Quality optimisation in colonoscopy:A function of time of colonoscopy or bowel preparation

To test the hypothesis claimed in recent studies that quality of bowel preparation for colonoscopy could be influenced by the time of the day colonoscopy is performed. Do patients in morning list have better bowel preparation than those on the afternoon list? Retrospective analysis of 736 consecutive patients who had colonoscopy from 1st August to 31st December 2012. Patients with poor bowel preparation (Boston Bowel Prep Score 6 or less) were identified (n = 242). Colonoscopy reports of these patients analysed. Patients were stratified into two groups (am and pm) and results compared. Mean patient age 63.9 years (range 19-89). Male to female ratio 1:1. 92% of patients were given Moviprep. for bowel preparation. 32.9% (242/736) of patients were identified as having inadequate bowel preparation. 37.7% of morning list patients had poor bowel preparation. 26.7% of afternoon list patients had poor bowel preparation. 14.7% (108/736) had incomplete colonoscopy, of which 26.9% (29/108) were due to poor bowel preparation. The commonest reasons for incomplete examination were patient discomfort & bowel looping. Our study demonstrates that morning session patients had poorer bowel preparation than the afternoon session patients in contrast to published evidence in recent literature. This implies that timing of bowel preparation is probably more important than timing of colonoscopy. Poor bowel preparation does not seem to have a significant impact on the colonoscopy failure rate in this series

Defunctioning stoma- a prognosticator for leaks in low rectal restorative cancer resection:A retrospective analysis of stoma database

Aims: Low anterior resection (LAR) has higher risk of anastomotic leak with its attendant morbidity -mortality. De-functioning loop ileostomy (DLI), claimed to mitigate the consequences of anastomotic leak, has been questioned in recent years. This study aims to evaluate the impact of ileostomy on LAR. Methods: A retrospective analysis of stoma database. 136 patients with stoma (March 2011–July 2015) were assessed. Data was analysed in respect to LAR anastomotic leak rate, impact on morbidity-mortality, short and long-term stoma complications, rate of ileostomy reversal and reasons for non-reversal. Results: 45 patients had loop ileostomy for LAR. Male (28) to female (17) ratio was 1.65:1 with median age of 69 (IQR: 56-75.5). Only 3 anastomotic leaks (3/45, 6.5%) occurred, all treated conservatively with no mortality. 29 had reversal, average reversal time is 10 months (3–24) and 5 awaiting. Reasons for non-reversal included patients' choice (7), death from cardiac cause (1), chemotherapy (1), unfit for surgery (1) and failed reversal (1). Acute complications included high output & reversible AKI (1), bleeding (3) and minor complications (6) as skin excoriation, separation and appliance issues. Parastomal hernia was repaired during reversal (12/15). Conclusions: De-functioning ileostomy for LAR is a safe procedure with low morbidity. Most stomas are reversible. Series highlights a late reversal contrary to the nationally recommended guidelines. Most interestingly, the study demonstrated de-functioning mitigated clinical consequences of anastomotic leak to an extent that reoperation was avoidable, in keeping with recent meta-analysis indicating a significantly low anastomotic leakage rates and reoperation. Larger study is invaluable to substantiate findings

THD and mucopexy: Efficacy and controversy

Aims: Transanal haemorrhoidal dearterialisation and mucopexy has evolved in recent years as a popular minimally invasive non-excisional surgery for symptomatic prolapsing haemorrhoids. The long-term outcome of this procedure however, remains to be established. We aim to analyse the long-term outcome of THD-mucopexy in the management of prolapsing haemorrhoids based on the evidence of a prospective data from a single institution. Methods: A prospective data was collected on 100 consecutive cases of grade 3 and 4 symptomatic haemorrhoids between the period 03/2010 and 06/2015 who underwent the procedure as a day case under general anaesthetic. Overall median follow up was for two years with average age of 54.4 ranges from 34 to 79 and gender ratio of 61% Male and 39% Female. Pre-and postoperative symptoms were assessed with a view to evaluate the nature of complications and long-term recurrence rate. Results: Conclusion: THD mucopexy is a safe and effective minimally invasive modality for prolapsing symptomatic haemorrhoids with acceptable complication rates and a recurrence rate of 13% majority of which could be dealt with a repeat procedure. Long terms follow up and randomised (THD VS Haemorrhoidectomy) multicentre trials are warranted to compare its efficacy with that of conventional excisional surgery

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially