Validation of the acute cholecystectomy rate as a quality indicator for emergency general surgery using the SWORD database.

INTRODUCTION: Despite an increasing emphasis on data-driven quality improvement, few validated quality indicators for emergency surgical services have been published. The aims of this study therefore were: 1) to investigate whether the acute cholecystectomy rate is a valid process indicator; and 2) to use this rate to examine variation in the provision of acute cholecystectomy in England. MATERIALS AND METHODS: The Surgical Workload and Outcomes Research Database (SWORD), derived from the Hospital Episode Statistics database, was interrogated for the 2012-2017 financial years. All adult patients admitted with acute biliary pancreatitis, cholecystitis or biliary colic to hospitals in England were included and the acute cholecystectomy rate in each one examined. RESULTS: A total of 328,789 patients were included, of whom 42,642 (12.9%) underwent an acute cholecystectomy. The acute cholecystectomy rate varied significantly between hospitals, with the overall rate ranging from 1.2% to 36.5%. This variation was consistent across all disease groupings and time periods, and was independent of the annual number of procedures performed by each NHS trust. In 41 (29.9%) trusts, fewer than one in ten patients with acute gallbladder disease underwent cholecystectomy within two weeks. CONCLUSIONS: The acute cholecystectomy rate is easily measurable using routine administrative datasets, modifiable by local services and has a strong evidence base linking it to patient outcomes. We therefore advocate that it is an ideal process indicator that should be used in quality monitoring and improvement. Using it, we identified significant variation in the quality of care for acute biliary disease in England.

Anti-platelet therapy does not influence the outcome of patients undergoing hepatic resection for colorectal liver metastases, an observational study.

AIM: To evaluate the impact of anti-platelet therapy on the outcomes of patients undergoing liver resection for CRLM. Secondary aim was to determine whether anti-platelet therapy influenced histo-pathological changes in CRLM. METHODS: Patients treated with liver resection for CRLM were identified from a prospectively maintained hepatobiliary database during an 11-year period. Collated data included demographics, primary tumour treatment, surgical data, histopathology analysis and clinical outcome. RESULTS: 454 patients that underwent primary hepatic resections for CRLM were included. 60 patients were on anti-platelet therapy. 241 patients developed recurrent disease and 131 patients have died. Multi-variate analysis identified 4 independent predictors of disease-free survival: tumour number; tumour size; peri-neural invasion; and resection margin. The presence of peri-neural invasion and multiple hepatic metastases were independent predictors of poorer overall survival on multi-variate analysis. Uni-variate analysis showed that the use of anti-platelet therapy was associated with larger tumour size (p=0.031) and vascular invasion (p=0.023). CONCLUSION: Anti-platelet therapy does not affect the survival outcome in patients with CRLM following liver resection. Anti-platelet therapy is associated with larger liver metastases and vascular invasion on histo-pathological analysis. SYNOPSIS: A large retrospective study looking at outcomes of patients taking pre operative anti platelet therapy who have undergone liver resection for colorectal liver metastases.

The front-line general surgery consultant as a new model of emergency care.

Introduction Emergency general surgery services in England are undergoing rapid structural change with the aim of improving care. In our centre, the key issues identified were high numbers of admissions, inappropriate referrals, prolonged waiting times, delayed senior input and poor patient satisfaction. A new model was launched in January 2015 to address these issues: the surgical triage unit (STU). This study assesses the success of the new service. Methods All emergency general surgical admissions during a five-month period before introduction of the STU were compared with those of a comparable five-month period after its introduction. Process, clinical and patient experience outcomes were assessed to identify improvement. Results Attendance fell from 3,304 patients in the 2014 cohort to 2,830 in the 2015 cohort. During the 2015 study period, 279 more patients were discharged on the same day. Resource requirement fell by 2,635 bed days (23%). The number of true surgical emergencies remained consistent. Rates for reattendance (7.8% for 2014 vs 8.1% for 2015) and readmission (5.7% for 2014 vs 5.7% for 2015) showed no significant difference. Patient experience data demonstrated a significant improvement in both net promoter score (64.1 vs 82.2) and number of complaints (34 vs 5). Clinical outcomes for low risk procedures remained similar. Emergency laparotomy in-hospital mortality fell (11.4% vs 10.3%) despite preoperative risk stratification suggesting a risk burden that was significantly higher than the national average. Conclusions This novel model of emergency general surgery provision has improved clinical efficiency, patient satisfaction and outcomes. We encourage other units to consider similar programmes of service improvement.

