Abstract Introduction More than 50% of patients undergoing emergency general surgery are >65 years. The Emergency Laparotomy and Frailty (ELF) study showed strong associations between frailty (CFS ≥ 5) and increased mortality, risks of complications, and length of hospital stay. Methods For nearly 10 years, we have had geriatric liaison input for general surgery and colorectal patients in a tertiary teaching centre. This has transformed into a fully embedded service involving consultant geriatrician, registrars and senior house offices, providing 3-day a week medical input. NELA best practice tariff (BPT) April 2023 emphasises perioperative Geriatric team involvement in frail patients aged 65 and above. The main metrics include CFS, an MDT-based risk assessment, treatment escalation decision making and perioperative geriatrician involvement. Results The service has previously demonstrated significant improvement in patient care and holistic management including reducing the length of stay in hospital (average decrease of 5.5 days). Simple job planning, use of current resources and efficiency can mean Trusts can incorporate geriatricians with essential skills to improve patient management and reach NELA BPT. Conclusion Changes in NELA BPT emphasise the importance of comprehensive geriatric assessment in the management of older laparotomy patients. Introducing a multidisciplinary geriatric liaison service into the general surgical department can achieve high levels of compliance with national guidelines, resulting in better outcomes for patients as well as financial benefits for Trusts. This is particularly pertinent given the financial constraints on many services across the NHS, this is an opportunity to increase revenue and build a geriatric workforce.
Abstract Aim To compare postoperative adverse events and recurrence following strictureplasty or bowel resection in patients with small bowel Crohn's disease (CD). Method A literature search was performed to identify studies published between 1980 and 2006 comparing outcomes of CD patients undergoing either strictureplasty or bowel resection. Hazard ratios were calculated from Kaplan–Meier plots of cumulative recurrence data. Quality assessment of the included studies was performed. Random‐effect meta‐analytical techniques were employed. Sensitivity analysis and assessment of heterogeneity were performed. Results Seven studies comprising 688 CD patients (strictureplasty n = 311, 45%; resection with or without strictureplasty n = 377, 55%) were included. Patients undergoing strictureplasty alone had a lower risk of developing postoperative complications than those who underwent resection (OR = 0.60, 95% CI: 0.31–1.16) although this was not statistically significant ( P = 0.13). Surgical recurrence after strictureplasty was more likely than after resection (OR = 1.36, 95% CI: 0.96–1.93, P = 0.09). Patients who had a resection had a significantly longer recurrence‐free survival than those undergoing strictureplasty alone (HR = 1.08, 95% CI: 1.02–1.15, P = 0.01). Conclusion Patients with small bowel CD undergoing strictureplasty alone may have fewer postoperative complications than those undergoing a concomitant bowel resection. However, surgical recurrence maybe higher following strictureplasty alone than with a concomitant small bowel resection. Patients may require appropriate preoperative counselling regarding the pros and cons of each operative technique.
Abstract Aims More than 50% of patients undergoing emergency general surgery are over 65 years of age. NICE guidelines emphasise frailty assessment in acute surgical settings, particularly in the preoperative period. Similarly, the Emergency Laparotomy and Frailty (ELF) study showed associations between frailty (CFS ≥ 5) and 90-day mortality, increased complication and length of hospital stay in older emergency laparotomy patients. NELA best practice tariff (BPT) April 2023 heavily focuses on perioperative team involvement in frailer, older patients. This is an audit from a city teaching hospital, with a surgical liaison team against standards set by NELA. Methods Review of patients aged ≥ 65 undergoing emergency laparotomies between August and November 2023 (pre-intervention) then December and January 2024 (post-intervention). Data collected includes whether patients had a documented frailty score, a clearly documented CPR decision & treatment escalation plan (TEP), pre- or post-operative medical review, and advanced-care planning (ACP) post-operatively. Intervention included dedicated members of surgical liaison team following patients throughout admission, weekly meetings to discuss laparotomy patients, older patient template being created capturing ceilings of care, frailty score, and social history. Results Post intervention, improvement in clear documentation regarding escalation, frailty level. Greater level of MDT collaboration with regards to older patients undergoing laparotomies. Conclusion Changes in NELA BPT emphasise the importance of comprehensive geriatric assessment in the management of older laparotomy patients. Even a basic surgical liaison service can achieve high levels of compliance with a few simple strategies, resulting in better outcomes for patients as well as financial benefits for Trusts.
Haemorrhoids are cushions of submucosal vascular tissue located in the anal canal starting just distal to the dentate line. Incidence is difficult to ascertain as many people with the condition will never consult with a medical practitioner, although one study found 10 million people in the USA complaining of the disease.We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for haemorrhoidal disease? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).We found 44 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.In this systematic review we present information relating to the effectiveness and safety of the following interventions: closed haemorrhoidectomy, haemorrhoidal artery ligation, infrared coagulation/photocoagulation, injection sclerotherapy, open excisional (Milligan-Morgan/diathermy) haemorrhoidectomy, radiofrequency ablation, rubber band ligation, and stapled haemorrhoidectomy.
