ANZ Journal of Surgery

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Table of Contents for ANZ Journal of Surgery. List of articles from both the latest and EarlyView issues.
Updated: 9 hours 21 min ago

Internal hernia post Roux‐en‐Y surgery: Radiological features for the surgeon

June 12, 2021 - 00:14
ANZ Journal of Surgery, EarlyView.

The floating rectum

June 12, 2021 - 00:09
ANZ Journal of Surgery, EarlyView.

Gender‐specific prevalence of pilonidal sinus disease over time: A systematic review and meta‐analysis

June 8, 2021 - 14:36

We aimed at determining whether pilonidal sinus disease (PSD) prevalence actually changed in men and women over time and found that, despite wide ranging socioeconomic and behavioural changes within the last decades, the male-to-female ratio of PSD remains 4:1, meaning that both genders are still equally exposed to PSD promoting factors. PSD seems to be a gender independent disease.


Abstract Background

Gender-specific risk factors have been suggested to promote a fourfold higher incidence of pilonidal sinus disease (PSD) in male as compared to female patients. However, in recent decades there has been an apparent shift towards an increasing prevalence of PSD in women, as body weight and other risk factors influence the disease. We aimed at determining whether PSD prevalence actually changed in men and women over time.

Methods

Following PRISMA guidelines (PROSPERO ID: 42016051588), databases were systematically searched. Papers reporting on PSD published between 1833 and 2018 in English, French, German, Italian and Spanish containing precise numbers of male and female participants were selected for analysis. Gender-specific prevalence of PSD over several decades was the main outcome measure.

Results

We screened 679 studies reporting on 104 055 patients and found that the male/female ratio in patients with PSD has remained constant over time, with women being affected in about 20% of all PSD cases (I 2 = 96.18%; meta-regression p < 0.001).

Conclusion

While the prevalence of PSD has risen over the past decades, the ratio between affected males and affected females has remained constant, with women invariably representing about 20% of patients despite wide ranging socioeconomic and behavioural changes.

Socioeconomic inequality: Accessibility and outcomes after renal transplantation in New Zealand

June 8, 2021 - 14:35

In the higher socioeconomic deprivation (SED) stratum of New Zealanders, the rate of renal transplantation was by 53% greater than in the lower SED stratum (odds ratio = 1.53; 95% confidence interval [CI]: 1.33–1.76; p < 0.00005). Both groups had similar allograft survival. The adjusted hazard ratio (HRadj) was 1.0 (95% CI: 0.54–1.86), p = 0.992. The higher and lower SED groups of RT recipients had similar survival, HRadj was 1.58 (95% CI: 0.96–2.6; p = 0.075).


Abstract Background

Socioeconomic deprivation (SED) is a risk factor for worse outcomes after renal transplantation (RTx). This study aimed to evaluate access to RTx in different SED strata of the New Zealand population. We also assessed patient survival, acute cellular allograft rejection (AR) and allograft loss.

Methods

This was an Australian and New Zealand Dialysis and Transplantation and Organ Donation Registries-based retrospective cohort study. Patients who underwent RTx in New Zealand from 2008 to 2018 were identified. Patients younger than 16 years of age and those who left the country after RTx were excluded. Results: In the higher SED stratum of New Zealanders, the rate of RTx was 53% greater than in the lower SED stratum (odds ratio = 1.53; 95% confidence interval: 1.33–1.76; p < 0.00005).

Results

One hundred and thirteen (23%) patients from the lower SED group and 51 (14.8%) patients from the higher SED group underwent living unrelated RTx, p = 0.0033. In 233 (67.5%) patients from the higher SED group and 265 (53.9%) patients from the lower SED group, transplanted kidneys were from deceased donors RTx, p = 0.0001. The incidence of allograft loss and patient survival were similar in these groups.

Conclusion

Our data demonstrated a lower overall survival in the more socioeconomically deprived patients than in the lower SED group however this was not statistically significant after adjustment for covariates. A larger study is required to determine whether SED is associated with reduced survival.