Damage control surgery in the era of damage control resuscitation.

Damage control surgery (DCS) is a concept of abbreviated laparotomy, designed to prioritize short-term physiological recovery over anatomical reconstruction in the seriously injured and compromised patient. Over the last 10 yr, a new addition to the damage control paradigm has emerged, referred to as damage control resuscitation (DCR). This focuses on initial hypotensive resuscitation and early use of blood products to prevent the lethal triad of acidosis, coagulopathy, and hypothermia. This review aims to present the evidence behind DCR and its current application, and also to present a strategy of overall damage control to include DCR and DCS in conjunction. The use of DCR and DCS have been associated with improved outcomes for the severely injured and wider adoption of these principles where appropriate may allow this trend of improved survival to continue. In particular, DCR may allow borderline patients, who would previously have required DCS, to undergo early definitive surgery as their physiological derangement is corrected earlier.

Peritoneal cooling may provide improved protection for uncontrolled donors after cardiac death: an exploratory porcine study.

Uncontrolled donation after cardiac death (DCD) renal transplantation relies on rapid establishment of organ preservation interventions. We have developed a model of the uncontrolled DCD, comparing current in situ perfusion (ISP) techniques with additional peritoneal cooling (PC). Ten pigs were killed and subjected to a 2 h ischemia period. The ISP group modeled current DCD protocols. The PC group (PC) modeled current protocols plus PC. Two animals were used as controls and subjected to 2 h of warm ischemia. Core renal temperature and microdialysis markers of ischemia were measured. Preservation interventions began at 30 min, with rapid laparotomy and kidney recovery performed at 2 h, prior to machine perfusion viability testing. The final mean renal temperature achieved in the ISP group was 26.3 degrees C versus 16.9 degrees C in the PC group (p = 0.0001). A significant cryopreservation benefit was suggested by lower peak microdialysate lactate and glycerol levels (ISP vs. PC, p = 0.0003 and 0.0008), and the superiority of the PC group viability criteria (p = 0.0147). This pilot study has demonstrated significant temperature, ischemia protection and viability assessment benefits with the use of supplementary PC. The data suggests a need for further research to determine the potential for reductions in the rates of ischemia-related clinical phenomena for uncontrolled DCDs.

Laparoscopic renal cooling device.

A new medical device has been designed for inducing hypothermia in kidneys, via laparoscopic deployment, without leaving residual fluid in the abdomen. It was tested in laboratory and animal trials to ascertain its suitability for achieving a target renal temperature of 15 degrees C for tissue preservation within a 30-min period. A simple theoretical model was developed to calculate cooling rates under ideal circumstances. In the laboratory, a potato was used as the model for the kidney and an average minimum temperature of 15.8 degrees C was reached in 30 min. The theoretical model calculated this as 9.9 degrees C. In the animal trials, an average minimum temperature of 11.4 degrees C was reached in 30 min, compared to the calculated temperature of 9.8 degrees C from the theoretical model. In conclusion, the new device can cool as affectively as other techniques trialled, with the added advantage that it does not release cold fluid or ice into the abdomen.

Evaluation of the ischemic protection efficacy of a laparoscopic renal cooling device using renal transplantation viability assessment criteria in a porcine model.

