Solve study: a study to capture global variations in practices concerning laparoscopic cholecystectomy.

BACKGROUND: There is a lack of published data on variations in practices concerning laparoscopic cholecystectomy. The purpose of this study was to capture variations in practices on a range of preoperative, perioperative, and postoperative aspects of this procedure. METHODS: A 45-item electronic survey was designed to capture global variations in practices concerning laparoscopic cholecystectomy, and disseminated through professional surgical and training organisations and social media. RESULTS: 638 surgeons from 70 countries completed the survey. Pre-operatively only 5.6% routinely perform an endoscopy to rule out peptic ulcer disease. In the presence of preoperatively diagnosed common bile duct (CBD) stones, 85.4% (n = 545) of the surgeons would recommend an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) before surgery, while only 10.8% (n = 69) of the surgeons would perform a CBD exploration with cholecystectomy. In patients presenting with gallstone pancreatitis, 61.2% (n = 389) of the surgeons perform cholecystectomy during the same admission once pancreatitis has settled down. Approximately, 57% (n = 363) would always administer prophylactic antibiotics and 70% (n = 444) do not routinely use pharmacological DVT prophylaxis preoperatively. Open juxta umbilical is the preferred method of pneumoperitoneum for most patients used by 64.6% of surgeons (n = 410) but in patients with advanced obesity (BMI > 35 kg/m2, only 42% (n = 268) would use this technique and only 32% (n = 203) would use this technique if the patient has had a previous laparotomy. Most surgeons (57.7%; n = 369) prefer blunt ports. Liga clips and Hem-o-loks® were used by 66% (n = 419) and 30% (n = 186) surgeons respectively for controlling cystic duct and (n = 477) 75% and (n = 125) 20% respectively for controlling cystic artery. Almost all (97.4%) surgeons felt it was important or very important to remove stones from Hartmann's pouch if the surgeon is unable to perform a total cholecystectomy. CONCLUSIONS: This study highlights significant variations in practices concerning various aspects of laparoscopic cholecystectomy.

Management of Complicated Acute Pancreatitis: The Role of Hub-and-Spoke Model.

OBJECTIVE: To determine the primary and secondary outcomes of patients with complicated acute pancreatitis (CAP) of moderate to severe intensity managed by using the hub-and-spoke model. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Department of Surgery, North Cumbria Integrated Care, Carlisle, UK, from January 2014 to December 2018. METHODOLOGY: Retrospective analysis of 496 episodes of acute pancreatitis managed in 405 patients was done. Data for demographic features and clinical outcomes were analysed. In patients with recurrent admissions, only index admission was considered for analysis. Complicated acute pancreatitis was defined by using the revised Atlanta classification and included all the acute pancreatitis patients with local and or systemic complications.    Results: The frequency of CAP was 21.7% (88/405). The mean patients' age was 62.11 ± 17.90 years. The intensive therapy unit (ITU) admission rate was 33% (n = 29), whereas the overall intervention rate was 43.2% (n = 38). The in-hospital mortality rate was 10.2% (n = 9), and the overall mortality rate was 14.8% (n = 13). A comparative analysis of clinical outcomes according to the revised Atlanta classification showed that the rate of complications, need for ITU admission, duration of hospital stay, in-hospital mortality and overall mortality were significantly higher in patients with moderately severe AP (MSAP) and severe AP (SAP). CONCLUSION: The rate of progression from mild AP to MSAP and SAP remains high. Patients with CAP are at higher risk of ITU admission, prolonged hospital stay, in-hospital mortality and overall mortality. To improve clinical outcomes, the progression of AP to severer forms should be prevented by developing newer strategies, and in cases where complications have already developed, the mortality rate needs to be improved by developing innovative treatment modalities. KEY WORDS: Acute pancreatitis, Complicated acute pancreatitis, Revised Atlanta classification, Morbidity, Mortality, Survival analysis, Hub and spoke model.

Novel Use Of Age-Adjusted Charlson Comorbidity Index (ACCI) As A Risk Stratification Tool For Development Of Postoperative SARS-COV-2 Infection In Surgical Patients.

BACKGROUND: Current study documents the role of Age adjusted Charlson Comorbidity Index (ACCI) as a stratification tool for the development of postoperative SARS-CoV-2 infection in surgical patients. METHODS: This prospective cohort study was conducted over the period of 8 weeks starting on 1st of March 2020. Sampling was convenience and purposive and included all consecutive patients who underwent any surgical procedure. Follow up period was 30 days. Outcomes included postoperative SARS-CoV-2 infection, morbidity and 30-day mortality. Risk factors for development of infection were detected by univariate and multivariate analysis. RESULTS: Postoperative SARS-CoV-2 infection developed in 37 cases while 131cases remained confirmed negative. Of 37 patients, 18 were male while 19 were female. Postoperative complications developed in 17 patients (45.9%). In-hospital 30-day mortality was 16.2% (n=6). The factors that increased the chances of postoperative SARS-CoV-2 infection (p<0·00) included increasing age, higher ACCI Score, emergency surgery, trauma, orthopaedic and vascular procedures, spinal anaesthesia, and surgeries of complex nature. In adjusted analyses, predictors of postoperative infection included ACCI score of 4 or more (5.54 [1·51-20.34], p<0·01), and orthopaedics or vascular procedures versus others (12.32 [1.98-76.46], p<0·007). Based on infection rates across the different scores of ACCI, cohort was divided into 3 groups. ACCI score of zero had postoperative SARS-CoV-2 infection rate of 1.9 % (negative predictive value, 98.1%) compared with 36.26% in patients with score of 4 or more (sensitivity, 89.19%). CONCLUSIONS: Low risk surgical patients (ACCI=0) should have universal precautions, while intermediate risk group (ACCI=1- 3) should have extra precautions. The options for high-risk patients (ACCI ≥4) include cancellation of nonurgent surgery; delaying the surgery till optimization of modifiable factors; or reverse isolation/ shielding in perioperative period if surgery cannot be cancelled.

Extra-luminal Air Fluid Level on Abdominal X-ray of a Patient with Isolated Jejunal Blow Out: Case report.

Patients with trivial blunt abdominal trauma may present with isolated jejunal blow out (IJBO). A high index of suspicion is required as delayed presentation or delayed diagnosis may increase morbidity. Presentation with frank perforation peritonitis can be diagnosed by abdominal X-rays. We report the case of a patient who presented with features of peritonitis 10 days after being injured by a knee kick trauma. An erect abdominal X-ray showed extraluminal air-fluid levels, suggesting a hollow viscous injury which on exploration was found to be IJBO.