Evaluation of independent risk factors associated with surgical site infections from caesarean section

BACKGROUND

The present study assessed factors associated with the risk of surgical site infections (SSI) after a caesarean section (C-section).

METHODS

Data were collected in 1682 women undergoing elective (53.9%) and emergency (46.1%) C-sections between 1st August 2020, and 30th December 2021, at a National Health Service hospital (Surrey, UK).

RESULTS

At the time of C-section, the mean age was 33.1 yr (SD ± 5.2). Compared to women with BMI < 30 kg/m2, those with a BMI ≥ 35 kg/m2 had a greater risk of SSI, OR 4.07 (95%CI 2.48-6.69). Women with a history of smoking had a greater risk of SSI than those who had never smoked, OR 1.69 (95%CI 1.05-2.27). Women with a BMI ≥ 30 kg/m2 and had a smoking history or emergency C-section had 3- to tenfold increases for these adverse outcomes. Ethnic minority, diabetes or previous C-section did not associate with any of the outcomes.

CONCLUSIONS

High BMI, smoking, and emergency C-section are independent risk factors for SSI from C-section. Women planning conception should avoid excess body weight and smoking. Women with diabetes and from ethnic minority backgrounds did not have increased risks of SSI, indicating a consistent standard of care for all patients.

Single-Centre Retrospective Study on the Effects of Bariatric Surgery on Nocturia

PURPOSE

The incidence of nocturia is increased in obesity, which causes significant negative impact on quality of life. Bariatric surgery is a reliable method in which to achieve major weight loss and this study aims to determine the effect of bariatric surgery on nocturia and other lower urinary tract symptoms (LUTS) in men and women.

MATERIALS AND METHODS

Retrospective study of patients undergoing bariatric surgery had pre- and post-operative questionnaires using the validated International Prostate Symptoms Score (IPSS) to assess nocturia between 2018 and 2021. The primary outcome was effect of bariatric surgery on nocturia RESULTS: A total of 99 patients were included with median age of 52.9 (44.9-60.2) and 83.8% being female. The median weight was 129.9kg (110-151.9) and median BMI was 45.5 (41.4-53.4). Improvements were demonstrated in all criteria assessed in IPSS and nocturia significantly improved with a decrease in 1.14 points (p < 0.05). Linear regression analysis showed that, in the post operative period assessed, there were no significant effect on variables measured such as obstructive sleep apnoea, type 2 diabetes on the effect of IPSS post-bariatric surgery within the follow-up period of 4-6 months.

CONCLUSION

Bariatric surgery can have significant improvements on nocturia symptoms in men and women with obesity. This is another means in how bariatric surgery can reduce morbidity and improve quality of life.

Preoperative Oesophagogastroduodenoscopy and the Effect on Bariatric Surgery: a Systematic Review and Meta-Analysis

Preoperative oesophagogastroduodenoscopy (OGD) in bariatric surgery remains a controversial topic, with a large variety in practice globally. An electronic database search of Medline, Embase and PubMed was performed in an aim to categorise the findings of preoperative endoscopies in bariatric patients. A total of 47 studies were included in this meta-analysis resulting in 23,368 patients being assessed. Of patients assessed, 40.8% were found to have no novel findings, 39.7% had novel findings which did not affect surgical planning, 19.8% had findings that affected their surgery and 0.3% were ruled to not be suitable for bariatric surgery. Preoperative OGD is altering surgical planning in one-fifth of patients; however, further comparative studies are required to determine if each patient should undergo this procedure especially if asymptomatic.

Mesenteric Defect Closure and the Rate of Internal Hernia in Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis

Internal hernias are a worrying complication from laparoscopic Roux-en-Y gastric bypass (LRGB), with potential small bowel necrosis and obstruction. An electronic database search of Medline, Embase, and Pubmed was performed. All studies investigating the internal hernia rates in patients whose mesenteric defects were closed vs. not closed during LRGB were analysed. Odds ratios were calculated to assess the difference in internal hernia rate. A total of 14 studies totalling 20,553 patients undergoing LRGB were included. Internal hernia rate (220/12,445 (2%) closure vs. 509/8108 (6%) non-closure) and re-operation for small bowel obstruction (86/5437 (2%) closed vs. 300/3132 (10%) non-closure) were reduced when defects were closed. There was no difference observed when sutures were used to close the defects compared to clips/staples.

