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.

Kidney bean and soybean lectins cause enzyme secretion by pancreatic acini in vitro

The responses of pancreas acini from Hooded-Lister rats to kidney bean E2L2 lectin or soybean agglutinin have been studied in vitro. Both lectins induced secretion of alpha-amylase from acini in a dose dependent manner. However, the concentrations of lectin required to cause enzyme secretion were approximately 14-fold higher than that necessary with CCK-8. In addition, the responsiveness of pancreas acini to lectins in vitro was significantly altered by the age and sex of the rats from which the acini were derived.

Benign Mucor colonization (fungus ball) associated with chronic sinusitis

Mucormycosis of the nasal cavity and paranasal sinuses is an aggressive, life-threatening condition characterized by fulminant destruction of soft tissues and bone, vascular invasion, and thrombosis. Patients who have this infection generally are immunosuppressed or diabetic. The most effective treatment is immediate surgical debridement of all involved tissue, along with systemic antifungal agents. We identified four patients with chronic sinusitis in whom Mucor organisms were histologically confirmed within the sinus contents but not in the sinus mucosa. All four were successfully treated with conservative debridement. Our dilemma was determining appropriate treatment for this apparently less aggressive condition. We conclude that conservative debridement is the treatment of choice in the absence of tissue invasion, and that systemic antifungal therapy is probably unnecessary.

The successful surgical removal of intracranial nasogastric tubes

Intracranial penetration during attempted nasogastric intubation is a rare, usually lethal, but avoidable complication. Such incidents are associated with facial and basilar skull fractures, acute neurologic deterioration, and litigation. We report two such incidents and the successful surgical procedure which utilized craniotomies positioned such that the nasogastric tubing could be removed in small, straight segments. The tubing in each case was removed without increasing the neurologic deficit, and the patients made an acceptable recovery considering their premorbid status.

Upper aerodigestive tract metastases in disseminated malignant melanoma

Cutaneous malignant melanoma sometimes metastasizes to the upper respiratory and digestive tracts. It may cause significant local symptoms such as airway obstruction and dysphagia, and, in some cases, may represent the initial manifestation of disseminated disease. Of the 8,823 patients with cutaneous malignant melanoma seen at The University of Texas-M.D. Anderson Hospital and Tumor Institute at Houston between 1944 and 1983, metastases to this region developed in 54 patients. The most common sites involved were the tonsil, tongue, nasopharynx, larynx, and lip. Five of ten cases in which an autopsy was performed were noted to have previously undiagnosed metastatic mucosal lesions. We conclude that metastases to the upper aerodigestive tract in patients with cutaneous malignant melanoma is a distinct possibility. Melanoma patients who manifest symptoms localized to this region should be carefully examined to exclude the possibility of metastatic tumor, since alternative treatment may be required. Local endoscopic treatment may be necessary to relieve airway or digestive tract obstruction.

Airway-obstructing epiglottic cyst

Laryngeal cysts, particularly epiglottic cysts, are generally benign lesions which cause mild dysphagia or hoarseness. We report a case of an epiglottic cyst that caused almost complete airway obstruction. A 43-year-old man presented with progressive dysphagia, hoarseness, and airway obstruction secondary to a large cystic mass involving the entire epiglottis and filling the hypopharynx. He required emergency tracheotomy to secure the airway, and the cyst was incised and drained. Following a subsequent recurrence, laser excision of the cyst was performed and the problem resolved. The cystic mass was found to fill the valleculae, and involved the lingual and laryngeal surfaces of the epiglottis and the left false vocal cord. A review of laryngeal cysts is presented with emphasis on anatomic and embryologic considerations. The potential lethal nature of these lesions is emphasized.