Early laparoscopic cholecystectomy service provision is feasible and safe in the current UK National Health Service.

INTRODUCTION: Despite increasing evidence of the benefits and safety of early laparoscopic cholecystectomy (LC) in acute gallstone disease, it is not widely practised in England. The Royal College of Surgeons of England support the separation of emergency and elective surgical care. The aim of this prospective study was to examine the impact of the implementation of 'Surgeon of the Week (SoW)' model on the number of early LCs performed and the efficiency of the emergency theatre activity in our hospital. This study also looked into its implications on specialist registrar training for early LC, and the financial impact to the hospital. PATIENTS AND METHODS: Between January 2007 and May 2008, demographic data, admission and discharge dates, complications, conversions to an open operation and deaths were collected for all patients who underwent early laparoscopic cholecystectomies. For ease of comparison, patients were divided into Group A representing before introduction of SoW (1 January 2007 to 30 August 2007) and Group B representing after introduction of SoW (1 October 2007 to 31 May 2008). The total numbers of operations performed in the emergency theatre list in the two groups were also calculated. RESULTS: A total of 1361 emergency operations were performed on the emergency theatre list in Group A, of which 951 were general surgical procedures. In Group B, the numbers of emergency procedures were 1537, of which 1138 were general surgical operations. There was a significant increase in the number of general surgical operations after introduction of SoW (P = 0.013). Before introduction of the SoW rota, 45 early LCs were performed. This increased to 118 after SoW which was significant (P < 0.001). In Group A, the number of early LCs performed by surgical trainees was 10 (22%). In Group B, the number of LCs performed by surgical trainees was 35 (30%; not significant). CONCLUSIONS: This study has demonstrated an increase in the efficiency of the emergency theatre with an increase in the number of early LCs on their index admission without extra morbidity following implementation of the SOW model in our hospital. We recommend the introduction of a suitable emergency surgical consultant on-call model separating emergency and elective surgical care depending on local circumstances. This can lead to significant cost savings and reduce re-admissions with gallstone-related complications.

Conservative treatment as an option in the management of pancreatic pseudocyst.

BACKGROUND: Management of pancreatic pseudocysts is associated with considerable morbidity (15-25%). Traditionally, pancreatic pseudocysts have been drained because of the perceived risks of complications including infection, rupture or haemorrhage. We have adopted a more conservative approach with drainage only for uncontrolled pain or gastric outlet obstruction. This study reports our experience. PATIENTS AND METHODS: A consecutive series of 36 patients with pancreatic pseudocysts were treated over an 11-year period in one district general hospital serving a population of 310,000. This study group comprised of 19 men and 17 women with a median age of 55 years (range, 10-88 years). Twenty-two patients had a preceding attack of acute pancreatitis whilst 12 patients had clinical and radiological evidence of chronic pancreatitis. The aetiology comprised of gallstones (16), alcohol (5), trauma (2), tumour (2), hyperlipidaemia (1) and idiopathic (10). RESULTS: All patients were initially managed conservatively and intervention, either by radiological-assisted external drainage or cyst-enteric drainage (by surgery or endoscopy), was only performed for persisting symptoms or complications. Patients treated conservatively had 6 monthly follow-up abdominal ultrasound scans (USS) for 1 year. Fourteen of the 36 patients (39%) were successfully managed conservatively, whilst 22 patients required intervention either by percutaneous radiological drainage (12), by endoscopic cystogastrostomy (1) or by open surgical cyst-enteric anastomosis (9). Median size of the pancreatic pseudocysts in the 14 patients managed conservatively (7 cm) was nearly similar to that of the 22 patients requiring intervention (8 cm). The most common indications for invasive intervention in the 22 patients were persistent pain (16), gastric outlet obstruction (4), jaundice (1) and dyspepsia with weight loss (1). Although one patient required surgery for persistent pain, no other patients required urgent or scheduled surgery for complications of untreated pancreatic pseudocysts. Two of the 12 patients treated by percutaneous radiological drainage had recurrence of pancreatic pseudocysts requiring surgery. Two patients developed an intra-abdominal abscess following cyst-enteric drainage of pancreatic pseudocysts and one patient had a pulmonary embolism. On the mean follow-up of 37.3 months, one patient with alcoholic pancreatitis died 5 months after surgical cyst-enteric bypass. CONCLUSIONS: These results suggest that many patients with pancreatic pseudocysts can be managed conservatively if presenting symptoms can be controlled.

Consequences of prolonged wait before gallbladder surgery.

The aim of this study was to document the morbidity associated with long waiting times for laparoscopic cholecystectomy and to relate this to the nature of initial presentation either routine out-patient consultation or emergency admission with acute symptoms. This study was performed over a 50-month period in a DGH (serving a population of 320,000) which lacked sufficient operating capacity to allow routine early cholecystectomy after emergency admission. A total of 387 patients underwent cholecystectomy but 22 of these had an early operation after initial emergency admission with signs of peritonitis and were excluded from the study. The median waiting time for cholecystectomy in this study population of 365 patients was 170 days (range, 6-484) days. Of these 365 patients, 246 (67.4%) were listed for surgery after initial out-patient assessment (out-patient cohort) and 119 (32.6%) were diagnosed after an index emergency admission with symptomatic gallstone disease (emergency cohort). Of the 365 patients, 42 (11.5%) had one or more emergency admissions (57 admissions) with gallstone-related complications whilst on the waiting list for surgery. Complications were acute cholecystitis/biliary colic (n = 40), jaundice/cholangitis (n = 8), acute pancreatitis (n = 6) and perforated gallbladder (n = 3). Re-admissions with gallstone-related complications were much more common in patients whose initial presentation had been as an emergency. Thus, 34 of the 119 emergency cohort (28.5%) required re-admission with complications whilst only 8 of 246 (2.8%) elective cohort were re-admitted. Of the 34 re-admissions in the emergency cohort, 22 occurred within 6 weeks of their discharge from hospital. Median total and postoperative stay were significantly shorter (P < 0.001) in the elective cohort (3 and 2 days, respectively) than the emergency cohort (10 and 3 days, respectively). These results document the high incidence of complications experienced by patients waiting for an elective laparoscopic cholecystectomy. Morbidity is highest in patients with an initial emergency admission. These results suggest that cholecystectomy should be offered to all patients presenting as an emergency with symptomatic gallstones on admission.