Reduction of adverse outcomes from caesarean section by surgical site infection prevention care bundles in maternity

OBJECTIVE

To reduce average surgical-site infection (SSI) rates to less than 7.5%, as well as other complications by incrementally implementing an SSI prevention care bundle in maternity: (1) ChloraPrep; (2) PICO dressings, performing elective cesarean sections in a main theater rather than a labor ward and warming blankets; (3) vaginal cleansing; and (4) Hibiscrub.

METHODS

In this prospective cohort study, the association between categorical variables was assessed by χ² tests, temporal trends in the monthly percentage change of SSI were measured using the Joinpoint Regression Program v4.7.0.0.

RESULTS

In all, 1682 women (mean age 33.1 ± 5.2 years) underwent either elective (53.9%) or emergency (46.1%) cesarean section. After a small initial increase (10.0%-11.8%), SSI progressively declined to 4.4% (χ²  = 22.1, P < 0.001), as did sepsis, reoperation or readmission for SSI: from 12.5% to 0.5% (χ²  = 90.1, P < 0.001). The rates of SSI fell progressively with the cumulative introduction care bundle components. The average monthly percentage change was -14.0% (95% confidence interval -21.8% to -5.4%, P = 0.004), and the average SSI rate was kept below 7.5% for the last 12 months of the study.

CONCLUSION

The maternal SSI prevention care bundle is simple and inexpensive; it effectively reduces SSI after a cesarean section and should be offered routinely to women undergoing cesarean section.

Greenhouse Gas Emission Savings in Relation to Telemedicine and Associated Patient Benefits: A Systematic Review

Introduction: Telemedicine is a rapidly expanding service in the digitization of health care systems. Recently emphasis has been placed on the decarbonization of health care systems with National and World Health Organization initiatives aimed at carbon neutrality toward the mid-21st century. This study investigates greenhouse gas emissions related to telemedicine, its potential role in achieving carbon neutrality and its role in determining policy. We further investigate patient benefits related to telemedicine. Methods: A systematic review was conducted of the PubMed, Medline, EMBASE, EMCARE, CINAHL, and HMIC databases. Eligibility of studies was determined by predefined criteria. Results: A total of 31 studies were identified totaling over 57,000 patients. Carbon savings ranged from 0.69 kg CO2e (carbon dioxide equivalent) to 893 kg CO2e per encounter. Distances saved also ranged from 6.1 to 3,386 km. Further analysis of 18 included studies was conducted for cost savings that ranged from €1.73 in fuel costs to over U.S. $900 in travel related expenses. Similarly, 15 included studies were analyzed for time savings, which ranged from 38 min to 24 h. Conclusions: There are substantial carbon savings to be made with telemedicine systems. Furthermore, there are substantial benefits to patients in terms of both time savings and cost savings. Rural and isolated communities or patients needing tertiary or quaternary care may be a particular cohort that might benefit disproportionally from telemedicine and is an area where the largest per capita emission savings can potentially be made.

SP3.2.10 Establishing an Emergency Surgical Ambulatory Care (ESAC) pathway for acute laparoscopic cholecystectomies: a single centre experience from a District General Hospital

Aims

Early laparoscopic cholecystectomy is the gold standard for acute cholecystitis and gallstone pancreatitis. In order to deliver this service, a local Emergency Surgical Ambulatory Care (ESAC) pathway with a dedicated ESAC theatre list was established. The aim of this audit was to determine whether ESAC was associated with (1) improved length of stay and (2) cost efficiencies.

Methods

Consecutive patients who underwent an emergency laparoscopic cholecystectomy between October 2018 to October 2019 were identified. Data related to patient demographics, operating time, complications length of stay (LOS), reason for inpatient stay and re-admissions were collected. A dedicated ESAC service was introduced in July 2020. Outcomes were re-audited (July – December 2020).

