Venous thromboembolism following colorectal resection

AIM

The study investigated the rate of significant venous thromboembolism (VTE) following colorectal resection during the index admission and over 1 year following discharge. It identifies risk factors associated with VTE and considers the length of VTE prophylaxis required.

METHOD

All adult patients who underwent colorectal resections in England between April 2007 and March 2008 were identified using Hospital Episode Statistics data. They were studied during the index admission and followed for a year to identify any patients who were readmitted as an emergency with a diagnosis of deep venous thrombosis or pulmonary embolism.

RESULTS

In all, 35 997 patients underwent colorectal resection during the period of study. The VTE rate was 2.3%. Two hundred and one (0.56%) patients developed VTE during the index admission and 571 (1.72%) were readmitted with VTE. Following discharge from the index admission, the risk of VTE in patients with cancer remained elevated for 6 months compared with 2 months in patients with benign disease. Age, postoperative stay, cancer, emergency admission and emergency surgery for patients with inflammatory bowel disease (IBD) were all independent risk factors associated with an increased risk of VTE. Patients with ischaemic heart disease and those having elective minimal access surgery appear to have lower levels of VTE.

CONCLUSION

This study adds to the benefits of minimal access surgery and demonstrates an additional risk to patients undergoing emergency surgery for IBD. The majority of VTE cases occur following discharge from the index admission. Therefore, surgery for cancer, emergency surgery for IBD and those with an extended hospital stay may benefit from extended VTE prophylaxis. This study demonstrates that a stratified approach may be required to reduce the incidence of VTE.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Definitive management of gallstone pancreatitis in England

INTRODUCTION

The aim of this study was to investigate whether definitive treatment of gallstone pancreatitis (GSP) by either cholecystectomy or endoscopic sphincterotomy in England conforms with British Society of Gastroenterology (BSG) guidelines and to validate these guidelines.

METHODS

Hospital Episode Statistics data were used to identify patients admitted for the first time with GSP between April 2007 and April 2008. These patients were followed until April 2009 to identify any who underwent definitive treatment or were readmitted with a further bout of GSP as an emergency.

RESULTS

A total of 5,454 patients were admitted with GSP between April 2007 and April 2008, of whom 1,866 (34.2%) underwent definitive treatment according to BSG guidelines, 1,471 on the index admission. Patients who underwent a cholecystectomy during the index admission were less likely to be readmitted with a further bout of GSP (1.7%) than those who underwent endoscopic sphincterotomy alone (5.3%) or those who did not undergo any form of definitive treatment (13.2%). Of those patients who did not undergo definitive treatment before discharge, 2,239 received definitive treatment following discharge but only 395 (17.6%) of these had this within 2 weeks. Of the 505 patients who did not undergo definitive treatment on the index admission and who were readmitted as an emergency with GSP, 154 (30.5%) were admitted during the 2 weeks immediately following discharge.

CONCLUSIONS

Following an attack of mild GSP, cholecystectomy should be offered to all patients prior to discharge. If patients are not fit for surgery, an endoscopic sphincterotomy should be performed as definitive treatment.

Loop ileostomy following anterior resection: is it really temporary?

INTRODUCTION

A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis if anastomotic dehiscence occurs following low colorectal anastomosis. Although it has been suggested that a loop ileostomy should be reversed within 12 weeks of formation, this is often not the case. We set out to analyse the use of loop ileostomy following elective anterior resection in England and to identify factors associated with non and delayed reversal.

METHOD

Hospital episode statistics for the years 2001-2006 were obtained from the Department of Health. Patients undergoing elective anterior resection with a loop ileostomy for a primary diagnosis of rectal or recto-sigmoid cancer between April 2001 and March 2003 were identified as the study cohort. This cohort was followed until March 2006 to identify patients undergoing reversal of an ileostomy in an English NHS Hospital.

RESULTS

A total of 6582 patients had an elective anterior resection between April 2001 and March 2003, of which 964 (14.6%) also had an ileostomy. Seven hundred and two (75.1%) patients were reversed before March 2006. Advancing age and comorbidity were statistically related to nonreversal. Median time to reversal was 207 days (Interquartile range 119-321.5 days). Postoperative chemotherapy and comorbidity significantly delayed reversal.

CONCLUSIONS

One in four loop ileostomies performed to defunction an elective anterior resection is not reversed, and in the presence of significant comorbidity one in three is not reversed. Only 12% is reversed within 12 weeks.

Use of Hartmann's procedure in England

INTRODUCTION

Hartmann's procedure is widely used in the management of complicated diverticular disease and for colorectal cancer. Very little national data are available about the reasons for performing this procedure and the reversal rate.

METHOD

Hospital episode statistics data were obtained from The Department of Health and exported to an Access database for analysis. A cohort of patients who underwent a Hartmann's procedure between April 2001 and March 2002 were identified and followed until April 2006 to identify patients undergoing reversal of Hartmann's.