How to do robotic low anterior resection using Da Vinci‐Xi system: Addressing the ergonomics dilemma

June 8, 2021 - 00:45

We describe six-arm, double-targeting, arm repositioning technique of performing robotic low anterior resection. This technique addresses the dilemma faced during traditional technique.


A NuvaRing caught in the wrong spot

June 7, 2021 - 21:31
ANZ Journal of Surgery, EarlyView.

Experience with NovoSorb® Biodegradable Temporising Matrix in reconstruction of complex wounds

June 4, 2021 - 15:31

The NovoSorb® Biodegradable Temporising Matrix (BTM) is a synthetic polyurethane dermal matrix used to reconstruct complex wounds. In this study, we explore a case series of 35 wounds of varying indications and report on outcomes and complications. We found that BTM offers a safe and reliable reconstructive option in challenging wounds that would otherwise require more complex operations.


Abstract Background

The NovoSorb® Biodegradable Temporising Matrix (BTM) is a synthetic polyurethane dermal matrix used to reconstruct complex wounds including deep dermal and full-thickness burns, necrotising fasciitis and free flap donor site. We hope to further explore its potential applications in this series.

Methods

Patients who received BTM application across four centres over an 18-month period were included. Patients were followed up to assess BTM and graft take, the aesthetic, the return of sensation and complications.

Results

A total of 27 patients with 35 wounds were identified with a range of aetiologies. Thirty-three wounds had 100% integration of BTM at the time of sealing membrane removal. Seven wounds had partial graft loss that later healed by secondary intention. In two cases, re-epithelialisation occurred with BTM alone without split-skin graft.

Conclusion

BTM offers a safe and reliable reconstructive option in challenging wounds that would otherwise require more complex operations.

Dedicated hip fracture services: A systematic review

June 4, 2021 - 15:29

This review demonstrates that centres with dedicated hip fracture units (HFUs) result in improved 30-day mortality. Further research may demonstrate more sustained improvements in outcomes. The implementation of dedicated HFUs within health systems should be considered.


Abstract Background

Hip fractures (HFs) are common and pose a significant burden to both the individual and the community. Prompt operative management and aggressive rehabilitation have been shown to improve outcomes. However, there is often a delay in treatment due to lack of theatre availability and appropriate perioperative multi-disciplinary care. This study reviews the literature and reports on outcomes of HFs treated in dedicated units with allocated theatre time and pre-determined multi-disciplinary perioperative pathways. It also provides comparison against outcomes data from HF registries, both domestically and internationally.

Methods

An electronic literature search was performed to identify original, English language studies reporting on patient outcomes from dedicated HF units (HFUs). Studies were graded using the Journal of Bone and Joint Surgery criteria. Data were extracted from the text, table and figures of the selected studies.

Results

Five appropriate studies, with a total cohort of 6633 patients (4032 of whom were treated in a dedicated HFU), were identified. Patients treated in these units sustained a lower mortality rate (Risk Ratio  = 0.62, p = 0.01).

Conclusions

This review demonstrates that centres with dedicated HFUs result in improved 30-day mortality. Further research may demonstrate more sustained improvements in outcomes. The implementation of dedicated HFUs within health systems should be considered.

Mapping timely access to emergency and essential surgical services: The Malaysian experience

June 2, 2021 - 15:22

Access to essential surgical care is an integral part of universal health care provision. This project maps the population's access to the Bellwether procedures (laparotomy, caesarean section and treatment of open fracture) within two hours in Malaysia.


Abstract Background

Surgical conditions form a significant proportion of the global burden of disease. Since the 2015 World Health Assembly resolution A68.15, there is recognition that the provision of essential surgical care is an integral part of universal access to health care. The Lancet Commission on Global Surgery proposed its first surgical indicator to measure a population's access to the Bellwether procedures (laparotomy, caesarean section and treatment of open fracture) within two hours. Bellwether access is a proxy for emergency and essential surgical care. This project aims to map essential surgical access to the Bellwether procedures in Malaysia.

