Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set

Background Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy

Augmentative biocontrol in natural marine habitats: persistence, spread and non-target effects of the sea urchin Evechinus chloroticus.

Augmentative biocontrol aims to control established pest populations through enhancement of their indigenous enemies. To our knowledge, this approach has not been applied at an operational scale in natural marine habitats, in part because of the perceived risk of adverse non-target effects on native ecosystems. In this paper, we focus on the persistence, spread and non-target effects of the sea urchin Evechinus chloroticus when used as biocontrol agent to eradicate an invasive kelp from Fiordland, New Zealand. Rocky reef macrobenthic assemblages were monitored over 17 months in areas where the indigenous algal canopy was either removed or left intact prior to the translocation of a large number of urchins (>50 ind.·m(-2)). Urchin densities in treated areas significantly declined ∼9 months after transplant, and began spreading to adjacent sites. At the end of the 17-month study, densities had declined to ∼5 ind.·m(-2). Compared to controls, treatment sites showed persistent shifts from kelp forest to urchin barrens, which were accompanied by significant reductions in taxa richness. Although these non-target effects were pronounced, they were considered to be localised and reversible, and arguably outweigh the irreversible and more profound ecological impacts associated with the establishment of an invasive species in a region of high conservation value. Augmentative biocontrol, used in conjunction with traditional control methods, represents a promising tool for the integrated management of marine pests

Patterns in invasiveness of the colonial ascidian <i>Didemnum vexillum</i> (Kott 2002)

<p>Temporal patterns of biofouling establishment and persistence were investigated at two field sites (Nelson, hereafter NN; Ruakaka Bay, hereafter RK) over a 19-month period between 19 December 2007 and 29 July 2009 (Fletcher et al. data.csv). The RK study site was situated within a fish farm located in New Zealand’s Marlborough Sounds region (41°12'40.2"S, 174°08'26.1"E), whereas the NN site was situated approximately 60 km west (41°15'23.7"S 173°16'33.7"E) within a commercial port at Nelson. The RK site was in relatively deep water (c. 30 m depth), while the NN site was shallower (c. 5 m depth) with a large (c. 4 m) tidal exchange.</p><p><br></p><p>Arrays of roughened black Perspex settlement plates (20 x 20 cm; n = 3 plates per array) were deployed from floating structures at each site (steel fish farm pontoons at RK and plastic marina pontoons at NN), with arrays spaced approximately 5 m apart. The settlement plates were positioned horizontally within each array, and configured to ensure they remained at a constant depth (0.5 - 1.5 m) with respect to the water surface. Sampling involved taking photographs of the downward-facing surface of each plate, reflecting the orientation where maximum D. vexillum recruitment occurs [32]. Plate photos were analysed using the random dot method in Coral Point Count software (CPCe v4.1), with 50 stratified random points overlaid on each image. Based on the frequency of occurrence of D. vexillum, other major taxa, bare space, or sediment at each point, percent cover was calculated. A margin of 1 cm around each experimental plate was excluded from analyses to avoid edge effects.</p><p><br></p><p>In a second concurrent study (Fletcher et al. data2.csv), we investigated the establishment and persistence of D. vexillum following exposure of settlement plates to ambient larval recruitment, compared with plates also exposed to larval recruitment, but to which a fragment of colony tissue was also attached. The treatments consisted of 10 blank settlement plates (‘Recruitment’ treatment) and 10 blank plates to which a D. vexillum fragment was attached to the downward-facing side (‘Fragment’ treatment). Hence, whereas all plates were exposed to ambient larval recruitment, half of them were additionally subjected to a single fragment inoculation event. Each fragment was c. 10 cm² in area (c. 20 g) and was secured within the central portion of each plate using two rubber bands. All Fragment plates were photographed and initial fragment size determined using the image analysis software ImageJ. </p

PERMANOVA of differences in benthic assemblage structure based on Bray-Curtis dissimilarities of log transformed data (using 9999 permutations).

<p>PERMANOVA of differences in benthic assemblage structure based on Bray-Curtis dissimilarities of log transformed data (using 9999 permutations).</p

Changes in sea urchin density through time for each A) treatment and B) distance.

<p>Data were pooled across sites (n = 20).</p

Predation limits spread of Didemnum vexillum into natural habitats from refuges on anthropogenic structures.

Non-indigenous species can dominate fouling assemblages on artificial structures in marine environments; however, the extent to which infected structures act as reservoirs for subsequent spread to natural habitats is poorly understood. Didemnum vexillum is one of few colonial ascidian species that is widely reported to be highly invasive in natural ecosystems, but which in New Zealand proliferates only on suspended structures. Experimental work revealed that D. vexillum established equally well on suspended artificial and natural substrata, and was able to overgrow suspended settlement plates that were completely covered in other cosmopolitan fouling species. Fragmentation led to a level of D. vexillum cover that was significantly greater than was achieved as a result of ambient larval recruitment. The species failed to establish following fragment transplants onto seabed cobbles and into beds of macroalgae. The establishment success of D. vexillum was greatest in summer compared with autumn, and on the underside of experimental settlement plates that were suspended off the seabed to avoid benthic predators. Where benthic predation pressure was reduced by caging, D. vexillum establishment success was broadly comparable to suspended treatments; by contrast, the species did not establish on the face-up aspect of uncaged plates. This study provides compelling evidence that benthic predation was a key mechanism that prevented D. vexillum's establishment in the cobble habitats of the study region. The widespread occurrence of D. vexillum on suspended anthropogenic structures is consistent with evidence for other sessile invertebrates that such habitats provide a refuge from benthic predation. For invasive species generally, anthropogenic structures are likely to be most important as propagule reservoirs for spread to natural habitats in situations where predation and other mechanisms do not limit their subsequent proliferation

Map of the study sites.

<p>Filled circles denote ‘Control’, empty circles ‘Adjacent’, empty squares ‘No Canopy’ and filled squares ‘Canopy’ sites</p