Background and aim: COVID-19 pandemic has predisposed patients undergoing surgery to post-operative infection and resultant complications. Appendicitis is frequently managed by appendicectomy. After the onset of the pandemic, selected cases of appendicitis were managed with antibiotics which is a recognised treatment option. Our objective was to compare the management of appendicitis and post-operative outcomes between pre- and post-COVID-19. Methods: Ninety-six patients were identified from before the onset of the pandemic (November 2019) to after the onset of the pandemic (May 2020). Data were collected retrospectively from electronic records including demographics, investigations, treatment, duration of inpatient stay, complications, readmissions and compared between pre- and post-COVID-19 groups. Results: One hundred percent underwent surgical treatment before the onset of pandemic, compared with 56.3% from the onset of the pandemic. A greater percentage of patients were investigated with imaging post-COVID-19 (100% versus 60.9%; p < 0.00001). There was no significant difference in the outcomes between the two groups. Conclusion: CT/MRI scan was preferred to laparoscopy in diagnosing appendicitis and conservative management of uncomplicated appendicitis was common practice after the onset of pandemic. Health boards can adapt their management of surgical conditions during pandemics without adverse short-term consequences. Long term follow-up of this cohort will identify patients suitable for conservative management.

Importance: A textbook outcome (TO) is a composite quality measure that incorporates multiple perioperative events to reflect the most desirable outcome. The use of TO increases the event rate, captures more outcomes to reflect patient experience, and can be used as a benchmark for quality improvement.Objectives: To introduce the concept of TO to elective laparoscopic cholecystectomy (LC), propose the TO criteria, and identify characteristics associated with TO failure.Design, Setting, and Participants: This retrospective cohort study was performed at 3 surgical units in a single health board in the United Kingdom. Participants included all patients undergoing elective LC between January 1, 2015, and January 1, 2020. Data were analyzed from January 1, 2015, to January 1, 2020.Main Outcomes and Measures: The TO criteria were defined based on review of existing TO metrics in the literature for other surgical procedures. A TO was defined as an unremarkable elective LC without conversion to open cholecystectomy, subtotal cholecystectomy, intraoperative complication, postoperative complications (Clavien-Dindo classification ≥2), postoperative imaging, postoperative intervention, prolonged length of stay (>2 days), readmission within 100 days, or mortality. The rate of TOs was reported. Reasons for TO failure were reported, and preoperative characteristics were compared between TO and TO failure groups using both univariate analysis and multivariable logistic regressions.Results: A total of 2166 patients underwent elective LC (median age, 54 [range, 13-92] years; 1579 [72.9%] female). One thousand eight hundred fifty-one patients (85.5%) achieved a TO with an unremarkable perioperative course. Reasons for TO failure (315 patients [14.5%]) included conversion to open procedure (25 [7.9%]), subtotal cholecystectomy (59 [18.7%]), intraoperative complications (40 [12.7%]), postoperative complications (Clavien-Dindo classification ≥2; 92 [29.2%]), postoperative imaging (182 [57.8%]), postoperative intervention (57 [18.1%]), prolonged length of stay (>2 days; 142 [45.1%]), readmission (130 [41.3%]), and mortality (1 [0.3%]). Variables associated with TO failure included increasing American Society of Anesthesiologists score (odds ratio [OR], 2.55 [95 CI, 1.69-3.85]; P < .001), increasing number of prior biliary-related admissions (OR, 2.68 [95% CI, 1.36-5.27]; P = .004), acute cholecystitis (OR, 1.42 [95% CI, 1.08-1.85]; P = .01), preoperative endoscopic retrograde cholangiopancreatography (OR, 2.07 [95% CI, 1.46-2.92]; P < .001), and preoperative cholecystostomy (OR, 3.22 [95% CI, 1.54-6.76]; P = .002).Conclusions and Relevance: These findings suggest that applying the concept of TO to elective LC provides a benchmark to identify suboptimal patterns of care and enables institutions to identify strategies for quality improvement.

Objective: The objective was to assess the interobserver agreement rate, progression rates and malignancy rates in the assessment of complex renal cysts (≥ Bosniak IIF) using a population-based database. Methods: A regional database identified 452 complex renal cysts in 415 patients between 2009 and 2019. Each patient was tracked and followed up using a unique identifier and deterministic linkage methodology. The interobserver agreement rate between radiologists was calculated using a weighted kappa statistic. Progression and malignancy rates of cysts (Bosniak ≥IIF) over the 11-year period were calculated. Results: The linear-weighted kappa value was 0.69 for all complex cysts. The rate of progression and regression of Bosniak IIF cysts was 4.6% (7/151) and 3.3% (5/151), respectively. All malignant IIF cysts progressed within 16 months of diagnosis. The malignancy rate of surgically resected Bosniak III and IV cysts was 79.3% (23/29) and 84.5% (39/46), respectively. Of all malignant tumours, 73.8% and 93.7% were of low ISUP grade and low stage, respectively. Conclusions: This study further confirms that there is a good degree of agreement between radiologists in classifying complex renal masses using the Bosniak classification. The progression rate of Bosniak IIF cysts is low, but the malignancy rates of surgically resected Bosniak IIF, III and IV cysts are high. Benign cysts are frequently resected, and a very high proportion of histopathologically confirmed cancers in complex renal cysts are of low grade and stage. Key Points: •There is a good degree of agreement between radiologists in classifying complex renal masses using the Bosniak classification. •The rate of progression of Bosniak IIF cysts is low, and malignant cysts progress early during surveillance. Although the malignancy rates of resected Bosniak IIF, III and IV cysts are high, the rate of benign cyst resection is significant.