Methods

The location and capability of hospitals to perform the Bellwether procedures was obtained from the Ministry of Health (MoH) and MoH hospital specific websites. The Malaysian population data were retrieved from the national department of statistics. Times for patients to travel to hospital were calculated by combining manual contouring and geospatial mapping.

Results

There were 49 Bellwether-capable MoH hospitals serving a national population of 32.5 million. Overall 94% of Malaysia's population have access to the Bellwethers within two hours. This coverage is universal in West (Peninsular) Malaysia, but there is only 73% coverage in East Malaysia, with 1.8 million residents of Sabah and Sarawak not having timely access. Malaysia's Bellwether capacity compares well with other countries in World Health Organisation's Western Pacific region.

Conclusion

There is good access to essential and emergency surgical services in Malaysia. The incomplete access for 1.8 million people in East Malaysia will inform national surgical planning.

Assessing operating theatre efficiency: A prospective cohort study to identify intervention targets to improve efficiency

June 2, 2021 - 15:22

Running operating theatres efficiently is complex as shown by this prospective observational study. While a large proportion of theatre time is spent on non-operative activities suggesting staff activities could be improved, this study found that staff motivation and team familiarity were more important to efficiently run operating theatres.


Abstract Background

Operating theatre efficiency is critical to providing optimum healthcare and maintaining the financial success of a hospital. This study aims to assess theatre efficiency, with a focus on staff activities, theatre utilisation and case changeover.

Methods

Theatre efficiency data were collected prospectively at a single centre in metropolitan Melbourne, Australia, over two 5-week periods. Characteristics of each case and various time points were collected, corresponding to either in-theatre staff activities or patient events.

Results

Two hundred and ninety-nine cases were prospectively audited over a range of surgical specialties. Setting up represented 42.4% (37.28 min), operating time 40.1% (35.28 min) and finishing up time 17.5% (15.43 min). Theatres were empty (turnover time) for 17.42 min, which was 39.4% of the non-operative time between operations (44.25 min, turnaround time). Plastic surgery operations required the shortest set-up and finishing times on most of the measured metrics, with general surgery and obstetrics/gynaecology having longer times. List order made a significant difference, with efficiency improving over the list and over the day for separate am and pm lists. When a patient was not on time to theatre, efficiency in both set up and finishing up metrics was significantly worse.

Conclusions

A large proportion of theatre time was being spent on non-operative tasks, making staff activities potential targets for operating theatre improvement interventions. Motivation and team familiarity were identified as the major factors behind efficiently run operating theatres, supporting the use of regular operating teams and maintenance of a highly motivated workforce.

Necrotising soft tissue infection in western Sydney: An 8‐year experience

June 2, 2021 - 15:20

This original research article reports an 8-year experience in managing necrotising soft tissue infections (NSTI) in a tertiary hospital in western Sydney. The high incidence of NSTI in the study was due to the greater number of Aboriginal and Torres Strait Islander, and Polynesian people who reside in the area and a greater prevalence of obesity, diabetes and smoking. Good patient outcomes with low mortality rate were achieved.


Abstract Background

This study aimed to assess the risk factors, management, imaging validity, Laboratory Risk Indicator for Necrotising infection (LRINEC) score and outcomes of necrotising soft tissue infection (NSTI) at a western Sydney tertiary hospital.

Methods

A retrospective study was conducted of all patients with NSTI from 2012 to 2019 at our institution. Patient characteristics, imaging, microbiology and site, LRINEC score, surgical management and outcomes/disposition were collected.

