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 impact of primary care delays on survival of colorectal cancer patients

Survival for colorectal cancer patients in the UK lags behind other Western European countries. This thesis aims to explore the impact of delays in referral and missed opportunities in primary care on survival for colorectal cancer patients. For this purpose patients were identified from the Clinical Practice Research Datalink (CPRD), a national electronic primary care medical record database, with a diagnosis of colorectal cancer in the National Cancer Registry. The initial studies validate the use of CPRD to fulfil the aims of this thesis, by confirming patients included are representative of the wider national cancer population. In the latter chapters the association of delays in referral with survival are investigated using a retrospective cohort design, while adjusting for patient demographics and co-morbidities. Delays are defined as a referral after three months or after three or more consultations. In addition, missed opportunity for non-emergency diagnosis were identified for emergency patients with a previous consultation in primary care. Survival between the urgent and non-urgent referral pathways are also explored. This thesis demonstrates delays were associated with a worse survival and later stage for patients presenting with red-flag symptoms (as defined by NICE) but not non-specific symptoms. Presenting with non-specific symptoms was associated with a worse stage and emergency diagnosis independently. There was no difference in survival or stage for patients referred by the non-urgent pathway compared with the two-wait-week pathway. Identification of cancer patients in primary care is a difficult task. These findings suggest patients presenting with red-flag symptoms, and in particular rectal bleeding are presenting at an earlier stage providing an opportunity for a better prognosis if the referral is prompt. Alternative methods to differentiate cancer from benign patients need to be considered, as relying only on symptoms is insufficient.Open Acces

Splenic abcess following sleeve gastrectomy: a systematic review of clinical presentation and management methods

Background: Splenic abscess is a rare complication following Sleeve Gastrectomy. Methods: We performed a systematic review to clarify its clinical significance, presentation, and management. PubMed, Embase, MEDLINE, Google Scholar, and The Cochrane Library were searched up to the 19th of July 2020. Results: A total of 18 patients were included, of which 11 were female, and 7 were male. The mean age was 34.1 ± 12.3 years, and the mean body mass index was 45.8 ± 7.6 kg/m2. Type 2 diabetes mellitus was reported in 11.1% of patients, and hypertension in 22.2%. Fever was the most common presenting symptom seen in 17 (94.4%) patients, followed by abdominal pain in 10 (55.6%). The mean duration from surgery to presentation was 98.6 ± 132.7 days (range 10 -547 days). Computed Tomography was used for investigations in 17/18 (94.4%) patients. Seven patients had reported leak, three reported bleeding, and 2 reported pleural effusion. 13 patients had unilocular abscess. All patients were treated with antibiotics. 4 patients needed Total Parenteral Nutrition, and three were given Proton Pump Inhibitor. In total, 11 patients needed percutaneous drainage as a part of treatment and 11 patients needed total splenectomy, and 1 needed partial splenectomy. Conclusion: Splenic abscess following sleeve gastrectomy is a rare identity. The etiology of formation of splenic abscess needs further studies. A computed tomography of the abdomen with contrast is the preferred diagnostic tool. There is no gold standard treatment for splenic abscess

Fate of the metabolically healthy obese-is this term a misnomer? A study from the Clinical Practice Research Datalink

INTRODUCTION: The metabolically healthy obese (MHO) phenotype may express typical characteristics on long-term follow-up. Little is known about the initiation of this phenotypes and its future stability. AIM: The Clinical Practice Research Datalink (CPRD) is a large-scale primary care database. The aim of this study was to assess the stability of, and evaluate the factors associated with a transition into an unhealthy outcome in, a MHO population in the UK. METHODS: The CPRD was interrogated for a diagnosis of 'obesity' and cross-referenced with a body mass index (BMI) ≥35 kg/m2; participants were further classified as MH using a clinical diagnostic code or a relative therapeutic code. A hazard cox regression univariate and multivariate analysis evaluated the time to transition for independent variables. RESULTS: There were 231,399 patients with a recorded BMI of 35 kg/m2 or greater. Incomplete records were eliminated and follow-up limited to 300 months, the cohort was reduced to 180,560 patients. The prevalence of MHO within the obese population from the CPRD was 128,191/180,560 (71%). MHO individuals, who were of male gender (hazard ratio (HR) 1.23 (1.21-1.25), p = < 0.01), older age group (HR 3.93 (3.82-4.04), p = < 0.01), BMI of 50-60 kg/m2 at baseline (HR 1.32(1.26-1.38), p = 0.01), smokers (HR 1.07(1.05-1.09), p = < 0.01) and regionally from North West England (HR 1.15(1.09-1.21), p = < 0.01) were more prone to an unhealthy transition (to develop comorbidities). Overall, of those MH at baseline, 71,485/128,191(55.8%) remained healthy on follow-up, with a mean follow-up of 113.5 (standard deviations (SD) 78.6) months or 9.4 (SD 6.6) years. CONCLUSIONS: From this unique large data set, there is a greater prevalence of MHO individuals in the UK population than in published literature elsewhere. Female gender, younger age group, and lower initial weight and BMI were found to be significant predictors of sustained metabolic health in this cohort. However, there remains a steady progressive transition from a healthy baseline over the years