A cost analysis of operative repair of major laparoscopic bile duct injuries

Includes bibliographical referencesMajor bile duct injuries occur infrequently after laparoscopic cholecystectomy but may result in life-threatening complications. Few data exist about the financial implications of bile duct repair. This study calculated the total inhospital costs of operative repair in a cohort of patients who underwent reconstruction of the bile duct after major ductal injury sustained during laparoscopic cholecystectomy. A prospective database was reviewed to identify all patients referred to the University of Cape Town Private Academic Hospital between 2002 and 2013 for assessment and repair of major laparoscopic bile duct injuries. The detailed clinical records and billing information were evaluated to determine all costs from admission to discharge. Total costs for each patient were adjusted for inflation between the year of repair and 2013. Forty four patients (33 women, 11 men, median age 48 years, range 30 - 78) underwent reconstruction of a major bile duct injury. First time repairs were performed at a median of 24.5 days (range 1 - 3662) after initial surgery. Median hospital stay was 15 days (range 6-86). Mean cost of repair was R215 711 (range R68 764 - 980 830). Major contributors to cost were theatre expenses (22%), admission to intensive care (21%), radiology (17%) and specialist fees (12%). Admission to a general ward (10%), consumables (7%), pharmacy (5%), endoscopy (3%) and laboratory costs (3%) made up the balance. The cost of repair of a major laparoscopic bile duct injury is substantial due to prolonged admission to hospital, complex surgical intervention and intensive imaging requirements

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy.

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI

Serum lipase should be the laboratory test of choice for suspected acute pancreatitis

CITATION: Hofmeyr, S., Meyer, C. & Warren, B. L. 2014. Serum lipase should be the laboratory test of choice for suspected acute pancreatitis. South African Journal of Surgery, 52(3):72-75, doi:10.7196/SAJS.2003.The original publication is available at http://sajs.redbricklibrary.com/index.php/sajsBackground. Serum lipase and amylase are biochemical analyses used to establish the diagnosis of acute pancreatitis (AP). Despite lipase having been shown internationally to be a more sensitive and specific test, amylase remains a popular first-line test. Objective. To provide a local basis for the recommendation of the best first-line laboratory test, an assessment of their performance in our local setting was undertaken. Methods. From a prospective dataset on patients with acute abdominal pain and raised serum lipase and/or amylase values, the sensitivity and specificity of serum lipase, amylase and the two in combination was calculated for the diagnosis of AP, as defined by the Atlanta criteria. Results. During the study period, 476 patients presented with acute upper or generalised abdominal pain and raised serum amylase and/or lipase values. The median age of the patients was 43 years (range 14 - 85), and 58% were men and 42% women. Of the patients, 322 (68%) presented with abdominal conditions other than AP, and 154 (32%) had AP. Ethanol abuse and gallstones accounted for 55% and 23% of cases of AP, respectively. Lipase displayed a sensitivity of 91% for AP, against 62% for amylase. Specificity was 92% for lipase and 93% for amylase. Dual testing with lipase and amylase had a sensitivity of 93%. Conclusions. Lipase is a more sensitive test than amylase when utilising cut-off levels to diagnose AP. Lipase should replace amylase as the first-line laboratory investigation for suspected AP.http://sajs.redbricklibrary.com/index.php/sajs/article/view/1853Publisher's versio

Modular control analysis of slipping enzymes.

A theory is developed that deals with the metabolic control exerted by enzymes that catalyze two or more, incompletely coupled reactions. The starting point is modular (top-down) metabolic control theory. Slipping enzymes are considered as modules with more than one independent flux. Control by the coupled reaction is distinguished quantitatively from control by the extent of slippage. This is achieved by appropriate linear transformation of fluxes or logarithms thereof. Different transformations are proposed and discussed. Our examples include free-energy transducing proton pumps and the Na, K –ATPase. It is shown that control coefficients can be calculated on the basis of a description of slipping enzymes in terms of linear non-equilibrium thermodynamics. © 1999 Elsevier Scienc