Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy

Background

Acute gallstone disease is a high‐volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance.

Methods

Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole‐QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods.

Results

Of 13 sites invited to join Chole‐QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole‐QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8‐day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals.

Conclusion

A surgeon‐led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Management of complex colonic polyps in the English Bowel Cancer Screening Programme

BACKGROUND

Large sessile or flat colonic polyps, defined as polyps at least 20  mm in size, are difficult to treat endoscopically and may harbour malignancy. The aim of this study was to describe their current management to provide insight into optimal management.

METHODS

This retrospective observational study identified patients with large sessile or flat polyps detected in the English Bowel Cancer Screening Programme between 2006 and 2009. Initial therapeutic modality (surgical or endoscopic), subsequent management and outcomes were recorded. The main outcome measures analysed were: presence of malignancy, need for surgical treatment, complications, and residual or recurrent polyp at 12 months.

RESULTS

In total, 557 large sessile or flat polyps with benign appearance or initial histology were identified in 557 patients. Some 436 (78.3 per cent) were initially managed endoscopically and 121 (21.7 per cent) were managed surgically from the outset. Seventy of those initially treated endoscopically subsequently required surgery owing to the presence of malignancy (19) or not being suitable for further endoscopic management (51). Residual or recurrent polyp was present at 12 months in 26 (6.0 per cent) of 436 patients managed endoscopically. There was wide variation between centres in the use of surgery as a primary therapy, ranging from 7 to 36 per cent. Endoscopic complications included bleeding in 13 patients (3.0 per cent) and perforation in two (0.5 per cent).

CONCLUSION

Management of large sessile or flat colonic polyps is safe and effective in the English Bowel Cancer Screening Programme. Wide variation in the use of surgery suggests a need for standardized management algorithms. Presented to a meeting of the British Society of Gastroenterology, Birmingham, U.K., March 2011.

Pouchitis

Pouchitis is one of the commonest and most debilitating complications of a restorative proctocolectomy. The cause remains elusive, though a number of approaches have been shown to alleviate the condition. This review outlines current evidence relating to pouchitis, obtained from randomised and nonrandomised studies. Medline, the Bath Information Data Service (BIDS) and PubMed were searched using the keywords 'pouchitis' and 'inflammatory bowel disease'. In addition, articles were cross-referenced, and the abstracts of recent colorectal meetings studied.

Should 'doughnut' histology be routinely performed following anterior resection for rectal cancer?

Stapled low anterior resection is widely employed in the treatment of rectal adenocarcinoma. The technique yields two tissue 'doughnuts' which are often submitted for histological examination. This process is labour intensive and not part of the minimum data set for colorectal cancer histopathology reports. A consecutive series of anterior resection doughnuts from 125 patients was reviewed retrospectively to assess the impact of doughnut pathology on the management of patients. Four doughnuts had a histological abnormality reported but none of these altered treatment. Routine histological examination of 'doughnuts' is not beneficial to the management of patients undergoing surgery for rectal adenocarcinoma.

A randomized trial of oral vs. topical diltiazem for chronic anal fissures

INTRODUCTION

Chemical sphincterotomy has proved effective in treating chronic anal fissure. Glyceryl trinitrate is the most widely used agent, and topical 0.2 percent glyceryl trinitrate ointment heals up to two thirds of chronic anal fissures. Unfortunately, however, many patients experience troublesome headaches as a side effect of this treatment. This study assessed the effectiveness of oral and topical diltiazem in healing chronic fissures.

METHODS

Fifty consecutive patients with chronic anal fissures were randomly assigned to receive oral (60 mg) or topical (2 percent gel) diltiazem twice daily for up to eight weeks. Anal manometry was performed before and after the first dose, and blood pressure was recorded at 15-minute intervals. Patients were reviewed fortnightly, pain was expressed with a visual linear analog scale, blood pressure was recorded, fissure healing was assessed, and side effects were noted.

RESULTS

Twenty-four patients received oral diltiazem, and 26 received topical diltiazem. Mean (+/- standard error of the mean) maximum resting anal pressures fell by 15 and 23 percent from 95 +/- 4 to 81 +/- 4 and from 102 +/- 5 to 79 +/- 5 cm H2O in the two groups, respectively. There was no significant reduction in blood pressure during the study or at follow-up in either group. Fissure healing was complete in 9 patients (38 percent) receiving oral diltiazem and 15 (65 percent) on topical treatment by eight weeks. Oral diltiazem caused side effects in eight patients (rash, two; headaches, two; nausea or vomiting, three; reduced smell and taste, one), whereas no side effects were seen in those receiving topical therapy (P = 0.001).

CONCLUSION

Oral and topical diltiazem heal chronic anal fissures. Topical diltiazem is more effective, achieving healing rates comparable to those reported with topical nitrates, with significantly fewer side effects.

Lateral repair of parastomal hernia

INTRODUCTION

Parastomal hernia is a common complication of stoma construction. Although the majority of patients are asymptomatic, about 10% require surgical correction.

AIMS

We describe a new surgical approach for the repair of parastomal hernias, which avoids both the need for laparotomy and stoma mobilization.

