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: 2 hours 57 min ago

Fresh frozen cadaver workshops for general surgical training

May 23, 2019 - 22:04
Background

The technical proficiency of a surgeon is intricately linked to training and experience. Reduction in working hours, decreased operating time and ethical imperatives to protect patients have all resulted in a decrease in hands‐on experience. The introduction of laparoscopic procedures has also decreased trainees' exposure to open operative procedures not routinely performed in the current era.

Methods

The Clinical Training and Evaluation Centre at The University of Western Australia introduced the Core Skills Workshop for general surgical trainees in 2007. The workshop provides cadaveric dissection time for a range of open procedures. We describe in this article the logistics of setting up and running a cadaveric workshop, the performance and report our trainees' evaluation of the workshop.

Results

The Clinical Training and Evaluation Centre has hosted 26 General Surgery Core Skills Workshops since 2007. There were 227 participants with 196 evaluations returned (response rate 86%). Feedback was strongly positive for the course meeting the participants' expectations as well as its contribution to their skillset. Participants value the use of cadavers and high instructor:student ratios along with performance of a large number of open procedures in the setting of a stress‐free workshop and looked forward to more similar courses in the future.

Conclusions

Fresh frozen cadaver workshops are of value in the face of current surgical training challenges in providing an efficient, effective and safe environment.

Time is of the essence: evaluation of emergency department triage and time performance in the preoperative management of acute abdomen

May 21, 2019 - 22:54

Time is of the essence: Evaluation of emergency department triage and time performance in the pre‐operative management of acute abdomen.


Background

Acute abdomen is a time‐critical condition, which requires prompt diagnosis, initiation of first‐line preoperative therapy and expedient surgical intervention. The earliest opportunity to intervene occurs at presentation to the emergency department triage. The aim of this audit was to evaluate the relationship between emergency triage and time performance measures in the preoperative management of abdominal emergencies.

Methods

Retrospective audit of time performance measures of key clinical events from emergency triage. Patient characteristics, elapsed time from triage to commencement of fluid resuscitation, intravenous antibiotics and emergency surgery and post‐operative outcomes were obtained from review of operative medical records data over a 1‐year duration.

Results

There was variability in triage allocation of patients with acute abdomen requiring urgent surgery. Category 3 was the most commonly assigned triage category (65.6%). The majority of patients (94.8%) had initial clinical assessment within the National Emergency Access Target ‘4‐hour’ rule, and 41.7% seen within 1‐h from triage. Despite this, in cases of intra‐abdominal sepsis, there was nearly a fourfold elapsed time for first dose intravenous antibiotics, beyond the 1‐h recommendation in the Sepsis Kills pathway. There was non‐significant trend in faster overall time performances with successive higher triage category allocation.

Conclusion

This study highlights an opportunity to consider alternative triage methods or fast‐track of patients with acute abdomen to promote early surgical assessment, resuscitation, antibiotic therapy and definitive intervention.

Role of nerve block as a diagnostic tool in pudendal nerve entrapment

May 15, 2019 - 18:40
Background

Pudendal nerve entrapment is a disabling condition which is difficult to diagnose and treat. Nantes criteria include the requirement of positive anaesthetic pudendal nerve block that is widely used to allow identification of patients likely to benefit from the definitive but invasive pudendal nerve release. This study aimed to determine if pudendal nerve blockade under general anaesthesia could diagnose and temporarily treat pudendal nerve entrapment in patients suffering from chronic pelvic/perineal pain and/or organ dysfunction.

Methods

This retrospective analysis of a prospectively maintained database examined the outcomes of all recipients of diagnostic pudendal nerve block in a quaternary referral centre between 2012 and 2017. Primary outcome was relief of perineal pain (transient or permanent). Secondary outcomes were demographics, referral patterns for definitive procedure and complication rates. Statistical analysis was performed using SPSS v 24.

Results

A total of 77 patients were included in the study. Mean age was 57.27 ± 13.55 years. Majority were females (n = 62, 80.5%). Relief of pain was experienced by 47 of 76 (68.1%) patients after initial injection. Complication rate of injection was 3.9% (n = 3) which in all cases was unilateral lower limb paraesthesia. Of the 37 patients (52.9%) referred, 20 underwent surgical decompression with 12 (60%) being successful.

