PARALLEL SESSION 3 - Free Paper Session 2a Surgery (Chairs: Dr Jane Montgomery & Mr David Bunting)

INTRODUCTION

There is increasing evidence for laparoscopic cholecystectomy (LC) to be performed at index admission. However this is difficult to implement due to challenges related to availability of theatre lists and experienced surgeons.LC attracts best practice tariff only if performed as a day-case. Our unit developed a Hot LC pathway where patients are discharged after index admission to come in within a week of discharge for a day-case LC performed on dedicated theatre lists. This study evaluates efficiency of our pathway.

METHODS

Consecutive patients referred to the Hot LC pathway were studied.  Referral criteria included fit patients with biliary colic, cholecystitis (<10 days duration) or pancreatitis. Postoperative length of stay, readmissions, total inpatient stay (index+LC), conversion rate and complications were analysed.

RESULTS

Hot LC was performed in 368 patients over a three year period with a conversion to open rate of 2%. Significant complications were bile leak in 2(0.54%) and hemorrhage in 1(0.27%). There were no bile duct injuries. Length of stay for hot LC was zero days in 48%; one day in 33% and >1 day in 19% patients. Readmission rate after Hot LC was 4.9%. Hot LC reduced mean total inpatient stay to 4 bed-days compared to 8 bed-days (historical controls). The minimum in-patient bed cost saved through this pathway was £800/patient.

CONCLUSION

Development of a Hot LC pathway has allowed us to offer LC in the acute setting safely and efficiently with no excess complications and with reduction in total stay.

Background and Aims:

Shoulder surgery is recognised as painful requiring patients treated generally as inpatients 

Barlborough NHS Treatment Centre (BTC) has introduced a new pathway for patients requiring total shoulder replacement, who meet predefined physical and social criteria, as day cases

BTC decision making focuses on the safety of the patients whilst embracing new and innovative practices

Methods:

Patients predefined physical and social criteria

The pre, peri and post-operative pathway is explained to the patient to meet patient expectations

Physiotherapists teach patient’s their post-operative exercises pre-operatively

Interscalene block with analgesia lasting up to 22 hours, no GA

The scheduling of the surgery is timed

The surgical technique has been enhanced to minimise operating time and to reduce blood loss.

Patients are given the consultants on call telephone number for their post-operative night

A post discharge call by a registered nurse or the operating surgeon is made on the day of discharge

A 1 day post-operation telephone call by the anaesthetist who performed the block and also a registered nurse

Physiotherapy review within a week

Results:

BTC is unaware of any other hospital in the UK who is able to offer this pathway. To date we have successfully treated thirteen patients. Clinical outcomes and patient satisfaction are to date excellent.

Conclusions:

Introduction
Although many breast procedures can be delivered as a day case safely, rates vary nationally, usually due to professional uncertainty about patient selection and outcome. Audit of the first 10 years of a day surgery pathway at King’s Breast Care was undertaken to challenge these perceptions. 

Methods
Demographic, histological and admission data was collected on all non-reconstructive breast cancer surgery from March 2006 until the end of February 2016. Use of drains and routine seroma aspiration had been stopped prior to 2006.Breast cancer prognosis was estimated using The Nottingham Prognostic Index (based on tumour size, grade, lymph node status), which defines five groups (excellent prognostic group, EPG: good prognostic group GPG: moderate prognostic group1, MPG1: moderate prognostic group2, MPG2; poor prognostic group, PPG). 

Results
1586 women underwent 1892 surgical procedures. Between 2006 to 2016, irrespective of surgical complexity, day case admissions increased from 56% to 97%. Eighty-three percent of bilateral surgeries were discharged the same day. The proportion having day surgery was not influenced by age (< 40 years 85%, > 80 years 84%) or prognostic group (EPG 89%; GPG 94%; MPG1 87%; MPG2 88%; PPG 84%).The median annual unplanned admission rate was 1.7% (range 0% to 5.2%); in-patient re-admission within 30 days was 0.6%, with a median duration of stay of 5 (range 2 to 11) days. 