Results

Prior to the introduction of ESAC, 142 patients (42% male, mean age 51 years (range 14 -82 years)) underwent an acute cholecystectomy, of which 13% were discharged on the same day. Median pre-operative LOS was 2 days (range 0-12 days) and median post-operative LOS was 1 day (range 1-16 days). Following the introduction of ESAC, 78 patients (32% male, mean age 49 years (range 22 – 89 years)) underwent an acute cholecystectomy, of which 76% were discharged on the same day and 90% within 1 day. Median pre-operative LOS was 0 days (range 0 to 7 days) and median post-operative LOS was 0 days (range 0-16 days).

Conclusions

Our results show that the introduction of a dedicated ESAC pathway improved both pre- and post-operative LOS. This subsequently saves approximately £80,000 per annum in hospital bed days.

NHS litigation in bariatric surgery over a ten year period

Negligence claims in the UK NHS has increased over the last 30 years. The aim of this present study was determine the number of claims and the cost of litigation in Bariatric Surgery and compare it to similar other specialties. Data was received from NHS Litigation Authority (NHSLA) in response to Freedom of Information data request. There was a total of 7 claims, of which 4 were successful. The total pay out sum was £210,000 in 10 years. This is a very low amount compared to other surgical specialties. This low level of litigation probably indicates that the current bariatric surgical services in the NHS are delivering safe care with good patient satisfaction. This needs to be carefully considered prior to changing the payment tariffs for bariatric surgery.

Straight to colonoscopy: the ideal patient pathway for the 2-week suspected cancer referrals?

INTRODUCTION

The UK has a higher mortality for colon cancer than the European average. The UK Government introduced a 2-week referral target for patients with colorectal symptoms meeting certain criteria and 62-day target for the delivery of treatment from the date of referral for those patients diagnosed with cancer. Hospitals are expected to meet 100% and 95% of these targets, respectively; therefore, an efficient and effective patient pathway is required to deliver diagnosis and treatment within this period. It is suggested that 'straight-to-test' will help this process and we have examined our implementation of 'straight-to-colonoscopy' as a method of achieving this aim.

PATIENTS AND METHODS

We carried out a retrospective audit of 317 patients referred under the 2-week rule over a 1-year period between October 2004 and September 2005 and were eligible for 'straight-to-colonoscopy'. Demographic data, appropriateness of referral and colonoscopy findings were obtained. The cost effectiveness and impact on waiting period were also analysed.

RESULTS

A total of 317 patients were seen within 2 weeks. Cancer was found in 23 patients and all were treated within 62 days. Forty-four patients were determined by the specialist to have been referred inappropriately because they did not meet NICE referral guidelines. No cancer was found in any of the inappropriate referrals. The use of straight-to-test colonoscopy lead to cost savings of £26,176 (£82.57/patient) in this group compared to standard practice. There was no increase in waiting times.

CONCLUSIONS

Straight-to-colonoscopy for urgent suspected cancer referrals is a safe, feasible and cost-effective method for delivery of the 62-day target and did not lead to increase in the endoscopy waiting list.

A pilot study of ultrasound guided Durasphere injection in the treatment of faecal incontinence

AIM

To assess injection of Durasphere under direct endoanal ultrasound guidance as a treatment for faecal incontinence.

METHOD

A total of 23 patients with varying degrees of persistent faecal leakage and/or soiling were recruited. Durasphere was injected in the intersphincteric plane under direct ultrasound guidance. All patients were given a general anaesthetic. Patients had ano-rectal physiology, endoanal ultrasound, continence scoring and quality of life measures assessed at 0, 1, 3, 6 and 12 months.

RESULTS

A total of 21 patients were followed up for at least 12 months, with two being excluded at the follow-up stage. Friedman two-way analysis of variance of the Cleveland Clinic Score, Faecal Incontinence Quality of Life Score and Diary Response Score demonstrated a significant sustained improvement. There was no significant improvement in number of bowel movements. There was a significant difference in anal squeeze pressure after therapy, but no significant difference in anal resting pressure. Six patients reported no improvement after Durasphere therapy.

CONCLUSIONS

Durasphere gave sustained improvements in quality of life and continence scores in this study group. Strict criteria are needed to ascertain suitability for Durasphere therapy.