Conclusion

Pudendal nerve injection is a safe and simple procedure that can provide accurate diagnosis and transient relief from this chronic and debilitating problem. This technique helps to isolate patients suitable for pudendal nerve decompression which offers high success rates.

Resectable recurrent colorectal liver metastasis: can radiofrequency ablation replace repeated metastasectomy?

May 15, 2019 - 01:13

As far as we know, this article is the first to compare the clinical results of radiofrequency ablation (RFA) versus repeated surgery for resectable colorectal liver metastases recurrence. We found that recurrence occurred more frequently and in shorter interval after RFA, especially in patients with tumor size >3 cm. Liver resection and percutaneous RFA achieved similar overall survival.


Background

Percutaneous radiofrequency ablation (RFA) is used as a first‐line treatment for colorectal liver metastases that recur after first liver resection in our institution. We aim to evaluate its therapeutic efficacy compared to repeated surgical resection.

Methods

A retrospective review was performed in 104 patients treated with curative intent for resectable recurrent colorectal liver metastases.

Results

Sixty‐one patients underwent RFA and 43 patients underwent surgery. The overall recurrence rates were 82% in the RFA group and 65.1% in the resection group (P = 0.05). The local recurrence rate on a lesion‐basis was markedly higher after RFA than that after resection (16.7% versus 7.3%, P = 0.04). The difference remained significant in patients with a maximum lesion diameter >3 cm (24.5% versus 7.6%, P = 0.01). RFA treatment was independently associated with recurrence on multivariate analyses (P = 0.01). 69.7% of RFA patients and 42.6% of surgery patients with intrahepatic recurrence were amenable to repeated local treatment (P = 0.05), leading to the equivalent actuarial 3‐year progression free survival rates (RFA: 29.1% versus Resection: 33.1%, P = 0.48) and 5‐year overall survival rates in the two treatment groups (RFA: 33% versus Resection: 28.4%, P = 0.36).

Conclusions

Surgery remains the treatment of choice for resectable recurrence. RFA may offer similar benefit in selected patients.

Assessing adequacy of informed consent for elective surgery by student‐administered interview

May 14, 2019 - 22:01
Background

Studies show that patients often sign consent documents without fully comprehending the risks, benefits and potential complications. There is currently no Asian study performed analysing adequacy of informed consent. This study aims to assess adequacy of informed consent by evaluating patient understanding and retention of key information and complications pertaining to surgery via medical student‐administered interview.

Methods

A prospective study was performed on 48 patients undergoing groin hernia surgery, laparoscopic cholecystectomy and total thyroidectomy from 2017 to 2018 in a teaching hospital. Standardized assessment forms including major common complications and key details of the surgery were prepared. Structured one‐to‐one interviews between students and patients were performed and recorded on the morning of surgery.

Results

Although 93.8% of the patients claimed to have understood the information regarding their surgery, only 19.4%, 44.4% and 62.5% of the patients could actually recall the serious complications of groin hernia surgery, laparoscopic cholecystectomy and thyroidectomy, respectively. Elderly patients (>65 years) had poorer understanding of surgical procedure compared to the young (80% versus 100%, respectively, P = 0.008) with 26.7% of elderly patients claiming that they did not understand the indication for surgery. High satisfaction rates with this preoperative interview were reported by both patients and students (95.8% and 97.9%, respectively). Time interval from informed consent to surgery did not make any difference.

Conclusion

Understanding of information and key complications was generally low, especially in the elderly population. The structured preoperative interview achieved the dual goal of reinforcing patient gaps in knowledge and improving student communication skills.

Response of the Australian Medical Services to restoration of mobile warfare on the Western Front in 1918 (part I)

May 14, 2019 - 22:00

On 21 March 1918, after nearly 4 years of static warfare on the Western Front, German forces launched a massive offensive from the Hindenburg Line against a depleted British Fifth Army. Elite storm troops smashed through British forward and battle zone positions and advanced more than 17 miles in 2 days. By 5 April, the Germans were outside the town of Villers‐Bretonneux, 40 miles from their starting position and 15 miles from the railway junction of Amiens. This paper examines the response of Australian Medical Services to the restoration of mobile warfare and explains the measures that were put in place to deal with the evacuation of casualties.