Abstract Aims General surgical teams are treating an increasing number of frail, older patients.1 Geriatrician involvement has shown improvement in length of stay.2 We sought to demonstrate that even with limited geriatrician involvement we could meet NELA targets of completing frailty scores, increasing frequency of geriatrician reviews and improving team education. Methods We introduced twice-weekly geriatrician-led team meetings followed by selected patient reviews to best optimise the care of older patients. Surgical trainees, nurses and allied health staff attended each meeting. The team was educated by the geriatrician about geriatric medicine and the importance of recognising frailty. They were also supported in performing independent frailty assessments. We measured frequency of frailty score recorded and geriatrician involvement pre- and post-set up of this limited service. We also conducted semi structured interviews of staff pre- and post-intervention related to educational impact. Results 94% (29/31) of patients aged over 65 had a clinical frailty score recorded post intervention compared to 9% (3/35) originally. All 31 had geriatrician involvement. Comments from the surgical team included: ‘pro-active approach to identifying frailty’, ‘early identification of barriers to discharging complex patients' and ‘improvement in understanding of geriatric giants’. Conclusions The Emergency Laparotomy and Frailty (ELF) study recognised that frailer individuals were vulnerable to adverse outcomes and longer hospital stays.3 Our limited geriatrician-led service supported surgical doctors and the MDT in understanding frailty and considering its impact. Within a short space of time we aligned with NELA recommendations, improved patient outcomes and improved MDT understanding of geriatric medicine.
Aim: Laparoscopic appendicectomies (LA) and cholecystectomies (LC) are safe procedures with a low bleeding and transfusion risk.We aimed to determine our post-operative transfusion risk for LA and LC and to determine whether routine group and save (G&S) is a necessary pre-operative investigation.Methods: Details of patients who underwent a LA and LC were retrieved from the clinical coding department at Cambridge University Hospitals between April 2015 and January 2018.The prospectively written electronic records were reviewed for operative details and transfusion history.Results: 877 LA and 1141 LC were identified.Mean age was 41.5 years (range 17-86 years).61% of patients were female.1015 patients had a historic G&S on file, of these 29% had no further G&S.853 (84%) had at least one further G&S (1290 extra samples).Of the remaining 1003 patients, 131(13%) had no G&S and 872 (86%) had at least 1 G&S performed pre-operatively (1289 extra samples).The cost associated with routine G&S was £47327.79excluding laboratory staffing costs.No patients undergoing a LA and only 0.26% of patients undergoing LC required a blood transfusion.The minimum time post operatively for patients to receive a transfusion was 2 days.No patients required an intra-operative or an immediate post-operative transfusion.Conclusion: LA and LC are safe procedures with a zero and 0.26% incidence of blood transfusion in this cohort respectively.Additional G&S samples are unnecessary for these procedures and abandoning their routine use is safe and cost-effective.
We present the results from a feasibility study which measures properties in the terahertz frequency range of excised cancerous, dysplastic and healthy colonic tissues from 30 patients. We compare their absorption and refractive index spectra to identify trends which may enable different tissue types to be distinguished. In addition, we present statistical models based on variations between up to 17 parameters calculated from the reflected time and frequency domain signals of all the measured tissues. These models produce a sensitivity of 82% and a specificity of 77% in distinguishing between healthy and all diseased tissues and a sensitivity of 89% and a specificity of 71% in distinguishing between dysplastic and healthy tissues. The contrast between the tissue types was supported by histological staining studies which showed an increased vascularity in regions of increased terahertz absorption.
Purpose: This study was designed to compare postoperative adverse events and functional outcomes after ileal pouch-anal anastomosis between patients with Crohn's disease and those with non-Crohn's disease diagnoses. Methods: A literature search was performed to identify studies published between 1980 and 2005 comparing outcomes of patients undergoing ileal pouch-anal anastomosis for Crohn's disease, ulcerative colitis, and indeterminate colitis. Random-effect, meta-analytical techniques were used and sensitivity analysis was performed. Results: Ten studies comprising 3,103 patients (Crohn's disease=225; ulcerative colitis=2,711; indeterminate colitis=167) were included. Patients with Crohn's disease developed more anastomotic strictures than non-Crohn's disease diagnoses (odds ratio, 2.12;P=0.05) and experienced pouch failure more frequently than patients with ulcerative colitis (Crohn's diseasevs.ulcerative colitis: 32vs.4.8 percent,P<0.001; Crohn's diseasevs.indeterminate colitis: 38vs.5 percent,P<0.001). Urgency was more common in Crohn's disease compared with non-Crohn's disease: 19vs.11 percent (P=0.02). Incontinence occurred more frequently in Crohn's disease compared with non-Crohn's disease patients: 19vs.10 percent (odds ratio, 2.4;P=0.01). Twenty-four-hour stool frequency did not differ significantly between Crohn's disease, ulcerative colitis, or indeterminate colitis. Patients with isolated colonic Crohn's disease were not significantly at increased risk of postoperative complications or pouch failure (P=0.06). Conclusions: Patients with Crohn's disease undergoing ileal pouch-anal anastomosis should be appropriately counseled toward poorer functional outcomes and higher failure compared with non-Crohn's disease patients. It maybe possible to preoperatively select patients with isolated colonic Crohn's disease who may benefit from ileal pouch-anal anastomosis with acceptable adverse outcomes.
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