Laparoscopic cholecystectomy: clinical and patient reported outcomes

Introduction: Laparoscopic cholecystectomy is one of the commonest general surgical operations performed, yet little is known about its impact on patient and clinical outcomes in the UK (United Kingdom) population. Where available, existing processes for measuring outcomes are not readily accessible or unable to provide real-time information to end users. Despite technological advances, there have been no significant changes in improving the communication and data-sharing processes between patients and clinicians. The aims of this study were to use Hospital Episode Statistics (HES) data to identify the burden of disease leading to cholecystectomy in the UK population, help develop the patient-facing application aboutmyop.org and pilot its use in routine clinical care for patients undergoing elective laparoscopic cholecystectomy. Methods: An analysis of HES data on acute cholecystitis was used to identify the breadth of disease burden in the United Kingdom, and a systematic review of current patient reported outcome measures was performed to help identify appropriate surveys for measuring patient outcomes using a digital platform. The aboutmyop.org site was created with the expertise of EIDO Healthcare Ltd. and experts in web development through a government grant. In addition to national ethics application, the involvement of local information governance teams and patient advisory groups were used to develop site content and perform beta-testing. Clinical outcomes were measured by prospective audit, and the aboutmyop.org site was used to collect information on post-operative outcomes, and patient reported outcomes. Results: Whilst symptomatic gallstones remain a large burden in the UK population, HES data demonstrate that emergency cholecystectomy for acute cholecystitis risks overtreatment in 50% of the population. Consequently, patients with symptomatic gallstones identified for elective laparoscopic cholecystectomy or interval cholecystectomy were invited to participate in this study. A total of 898 patients were invited to use the aboutmyop.org system, but due to stringent security rules only 349 patients (38.9%) managed to complete the registration process for the aboutmyop.org site. The majority of participants were female (79.1%), with a mean age of 47.6 years (SD 14.9, IQR 35.2 – 58.8 years). Only 200 (57.3%) of all participants went on to undergo a laparoscopic cholecystectomy, and a small proportion of these completed their post-operative interactions; 7-day digital follow-up (42.5%), and post-operative ePROMs at 30-days (30.5%), 3-months (27.0%), and 6-months (19.0%). Conclusion: National data from HES emphasise the magnitude of the problem that gallstones have on the UK population. The aboutmyop.org system demonstrates a method to improve information accessibility for these patients and a novel method for collecting outcomes data, and data-sharing between patients and clinicians. Digital follow-up was identified as a safe alternative for laparoscopic cholecystectomy follow-up, and ePROMs demonstrated a significant improvement in quality of life in post cholecystectomy patients. Whilst this feasibility study demonstrates a willingness for patients to engage in virtual recruitment and digital surveys utilising the aboutmyop.org system, further amendments and system improvements are necessary prior to mainstream use

The Impact of Sham Feeding with Chewing Gum on Postoperative Ileus Following Colorectal Surgery: a Meta-Analysis of Randomised Controlled Trials

© 2020, The Author(s). Background: Chewing gum as a form of sham feeding is an inexpensive and well-tolerated means of promoting gastrointestinal motility following major abdominal surgery. Although recognised by the Enhanced Recovery After Surgery (ERAS) Society as one of the multimodal approaches to expedite recovery after surgery, strong evidence to support its use in routine postoperative practice is lacking. Methodology: A comprehensive literature review of all randomised controlled trials (RCTs) was performed in the Medline and Embase databases between 2000 and 2019. Studies were selected to compare the use of chewing gum versus standard care in the management of postoperative ileus (POI) in adults undergoing colorectal surgery. The primary outcome assessed was the incidence of POI. Secondary outcomes included time to passage of flatus, time to defecation, total length of hospital stay and mortality. Results: Sixteen RCTs were included in the systematic review, of which ten (970 patients) were included in the meta-analysis. The incidence of POI was significantly reduced in patients utilising chewing gum compared to those having standard care (RR 0.55, 95% CI 0.39, 0.79, p = 0.0009). These patients also had a significant reduction in time to passage of flatus (WMD − 0.31, 95% CI − 0.36, − 0.26, p < 0.00001) and time to defecation (WMD − 0.47, 95% CI − 0.60, − 0.34, p < 0.00001), without significant differences in the total length of hospital stay or mortality. Conclusion: The use of chewing gum after colorectal surgery is a safe and effective intervention in reducing the incidence of POI and merits routine use alongside other ERAS pathways in the postoperative setting

A systematic review of patient reported outcome measures (PROMs) and quality of life reporting in patients undergoing laparoscopic cholecystectomy

