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Annals of The Royal College of Surgeons of England logoLink to Annals of The Royal College of Surgeons of England
. 2006 May;88(3):323. doi: 10.1308/003588406X106423

Publication of Abstracts from the Best Regional Presentations

Editor: Linda de Cossart
PMCID: PMC1963663
Ann R Coll Surg Engl. 2006 May;88(3):323. doi: 10.1308/003588406X106423

Reducing Admission Rates in Patients with Lower Gastrointestinal Bleeding

GR Wynn 1, PH Rowe 1

Introduction

Patients with lower gastrointestinal bleeding form a significant part of the emergency surgical workload and many of them occupy hospital beds for extended periods. There are currently no guidelines regarding the admission to hospital of these patients.

Patients and Methods

All patients attending a dedicated surgical assessment unit over the period of a year whose primary problem was lower gastrointestinal bleeding were included in the study. Various relevant data sets were collected for each patient and these were compared to the binary outcome measure of blood transfusion. We aimed to define more clearly those high-risk patients that require admission to hospital for observation or treatment.

Results

A total of 90 patients were assessed in the unit during the study period and only 5 were discharged (admission rate of 94%). Of those that were admitted, over half (52%) received no in-patient investigation or treatment other than observation. Independent factors that made a blood transfusion more likely were: anticoagulation, a past history of diverticular disease, passage of dark blood and initial haemoglobin of < 11.5 g/dl for men and < 10.5 g/dl for women. Using these indicators, the admission rate could have been reduced from 94% to 61%. In addition, knowing that patients without these factors bleed for a mean duration of 2 days, a minimum saving of 62 bed-occupancy days per year is possible.

Discussion

Blood transfusion is an appropriate outcome measure in this study because it requires admission in its own right and is an excellent marker for in-patient investigation and treatment. We have defined a group of high-risk patients that should always be admitted for observation after an acute lower gastrointestinal bleed. Those patients that fall outside this group can be discharged after initial assessment with the understanding that persistent (> 48 h) or further heavy bleeding will require admission and that appropriate out-patient investigation will be organised.

Ann R Coll Surg Engl. 2006 May;88(3):323–324. doi: 10.1308/003588406X106423

Attitudes to Laparoscopic Appendicectomy

Neil Kukreja 1

Introduction

Laparoscopic appendicectomy represents the biggest change in the management of acute appendicitis since the introduction of the open procedure. Minimal access surgery is employed because it is thought to reduce physical trauma and, therefore, allow a shorter recovery period. Laparoscopic appendicectomy has also been advocated by a number of sources to be a good training operation. This paper describes an audit to assess the current practice amongst registrars and willingness to provide training by consultants.

Materials and Methods

Two postal questionnaires were designed and sent to 123 registrars and 179 consultants in South East England.

Results

A total of 53% of consultant questionnaires were returned and 68% of registrar questionnaires. Of consultants, 61% perform laparoscopic appendicectomy; 93% indicated that they would teach between 8am–5pm and 53% indicated that they would teach after 5pm. Of trainees, 39% can perform laparoscopic appendicectomy but 53% of trainees work in hospitals where there is no policy regarding the management of appendicitis. Of hospitals, 16% allow open appendicectomy only.

Of trainees, 61% cannot perform laparoscopic appendicectomy and 59% of these trainees perform diagnostic laparoscopy followed by an open appendicectomy. Of trainees, 88% would like training in laparoscopic appendicectomy and 22% of trainees have received training in the last 12 months. Of trainees, 73% felt unable to call upon their consultants for out-of-hours for training.

Conclusions

Training levels were adequate but more efficient use of training opportunities needs to be made.

Ann R Coll Surg Engl. 2006 May;88(3):324. doi: 10.1308/003588406X106423

Emergency Admissions of Surgical Patients Aged 80 Years or Over: Audit of Outcome

J Krysa 1, A Sandison 1

Introduction

The 1999 NCEPOD report Extremes of Age stated that ‘the decision to operate on elderly patients is difficult and should be made at consultant level’. As the number of elderly surgical patients increases, we decided to audit the outcome of patients over 80 years who underwent surgery.

Patients and Methods

We used the JOE computer Patient Information System in our hospital to identify all surgical patients, aged 80 years or more (80+), admitted under four general surgeons, over a 6-month period. We specifically looked at emergency admissions and outcome in those who were treated conservatively and those who underwent a surgical procedure. As patients who are admitted to an ITU have a high mortality, we also analysed surgical admissions to an ITU over a 10-year period.

Results

A total of 286 surgical patients, aged 80+, were admitted over a 6-month period (15% of all surgical admissions). Of these, 127 were emergency admissions (44%) and 25% of all emergency admissions over 80 years died within 6 months of admission (not necessarily during the admission). Further data were not available in 16/127 cases. Overall, 65% (72/111) did not require surgery (3% mortality), 23% (26/111) had surgery (42% mortality) and 12% (13/111) were treated conservatively despite requiring surgery as they were too unfit (77% mortality). The median ASA score for those who had an operation and died was 4 (range, 2–5) whereas those who survived the surgery scored 3 (range, 1–4). None of the patients who underwent minor or intermediate surgery died whereas those who underwent a laparotomy had a 60% mortality.

Over 10 years, 56 emergency surgical patients aged 80+ were admitted to an ITU with a mortality of 89%. Of these, 52 underwent surgery with a mortality of 89%.

Conclusions

In our experience, patients over 80 years who undergo emergency laparotomy have a 60% mortality. If they require admission to an ITU postoperatively, their mortality increases to 89%. These results re-inforce the need for careful patient selection. If the need for an ITU could be reliably predicted pre-operatively, it may help in selecting a subgroup of patients with an excessively high mortality.

Articles from Annals of The Royal College of Surgeons of England are provided here courtesy of The Royal College of Surgeons of England

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