Results

Thirty-six patients met the inclusion criteria with mean age of 52 years and body mass index of 38.1; 55.6% were male, 48% of Polynesian descent and 55.6% were diabetic. The most frequent sites of NSTI were perineal (30.6%), lower limb (30.6%), perianal (19.3%) and trunk (11.1%). A total of 64% of patients underwent computed tomography radiological imaging with diagnostic accuracy of 50%. The mean LRINEC score was 7 (1–20). A total of 52.8% were transferred from another facility or non-surgical teams which delayed surgical review by 11.4 h (P < 0.03) and operating time by 12.4 h (P < 0.04) compared with direct emergency department referrals to the on-call surgical team. There was no statistical difference in outcomes in both groups. The overall average time to surgical debridement was 16.2 h (standard deviation 19.6, range 3.4–105.1). The mean hospital length of stay was 20.9 days; 44.4% of patients were transferred for rehabilitation or plastic reconstruction with a single mortality from multi-organ failure.

Conclusion

The optimal management of NSTI requires a high index of suspicion and LRINEC score is a useful adjunct in aiding a clinician's decision. Early surgical debridement within 24 h of diagnosis and a multidisciplinary approach is associated with a lower mortality rate.

The management of women with ductal carcinoma in situ of the breast in Australia and New Zealand between 2007 and 2016

June 2, 2021 - 15:18

The aim of this study was to describe the management of women diagnosed with ductal carcinoma in situ (DCIS) in Australia and New Zealand. Using the BreastSurgANZ Quality Audit database, we conducted a descriptive study of the management of DCIS from 2007 to 2016. The clinical management of women diagnosed with DCIS appears stable over time.


Abstract Background

The incidence of detected ductal carcinoma in situ (DCIS) continues to increase and now accounts for 14% of all breast cancer, and 20%–25% of screen-detected cases. Treatment trends of DCIS are important in order to inform the ongoing debate about possible overdiagnosis and overtreatment, but have not been investigated for over a decade in Australia and New Zealand. Against this background, we aimed to describe the temporal trends in management of DCIS in Australian and New Zealander women.

Methods

Using the BreastSurgANZ Quality Audit (BQA) database, we conducted a descriptive study of the trends of management of DCIS in Australia and New Zealand from 2007 to 2016. We assessed the frequency of surgical treatments, adjuvant therapies, and axillary surgery conducted in women with pure DCIS.

Results

There were 17 883 cases of pure DCIS in 2007–2016 in Australia and New Zealand recorded in the BQA database. The treatment patterns were consistent with no changes over time. The most common surgical treatment was breast-conserving surgery (66%), followed by mastectomy (37%), and 36% of women with DCIS received sentinel node biopsy (SNB).

Conclusion

The clinical management of women diagnosed with DCIS in Australia and New Zealand, appears stable over time. A substantial proportion of women with DCIS receive SNB and this aspect of surgical care warrants further exploration to determine whether it represents appropriate care. These results, alongside the outcomes of the ongoing clinical trials on the management of DCIS, will help inform if any changes to best practice treatment are required.

Balloon dilation eustachian tuboplasty for dilatory dysfunction: Safety and efficacy analysis in an Australian cohort

June 2, 2021 - 15:18

Sixty-two operations were included in this retrospective case series. The patient cohort showed statistically significant improvement of mean EDTQ-7 score from 4.7 to 2.9 with improvement in EDTQ-7 was achieved in 83.9% of the cases. There were no adverse safety events associated with the procedures.


Abstract Background

Eustachian tube dysfunction (ETD) is a common clinical condition encountered by otolaryngologists. The severity and duration of symptoms range from the mild and transient to the chronic and severe along with secondary pathologies. Balloon dilation eustachian tuboplasty (BDET) as a treatment, was first described in 2010 and has been studied extensively. This study evaluates the efficacy and safety of BDET in an Australian cohort.

Methods

Retrospective chart review on all patients who underwent BDET from September 2016 to March 2020 was performed. The Eustachian Tube Dysfunction Patient Questionnaire (ETDQ-7) was chosen as the primary outcome measure. Secondary outcome measures included subjective global assessment of presenting symptoms, ability to perform Valsalva maneuver and tympanometry. Any complications related to the procedures were reported.