Background Patient Reported Outcome Measures (PROMs) provide a valuable means of measuring outcomes subjectively from a patient's perspective, facilitating the assessment of service quality across healthcare providers, and assisting patients and clinicians in shared decision making. The primary aim of this systematic review was to critically appraise all historic studies evaluating patient reported quality of life, in adult patients undergoing laparoscopic cholecystectomy for symptomatic gallstones. The secondary aim was to perform a quality assessment of cholecystectomy-specific PROM-validation studies. Methods A literature review was performed in PubMed, Google ScholarTM, the Cochrane Library, Medline, CINAHL, EMBASE and PsychINFO databases up to September 2017. Study characteristics, PROM-specific details and a bias assessment were summarised for non-validation studies. A COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) analysis was performed to assess the methodological quality of identified PROM-validation studies. Results Fifty one studies were found to evaluate Health-Related Quality of Life (HRQoL) after laparoscopic cholecystectomy. Although 94.1% of these studies included PROMs as a primary outcome measure

Utilising Electronic PROMs to Measure a Change in Health Following Elective Laparoscopic Cholecystectomy: A Feasibility Study

BackgroundThe collection of patient-reported outcome measures (PROMs) has many benefits for clinical practice. However, there are many barriers that prevent them from becoming a part of routine clinical care. The aim of this feasibility study was to pilot the use of a digital platform to facilitate the routine collection of pre- and post-operative electronic PROMs (ePROMs) in participants undergoing elective laparoscopic cholecystectomy and to validate the use of existing patient-reported outcomes for our population.MethodsParticipants scheduled for elective laparoscopic cholecystectomy were asked to complete digital versions of the Otago gallstones Condition-Specific Questionnaire (CSQ), and the RAND 36-item health survey (SF36). An assessment of methodological quality of ePROM questionnaires was also performed.ResultsPreoperative ePROMs were completed by 200 participants undergoing laparoscopic cholecystectomy. Post-operatively attrition was high (completion at 30 days, 3 months, and 6months: n = 61, 54, and 38, respectively) due to difficulties accessing our ePROMs portal. Of those able to complete, a significant improvement in quality of life was seen across all health domains post-operatively when compared with baseline preoperative values for both disease-specific and generic PROMs. Methodological quality was assessed as good to excellent in both digital questionnaires.ConclusionThe collection of ePROMs is possible with current technological advances. Although it may be an acceptable, and convenient process for patients, and a useful measure of quality-of-life trends for clinicians, further developmental work is necessary to improve accessibility for patients, improve compliance, and reduce reporting bias from high attrition rates

Digital Informed Consent: Modernising Information Sharing in Surgery to Empower Patients

Background Despite the 2015 Montgomery Ruling highlighting key requisites for informed consent, little has changed to modernise data-sharing and documentation of the consent process. It can be difficult to gauge patient understanding and address all patient concerns in time-limited appointments. We aimed to assess the feasibility of a digital information-sharing platform to support a move towards a digital informed consent process.Methods All adult patients referred to a single centre with symptomatic gallstones were invited to use a digital information-sharing platform to support the informed consent process prior to their first surgical clinic appointment. The platform provided patients with multimedia information on gallstones and available treatment options. It recorded the time spent accessing information, asked patients multiple choice questions (MCQs) to allow a self-test of understanding, documented a summary medical history, and allowed free text for patient questions. This information was summarised into a clinical report to support outpatient clinic consultations.Results Of the 349 patients registered to use the digital platform, 203 (58.2%) [165 (81.3%) female, mean age 47.6 years (range 19–84 years)] completed all modules necessary to generate a clinical report. Some 130 patients (64.0%) answered all 10 MCQs correctly and spent a mean of 18.7 min (range 3–88 min) reading the consent information. Most patient-reported medical histories were deemed to be accurate.Conclusion Despite difficulties with access, resulting in drop-outs, patients welcomed the opportunity to receive information digitally, prior to their consultation. Patients described feeling empowered and better informed to be involved in decision-making

Digital Follow-Up After Elective Laparoscopic Cholecystectomy: A Feasibility Study.