Do guidelines improve clinical practice? - a national survey on surveillance colonoscopies

BACKGROUND

Colonoscopic services are increasingly being utilized in surveillance of conditions predisposing to colorectal cancers (CRC). The ACPGBI/BSG guidelines are the most commonly followed recommendations. Numerous retrospective studies have shown poor compliance with them. We conducted a national survey of colonoscopic practitioners investigating attitudes, awareness and implementation of surveillance guidelines.

METHOD

A postal questionnaire was sent to a random population of 250 ACPGBI and 200 BSG members. Questions assessed practice as regards colorectal polyp surveillance, family screening and surveillance for past history of CRC.

RESULTS

The ACPGBI/BSG guidelines were the most commonly followed recommendations. Only 17.2% of practitioners used the criteria that would ensure accurate implementation of guidelines for colorectal adenoma surveillance. With regards to familial surveillance for CRC, 53.5% respondents assessed familial risk accurately, while 69.3% recommended surveillance incorrectly. A total of 48.8% of ACPGBI members recommended five yearly colonoscopies following curative treatment for CRC.

CONCLUSION

This study has revealed the widespread ignorance of guidelines, which will potentially translate into the gross over utilization of colonoscopic resources. Strategies to improve and audit guideline implementation must be integral to guideline formation. Methods to improve accurate guideline implementation need to be explored.

Surveillance colonoscopies for colorectal polyps--too often, too many! An Audit at a Large District General Hospital

INTRODUCTION

The British society of Gastroenterologists (BSG) have laid down guidelines for surveillance colonoscopies in patients with large bowel adenomatous polyps. However, numerous studies have shown the gross over-utilization of colonoscopic services in their management. We audited our practice of polyp management and looked at guideline compliance amongst patients on our colonoscopic surveillance list.

METHOD

All patients undergoing adenoma surveillance and those with newly detected adenomas over a 2-month period were included in the first loop of the audit. Data on the colonoscopic findings, histology and management were retrieved from paper and on-line records. The BSG guidelines were printed, laminated and displayed in the colorectal clinics. Following this, we re-audited (second loop) our practice. In the second part of the study, we randomly retrieved 533/1800 case notes from our colonoscopic waiting list. Amongst those on surveillance for polyps, compliance was ascertained as regards need for procedure and appropriateness of surveillance interval.

FINDINGS

Fifty-four patients were included in the first loop and 59 during the second loop of the audit. Guidelines were followed in 16% (4/25, 95% CI: 0.054-0.33) of patients in the first loop and 46.5% (13/28, 95% CI: 0.293-0.642) in the second loop (P = 0.017). Of the patients on our colonoscopic waiting list for adenomatous polyps, 17.7% satisfied guidelines, 23.4% did not require any further surveillance and 58.9% were booked for a procedure earlier than recommended.

CONCLUSION

The mere framing of guidelines is insufficient to improve clinical practice. Strategies to improve implementation need to be explored. Audit of individual practice is recommended.

Systematic review: adipose tissue, obesity and gastrointestinal diseases

BACKGROUND

Obesity is increasingly being recognized as a risk factor for a number of benign and malignant gastrointestinal conditions. However, literature on the underlying pathophysiological mechanisms is sparse and ambiguous. Insulin resistance is the most widely accepted link between obesity and disease, particularly colorectal cancer. The recognition that intra-abdominal fat is immunologically active sheds new light not only on the pathogenesis of obesity-related gastrointestinal conditions, but also on inflammatory conditions such as Crohn's disease.

AIM

To describe the biology of adipose tissue, its impact on the immune system and explores the possible underlying mechanisms linking obesity to gastrointestinal diseases. It also looks at the role of mesenteric fat in determining severity and course of Crohn's disease.

METHODS

Relevant English-language literature and abstracts cited on MEDLINE database were reviewed.

RESULTS

Our recent finding of an association between obesity and subclinical bowel inflammation suggests that, apart from promoting generalized immune activation, fat also evokes local immune responses. We propose that the proinflammatory milieu promoted by obesity could underlie many of these associations and that the mechanism implicating insulin resistance may merely represent an epiphenomenon. In Crohn's disease, on the other hand, intra-abdominal fat may provide a protective mechanism.

CONCLUSION

The potential of adipose tissue as a therapeutic target is vast and needs exploration.