On 21 March 1918, after nearly 4 years of static warfare on the Western Front, German forces launched a massive offensive from the Hindenburg Line against a depleted British Fifth Army. Elite storm troops smashed through British forward and battle zone positions and advanced more than 17 miles in 2 days. By 5 April, the Germans were outside the town of Villers‐Bretonneux, 40 miles from their starting position and 15 miles from the railway junction of Amiens. This paper examines the response of the Australian Medical Services to the restoration of mobile warfare and explains the measures that were put in place to deal with the evacuation of casualties.

Response of the Australian Medical Services to restoration of mobile warfare on the Western Front in 1918 (part II)

May 14, 2019 - 22:00

On 4 July 1918, at the Battle of Hamel, Australian Medical Services used a Field Ambulance Resuscitation Team for the first time, delivering life‐saving blood transfusion and early definitive surgery to badly wounded soldiers very soon after their wounds had been inflicted. During the closing months of the war, many lives and limbs were saved by early resuscitation and effective surgery, an achievement which stands out in marked contrast to the situation in 1914, when inadequate resuscitation, outdated surgical methods and appalling delays in delivering treatment resulted in great numbers of unnecessary deaths.


On 4 July 1918, at the Battle of Hamel, the Australian Medical Services used a Field Ambulance Resuscitation Team for the first time, delivering life‐saving blood transfusion and early definitive surgery to badly wounded soldiers very soon after their wounds had been inflicted. During the closing months of the war, many lives and limbs were saved by early resuscitation and effective surgery, an achievement that stands out in marked contrast to the situation in 1914, when inadequate resuscitation, outdated surgical methods and appalling delays in delivering treatment resulted in great numbers of unnecessary deaths.

Outcomes following radical cystectomy: a population‐based study from Queensland, Australia

May 14, 2019 - 21:59

This population‐based study of outcomes following radical cystectomy found 30‐ and 90‐day mortality was low. Some population sub‐groups, such as older patients are at heightened risk of post‐operative mortality. Regular monitoring of outcomes following oncologic surgery using quality indicators allows clinicians to reflect on practice and helps to identify areas for improvement.


Background

Radical cystectomy (RC) is a complex uro‐oncology surgical procedure with high surgical morbidity. We report on outcomes following RC for bladder cancer using a population‐based cohort of patients.

Methods

Patients receiving an RC from 2002 to 2016 were included and linked to their cancer‐related surgical procedures. Hospitals were categorized as high (>7 RCs/year) and low (≤7 RCs/year). Outcomes included 30‐ and 90‐day mortalities and 2‐year overall survival (OS). Multivariable logistic regression models were used to examine factors associated with the outcomes of interest. OS was estimated using the Kaplan–Meier survival function.

Results

During the 15‐year study period, 1230 patients underwent an RC for invasive bladder cancer. In‐hospital mortality was 1.1%, and 30‐ and 90‐day mortality was 1.4% and 2.9%, respectively. Both 30‐ and 90‐day mortalities were significantly higher for older versus younger patients (P = 0.01 and P < 0.001, respectively), and lymph node involvement was significantly associated with 90‐day mortality (P = 0.002). Patients treated more recently were about 80% less likely to die within 90 days. The 2‐year OS was 71.5%, with significant improvements observed over time (P < 0.001). While we found no evidence of a hospital‐volume relationship for post‐operative mortality or survival, patients treated in low‐volume compared to high‐volume hospitals were more likely to have surgical margin involvement (10.9% versus 7.1%, respectively, P = 0.03).

Conclusion

We observed low post‐operative mortality rates overall, with rates decreasing significantly over time. Some subgroups of patients experience poorer post‐operative outcomes. Reporting on post‐operative outcomes, and survival over time helps monitor clinical progress and identify areas for improvement.

Life‐threatening gastrointestinal bleeding from a giant ileal lipoma

May 14, 2019 - 03:35
ANZ Journal of Surgery, EarlyView.

Giant double‐barrel recto‐uterine prolapse

May 14, 2019 - 03:34
ANZ Journal of Surgery, EarlyView.

Prolonged surgical duration, higher body mass index and current smoking increases risk of surgical site infection after intra‐articular fracture of distal femur

May 13, 2019 - 22:02

The incidence rate of surgical site infection (SSI) following surgery of a distal femur intra‐articular fracture is 4.0%. Open fracture, prolonged surgical duration, increased body mass index and current smoking were identified as independent risk factors associated with the SSI. Modification of these risk factors might be very difficult, but they do prove useful for preoperative counseling of patients and their relatives regarding their own risk profile of SSI, and the perioperative medical optimization.


