Fast-track management of patients undergoing proximal pancreatic resection

INTRODUCTION

To avoid the risk of complications of biliary drainage, a feasibility study was carried out to determine whether it might be possible to fast-track surgical treatment, with resection before biliary drainage, in jaundiced patients with proximal pancreatic/peri-ampullary malignancy.

PATIENTS AND METHODS

Over an 18-month period, based on their presenting bilirubin levels and other logistical factors, all jaundiced patients who might be suitable for fast-track management were identified. Data on complications and hospital stay were compared with those patients in whom a conventional pathway (with biliary drainage) was used during the same time period. Data were also compared with a group of patients from the preceding 6 months.

RESULTS

Nine patients were fast-tracked and 49 patients treated in the conventional pathway. Fast-track patients mean (SD) serum bilirubin level was 265 micromol/l (81.6) at the time of the operation compared to 43 micromol/l (51.3; P > or = 0.0001) in conventional patients. Mean (SD) of time from referral to operation, 14 days (9) versus 59 days (36.9), was significantly shorter in fast-track patients than conventional patients (P < or = 0.0001). Length of hospital stay mean (SD) at 17 (6) days versus 22 days (19.6; P = 0.2114), surgical complications and mortality in fast-track patients were similar to conventional patients. Prior to surgery, the 49 conventional patients underwent a total of 73 biliary drainage procedures resulting in seven major complications. Comparison with the group of patients from the previous 6 months indicated that the conventional group were not disadvantaged.

CONCLUSIONS

Fast-track management by resection without biliary drainage of selected patients with distal biliary strictures is safe and has the potential to reduce the waiting time to surgery, overall numbers of biliary drainage procedures and the complications thereof.

Sick notes, general practitioners, emergency departments and fracture clinics

BACKGROUND

General practitioner waiting times are increasing. The two national surveys regarding general practice showed that the number of patients waiting for >or=2 days for an appointment rose from 63% to 72% between 1998 and 2002, with 25% waiting for >or=4 days. The Department of Health recognised that many patients discharged from hospitals and outpatient clinics required to visit their general practitioner for the sole purpose of obtaining a sick note. The report entitled Making a difference: reducing general practitioner paperwork estimated that 518 000 appointments (and 42 000 GP h) could be saved by ensuring that these patients were issued with a sick note directly from hospital rather than being referred to their general practitioner. This practice was to be adopted from July 2001 and included patients discharged from wards as well as those seen in outpatient departments.

METHOD

50 emergency departments and fracture clinics in Scotland and England were contacted to assess whether these guidelines had been adopted. Only hospitals with both accident and emergency and fracture clinics were included; nurse-led and paediatric departments were excluded.

RESULTS

Of the 25 Scottish emergency hospitals contacted, 4 (16%) accident and emergency departments and 8 (32%) fracture clinics issued sick notes. This was compared with 5 of 25 (20%) accident and emergency departments and 12 of 25 (48%) fracture clinics in England. Four Scottish and five English accident and emergency departments stated that it was policy to give sick notes, three Scottish and four English departments said that it was policy not to give them and the rest (72% in Scotland and 64% in England) stated that they had no clear policy but "just don't give them".

CONCLUSION

The 2001 guidance from the joint Cabinet Office/Department of Health has not been fully incorporated into standard practice in Scotland and England. If all emergency departments and fracture clinics were to issue sick notes to patients requiring >7 days absence from work, this could reduce general practitioner consultations and improve waiting times.

Cell death in cranial neural crest development

The rhombencephalic neural crest, crucial to the patterning and development of many craniofacial structures, migrates laterally from the dorsal hindbrain, but not as a continuous sheet. We have used a vital dye to demonstrate a discontinuous pattern of cell death in the dorsal midline of the avian rhombencephalon associated with the migration of the neural crest. Whilst cell death commences in the dorsal midline of the presumptive mesencephalon at stage 8, two distinct domains of cell death are apparent in the rhombencephalon by stage 11. The rostral domain lies over primary rhombomere RhA1 and rhombomere rh3, while the caudal domain occurs on the neural midline between the otic vesicles, in the region of rh5. Using a marker for the neural crest, we show that the rostral and caudal domains of cell death correlate with the absence of neural crest migration from rh3 and rh5. Thus segment-specific cell death in the dorsal region of particular rhombomeres may account for their subsequent failure to contribute to the cranial neural crest.