Timing of operative intervention in the management of acutely fractured ankles and the cost implications.

A study of the length of the time between the diagnosis of an ankle fracture and operative intervention and the length of subsequent hospital stay was undertaken. The delay in operative fixation beyond 24 h from injury was associated with a lengthening of stay. The cost implication of a longer stay was assessed. Eighty-seven patients with 87 fractures fulfilled the inclusion criteria of having an acute closed fracture of the ankle requiring open reduction and internal fixation (ORIF). There were 34 unimalleolar, 35 bimalleolar and 18 trimalleolar fractures. Only 47 (54%) of the patients were operated on within 24 h of injury, even though 74 had presented by 6 h and a further five by 24 h. The mean inpatient stay was 9.6 days for this early operation group. The patients who had their operation delayed were in hospital for a mean of 14 days, a significant difference (P<0.0001) (using Wilcoxon's Signed Rank test). The cost per patient per day of an acute trauma bed is estimated at pound sterlings 225. This translates into an average cost of pound sterlings 990 more per patient whose operation is delayed. We recommend that policies be put in place to provide early operative intervention for patients with fractured ankles as this would result in significant financial savings.

Minilaparotomy ureterolithotomy: the third world treatment of choice for ureteric calculi? - abstract

Since the development of stone shattering and endourological techniques for the management of renouretic calculi, open surgery has been replaced as a first time treatment option in major urological centres. However, there are significant economic implications for these advantages and also many Caribbean countries cannot offer specialist urological services. Minimal access surgery has been shown, in other situations, to result in minimal metabolic disturbance, little pain, short hospital stay and early return to work. We developed a minilaparotomy muscle-splititng incision to achieve these results in ureteric stones and studied it prospectively in consenting patients. We reported 82 manilap ureterolithotomies with a 4-7 cm skin incision, mean operating time 28 minutes (10 - 44) and a mean hospital stay of 42 hours (24 -72). Because a muscle splitting technique is used pain is minimal and time to resumption of work averaged 16 days (8 - 35). We believe that manilap ureterolithotomy offers significant advantages over many currently employed techniques. These include reduced cost, operating time and duration of postoperative recovery, no need for specialist operative training and equipment and improved cosmetic results. We recommend it as the treatment of choice for ureteric calculi in most Caribbean territories. (AU)

Minilaparotomy cholecystectomy: the Third World solution for gallstones - abstract

Although many authors view laparoscopic cholecystectomy as the treatment of choice for gallstones there is evident that it has probably caused more deaths and major postoperative morbidity than open cholecystectomy. The Medical Defence Union has reported increased claims for bile duct injury from laparoscopic cholecystectomy (LC). The technology is expensive and not readily available in third world countries. Because minilaparotomy cholecystectomy (MC) also minimally invasive and offers similar advantages to LC we studied it prospectively and report our experience. MC was performed in 160 consecutive patients through a 4.8 cm (3 - 6 cm) incision, with operating time of 35 minutes (18 - 80 ). No major ductal injury and no reoperation occurred. Patients were discharged after 38 hours (range 16 - 60 hours). The operating time is much shorter, hospital stay and postoperative morbidity similar to LC. Review of the world literature shows no clear advantage of LC over MC. Because MC is cheap, effective, requires no specialised training or expensive equipment and can be done by any competent surgeon in most hospitals in the developing world, we recommend it as treatment of choice for gall stones in the third world. (AU)