Results

One hundred and nineteen eustachian tube operations were included in this study. The patient cohort showed statistically significant improvement of mean EDTQ-7 score from 0.7 to 2.9. Improvement in EDTQ-7 was achieved in 83.9% of the cases. All patients in the baro-challenge-induced subgroup achieved improvement in ETDQ-7 score. Complete resolution of symptoms with an ETDQ <2.1 was achieved in 37.1% of the cohort. There were no adverse safety events associated with the procedures.

Conclusion

BDET resulted in improvement of the EDTQ-7 score in most of patients in this Australian cohort with no reported complications. BDET was most successful in baro-challenge-induced subgroup with universal improvement. Lower success rates were seen in patients with secondary pathology from their ETD.

Open versus laparoscopic surgery for the treatment of diverticular colovesical fistulas: A systematic review and meta‐analysis

May 31, 2021 - 17:42

Laparoscopic surgery is associated with a tendency toward reduced total postoperative complications and shorter hospital length of stay in comparison with open surgery for the treatment of diverticular colovesical fistulas.


Abstract Background

The aim of this study was to analyze the evidence regarding open versus laparoscopic surgery for the treatment of diverticular colovesical fistula (CVF) in terms of perioperative outcomes.

Methods

A systematic review was performed using PubMed, Cochrane, Google Scholar, and Web of Science databases for studies comparing laparoscopic versus open surgery for CVF. We pooled odds ratios (OR) and mean differences (MD) using random or fixed effects models.

Results

Five non-randomized studies with 227 patients met the inclusion criteria. All were retrospective studies, published between 2014 and 2020. For laparoscopic surgery, the pooled rate for conversion to laparotomy was 36%. Laparoscopic and open procedures required similar operative time (MD: −11.62; 95% confidence interval [CI]: −51.41 to 28.16). No difference was found in terms of stoma rates between laparoscopic and open surgery (OR: 1.12; 95% CI 0.44–2.86). Overall, the rate of total postoperative complications was lower in the laparoscopic group (OR: 0.55; 95% CI: 0.30–0.99). The pooled analysis showed equivalent rates of anastomotic leaks (OR: 0.61; 95% CI 0.15–2.45), surgical site infections (OR: 0.44; 95% CI 0.19–1.01), and mortality (OR: 0.18; 95% CI 0.03–1.15). The length of stay was significantly reduced with laparoscopic surgery (MD: −2.89; 95% CI −4.20 to −1.58).

Conclusion

Among patients with CVF, the laparoscopic approach appears to have shorter hospital length of stay, with no differences in anastomotic leaks, surgical site infections, stoma rates, and mortality, when compared with open surgery.

Penetrating colonic trauma and damage control surgery: Anastomosis or stoma?

May 31, 2021 - 17:39

Management of colonic trauma in damage control surgery (DCS) remains controversial. Delayed anastomosis at the time of relook laparotomy after DCS is associated with increased anastomotic leak rates.


Abstract Background

The management of colon injuries in damage control surgery (DCS) remains controversial.

Methods

A retrospective study investigating outcomes of penetrating colonic trauma in patients who survived beyond the initial repeat laparotomy (IRL) after DCS was performed. Patients over 18 years with penetrating colon injury and who underwent DCS from 2012 to 2020 were included from our electronic trauma registry. Demographic data, admission physiology and Injury Severity Score (ISS) were reviewed. Patients were classified into three groups: primary repair of non-destructive injuries at DCL, delayed anastomosis of destructive injuries at IRL and diversion of destructive injuries at IRL. Outcomes observed included leak rates, length of intensive care unit stay, length of hospital stay, morbidities, mortality and colon-related mortality.

Results

Out of 584 patients with penetrating colonic trauma, 89 (15%) underwent DCS. After exclusions, 74 patients were analysed. Mean age was 32.8 years (SD 12.5); 67 (91%) were male. Mechanism of injury was gunshot in 63 (85%) and stab 11 (15%) patients. Seventeen patients underwent primary repair at DCS, of which one leaked. Twenty patients underwent delayed anastomosis at IRL. Of these, five (25%) developed leaks. Mortality was significantly higher for those with an anastomotic leak compared to those without (p < 0.001). Thirty-seven patients were diverted at IRL. Overall mortality (p = 0.622) and colon-related mortality (p = 0.592) were not significantly different across groups.

