Abstract AIM Despite the obvious advantages of intraoperative sentinel lymph node (SLN) analysis in the form of One Step Nucleic Acid Amplification (OSNA), this technique has not been widely adopted in the United Kingdom. The aim of this study was to investigate the health economic implication of the technique. METHODS Data were collected prospectively on all patients undergoing OSNA at a single institution between September 2011 and February 2013. Initially patients were selected using the Sloan Kettering Nomogram for additional non SLN axillary disease [http://nomograms.mskcc.org] and patients with micrometastases were offered an axillary clearance. From August 2012, all patients undergoing sentinel node biopsy were offered OSNA. A cost analysis was done on the basis of up front purchase costs, OSNA cost per patient minus the cost of standard Haematoxylin and Eosin stain analyses at our institution and HRG4 codes. RESULTS Data were collected on 258 patients with a median age of 69. 209 (81%) had invasive ductal carcinoma. 208(80%) were oestrogen receptor positive and approximately 30% had lymphovascular invasion. Table 2 demonstrates the OSNA results. Table 1 - OSNA results Pre August 2012Post August 2012Total n%n%n%No. of patients169 88 257 Mean no. of nodes2.38 1.98 2.24 OSNA Negative11668.645461.3617066.15OSNA Micrometastases2715.982123.864818.68OSNA Macrometastases2112.431314.773413.23OSNA Inhibited52.960051.95Total no. undergoing Axillary Clearance5130.181820.456926.85Axillary Clearance for Micrometastases2313.6144.552710.51Additional nodes positive overall: 03772.55950.004666.671-3 nodes1121.57738.891826.094-7 nodes11.96211.1134.358-12 nodes11.96 11.45gt]12 nodes[11.96 11.45Additional nodes positive for OSNA Micrometastases: 021 22385.191-3 nodes2 414.81 The capital investment for setting up OSNA in our institution was £40,000. By carrying out OSNA on all patients undergoing sentinel node biopsy we saved a second procedure on 20% of patients. Table 2 outlines the costs saving per year based on the HRG4 code for the cost of second admission and axillary clearance. Table 2 - Health Economic Analysis TotalNo. patients undergoing OSNA per year235 Cost of OSNA per patient£286£67,210Cost of H & E analysis based on 2 nodes per patient£101,60£23,876Net costs of OSNA per patient£184,40£43,334No. patients undergoing axillary clearance (20% of 235)47 Cost of axillary clearance (based on HRG4 JA07)£2,030£95,410Total saving per year with OSNA £52,076 CONCLUSION The use of OSNA as an intraoperative assessment of sentinel lymph nodes in breast cancer is a highly sensitive and efficient way of determining the sentinel node status. It saves patients undergoing a second admission and procedure. By offering OSNA to all patients undergoing SLN, the capital investment will be recouped in less than a year and the local health economy will save over £50,000 per year in subsequent years. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-11.
To evaluate the feasibility and safety of laparoscopic cholecystectomy in severe acute cholecystitis.Analysis of data collected prospectively from a consecutive series of 350 laparoscopic operations.Two general surgical units in a teaching hospital.31 patients with a diagnosis of severe acute cholecystitis based on clinical examination, investigation results, and operative findings.Initial intravenous fluids and broad spectrum antibiotics followed by laparoscopic cholecystectomy within 72 hours of presentation.Failure to complete the operation laparoscopically, length of postoperative stay in hospital, early postoperative morbidity, interval from operation to full activity, and return to work.Laparoscopic cholecystectomy was attempted in 19 patients with empyema of the gall bladder and 12 who had severe cholecystitis which failed to settle on medical management. A total of 29 operations were successfully completed with two conversions to open surgery. Two minor postoperative complications occurred, and one case of retained common bile duct stones with jaundice was treated by endoscopic retrograde cholangiopancreatography and papillotomy. Median postoperative hospital stay was two days, with return to normal activity in seven days and to work in two weeks. There were no deaths related to the operation.In the presence of severe acute cholecystitis laparoscopic cholecystectomy is feasible in most patients, with minimal risk of injury to surrounding structures and considerable benefits. It is recommended that laparoscopic cholecystectomy should be attempted in these patients when appropriate surgical skill is available.
Abstract Aim We explored the patients’ views and experiences of surgery for colorectal cancer within an enhanced recovery programme (ERP). Method Semi‐structured home interviews were performed within 6 weeks of hospital discharge with participants of a randomized trial comparing laparoscopically assisted surgery with open surgery for colorectal cancer within an ERP. Interviews were tape‐recorded, transcribed and analysed using qualitative techniques of constant comparison based upon grounded theory. Results Interviewees ( n = 22) had similar baseline characteristics and clinical outcomes to participants in the full trial. Many participants were pleased to be discharged quickly and they considered that being in their own home‐improved recovery because it allowed them to choose how and when to undertake daily activities rather than following the hospital routine. Some participants ( n = 9) were less satisfied with the process, and the reasons for this were related to complications requiring readmission or needing to contact a health professional for information after discharge. Conclusion Although many participants reported benefits from an ERP, the study highlighted areas for improvement. In particular participants reported the need for better access to information and specialist advice in the early days after hospital discharge.
"Haemangiopericytoma of the sigmoid mesocolon. An unexpected finding during laparoscopic tubal evaluation." Journal of Obstetrics and Gynaecology, 22(5), pp. 563–564
Daily ultrasonography of the gallbladder bed was performed in patients with suction or passive tube drains after elective cholecystectomy. A total of 19 patients was randomized to suction drainage and 17 to passive tube drainage. A policy of early drain removal was followed. No significant difference was found between the volume drained and the size of collection detected in either group. Significant bile leaks were detected and were adequately drained by suction and passive tube drains. There were no complications from drains. In view of these findings, we advocate short-term drainage of the gallbladder bed after both open and laparoscopic cholecystectomy using the drain of the surgeon's choice.
Laparoscopic resection of colorectal cancer may improve short-term outcome without compromising long-term survival or disease control. Recent evidence suggests that the difference between laparoscopic and open surgery may be less significant when perioperative care is optimized within an enhanced recovery programme. This study compared short-term outcomes of laparoscopic and open resection of colorectal cancer within such a programme.Between January 2002 and March 2004, 62 patients were randomized on a 2 : 1 basis to receive laparoscopic (n = 43) or open (n = 19) surgery. All were entered into an enhanced recovery programme. Length of hospital stay was the primary endpoint. Secondary outcomes of functional recovery, quality of life and cost were assessed for 3 months after surgery.Demographics of the two groups were similar. Length of hospital stay after laparoscopic resection was 32 (95 per cent confidence interval (c.i.) 7 to 51) per cent shorter than for open resection (P = 0.018). Combined hospital, convalescent and readmission stay was 37 (95 per cent c.i. 10 to 56) per cent shorter (P = 0.012). The relative risk of complications, quality of life results and cost data were similar in the two groups.Despite perioperative optimization of open surgery for colorectal cancer, short-term outcomes were better following laparoscopic surgery. There was no deterioration in quality of life or increased cost associated with the laparoscopic approach.
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