Prostatectomy at a district general hospital.

The mortality and morbidity in 600 patients undergoing prostatectomy at a district general hospital are reviewed. Below the age of 70 years the operative mortality was 1% compared with an overall mortality of 2.3%. Cardiorespiratory disease accounted for the majority of deaths. The increase of postoperative stay due to complications may be reduced by lowering the complication rate and, in the long term, reducing pre-existing cardiorespiratory disease.     

Chest injuries in a district general hospital.

Patients with chest injuries requiring admission to the Kent and Canterbury Hospital over a period of one year have been reviewed. Good survival figures are possible when these patients are managed by general surgeons and anaesthetists once the initial traumatic insult and immediate resuscitation period are survived. Among the 54 patients admitted there were 11 deaths, of which 10 occurred within a few hours of the patient's reaching hospital. It seems unlikely that even with specialist facilities the outcome would have been different in these 10 patients. Provided that a combination of experienced surgical and anaesthetic teams supported by intensive care facilities are mobilised quickly enough the absence of specialised cardiothoracic expertise is not important.     

Urodynamic investigation in a district general hospital.

In patients with disorders of micturition there is a poor correlation between clinical diagnosis and urodynamic findings. Thirty-three out of 82 patients studied in a Urodynamic Unit had their treatment plan altered as a result of the investigation.     

Abdominal aortic aneurysms in a district general hospital.

The management of all patients with abdominal aortic aneurysms attending a district general hospital over a 6-year period is reviewed. The hazards of delaying surgical treatment are emphasised. An operative mortality of 12% for non-leaking and 55.6% for leaking aneurysms is discussed with reference to other published results. Attention is drawn to the relatively high proportion of patients not undergoing surgical treatment. Some ways in which the mortality of the condition might be reduced are considered.     

Relaparotomy in a district hospital. Causes and results

During the last 6 years (1977 to 1982), there were 2,064 cases of abdominal surgery. 85 of our patients (4.1%) underwent relaparotomy, 22 of them twice or more times. The death rate came up to 18.8%. The causes of relaparotomy and the therapeutic measures taken are dealt with in detail.     

Surgery in a district general hospital

All operations performed in all surgical specialties in a district general hospital over a 4-week period were monitored. Although most elective operations were performed or supervised by trained staff, the service, particularly emergency care, was heavily dependent on incompletely trained doctors. Consultants, who operated on 41% of elective cases, were more likely to perform major operations. Supervision of junior surgeons for elective surgery was considered satisfactory. Thirty-one per cent of all major cases were performed by doctors in training, usually under supervision. However, 86% of all emergency operations were performed by trainee surgeons without consultant supervision. A consultant anaesthetist or clinical assistant attended all elective operating lists and either supervised or gave the anaesthetic. However, anaesthetists in training were not usually supervised for emergency cases outside normal working hours. It is worrying that one-third of all procedures were undertaken by surgeons who had been on duty for periods in excess of 24 h.     

Audit of open cholecystectomy in a district general hospital.

This retrospective study audited all non-malignant biliary surgery carried out in a district general hospital between January 1985 and December 1990. Surgery was performed on 722 patients: 555 (77 per cent) were women and 167 (23 per cent) were men. The mean(s.d.) age of the patients was 49(16) years. Elective admissions accounted for 70 per cent of cases and 30 per cent were emergency admissions. Ultrasonography confirmed the diagnosis in 93 per cent of cases. An elective operation was performed in 542 patients and 180 patients underwent an urgent or emergency operation. Simple cholecystectomy was performed on 616 patients (85 per cent); 92 (13 per cent) also underwent common bile duct exploration and 14 (2 per cent) had an additional unrelated procedure. The mean(s.d.) hospital stay was 12.3(6.3) (range 4-34) days. There was one perioperative death. The general overall morbidity rate was 25 per cent and the procedure-related morbidity rate was 7 per cent. For simple cholecystectomy (n = 630) there were no deaths; the general morbidity rate was 15 per cent and the procedure-related rate was 3 per cent.     

Management of perianal sepsis in a district general hospital.

Perianal sepsis remains a common surgical problem. A total of 121 patients undergoing surgery for perianal abscess and/or fistulae over a 2-year period was studied. Of these, 50 patients (41.3%) had suffered from previous perianal sepsis (not necessarily resulting in hospital attendance). Ninety-one patients underwent incision and drainage of abscesses (ischiorectal and perianal) for the first time, whereas eight patients underwent drainage of recurrent abscesses. Fistulae were identified when the abscess was drained in 14 of 91 patients, and a further ten patients subsequently developed fistulae. Twenty-two patients presented with a discharging fistula. A high yield of bowel organisms was present in patients with coexisting fistulae (88%), recurrent abscesses (75%) and in those who subsequently developed fistulae (83%). We confirm that such a growth can be used to identify patients who will benefit from further examinations.     

The workload of a surgical unit in a district general hospital.

A 3-month prospective study of the workload of a surgical unit in a district general hospital was performed to identify the relationship between outpatient work, admissions to hospital, and scheduled operating lists. We have shown that under 60% of all new cases seen in the outpatient clinic had admissions arranged after initial consultation. Over two-thirds of inpatient admissions were for emergencies or urgent cases, and thus not able to be controlled by the surgical team. One-third of emergency admissions had an operation within 24 h of admission. One third of the total number of cases on scheduled lists were emergency or urgent cases (taking up approximately 50% of the operating time). Of all admissions, 32% were as day cases. Of all routine operations, 35% were performed at a community hospital taking only 18% of all our admissions.     

Nurse endoscopy in a district general hospital

INTRODUCTION: This study describes the first full year of independent practice by a newly appointed nurse endoscopist in a district general hospital. PATIENTS AND METHODS: Patients underwent either 'one stop' flexible sigmoidoscopy and barium enema or flexible sigmoidoscopy alone. Barium enema results, video photography, clinical follow-up, and histology were used to validate the results of the flexible sigmoidoscopy. One stop clinic: 161 endoscopies were performed, with 104 female patients (65%), and a mean age of 64 years. There was one failed endoscopy due to poor bowel preparation. Abnormalities were identified in 84% of endoscopies. Flexible sigmoidoscopy detected abnormalities not seen on the barium enema in 28 cases, all of which were polyps (18%). Barium enema identified one abnormality within reach of the flexible sigmoidoscope not identified at endoscopy (small polyp in sigmoid; 1%). Elective flexible sigmoidoscopy list: 121 endoscopies were performed, with 65 female patients (54%), and a mean age of 59 years. There were two failed endoscopy procedures, both attributed to poor bowel preparation. Two-thirds of patients had an abnormality on investigation. There were no complications in either group of patients. CONCLUSIONS: The nurse-led endoscopy service has been successfully initiated with a high completion rate for flexible sigmoidoscopies. All significant conditions were identified with 99% sensitivity. Nurse endoscopy is a safe, useful and practical procedure in the setting of this district general hospital.