Background

This study aimed to investigate incidence of surgical site infection (SSI) following the surgery of intra‐articular fractures of distal femur.

Methods

Between July 2014 and December 2017, inpatient medical records of consecutive patients who had intra‐articular fractures of distal femur treated by open reduction and plate/screw fixation were inquired to identify whether they had a SSI. After discharge, patients who had a SSI and were readmitted for treatment of SSI were also allocated to the case group. Univariate and multivariate logistic regression analyses were performed to determine whether some clinical factors were independently associated with SSI, after adjustment for confounding variables.

Results

During the study period, 434 patients were evaluated and 21 patients were confirmed to develop a SSI, indicating the accumulated incidence of 4.8% within 1 year. A total of six deep and 15 superficial SSIs were identified, with respective incidence being 1.4% and 3.4%. The most common causative pathogen was Staphylococcus aureus (8, 50.0%), followed by mixed bacteria (5, 31.3%). Open fracture, prolonged surgical duration, increased body mass index and current smoking were identified as independent risk factors for development of SSI (P < 0.05).

Conclusions

It should be noted that it was likely difficult to modify these risk factors, but they do prove useful for preoperative counselling of patients and their relatives regarding their own risk profile of SSI, and the perioperative medical optimization.

Analysis of portal vein thrombosis after liver transplantation

May 13, 2019 - 22:01
Background

Portal vein thrombosis (PVT) is one of the most deadly complications after orthotopic liver transplantation (OLT). This study aimed to identify risk factors and summarize the experience of PVT management after OLT.

Methods

The clinical data of 407 adult patients received OLT from July 2011 to December 2015 was retrospectively investigated.

Results

The incidence rate of PVT was 2.9% (12/407). Pre‐transplant PVT (P = 0.001), post‐operative transfusion of erythrocyte (P = 0.006) and platelet (P = 0.036) were significantly associated with PVT in the univariate analysis and the appearance of pre‐transplant PVT (P = 0.002, odds ratio 6.05) was the independent risk factor according to binary logistic regression. Among patients with PVT, three cases (3/12) received balloon dilation through selective catheterization of portal vein, five (5/12) received balloon‐expandable stent placement, three (3/12) received thrombectomy and surgical revascularization and one (1/12) received retransplantation. Six patients (6/12) died from various complications and the remaining six were followed up with normal liver function and patent portal vein.

Conclusions

The risk factors were pre‐transplant PVT and post‐operative transfusion of erythrocyte and platelet. To recipients with high risk, early diagnosis and prompt management of PVT are essential to improve prognosis.

How to do the bottle suction method for removal of a silicone gel breast implant

May 13, 2019 - 22:01

There is a growing prevalence of silicone breast implant rupture and need for removal. This article identifies a novel method of removing silicone gel breast implants which addresses issues identified with the current methods. Our technique is an efficient and effective method but most importantly complies to strict Therapeutic Goods Administration guidelines for equipment used in surgery.


Acute variceal haemorrhage in the context of posterior flail chest

May 13, 2019 - 22:01
ANZ Journal of Surgery, EarlyView.

Clinical clearance of the thoracic and lumbar spine: a pilot study

May 13, 2019 - 21:59

This pilot study was to test the feasibility and accuracy of a clinical decision tool focused towards clearance of the thoracolumbar spine during assessment of patients in the Emergency Department after trauma. In this pilot study, sensitivity of the clinical decision tool was 100% (95% confidence interval: 87.3–100%) for the detection of a thoracic or lumbar vertebral fracture.


Background

In patients who are awake with normal mental and neurologic status, it has been suggested that the thoracolumbar (TL) spine may be cleared by clinical examination, irrespective of the mechanism of injury. The aim of this pilot study was to test the feasibility and accuracy of a clinical decision tool focused towards clearance of the TL spine during assessment of patients in the emergency department after trauma.

Methods

A prospective interventional study was conducted at two major trauma centres. The intervention of a clinical decision tool for assessment of the TL spine was applied prospectively to all patients with subsequent imaging results acting as the comparator. The primary outcome variable was fracture of the thoracic or lumbar vertebra(e). The clinical decision tool was assessed using sensitivity and specificity for detecting a TL fracture and reported with 95% confidence intervals (CIs).

