Variation in the practice of cholecystectomy for benign biliary disease in Aotearoa New Zealand: a population-based cohort study

INTRODUCTION

Cholecystectomy for benign biliary disease is common and its delivery should be standardised. However, the current practice of cholecystectomy in Aotearoa New Zealand is unknown.

METHODS

A prospective, national cohort study of consecutive patients having cholecystectomy for benign biliary disease was performed between August and October 2021 with 30-day follow-up, through STRATA, a student- and trainee-led collaborative.

RESULTS

Data were collected for 1171 patients from 16 centres. 651 (55.6%) had an acute operation at index admission, 304 (26.0%) had delayed cholecystectomy following a previous admission, and 216 (18.4%) had an elective operation with no preceding acute admissions. The median adjusted rate of index cholecystectomy (as a proportion of index and delayed cholecystectomy) was 71.9% (range 27.2%-87.3%). The median adjusted rate of elective cholecystectomy (as proportion of all cholecystectomies) was 20.8% (range 6.7%-35.4%). Variations across centres were significant (p < 0.001) and inadequately explained by patient, operative, or hospital-factors (index cholecystectomy model R² = 25.8, elective cholecystectomy model R² = 50.6).

CONCLUSIONS

Notable variation in the rates of index and elective cholecystectomy exists in Aotearoa New Zealand not attributable to patient, operative or hospital factors alone. National quality improvement efforts to standardise availability of cholecystectomy are needed.

Evaluation of the inflammatory profile following uncomplicated elective colectomy

Background

Attenuation of the inflammatory response in patients undergoing colectomy with modern perioperative care and laparoscopic surgery has been a focus of research in recent years. Despite reported benefits, significant heterogeneity remains with studies including patients undergoing both rectal and colon surgery and including surgery with postoperative complications. Therefore, the aim of the study was to evaluate the inflammatory response in patients undergoing elective colectomy without complications, specifically comparing open and laparoscopic approaches.

Methods

A multicenter prospective study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were included over a 3‐year period. Perioperative blood samples were collected and analysed for the following inflammatory markers: IL‐6, IL‐1β, TNFα, IL‐10, CRP, leucocyte and neutrophil count. Statistical analysis was performed using SPSS statistical software.

Results

A total of 168 colectomy patients without complications were included in the analysis. Patients that underwent laparoscopy had significantly reduced IL‐6, neutrophils and CRP on postoperative day (POD) 1 (p < 0.05) compared to an open approach. IL‐10 and TNFα were significantly reduced on POD 2 (p < 0.05) in laparoscopic patients. Patients with a Body Mass Index (BMI) greater than 30 kg/m² had significantly higher levels of CRP regardless of operative approach. Statins altered both preoperative and postoperative inflammatory markers.

Conclusion

The postoperative inflammatory response is influenced by surgical approach, perioperative medications, and patient factors. These findings have important implications in the utility of biomarkers in the diagnosis of postoperative surgical complications, in particular in the early diagnosis of anastomotic leak.

Changing the routine: a move to patient initiated follow up to improve surgical outpatient clinic

Introduction

Patient initiated follow up (PIFU) allows patients to initiate a hospital follow up appointment on an ‘as required’ basis in contrast to the traditional physician‐initiated model. We present a clinical pathway for patients referred with rectal bleeding at a large tertiary public hospital in South Auckland, New Zealand and demonstrate the utility of PIFU and its impact on reducing follow up appointments.

Method

The purpose of the pathway was to allow standardized care by the clinicians and allow for PIFU. Two separate protocols were developed ‐ ‘Painful PR bleeding’ and ‘Painless PR bleeding’. A new clinic (NC) was started following these protocols, and this was compared to historical controls (HC). The primary outcome was the rate of follow up appointments.

Results

There were 133 patients in the NC and 135 in the HC, with significantly less follow ups in the NC (6% versus 45%, p < 0.0001). A small percentage of patients in the NC group were directly discharged (10%) whilst 70% of patients were discharged with a PIFU card. Thirty phone calls were made using PIFU, with 10 patients returning to clinic and 20 requiring advice and reassurance only. At 5 year follow up, there was a single colorectal malignancy found in both groups.

