Conjoint Professor Jonathan Gani

© 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland Introduction: Previous studies have shown single CRP measurements at time of presentation to have limited predictive benefit for appendicitis. Our objective was to determine the diagnostic utility of serial CRP measurements (to determine CRP velocity [CRPv]) in patients with right iliac fossa (RIF) pain. Methods: A single-centre prospective observational study was conducted on adult patients admitted with RIF pain. CRP was measured on admission, at midnight, and the following morning. Appendicitis was diagnosed on histopathology, or diagnostic imaging in non-operatively managed patients. Therapeutic interventions included all appropriate operative procedures and effective non-operative treatment with antibiotics. Logistic regression was used to generate predictors of therapeutic intervention, and then used to create a new risk score incorporating CRPv. Results: 98 of 112 (87.5%) participants had complete CRP data. 58 patients met the criteria for appendicitis (59.2%). Most patients presented with intermediate Modified Alvarado Scores (MAS) 5¿6 (40.8%) or Appendicitis Inflammatory Response Scores (AIRS) 5¿8 (49%). Our risk score had an AUROC of 0.88 (95% CI 0.81¿0.96) in predicting therapeutic intervention. This score was superior to MAS, AIRS, and single admission biomarker measurements. Patients with an increasing CRPv had 14 times the odds (OR 14.07, 95% CI 0.63¿315.2) of complicated appendicitis, and no cases of complicated appendicitis were observed in patients with a flat CRPv. Conclusions: CRP velocity is superior to single CRP at predicting intervention. Our v-Score shows promise as a decision making-aide by predicting the need for surgical intervention in RIF pain. A flat CRPv identifies a group of patients with a very low risk of complicated appendicitis.

© 2016 Royal Australasian College of Surgeons Currently in Australasia, concomitant cholecystolithiasis and choledocholithiasis are usually managed with two procedures: laparoscopic cholecystectomy (LC) and pre or postoperative endoscopic retrograde cholangiopancreatography (ERCP). This approach exposes the patient to the risk of complications from the common bile duct stone(s) while awaiting ERCP, the risks of the ERCP itself (particularly pancreatitis) and the need for a second anaesthetic. This article explores the evidence for a newer hybrid approach, single stage LC and intraoperative ERCP (SSLCE) and compares this approach with the commonly used alternatives. SSLCE offers reduced rates of pancreatitis, reduced length of hospital stay and reduced cost compared with the two-stage approach and requires only one anaesthetic. There is a reduced risk of bile leak compared with procedures that involve a choledochotomy, and ductal clearance rates are superior to trans-cystic exploration and equivalent to the standard two-stage approach. Barriers to widespread implementation relate largely to operating theatre logistics and availability of appropriate endoscopic expertise, although when bile duct stones are anticipated these issues are manageable. There is compelling justification in the literature to gather prospective evidence surrounding SSLCE in the Australian Healthcare system.

Introduction: Acute general surgical units (AGSUs) are changing the way in which acute appendicitis is managed. In the AGSU at John Hunter Hospital, some patients wait more than 48 hours from admission to undergo an appendicectomy, usually because they are not unwell enough to precipitate an operation before that time. We analysed this subgroup of appendicectomy patients to determine how effectively they are being managed and how this might be improved. Methods: A retrospective review of prospectively collected data was conducted of all patients who received an appendicectomy while admitted under the AGSU at John Hunter Hospital in the five years between January 2009 and December 2013. Results: A total of 1,039 appendicectomies were performed in the study period, with 81 patients (7.8%) waiting > 48 hours for their operation (delayed appendicectomy group). Overall, the negative appendicectomy (NA) rate was 21.6%; the NA rate in delayed appendicectomies was 50.62% and a non-therapeutic operation occurred in 47% of this group (n=38). No significant difference was found in the incidence of perforation/gangrenous appendicitis between patients having surgery in <48 hours and the delayed appendicectomy groups (11.2% vs 9.9%, p=0.85). A combination of negative diagnostic imaging result, a normal white cell count and normal C-reactive protein (ie a negative 'triple test') was the best predictor of a negative appendicectomy (p=0.0158, negative predictive value: 0.91, 95% confidence interval: 0.59-0.99), in the delayed appendicectomy group. Conclusions: In the delayed appendicectomy group, the incidence of perforation/gangrenous appendicitis was not significantly different from that found in patients having appendicectomy performed sooner. However, the NA and non-therapeutic operation rates were unacceptably high. An appendix triple test can improve diagnostic accuracy significantly without an unacceptable rise in the rates of perforation/gangrenous appendicitis.

Introduction: Hepaticojejunostomy is the standard biliary bypass technique for periampullary cancer when trial dissection reveals unresectable disease or endoscopic stent placement is not possible. This anastomosis can be technically demanding and potentially difficult. The simpler technique of hepaticocholecystoenterostomy (HCE) has only previously been reported in very limited numbers and without outcome data. Methods: All patients undergoing HCE for the management of periampullary cancer were identified from a prospectively maintained computerised database of a single surgeon and were reviewed retrospectively. The HCE technique achieves a biliary bypass by two anastomoses, using the gallbladder as a conduit. It involves an anastomosis of the infundibulum of the gallbladder to the common hepatic duct followed by a second anastomosis of the gallbladder fundus to the proximal small bowel. Results: From 1996 to 2010, 30 patients with pancreatic adenocarcinoma required a biliary bypass after a failed trial of Whipple procedure (80%) or failed endoscopic stenting (20%). There were 19 men and 11 women with a mean age of 64.5 years. The mean operative time for HCE alone was 92 minutes. The mean length of hospital stay was nine days. There was a single grade 2 complication (readmission with gastric emptying delay) and a single grade 3 complication (bile leak requiring reoperation). Thirty-day mortality was zero and the mean survival was 12 months (with one patient still alive at the time of writing). There were no readmissions with recurrent biliary obstruction or cholangitis. One patient had developed an incisional hernia by the 24-month follow-up appointment. Conclusions: HCE in periampullary cancer is safe and effective in selected patients. It involves two simple anastomoses with good access rather than one more demanding anastomosis. Morbidity, patency and overall survival are comparable with contemporary published series of hepaticojejunostomy.