Although recommendations exist for patients to be offered a post-operative helpline or telephone follow-up appointment at discharge after cholecystectomy, implementation of these is resource-intensive. Whilst the benefits of telephone follow-up are well documented, the use of digital modalities is less so. We aimed to identify if digital follow-up (DFU) was equivalent to routine care with telephone follow-up (TFU), for patients undergoing elective laparoscopic cholecystectomy. All patients listed for elective laparoscopic cholecystectomy between August 2016 and March 2018 were offered routine post-operative care (TFU or no follow-up) or DFU at a tertiary referral centre in Nottingham. Of 597 patients undergoing laparoscopic cholecystectomy, 199 (33.3%) opted for TFU, and 98 (16.4%) for DFU. DFU was completed for 85 (86.7%) participants and TFU for 125 (62.8%), p < 0.0001. Over 5 times as many patients who chose TFU missed their appointment compared to DFU (5.6% vs. 30.9%, p < 0.001). At 30-days post-operatively, patients undergoing TFU had significantly more post-operative wound infections identified then those undergoing DFU (17.6% vs 5.9%, p = 0.01). However, this did not impact the incidence of 30-day readmissions between groups (7.2% TFU vs. 7.1% DFU). No complications were missed by either the DFU or TFU modalities. DFU was completed significantly earlier than TFU (median 6 days vs. 13.5 days, p = 0.001) with high patient acceptability, identifying complications and alerting clinicians to those patients requiring an early review. This feasibility study has demonstrated that digital follow-up is an acceptable alternative to telephone follow-up after elective laparoscopic cholecystectomy. [Abstract copyright: © 2022. The Author(s).

Burnout among surgeons in the United Kingdom during the COVID-19 pandemic: A cohort study

Background: Surgeon burnout has implications for patient safety and workforce sustainability. The aim of this study was to establish the prevalence of burnout among surgeons in the UK during the COVID-19 pandemic. Methods: This cross-sectional online survey was set in the UK National Health Service and involved 601 surgeons across the United Kingdom of all specialities and grades. Participants completed of the Maslach Burnout Inventory and bespoke questionnaire. Outcome measures included emotional exhaustion, depersonalisation and personal accomplishment, as measured by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Results: 142 surgeons reported having contracted COVID-19. Burnout prevalence was particularly high in the emotional exhaustion (57%) and depersonalisation (50%) domains, while lower on the personal accomplishment domain (15%). Burnout prevalence was unrelated to COVID-19 status; however, the greater the perceived impact of COVID-19 on work, the higher the prevalence of emotional exhaustion and depersonalisation. Degree of worry about contracting COVID-19 oneself and degree of worry about family and friends contacting COVID-19 was positively associated with prevalence on all three burnout domains. Across all three domains burnout prevalence was exceptionally high in the Core Trainee 1-2 and Specialty Trainee 1-2 grades. Conclusions: These findings highlight potential undesirable implications for patient safety arising from surgeon burnout. Moreover, there is a need for ongoing monitoring in addition to an enhanced focus on mental health self-care in surgeon training and the provision of accessible and confidential support for practising surgeons

Winter cancellations of elective surgical procedures in the United Kingdom: A questionnaire survey of patients on the economic and psychological impact

Objectives: To quantify the economic and psychological impact of the cancellation of operations due to winter pressures on patients, their families and the economy.Design: This questionnaire study was designed with the help of patient groups. Data were collected on the economic and financial burden of cancellations. Emotions were also quantified on a 5-point Likert scale.Setting: Five NHS Hospital Trusts in the East Midlands region of England.Participants: We identified 796 participants who had their elective operations cancelled between 1 November 2017 and 31 March 2018 and received responses from 339 (43%) participants.Interventions: Participants were posted a modified version of a validated quality of life questionnaire with a prepaid return envelope.Main outcome measures: The primary outcome measures were the financial and psychological impact of the cancellation of elective surgery on patients and their families.Results: Of the 339 respondents, 163 (48%) were age

Fasting and surgery timing (FaST) audit

Background & aimsInternational guidance advocates the avoidance of prolonged preoperative fasting due to its negative impact on perioperative hydration. This study aimed to assess the adherence to these guidelines for fasting in patients undergoing elective and emergency surgery in the East Midlands region of the UK.MethodsThis prospective audit was performed over a two-month period at five National Health Service (NHS) Trusts across the East Midlands region of the UK. Demographic data, admission and operative details, and length of preoperative fasting were collected on adult patients listed for emergency and elective surgery.ResultsOf the 343 surgical patients included within the study, 50% (n = 172) were male, 78% (n = 266) had elective surgery and 22% (n = 77) underwent emergency surgery. Overall median fasting times (Q1, Q3) were 16.1 (13.0, 19.4) hours for food and 5.8 (3.5, 10.7) hours for clear fluids. Prolonged fasting >12 h was documented in 73% (n = 250) for food, and 21% (n = 71) for clear fluids. Median fasting times from clear fluids and food were longer in the those undergoing emergency surgery when compared with those undergoing elective surgery: 13.0 (6.4, 22.6) vs. 4.9 (3.3, 7.8) hours, and 22.0 (14.0, 37.4) vs. 15.6 (12.9, 17.8) hours respectively, p < 0.0001.ConclusionsDespite international consensus on the duration of preoperative fasting, patients continue to fast from clear fluids and food for prolonged lengths of time. Patients admitted for emergency surgery were more likely to fast for longer than those having elective surgery