Conclusion

Initiating a protocol that includes patient initiated follow up vastly reduces the need for routine return to clinic for the majority of patients, without sacrificing patient care. A protocolised approach to clinic for other areas in general surgery should be considered.

Antibiotics Do Not Reduce Length of Hospital Stay for Uncomplicated Diverticulitis in a Pragmatic Double-Blind Randomized Trial

BACKGROUND & AIMS

Antibiotic treatment is the standard care for patients with uncomplicated acute diverticulitis. However, this practice is based on low-level evidence and has been challenged by findings from 2 randomized trials, which did not include a placebo group. We investigated the non-inferiority of placebo vs antibiotic treatment for the management of uncomplicated acute diverticulitis.

METHODS

In the selective treatment with antibiotics for non-complicated diverticulitis study, 180 patients hospitalized for uncomplicated acute diverticulitis (determined by computed tomography, Hinchey 1a grade) from New Zealand and Australia were randomly assigned to groups given antibiotics (n = 85) or placebo (n = 95) for 7 days. We collected demographic, clinical, and laboratory data and answers to questionnaires completed every 12 hrs for the first 48 hrs and then daily until hospital discharge. The primary endpoint was length of hospital stay; secondary endpoints included occurrence of adverse events, readmission to the hospital, procedural intervention, change in serum markers of inflammation, and patient-reported pain scores at 12 and 24 hrs.

RESULTS

There was no significant difference in median time of hospital stay between the antibiotic group (40.0 hrs; 95% CI, 24.4-57.6 hrs) and the placebo group (45.8 hrs; 95% CI, 26.5-60.2 hrs) (P = .2). There were no significant differences between groups in adverse events (12% for both groups; P = 1.0), readmission to the hospital within 1 week (1% for the placebo group vs 6% for the antibiotic group; P = .1), and readmission to the hospital within 30 days (11% for the placebo group vs 6% for the antibiotic group; P = .3).

CONCLUSIONS

Foregoing antibiotic treatment did not prolong length of hospital admission. This result provides strong evidence for omission of antibiotics for selected patients with uncomplicated acute diverticulitis.

ACTRN

12615000249550.

Metronidazole following excisional haemorrhoidectomy: a systematic review and meta-analysis

BACKGROUND

Post-operative pain is a major issue following excisional haemorrhoidectomy. Although metronidazole by both oral and topical administration routes has been shown to reduce pain after haemorrhoidectomy, its use remains a contentious issue. This systematic review and meta-analysis aims to investigate the effect of metronidazole on post-operative pain after excisional haemorrhoidectomy.

METHODS

A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs) published in PubMed/MEDLINE, EMBASE, CENTRAL and CINAHL, from inception to December 2016 were retrieved. The primary outcome investigated was post-operative pain reported as visual analogue score (VAS). Secondary outcomes were analgesia use, complications and time to return to normal activity. Meta-analysis was performed using Review Manager version 5.3 software.

RESULTS

Nine randomized controlled trials including 523 patients were included in the final analysis. Five studies used oral administration and four used topical. Meta-analysis showed that post-operative VAS of patients receiving metronidazole by either route was significantly less than those in comparison groups. VAS means decreased at all the time points for both oral and topical metronidazole. Topical and oral routes of administration were not compared in any study. There was no increase in complication rates and return to normal activity was significantly earlier for patients receiving metronidazole (-4.49 days; 95% confidence interval [-7.70, -1.28]; P = 0.006).

CONCLUSIONS

Both topical and oral metronidazole reduce post-operative pain without an increase in complication rates and result in an earlier return to normal activity. Further work is required to determine which the optimum route of administration is.