Background: Subtotal cholecystectomy aims to reduce the likelihood of bile duct injury but risks a multitude of less severe, yet significant complications. The primary aim of the present study was to report peri‐operative outcomes of subtotal laparoscopic cholecystectomy (SLC) relative to total laparoscopic cholecystectomy (TLC) to inform the consent process.Method: All laparoscopic cholecystectomies between 2015 and 2020 in one health board were included. The peri‐operative outcomes of SLC (n = 87) and TLC (n = 2650) were reported. Pre‐operative variables were compared between the two groups to identify risk factors for SLC. The outcomes between the SLC and TLC were compared using univariate, multivariate and propensity analysis.Results: Risk factors for SLC included higher age, male gender, cholecystitis, increased biliary admissions, ERCP, cholecystostomy and emergency cholecystectomy. Following SLC, rates of post‐operative complication (45.9%), imaging (37.9%) intervention (28.7%) and readmission (29.9%) were significant. The risk profile was vastly heightened compared to that of TLC: intra‐operative complications (RR 9.0; p < 0.001), post‐operative complications [bile leak (RR 58.9; p < 0.001), collection (RR 12.2; p < 0.001), retained stones (RR 7.2; p < 0.001) and pneumonia (RR 5.4; p < 0.001)], post‐operative imaging (RR 4.4; p < 0.001), post‐operative intervention (RR 12.3; p < 0.001), prolonged PLOS (RR 11.3; p < 0.001) and readmission (RR 4.5; p < 0.001). The findings were consistent using multivariate logistic regression and propensity analysis.Conclusion: The relative morbidity associated with SLC is significant and high‐risk patients should be counselled for the peri‐operative morbidity of subtotal cholecystectomy.

In comparison to delayed laparoscopic cholecystectomy, emergency laparoscopic cholecystectomy has a shorter length of stay and eliminates the risk of recurrent episodes of acute cholecystitis. Nevertheless, there is concern that emergency laparoscopic cholecystectomy is associated with higher morbidity in acute cholecystitis patients. The present large cohort study compares operation-related adverse outcomes between emergency and delayed laparoscopic cholecystectomy and determines the risk of readmission before delayed laparoscopic cholecystectomy to guide surgical decision-making. Patients diagnosed with acute cholecystitis who underwent emergency or delayed laparoscopic cholecystectomy between 2015 and 2019 were included. Perioperative outcomes were compared using univariate and multivariate analysis, adjusting for preoperative variables. The rate of readmission before delayed laparoscopic cholecystectomy was determined. In total, 811 patients were included (median age, 58 years; male:female, 1:1.5): 227 emergency laparoscopic cholecystectomies (28.0%), 555 delayed laparoscopic cholecystectomies (68.4%), and 29 emergency laparoscopic cholecystectomies whilst awaiting delayed laparoscopic cholecystectomy (3.6%). Emergency laparoscopic cholecystectomy was associated with increased incidences of subtotal cholecystectomy (OR 1.94; P = .011), bile leak (OR 2.38; P = .013), intraoperative drains (OR 2.54; P < .001), prolonged postoperative length of stay (OR 7.26; P < .001), postoperative imaging (OR 1.83, P = .006), and postoperative readmission (OR 1.90; P = .005). There was a 13.5% risk of readmission over 2 months while waiting delayed laparoscopic cholecystectomy and a 22.5% risk over the median waiting time (5 months, 9 days). Emergency laparoscopic cholecystectomy is positively associated with a multitude of operation-related adverse outcomes in acute cholecystitis, compared to delayed laparoscopic cholecystectomy. The benefit of delayed laparoscopic cholecystectomy should be balanced against the significant readmission risk before delayed laparoscopic cholecystectomy. Emergency laparoscopic cholecystectomy may be the most pragmatic strategy for centers dealing with high volumes of biliary admissions and long elective-surgery waiting times. When opting for delayed laparoscopic cholecystectomy, confirming the date of surgery before discharge may ensure timely intervention and avoid the morbidity and expense of readmission.

Introduction: An emergency laparoscopic cholecystectomy (EMLC) is commonly performed for all biliary pathology, yet EMLC can be challenging due to acute inflammation. Understanding the risks of EMLC is necessary before patients can make an informed decision regarding operative management. The aim of the present study was to compare rates of operative and post-operative outcomes between EMLC and elective LC (ELLC) using a large contemporary cohort, to inform the consent process and influence surgical decision making. Methods: All patients who underwent EMLC and ELLC in one UK health board between January 2015 and December 2019 were considered for inclusion. Data were collected retrospectively from multiple regional databases using a deterministic records-linkage methodology. Patients were followed up for 100 days post-operatively for adverse outcomes and outcomes were compared between groups using both univariate and multivariate analysis adjusting for pre-operative factors. Results: A total of 2768 LCs were performed [age (range), 52(13–92); M:F, 1:2.7]. In both the univariate and multivariate analysis, EMLC was positively associated with subtotal cholecystectomy (RR 2.0; p < 0.001), post-operative complication (RR 2.8; p < 0.001), post-operative imaging (RR 2.0; p < 0.001), post-operative intervention (RR 2.3; p < 0.001), prolonged post-operative hospitalisation (RR 3.8; p < 0.001) and readmission (RR 2.2; p < 0.001). EMLC had higher rates of post-operative mortality in univariate analysis (RR 10.8; p = 0.01). Discussion: EMLC is positively associated with adverse outcomes versus ELLC. Of course this study does not focus on a specific biliary pathology; nevertheless, it illustrates the additional risk associated with EMLC. This should be clearly outlined during the consent process but should be balanced with the risk of further biliary attacks. Further studies are required to identify particular patient groups who benefit from elective surgery.