RESULTS

Approximately 3950 Hartmann's procedures were performed between April 2001 and March 2002, 2853 as an emergency and 1097 as an elective procedure. Most emergency Hartmann's were performed for benign disease (2067, 72.5%) whereas a majority of the elective Hartmann's were performed for cancer (756, 68.9%). Seven hundred and thirty six (23.3%) of these patients underwent reversal during the study period. The median time interval between a Hartmann's procedure and reversal was 284.5 days (interquartile range 181-468.25).

CONCLUSION

This study represents the single largest cohort in whom outcome after Hartmann's procedure has been studied. A majority of Hartmann's are performed as an emergency for benign diseases and most of them are not reversed.

Management of acute gallbladder disease in England

BACKGROUND

Recent literature suggests that early laparoscopic cholecystectomy for acute gallbladder disease is safe and efficacious, but few data are available on the management of acute gallbladder disease in England.

METHODS

Hospital Episode Statistics data for the years 2003-2005 were obtained from the Department of Health. All patients admitted as an emergency with acute gallbladder disease during the period from April 2003 to March 2004 were included as a cohort. Repeat emergency admissions for acute gallbladder disease, and cholecystectomies performed during the first admission, an emergency readmission or an elective admission were followed up until March 2005.

RESULTS

Some 25,743 patients were admitted as an emergency with acute gallbladder disease, of whom 3791 had an emergency cholecystectomy during the first admission (open cholecystectomy (OC) 29.8 per cent, laparoscopic conversion rate (LCR) 10.7 per cent) and 9806 patients had an elective cholecystectomy (OC 11.3 per cent, LCR 8.3 per cent) during the study period.

CONCLUSION

Early cholecystectomy for acute gallbladder disease is not widely practised by surgeons in England. Open cholecystectomy is more commonly used in the emergency than in the elective setting. Early laparoscopic cholecystectomy following an emergency admission carries a higher conversion rate than elective cholecystectomy.

Oesophagectomy practice and outcomes in England

Background

The 2001 UK National Health Service guidance on improving outcomes recommended centralization of oesophageal resection. The aim of this study was to analyse national trends in oesophageal resection in England to determine whether centralization has occurred and its impact on outcomes.

Methods

The study used data from Hospital Episode Statistics for 1997–1998 to 2003–2004 and included patients who had resection for oesophageal cancer. The annual hospital volume was grouped into five categories based on the recommendation for annual volume for a designated centre.

Results

A total of 11 838 oesophageal resections were performed. The total number of hospitals performing resections decreased, mainly owing to a fall in the number of very low-volume hospitals (117 in 1997 to 45 in 2003). The proportion of resections performed in very high-volume hospitals increased from 17·8 per cent during 1997–1999 to 21·9 per cent during 2002–2003 (P < 0·001). The overall in-hospital mortality rate was 10·1 per cent, with a significant reduction over time (from 11·7 to 7·6 per cent; P < 0·001). The decline in mortality rate may be due to increased numbers of patients undergoing surgery in higher-volume hospitals. There was an increase in the annual number of new patients from 5672 to 6230 during the study, although a fall in the proportion of resections from 31·5 to 26·0 per cent (P < 0·001).

Conclusion

Centralization and multidisciplinary team expertise partly explain the improvement in mortality rate, but changes in preoperative selection also play a part.

Starch powder contamination of surgical wounds

OBJECTIVES

To determine if (1) lubricating starch glove powder contaminates surgical wounds even after powdered gloves have been washed and/or wiped: (2) starch powder can be eliminated from surgical wounds when the surgical team wears only powderless gloves; and (3) starch powder introduced into surgical wounds may increase scar formation.

DESIGN AND OUTCOME MEASURES

Human surgical wounds were irrigated at the end of operations in which various combinations of powdered and powderless gloves were used. Team members who wore powdered gloves washed them in a saline solution and wiped them on surgical towels. The starch particles in the irrigant were counted. In addition, two series of breast biopsies were performed, one in which the surgeon wore powdered gloves and the other, powderless gloves. Pathologic specimens from reexcisions (for carcinoma) were examined for starch granules and inflammation.

RESULTS

Starch granules were found in proportion to the number of surgical team members who wore powdered gloves and to the proximity of the wearer(s) to the operative site. Exclusive use of powderless gloves eliminated the presence of starch powder. Starch-containing phagocytes in tissue were surrounded by an inflammatory reaction, and in one patient the inflammation and scarring were severe.

CONCLUSIONS

Starch powder is introduced into wounds by the use of powdered gloves despite glove washing and wiping. It can be eliminated by the exclusive use of powderless gloves. The inflammatory reaction to starch is variable and can be severe.

Pyruvate kinase and alanine synthesis in skeletal muscle

L-Phenylalanine is an allosteric inhibitor of M1-type pyruvate kinase. Accordingly, the effects were studied of 20 mM phenylalanine on the metabolism of 5 mM [U-14C]glucose and 3 mM L-[U-14C]glutamate by isolated hemidiaphragms from starved rats. Phenylalanine inhibited lactate and 14CO2 production from both substrates and stimulated alanine release. It is concluded that pyruvate kinase may have a dual role in intermediary metabolism in skeletal muscle: the enzyme is a component of the lower glycolytic pathway and is implicated in a pathway of amino acid oxidation and alanine synthesis.