PURPOSE: We assessed the efficacy of a prototype laparoscopic topical cooling device. The aim of regional renal hypothermia in laparoscopic surgery is to limit ischemic injury and extend safe operative time. A reliable model for assessing renal ischemic injury exists in the field of nonheart beating donor renal transplantation. Hypothermic machine perfusion allows calculation of the pressure flow index and measurement of glutathione S-transferase in the perfusate. These parameters allow accurate assessment of the extent of renal damage. MATERIALS AND METHODS: The device incorporates a 2-layer cooling bag and coolant circuit. The system achieves hypothermia by circulating coolant across the surface of the kidney. Using 10 pigs individual kidneys were subjected to periods of renal ischemia with or without device in situ cooling. Each kidney was then machine perfused and assessed using nonheart beating donor viability criteria. RESULTS: The best performance of the device achieved a renal parenchymal temperature of 15C in 11.2 minutes (mean +/- SD 21.4 +/- 8.42). In the warm ischemia groups significant deterioration of pressure flow index compared to controls occurred by 60 minutes (p = 0.0001). In cooled kidneys at 60 minutes the mean pressure flow index was not significantly different from that in controls. Greater mean glutathione S-transferase measurements were associated with the warm ischemia groups. CONCLUSIONS: Our study reinforces the efficacy of topical renal cooling in the laparoscopic setting. We report the use of assessment techniques capable of accurate quantitative measurement of renal injury in an animal model. Our cooling device is currently undergoing further development to enhance its efficiency.

Donation after cardiac death kidneys with low severity pre-arrest acute renal failure.

The widening gap between supply and demand for renal transplantation has prompted many centers to use donors after cardiac death. Some of these donors exhibit signs of acute renal failure (ARF) prior to cardiac arrest. Concern has been expressed about poor quality of graft function from such donors. In response to this perception, we reviewed 49 single renal transplant recipients from category III donors after cardiac death between 1998 and 2005, at our center. All kidneys but one had hypothermic machine perfusion and viability testing prior to transplantation. According to the RIFLE criteria, nine recipients had kidneys from donors with "low severity pre-arrest ARF". The remainder of the recipients were used as control group. There was no statistical significant difference in delayed graft function and rejection rates between these two groups. Recipients GFR at 12 months was 44.4 +/- 17.1 and 45.2 +/- 14.7 (mL/min/1.73m(2)) from donors with ARF and without ARF, respectively (p = 0.96). In conclusion, low severity ARF in kidneys from controlled after cardiac death donors can be a reversible condition after transplantation. Short-term results are comparable to the kidneys from same category donors without renal failure, providing that some form of viability assessment is implemented prior to transplantation.

Dual renal transplantation for kidneys from marginal non-heart-beating donors.

Kidneys transplanted from non-heart-beating donors (NHBD) are generally regarded as marginal or extended criteria grafts due to the associated period of warm ischemia. The most prolonged periods occurring in the category II (uncontrolled) donor. This potential for injury can adversely affect the glomular filtration rate (GFR), which in severe cases results in primary nonfunction. Viability testing can identify a group of kidneys that, although unsuitable for solitary transplantation, may be considered for dual transplant. This retrospective study examined a series of 11 dual renal transplants, comparing 3- and 12-month GFR outcome data with 81 single NHBD transplants. The mean GFR at 3 months in the dual group was 47.6 and at 12 months was 48.6. In the single group the GFR at 3 months was 40.6 and at 12 months was 41.9. Thus using viability testing to identify NHBD kidneys suitable for dual transplant appears reliable and predictable.

Renal transplants from category III non-heart-beating donors with evidence of pre-arrest acute renal failure.

Kidneys transplanted from non-heart-beating donors (NHBDs) have been exposed to varying degrees of ischemic damage after death. Category III donors have invariably been managed, treated, and investigated in a hospital setting prior to arrest and death. Some therefore exhibit evidence of renal dysfunction and even acute renal failure (ARF) before death. Many surgeons would regard a NHBD with pre-arrest evidence of ARF as too marginal for renal transplantation. This retrospective study examines five Maastricht category III NHBD donors with evidence of pre-arrest ARF. We compare 3- and 12-month GFR outcome data from the nine resulting transplants with 40 category III NHBD transplants with normal pre-arrest renal function. The mean GFR at 3 months was 45.4 and 43.8 for the ARF and normal group, respectively. At 12 months the GFR was 42.2 and 44.7 in the ARF and normal groups, respectively. Thus evidence of ARF pre-arrest does not preclude successful category III NHBD renal transplantation.