PATIENTS AND METHODS

Nine patients (4 female) with parastomal hernia underwent surgical repair. Median age was 55 years (range 38-73 years). There were 8 para-ileostomy herniae and one paracolostomy hernia. A lateral incision was made approximately 10 cm from the stoma, and carried down to the rectus sheath. The dissection was carried medially towards the stoma, and around the defect in the abdominal musculature. The hernia sac was excised when possible and the fascial defect closed with non-absorbable, monofilament suture. A polyprolene mesh was placed round the stoma by making a slit in the mesh. The skin was closed with subcuticular monofilament absorbable suture.

RESULTS

All patients returned to normal diet on the first postoperative day, and were discharged from hospital within 72 h. There were no wound infections, and no recurrences after a median follow up of 6 months (range 3-12 months).

DISCUSSION

The technique we describe is simple and avoids the need of laparotomy. The mucocutaneous junction of the stoma is not disturbed, reducing the risk of contamination of the mesh, stenosis or retraction of the stoma. Grooving of the stoma and difficulty in fitting appliances is avoided because the wound is not placed near the mucocutaneous junction. This approach may be superior to other mesh repairs for parastomal hernia.

Faecal incontinence in myotonic dystrophy

Two siblings with myotonic dystrophy presented for treatment of faecal incontinence. The pathophysiology of this functional disorder is described with the results of anorectal manometry, EMG, and biopsy of smooth and striated muscle of the anorectal sphincters. Both medical and surgical management of the incontinence was unsatisfactory in the long term. Involvement of gastrointestinal musculature is a characteristic feature the disease.

The electrically stimulated gracilis neosphincter incorporated as part of total anorectal reconstruction after abdominoperineal excision of the rectum

OBJECTIVE

The authors investigated the feasibility and effectiveness of combining electrically stimulated gracilis neoanal (ESGN) sphincter and a coloperineal anastomosis in selected patients after abdominoperineal excision of the rectum (APER).

SUMMARY BACKGROUND DATA

The ESGN is effective in the treatment of idiopathic fecal incontinence.

METHODS

Between March 1989 and September 1993, 12 patients (9 men, 3 women) with a median age of 59.25 years (range, 45-70) underwent the procedure. The underlying disease was adenocarcinoma in 10, anal malignant melanoma in 1, and a sweat gland tumor in the other. In all patients, a sphincter saving resection was contraindicated. The procedure was performed in stages. Stage 1 involved a conventional APER with the formation of a perineal stoma. Eleven patients underwent a vascular delay procedure. All patients were defunctioned. In stage 2, the gracilis was mobilized, transposed around the anal canal, and the electrodes and hardware needed for electrical stimulation were implanted. Once muscle conversion was complete, the defunctioning stoma was closed.

RESULTS

Eight patients were closed successfully. In seven of the eight patients, complete physiologic measurements were taken. Median basal and maximum neosphincter pressures were 30 and 122 cm H2O, respectively, at the start of electrical stimulation and 22.5 and 76.2 cm H2O, respectively, after 1 year. Median functioning neosphincter pressure was 36 cm H2O at 1 year. All of the patients whose stomas were closed experienced episodes of incontinence to solid stool and wore pads for persistent fecal soiling. They all reported difficulty in evacuation. Despite imperfect continence, no patient wished to go back to life with a stoma.

CONCLUSIONS

The incorporation of ESGN as part of total anorectal reconstruction is technically feasible. The majority of patients are satisfied with their function and pleased to avoid a permanent stoma.

Transposition of the anorectum to the abdominal wall

A unique procedure is described in which the anorectum is mobilized on the inferior mesenteric vascular pedicle and transposed to the anterior abdominal wall. The aim is to preserve maximal intestinal length in patients with short bowel syndrome and intractable diarrhoea. Unique physiological data provided by the second case demonstrate that the specialized sensory functions of the rectum reside in the rectal wall and are subserved by an autonomic nervous supply that is independent of the pudendal nerves.

Total anorectal reconstruction results in complete anorectal sensory loss

Six patients underwent objective measurement of anorectal sensory function following abdominoperineal excision of the rectum and total anorectal reconstruction. No patient perceived neorectal distension as a desire to defaecate or as a feeling of flatus. Anal mucosal sensation was preserved in two patients in whom some anal mucosa was retained. These sensory deficiencies may result in faecal retention and incontinence in patients undergoing reconstructive surgery. The loss of rectal sensation suggests that the prime sensors of rectal filling may lie within the rectum itself.

Perianal abscess in children

The records of 16 children presenting with a diagnosis of perianal abscess, over a 5-year period, were reviewed. The clinical and microbiological features of paediatric perianal abscesses are similar to those found in adults, although the incidence of associated diseases is higher in paediatric patients. Perianal abscesses in children are best treated by incision and drainage. The presence of an underlying contributing disease should be excluded.

Diagnosis and Management of Renal Angioma

Five patients with symptomatic renal angiomata are described. All presented with heavy haematuria and unilateral ureteric obstruction without evidence of a mass distorting the renal architecture. Renal angiomata are most easily diagnosed by selective renal angiography. They may be treated by intra-arterial embolization, avoiding the need for major ablative surgery.