hallmark of surgical competence and safe postoperative care. Healthcare-Failure-Mode-Effects-Analysis (HFMEA) is a methodology adapted from safety-critical industries, which allows for hazardous process failures to be prospectively identified and solutions to be recommended. METHODS: Forty-two hours of ethnographic observations on surgical wards in 3 London hospitals (phase 1) formed the basis of an escalation process diagram. A risk-assessment survey identified failures associated with process steps and attributed hazard scores (phase 2). Patient safety and clinical risk experts validated hazard scores through a group consensus meeting (phase 3). Hazardous failures were taken forward to multidisciplinary HFMEA where cause analysis was applied and interventions were recommended (phase 4). RESULTS: Observations identified 33 steps in the escalation process. The risk-assessment survey (30 surgical staff members, 100% response) and expert consensus group identified 18 hazardous failures associated with these steps. The HFMEA team identified 3 adequately controlled failures; therefore, 15 were subjected to cause analysis. Outdated communication technology, understaffing, and hierarchical barriers were identified as root causes of failure. Participants recommended interventions based on these findings including defined escalation protocols, human factors education, enhanced communication technology, and improved clinical supervision. CONCLUSIONS: Failures in the escalation process amenable to intervention were systematically identified. This mapping of the escalation process will allow tailored interventions to enhance surgical training and patient safety.

A tool for training in decision making for emergency general surgery--explicit training is possible through facilitation.

BACKGROUND: Emergency general surgery is increasingly recognized as an area for improvement within the National Health Service in the United Kingdom. Our aim was to test the feasibility of a tool we developed in assessing and facilitating surgical decision making by trainees in the emergency setting. METHODS: A decision-making tool based on common decisions in surgery was designed and incorporated prospectively into patient clerking. The 10 decisions available to surgeons were divided into 3 major headings: discharge decisions, observation decisions, and operative decisions. "Ideal decisions" were derived from the final diagnosis on discharge by 2 independent clinicians and compared with initial decisions made by surgeons. We analyzed the data with a view to validate the tool using 2 methods. Firstly, we looked at the percentage of correct decisions made by different grades of surgeon, and secondly, we analyzed the trends in deviations from ideal decisions. RESULTS: The decision-making tool was completed for 136 emergent surgical admissions over 2 months. Interns made less "ideal" decisions compared with residents (45% vs 56%, respectively; p = 0.10, Fisher exact test) and attending surgeons (45% vs 70%, respectively; p = 0.0001). Interns made more "admit and observe or investigate" decisions compared with residents (63% vs 55%, respectively; p = 0.27) and attending surgeons (63% vs 51%, respectively; p = 0.01), who were more likely to decide to operate on or discharge patients. A repeat study over the subsequent 2-month period has shown comparable findings in proportion of ideal decisions for each grade of surgeon. CONCLUSIONS: There are significant differences in the proportion of "ideal decisions" and types of decisions between interns and attending surgeons suggesting a learning curve and potential for using this tool in decision-making training. The tool inherently facilitates discussion over decisions made by making these explicit. Repeating the study revealed an internal consistency.

A rare case of small bowel obstruction secondary to ovarian torsion in an IVF pregnancy.

A 39- year-old woman, who conceived following in vitro fertilisation (IVF) treatment, presented at 12 weeks gestation with symptoms of ovarian hyperstimulation syndrome (OHSS), abdominal pain, vomiting and diarrhoea. Subsequent investigations found small bowel obstruction  secondary to ovarian torsion. Surgical management to remove a necrotic ovary and fallopian tube led to a good recovery from the acute illness. A postoperative ultrasound scan confirmed a viable pregnancy and the patient was discharged. Her case demonstrates a rare complication of OHSS and ovarian torsion leading to small bowel obstruction.