Conclusion

Delayed anastomosis at IRL following DCL was associated with a leak rate of 25% in this study. When anastomotic leak did occur, it was associated with significant mortality. Delayed anastomosis should only be undertaken in highly selected patients.

Is pathological complete response predictable after neoadjuvant chemotherapy in breast cancer? A single institution's retrospective experience

May 31, 2021 - 17:38

Retrospective review of radiological and pathological response to neoadjuvant chemotherapy. Can magnetic resonance imaging be used to predict complete pathological response? A single institutional retrospective case series.


Abstract Background

Pathological complete response (pCR), in breast cancers, after neoadjuvant chemotherapy is linked to improved survival. Determining complete response to chemotherapy prior to surgery has remained elusive even using a combination of pathological factors and imaging modalities, making surgery still a necessity.

Methods

A retrospective analysis was performed from a single institution from 2013 to 2018. Breast cancer patients treated with neoadjuvant chemotherapy with pre- and post-chemotherapy magnetic resonance imaging (MRI) were included. Patients receiving other neoadjuvant modalities were excluded. Imaging characteristics, including response to chemotherapy and pathological factors, were recorded.

Results

Analysis showed 134 patients were identified with 40/134 (29.9%) noted to have radiological complete response and 34/134 (25.6%) had pCR. The positive predictive value for MRI to detect pCR was greatest for oestrogen receptor (ER) negative and human epidermal growth factor receptor 2 (HER2) negative tumours at 81.8% and worst for ER+ HER2− tumours at 25%. The negative predictive value was greatest for ER+ HER2− tumours at 93.9% and worst for ER− HER2− tumours at 77.4%.

Conclusion

MRI after neoadjuvant chemotherapy for breast cancer even combined with tumour factors is not an accurate predictor of pCR.

Increased risk of complications in smokers undergoing reversal of diverting ileostomy

May 31, 2021 - 17:35

A retrospective analysis of patients undergoing reversal of diverting loop ileostomy was conducted with significantly more post-operative complications in smokers and less post-operative complications in patients who had received adjuvant chemotherapy. No differences in post-operative complications were identified with respect to delayed closure or type of anastomosis.


Abstract Background

Diverting ileostomy (DI) is utilised in rectal cancer surgery to mitigate the effects of anastomotic leak. The aim of this study was to assess the clinical risk factors associated with post-operative complications of DI reversal.

Methods

A single-centre retrospective analysis of patients who underwent surgical resection for rectal cancer and subsequent DI reversal between January 2012 and December 2020 was undertaken. Medical records were reviewed to extract clinical, operative and pathologic details and post-operative complications according to the Clavien-Dindo classification. Univariate and multivariable analyses were undertaken to assess risk factors associated with post-operative complications of DI reversal.

Results

One hundred and twenty-six adult patients who underwent DI reversal were included of which 49 had a post-operative complication (39%). The most common complication was prolonged post-operative ileus, which occurred in 24 patients (19%). On multivariable analysis smoking was significantly associated with overall complications (odds ratio [OR] = 5.60, 95% confidence interval [CI] 1.90–16.52, p = 0.0018), and high Clavien-Dindo (2–5) category complications (OR = 4.60, 95% CI 1.81–11.68, p = 0.0013). In addition, patients who received adjuvant chemotherapy were less likely to have a reversal of DI complication (OR = 0.43, 95% CI 0.19–0.94, p = 0.0342) and less likely to have a high Clavien-Dindo (2–5) category complication (OR = 0.44, 95% CI 0.20–0.93, p = 0.0311).

Conclusion

Smokers who have undergone surgical resection of rectal cancer have a significantly increased risk of post-operative complications after DI reversal. In these patients, the importance of smoking cessation must be emphasised. The decreased complication rate observed in patients who received adjuvant chemotherapy was an unexpected finding.