202 Consenting Practice for Post-Cholecystectomy Diarrhoea After Laparoscopic Cholecystectomy – Are We Missing A Trick?

Aim

The landmark case of Montgomery v Lanarkshire Health Board led to the defensive Bolam test being discredited and paved the way healthcare professionals (HCP) obtain informed consent. The recent GMC guidance on Decision Making and Consent 2020, states that the HCP should discuss recognised risks that they believe anyone in the patient’s position would want to know. Laparoscopic cholecystectomy is one of the most common general surgical procedures performed in the UK. Chronic diarrhoea is a well-recognised complication with significant impact on patient quality of life (QoL). We aimed to assess quality of consent forms for laparoscopic cholecystectomies with emphasis on documentation of chronic diarrhoea being a consequence of the procedure.

Method

A retrospective review of all elective laparoscopic cholecystectomy consent forms over a 2-month consecutive period from July 1st 2020 to August 31st 2020 was carried out.

Results

43 consent forms were audited. The majority of these consent forms were done by consultants (74.4%: 32/43) while 23.2% (10/43) by registrars. Overall, 39.5% (17/43) of patients were consented for experiencing chronic diarrhoea. Registrars more commonly mentioned diarrhoea (60%: 6/10) compared to consultants (31.2%: 10/32).

Conclusions

The majority of patients undergoing laparoscopic cholecystectomy are not consented for post-cholecystectomy diarrhoea which is a significant QoL-altering complication. Education combined with a standardised consent form and issuing of patient leaflets will improve consenting for chronic diarrhoea.

606 AUDIT: IV Fluid Prescribing in Surgical Patients

Aim

A recent change to electronic fluid prescribing has enabled us to evaluate our adherence to recommendations. NICE clinical guideline 174 states that patients should receive 25-30ml/kg/day water and 1mmol/kg/day of sodium, potassium, and chloride with regards to maintenance fluid therapy. We retrospectively audited our practice in surgical patients.

Method

Patients were selected from two surgical inpatient wards in a district general hospital utilising random sampling over a one-month period. Prescribed intravenous fluid (IV) therapy over a 24-hour period was collected; in addition to weight, presence of an acute kidney injury (AKI) and indication for IV replacement (maintenance versus resuscitation).

Results

50 patients were identified during the period. All of them were emergency presentations. Maintenance fluids were prescribed for 76% of patients. No patients had an AKI at time of data collection. The mean weight was 75kg. Overall, patients received a mean fluid volume of 2.3L/day. The mean concentration of electrolytes administered over a 24-hour period were: Sodium 297mmol, Potassium 13mmol, Chloride 237mmol. When adjusting for patient weight, this resulted in a net administration of: Sodium +221mmol, Potassium -62mmol, Chloride +162mmol.

Conclusions

Three quarters of surgical patients were administered maintenance fluids. The electrolyte contents of these fluids were inadequate. Patients received 295% excess Sodium, 216% excess Chloride, and 82% less than the recommended daily requirement of Potassium. We aim to introduce a protocol for maintenance fluid prescribing, in addition to teaching sessions, that would allow for adherence to guidelines and improve patient care.

1074 Gallstone Ileus: Two Decades After Cholecystectomy

Introduction

Gallstone ileus is a rare complication of gallstones that occurs in 1%-4% of all cases of bowel obstruction. We present a surprising case of gallstone ileus causing small bowel obstruction 19 years after open cholecystectomy.

Case Report

A 77-year-old male presented with a 3-day history of abdominal pain, 4 episodes of vomiting and absolute constipation. He had a surgical background of an open cholecystectomy and open appendicectomy 19 years and 45 years ago respectively. Medically, he had well-controlled hypertension and experienced a TIA 5 years prior. Computed Tomography Scan of the abdomen and pelvis revealed features consistent with an obstructing, heterogenous opacity in the distal small bowel without pneumobilia. The patient subsequently underwent diagnostic laparoscopy. Intraoperatively, an obstructing gallstone, measuring 4 cm, was found 50cm proximal to the ileocaecal junction, with dilatation of the proximal small bowel and distal collapse. Enterotomy and removal of the stone was done. Post-operatively, this gentleman recovered without complications and was discharged home two days later after being able to tolerate a solid diet.

Conclusions

This is the second reported case of gallstone ileus in a patient with previous cholecystectomy about two decades ago, according to our literature search. Although extremely rare, absence of the gallbladder does not exclude the possibility of gallstone ileus.

Clinical spectrum of systemic lupus erythematosus at the Aga Khan University Hospital

BACKGROUND

Systemic lupus erythematosus is a disease of unknown etiology, which at onest may involve only one organ system or be multisystemic. The aim of our study is to determine the clinical presentation of SLE patients presenting to AKUH to establish whether guidelines laid down about this disease are in agreement with our experience.

METHODS

A retrospective log review was carried out at AKUH, based on data obtained from 165 files of individuals admitted to the hospital over a period of 12 years with a confirmed diagnosis of SLE.

RESULTS

From the sample size of 165, 143 (86.7%) were females and 22 (13.3%) males. The mean age of diagnosis was 30.9 years. Frequency of symptomatology was observed to be in the following order: systemic 78.8%, musculoskeletal 63% and hematological 60.6%. Oninvestigation ANA levels were positive in 112 patients.

CONCLUSION

Our result lead us to conclude that the classification set forth by the American Rheumatological Association is applicable to patients presenting with SLE in our setting.

Results of surgical treatment of oesophageal cancer

Oesophagogastrectomy is the best available treatment for patients with carcinoma of the oesophagus or cardia. A retrospective analysis of our experience with 485 patients who were treated surgically forms the basis of this report. Of the 317 patients who underwent resection (resectability rate of 65%) only 210 were considered to be potentially curative. Overall, the 5-year survival rate for oesophageal cancer was 3%, whilst curative resection had a 5-year survival rate of 22% and varied according to stages. Five-year survival rate was 67.7% for patients with Stage I disease compared with 27.6, 9.4 and 6.4% for Stages IIa, IIb and III disease respectively. There were no 5-year survivors with Stage IV disease or with those patients who underwent an incomplete resection. Curative resection carried a mortality rate of 3.8%, whereas incomplete resection or palliative procedure carried higher mortality rates of 14 and 20.7% respectively. Adequate post-operative analgesia was provided by continuous extrapleural intercostal nerve block. Morbidity, mainly caused by respiratory complications, occurred in 30 patients (6.2%), with three patients requiring ventilatory support. Outcome was influenced mostly by the extent of the disease and the completeness of surgical resection rather than by histological type. We conclude that surgical treatment provides better longevity than any other type of therapy and remains the standard against which combined modality treatment should be compared. Our experience suggests that surgical treatment can be achieved with minimal morbidity and mortality.