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

Host status of purple passionfruit for the Mediterranean fruit fly (Diptera: Tephritidae)

The Mediterranean fruit fly Ceratitis capitata (Wiedemann) (Diptera: Tephritidae) is a key pest of a wide range of fruit crops and the focus of rigid quarantine restrictions and eradication measures in several countries. In Colombia, the susceptibility of purple passionfruit ( Pasiflora edulis f . edulis Sims; Violales: Passifloraceae) to C. capitata is uncertain. Field collections of fruit were made to evaluate natural infestation. Forced infestation studies were conducted in the laboratory with punctured and intact fruit to determine the acceptability of fruit at different stages of maturity and physiological suitability of fruit to development. No C. capitata larvae were found and no adults emerged from a total of 976 hand-picked fruit and 623 fallen fruit. In the meantime, trap data indicated that C. capitata is not present in the principal passionfruit production regions. For intact fruit, C. capitata females oviposited exclusively in fruit of maturity level zero, with 41.67% of fruit accepted for oviposition and an average of 183.1 ± 33.8 eggs per fruit. No oviposition was recorded in fruit of maturity levels 2 and 4. For punctured fruit, C. capitata oviposited a total of 84,410 and 84,250 eggs into fruit of maturity levels 0 and 2, respectively, but no C. capitata adults emerged from fruit at either maturity level. Laboratory tests suggest that purple passionfruit is a non-host for C. capitata. = La mosca del Mediterráneo Ceratitis capitata (Wiedemann) (Diptera: Tephritidae) es una plaga clave de una amplia gama de frutales y es el foco de estrictas restricciones cuarentenarias y medidas de erradicación en varios países. En Colombia, la susceptibilidad del maracuyá morado (Pasiflora edulis f. edulis Sims; Violales: Passifloraceae) a C. capitata es incierta. Se hicieron colectas de frutos en campo para evaluar el nivel de infestación. En el laboratorio se desarrollaron estudios de infestación forzada con frutos perforados e intactos para determinar la aceptabilidad del fruto en los diferentes estados de maduración e idoneidad fisiológica del desarrollo de los frutos. No se encontraron larvas de C. capitata ni adultos emergidos en un total de 976 frutos recogidos manualmente y 623 frutos caídos. Mientras tanto, los datos de captura indicaron que C. capitata no está presente en las principales regiones de producción del maracuyá. Para frutos intactos, las hembras de C. capitata ovipositaron exclusivamente frutos de nivel de maduración cero, con 41.67% de aceptación de frutos para oviposición y en un rango de 183.1 ± 33.8 huevos por fruto. No se registró oviposición en frutos con niveles de maduración 2 y 4. Para frutos perforados, C. capitata ovipositó un total de 84,410 y 84,250 huevos dentro de frutos con nivel de maduración 0 y 2 respectivamente, pero no emergieron adultos de C. capitata de los frutos en ningún nivel de maduración. Las pruebas de laboratorio sugieren que el maracuyá morado no es hospedero para C. capitata