367 Can We Justify Routine Group & Screen Testing Prior to Appendicectomies? - A Single Centre Analysis

Aim

Numerous sources have suggested that routine preoperative Group & Screen (G&S) testing prior to cholecystectomies1–4, breast surgery5 and gynaecological procedures including Caesarean sections6 may be unnecessary because perioperative blood transfusion incidence remains low.

This project aimed to understand whether routine pre-appendicectomy G&S testing can be justified by analysing blood transfusion incidence for appendicectomies completed at our hospital. To further comment on their relevance to clinical practice, we also aimed to investigate any potential delay to surgery that G&S tests may pose, and their cost implications.

Method

For all appendicectomies undertaken at our hospital from 2018 to 2021 (n = 257), we noted if the patient received a blood transfusion anytime during their admission. The date and time of G&S sample collection and of the surgery were recorded, including any documentation of delays to surgery.

Results

0% of appendicectomies between 2018 – 2021 required a blood transfusion during the admission. On average, 3.9% of appendicectomies per year were delayed due to preoperative G&S testing with an average delay to surgery of 78.71 minutes.

The total cost of G&S tests undertaken for appendicectomy patients between 2018 – 2021 was £5768.03.

Conclusions

It is difficult to justify routine pre-appendicectomy G&S testing when our data suggests such a low risk of blood loss necessitating transfusion, and that these tests delay treatment. This may warrant pre-appendicectomy risk stratification to streamline G&S testing. Additionally, should an emergency occur, uncrossmatched blood is readily accessible and poses minimal risk to patients7.

Surgical outcome of safe surgery system trabeculectomy combined with cataract extraction

PURPOSE

To determine the efficacy of safe surgery system trabeculectomy combined with manual small incision cataract surgery/phacoemulsification in primary glaucoma coexistent with cataract.

METHODS

This is a retrospective analysis of 105 cases who underwent single-site combined surgery between January 2008 and December 2009. Safe surgery system trabeculectomy with diffuse and posterior application of mitomycin C was performed in all cases. Cataract extraction was done either by Manual Small Incision Cataract Surgery (MSICS) or phacoemulsification. Main outcome measures were success rate of trabeculectomy, as determined by four different IOP goals and incidence of postoperative complications. Analysis was performed using R-2.15, and the significance was tested at 5% level.

RESULTS

The minimum follow-up period was 12 months. The overall success rates (with or without medication) when safe surgery system trabeculectomy was combined with MSICS were 91, 70, and 51% for IOP ≤18, ≤15, and ≤12 mm Hg, respectively, and target IOP was achieved in 72% cases. The mean IOP reduction was 43.8% with MSICS and 42.08% with phacoemulsification. The surgical outcome was not significantly different for both techniques. Postoperative complications were infrequent and comparable.

CONCLUSION

The Safe Surgery System Trabeculectomy combined with cataract surgery offers excellent IOP control with minimal postoperative complications. It offers an effective and improved solution for primary glaucoma coexistent with cataract found in developing countries.

Telephonic management of rectal bleeding in young adults: a prospective randomized controlled trial

OBJECTIVE

The majority of young adults referred with rectal bleeding to a colorectal specialist clinic have a very low risk of serious disease such as cancer, and a high chance of gaining symptom relief by simple dietary changes. To determine whether young low-risk patients with rectal bleeding can be managed with a structured telephonic interview and dietary advice, rather than an outpatient visit.

METHOD

A single-blinded, prospective, randomized controlled trial was performed in two stages. Patients under 40 years with rectal bleeding only were offered inclusion. Part-I trial: Patients were interviewed on telephone by the colorectal nurse specialist (CNS) and randomized to receive dietary advice (Advice Group) or not (Control Group). All patients were seen in clinic 6 weeks later by a doctor 'blinded' to their trial status. Part-II trial: Patients were interviewed on telephone by the CNS and again randomized to an Advice Group or a Control Group. The Control Group were seen in clinic 6 weeks later. The Advice Group were telephoned again 6 weeks later, and if their bleeding had stopped, were not brought to clinic. All patients were tracked for a year after the study to ensure no adverse diagnoses came to light.

RESULTS

Part-I trial: 63 of 89 eligible patients were contactable and none refused the study. Seventy per cent of the Advice Group compared with 33% (P = 0.001) of the Control Group had symptomatic improvement when seen in clinic. Approximately 30% of each group required further treatment. Part-II trial: 54 of 94 eligible patients were contactable. However a further nine declined to enter the trial; 90% of patients in the Advice Group had improved at 6 weeks as judged by telephone interview compared with 56% of patients in the Control Group (P = 0.024) who were seen in clinic. The 90% of patients who improved in the Advice Group did not need to come to clinic to be seen. In both parts of the trial, the CNS identified a small number of patients with urgent symptoms at interview and brought them to clinic. The majority had anal fissures or haemorrhoids although in Part-II, one patient had ulcerative colitis and one had colorectal cancer.

CONCLUSION

Telephonic consultation is an effective way of identifying those patients with urgent symptoms among a cohort of young adults referred to the hospital with rectal bleeding. Telephonic dietary advice leads to resolution of rectal bleeding in the majority of patients without urgent symptoms.

Changing trends in the management of colorectal cancers and its impact on cancer waiting times

OBJECTIVE

The aim of this study was to compare the differences in the presentation, management and waiting times for new colorectal cancer (CRC) patients over 5 years in a single metropolitan cancer centre.

METHODS

A retrospective comparative study of new patients with CRC presenting in the years 1998 and 2003. The groups were compared for referral type, Dukes' stage, site, cancer waiting times and primary treatment.

RESULTS

There were 72 new patients in 1998 and 77 in 2003. In 1998 33% were seen urgently and 28% as emergencies whereas in 2003 55% of patients were seen as urgent or target wait patients and 16% as emergencies. The 2-week target for urgent referrals was met in 50% of cases in 1998 and 90% in 2003. In 2003 a higher proportion of patients received adjuvant or neoadjuvant treatment. Stage at diagnosis was similar in both groups, except stage 'D' which was 21% in 1998 and only 12% in 2003. The 31-day Cancer Waiting Time (CWT) target from decision to treat to first treatment would have been met in 81% of cases in 1998 and 79% in 2003. The 62-day overall CWT target from referral to first treatment for urgent GP referrals would have been met in 46% of cases in 1998 and 57% in 2003.

CONCLUSION

More CRC patients were referred urgently in 2003. Most, but not all of these were referred as target waits. The time taken for the patient's journey did not improve between the two cohorts, possibly in part, because more complex treatments are now provided. Further work and perhaps new thinking are needed in order to achieve Cancer Waiting Time targets.

Nosocomial surgical infections: Incidence and cost in a developing country

Eight hundred twenty-nine patients were monitored for nosocomial surgical infections from January to December 1980 at the University Hospital of the West Indies. Two hundred twenty-five patients (27%) had 189 postoperative wound infections (POWI) and 295 other nosocomial infections, with an average of 2.1 infections per infected patient. The incidence of POWI was 22.8%, varying from 7.3% in clean to 82.2% in infected wounds. The most common organisms isolated were gram-negative bacilli and Staphylococcus aureus. The most frequent nosocomial infection other than POWI was urinary tract infection (27.8%). A statistically significant number of urinary tract infections and septicemias were associated with the use of medical devices such as indwelling urethral catheters and central venous pressure lines (p less than 0.001). Septicemia was frequently associated with operations on the lower gastrointestinal and hepatobiliary tracts (p less than 0.001). The postoperative stay of an infected patient was prolonged by an average of 18 days. The total excess cost of hospitalization for the infected patients was U.S. $170,000.