Results

There were 188 cases included for analysis that all underwent imaging of the thoracic and/or lumbar vertebrae. There were 34 (18%) patients diagnosed with fractures of the thoracic and/or lumbar vertebrae. In this pilot study, sensitivity of the clinical decision tool was 100% (95% CI 87.3–100%) and specificity was 37.0% (95% CI 29.5–45.2%) for the detection of a thoracic or lumbar vertebral fracture.

Conclusions

Feasibility of clinical clearance of the TL spine in two major trauma centres was demonstrated in a clinical study setting. Evaluation of this clinical decision tool in patients following blunt trauma, particularly in reducing imaging rates, is indicated using a larger prospective study.

Intraoperative detection of aberrant biliary anatomy via intraoperative cholangiography during laparoscopic cholecystectomy

May 13, 2019 - 21:59

Intraoperative cholangiography (IOC) is widely used as an adjunct to laparoscopic cholecystectomy, but there is still no worldwide consensus on the value of its routine use. The purpose of this study was to assess the adequacy of and the reporting of 300 IOCs during laparoscopic cholecystectomy. Aberrant right sectoral ducts were identified in 15.2% of the complete IOCs, and 2.6% demonstrated left sectoral or confluence anomalies. Only 20.4% of these were reported intraoperatively. Surgeons generally demonstrate biliary anatomy well on IOC, but reporting of sectoral duct variation can be improved.


Background

Laparoscopic cholecystectomy (LC) is the standard of treatment for symptomatic cholelithiasis. Although intraoperative cholangiography (IOC) is widely used as an adjunct to LC, there is still no worldwide consensus on the value of its routine use. Anatomical studies have shown that variations of the biliary tree are present in approximately 35% of patients with variations in right hepatic second‐order ducts being especially common (15–20%). Approximately, 70–80% of all iatrogenic bile duct injuries are a consequence of misidentification of biliary anatomy. The purpose of this study was to assess the adequacy of and the reporting of IOCs during LC.

Methods

IOCs obtained from 300 consecutive LCs between July 2014 and July 2016 were analysed retrospectively by two surgical trainees and confirmed by a radiologist. Biliary tree anatomy was classified from IOC films as described by Couinaud (1957) and correlated with documented findings. The accuracy of intraoperative reporting was assessed. Biliary anatomy was correlated to clinical outcome.

Results

A total of 95% of IOCs adequately demonstrated biliary anatomy. Aberrant right sectoral ducts were identified in 15.2% of the complete IOCs, and 2.6% demonstrated left sectoral or confluence anomalies. Only 20.4% of these were reported intraoperatively. Bile leaks occurred in two patients who had IOCs (0.73%) and two who did not (7.4%).

Conclusion

Surgeons generally demonstrate biliary anatomy well on IOC but reporting of sectoral duct variation can be improved. Further research is needed to determine whether anatomical variation is related to ductal injury.

Health economic implications of postoperative complications following liver resection surgery: a systematic review

May 13, 2019 - 21:59

Limited data exists concerning the health economics of liver resection, with even less information on the costs emerging from complications. To address the need for evidence of the economic burden of complications following liver resection, we performed a systematic review aiming to compile worldwide evidence regarding the cost of liver resection into a clear and concise format.


Background

Limited data exists concerning the health economics of liver resection, with even less information on the costs emerging from complications, despite this remaining an important target from a health economic perspective. Our objective was to describe the financial burden of complications following liver resection.

Methods

We conducted a systematic search and included studies reporting resource use of in‐hospital complications during the index liver resection admission. All indications for liver resection were considered. All techniques were considered. Data was collected using a data extraction table and a narrative synthesis was performed.

Results

We identified 12 eligible articles. There was considerable heterogeneity in study designs, patient populations and outcome definitions. We found weak evidence of increased costs associated with major liver resection compared to minor resections. We found robust evidence supporting the increasing economic burden arising from complications after liver resection. Acceptable evidence for increased cost due to the presence and grade of complication was found. Strong evidence concerning the association of length of stay with costs was demonstrated.

Conclusions

The presence and grade of complications increase hospital cost across diverse settings. The costing methodology should be transparent and complication grading systems should be consistent in future studies.

It is not appendicitis? An uncommon case of appendiceal tumour

May 13, 2019 - 21:58
ANZ Journal of Surgery, EarlyView.