A systematic review of leadership training for medical students

BACKGROUND

Leadership is increasingly being recognised as an essential requirement for doctors. Many medical schools are in the process of developing formal leadership training programmes, but it remains to be elucidated what characteristics make such programmes effective, and to what extent current programmes are effective, beyond merely positive learner reactions. This review's objective was to investigate the effectiveness of undergraduate medical leadership curricula and to explore common features of effective curricula.

METHODS

A systematic literature search was conducted. Articles describing and evaluating undergraduate medical leadership curricula were included. Outcomes were stratified and analysed according to a modified Kirkpatrick's model for evaluating educational outcomes.

RESULTS

Eleven studies met inclusion criteria. Leadership curricula evaluated were markedly heterogeneous in their duration and composition. The majority of studies utilised pre- and post- intervention questionnaires for evaluation. Two studies described randomised controlled trials with objective measures. Outcomes were broadly positive. Only one study reported neutral outcomes.

CONCLUSIONS

A wide range of leadership curricula have shown subjective effectiveness, including short interventions. There is limited objective evidence however, and few studies have measured effectiveness at the system and patient levels. Further research is needed investigating objective and downstream outcomes, and use of standard frameworks for evaluation will facilitate effective comparison of initiatives.

Intravenous lignocaine in colorectal surgery: a systematic review

BACKGROUND

Colorectal surgery leads to morbidity during recovery including pain and fatigue. Intravenous (IV) lignocaine (IVL) has both analgesic and anti-inflammatory effects that may improve post-operative pain and recovery. The aim of this review is to compare the effectiveness of IVL to other perioperative analgesia regimens for reducing pain and opioid consumption following colorectal surgery.

METHODS

Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, a literature search was conducted to identify randomized clinical trials that compared IVL with IV placebo or epidural anaesthesia in open or laparoscopic colorectal surgery. The primary outcomes were opioid requirements and pain scores assessed by visual analogue score. Data were entered into pre-designed electronic spreadsheets.

RESULTS

The literature search identified 2707 studies. A total of nine randomized clinical trials met the inclusion criteria. Five studies investigated IVL compared with IV placebo and four studies investigated IVL compared with epidural anaesthesia. Two out of the five studies comparing IVL and placebo showed statistically significant reductions in opioid consumption with IVL. There was a variable degree of improvement in pain scores when IVL was compared with epidural. Two studies showed a significant difference, with lower opioid consumption and pain scores in the epidural group. Laparoscopic and open procedures could not be compared between the IVL and placebo group.

CONCLUSION

IVL has shown limited benefit towards reducing early pain and morphine consumption when compared with placebo in colorectal surgery. However, IVL did not show any significant reduction in pain or opioid consumption when compared with epidural. Further research investigating IVL combined with intraperitoneal local anaesthetic is warranted.

Efficacy of patient-initiated follow-up clinics in secondary care: a systematic review

Patient-initiated follow up (PIFU) is an initiative that allows patients to initiate hospital follow-up appointments on an 'as required' basis compared with the traditional 'physician-initiated' model. The main principle is to reduce inappropriate regular follow-up appointments. In this systematic review, we attempt to address its efficacy for outpatient secondary level care. Using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, an electronic literature search was performed independently by two authors using pre-defined search terms across EMBASE, Ovid MedLine, PubMed, PSYCINFO and the Cochrane Library databases. Articles were included if they specifically evaluated any aspect of PIFU. Studies evaluating non-outpatient-based, primary level-based and nurse-led clinic appointments were excluded. A total of 747 articles was reviewed, and six were finally included for the systematic review. Three studies analysed efficacy of PIFU with regards to rheumatological disease and found that there was no deleterious clinical effect and a trend towards increased satisfaction and quality of life including lower costs in the PIFU group. Two studies looked at PIFU and inflammatory bowel disease and identified some clinical benefit and lower costs and equivalent satisfaction and QoL with the PIFU group. A further study looked at PIFU in stage 1 breast cancer and did not find any significant differences in outcomes. There is evidence to suggest that PIFU systems result in fewer overall outpatient appointments in secondary care led services while maintaining equivalent if not better patient satisfaction, quality of life and clinical outcomes across a range of chronic conditions.