Conclusions
Use of established pre-operative eligibility criteria are safe when designing a breast day surgery pathway. Re-admission rates are not increased if drains and routine seroma aspiration are omitted. 

Introduction

Recent advances means that booking patients for day surgery has become the default for many elective surgeries. Guidance suggests day case surgery should be performed consultants due to the increasingly complex nature of these patients. This could affect training in general surgery. Few studies have assessed the general surgical trainee experience of day surgery.   

Methods

The logbooks of 5 core surgical trainees (CSTs) were examined over a three month period (07/12/2017 – 06/03/2018). Statistical analysis was performed using Fisher exact test to identify factors affecting trainee involvement in surgical cases.

Results

A total of 281 procedures were recorded of which the majority were planned day case procedures (n=165).

Trainees were exposed to a mean of 33 day case procedures compared to 19 emergency cases each. Trainees recorded 39.5% of day case procedures as performed by them compared to 0% of elective procedures requiring planned admission (p=0.0001).

Day surgery case mix included 60 abdominal wall hernia repairs, 40 laparoscopic cholecystectomies, 34 simple skin biopsy / excisions and 31 other.

Trainees were more likely to perform a procedure when attending a day case list with the consultant only (p=0.0004).

Conclusions

Day surgery provides good training to general surgical trainees compared to emergency theatre and other elective surgery. Trainees are exposed to a reasonable case mix, performing a high percentage of cases. This is particularly the case when supervised by a consultant. Further research should be undertaken to assess the benefits of day surgery and how to formally incorporate this into surgical training.

Introduction 

To describe the implementation of a robotically-assisted radical prostatectomy (RALP) programme in a UK cancer centre within an established enhanced recovery programme (ERP), including the impact on length of stay (LOS). We also describe our experience of providing RALP as ambulatory (daycase) surgery. The Exeter ERP has been described previously and has been in place at our institution for cystectomy and open radical prostatectomy since 2008.

Methods

972 consecutive patients underwent RALP between January 2013 and August 2017, by 6 consultant surgeons. All patients were entered into an ERP. Data were collected prospectively on the British Association of Urological Surgeons (BAUS) audit and data platform, and downloaded to an Excel spreadsheet for analysis. Data were supplemented as required by review of electronic patient records.

Results

970 consecutive patients underwent robotically-assisted surgery, with the remainder converted to open. Median LOS was 1 day (mean 1.25 days), including 38 patients who underwent ambulatory surgery. The rate of Clavien Dindo ≥3 complications was 1.1% during the initial admission, with a 5.1% re-admission rate, the majority of which were for low grade complications.

Conclusions

RALP can be safely implemented within an established ERP, with an associated short LOS and a low complication rate. With careful patient selection and education, ambulatory surgery can also be offered.

Introduction

Obesity is a known risk factor for the formation of gallstones and has a prevalence of 27% in the UK. High body mass index (BMI) has been associated with poorer perioperative outcomes such as increased operative time and a higher incidence of conversion to open surgery though this risk may be an overestimation. The purpose of this study is to evaluate the outcomes and costs associated with day case laparoscopic cholecystectomy (DCLC) in morbidly obese patients.

Methods

A retrospective analysis of patients who underwent DCLC between December 2015 and November 2017 was performed. Anaesthetic and operating times, pre-operative complications, 28-day readmissions and average costs were compared among WHO classifications for BMI.

Results

There were 332 patients who were listed for DCLC. Morbidly obese patients had a longer anaesthetic and operative time of 4 and 8 minutes respectively compared to healthy patients (24 vs 20, p<0.005; 60 vs 52 p<0.001) There was no significant difference in postoperative complications (2 vs 1, p=0.392) cost (£161.96 vs £162.40 p=0.364) or readmissions (8 vs 2, p=0.149) between morbidly obese and healthy patients.  There was no difference in length of stay postoperative (0 vs 0, p=0.371) or proportion of successful DCLC (66 vs 62%, p=0.655).

Conclusions

With rising prevalence of obesity in the UK and chronic bed shortages, indications for inpatient admissions in under scrutiny. This study has shown that morbid obesity is not a contraindication to DCLC and is neither associated with worse outcomes or higher costs.