ANZ Journal of Surgery

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Morbidity and mortality with atrial fibrillation following colorectal surgery

March 14, 2018 - 19:35

Post-operative atrial fibrillation (POAF) is a common, self-limiting complication following non-cardiac surgery. It is associated with other complications such as pneumonia and sepsis, increased hospital stay and in-hospital mortality. The aim of the study is to identify risk factors, morbidity and mortality associated with POAF.

Methods

Retrospective cohort study of 571 consecutive patients who presented for colorectal surgery at The Canberra Hospital. Seventy-four patients were excluded due to history of atrial fibrillation and a further 124 patients were lost to follow-up at 1 year. Patient characteristics, intraoperative factors and post-operative outcomes were retrospectively collected. One-year mortality data were collected for 373 patients in the cohort.

Results

A total of 497 patients were included, 33 (6.6%) developed POAF within 30 days of surgery. POAF is associated with ischaemic heart disease (24.2 versus 11.6%, P = 0.035), emergency (66.7 versus 34.1%, P = 0.0001) and open procedures (87.9 versus 70.9%, P = 0.036). There is a higher incidence of post-operative complications including pneumonia (24.2 versus 9.1%, P = 0.006), abdominal collection (21.2 versus 9.7%, P = 0.049) and sepsis (21.2 versus 7.5%, P < 0.0001). POAF had a higher in-hospital mortality (9.1 versus 2.6%, P = 0.035) and 1-year mortality (33.3 versus 8.8%, P < 0.0001).

Conclusion

POAF is a common presentation following colorectal surgery and is associated with infective complications, reflecting an inflammatory process. Risk factors for POAF have been clearly identified in the literature; however, further studies need to be conducted on preventative strategies. There is a significantly higher 1-year mortality rate compared with the controls, the aetiology of which has not yet been widely reviewed.

Role of super-selective embolization in lower gastrointestinal bleeding

March 14, 2018 - 19:35
Background

Lower gastrointestinal bleeding (LGIB) is a common acute general surgical condition that is typically self-limiting; however in refractory cases it can necessitate life-saving intervention. When bleeding is refractory, super-selective embolization (SSE) becomes an important management strategy. This study aims to evaluate outcomes of this procedure at our institution and identify predictors of clinical success.

Methods

A retrospective analysis of patients with positive computed tomography angiograms for LGIB at a tertiary centre between December 2007 and May 2017.

Results

Of 87 600 acute general surgical admissions, 2700 were for LGIB. Computed tomography angiography demonstrated active bleeding in 104 patients who then had mesenteric angiograms. SSE was performed in 77 patients of whom 66 (86%) demonstrated active bleeding. Technical success was achieved in 75 patients (97%). Clinical success was achieved in 63 patients (81%). Re-bleeding occurred in 14 patients (19%), with four requiring surgery. One patient went forward for re-embolization. Bowel ischaemia occurred in four patients (5.2%), with two requiring bowel resection. A 30-day mortality following SSE was 6.5%, with one death attributable to bowel ischaemia and four deaths from medical comorbidity. Median age (years) of those who had clinical success was 78 (interquartile range (IQR) 16.4) and those who did not was 65 (IQR 20.2) (P = 0.031). Clinical success was more common in those who had diverticular related bleeding (61.9%) compared to other pathologies (38.1%) (P = 0.036).

Conclusion

SSE was successful in a high proportion of patients in this series with low complication rates. Clinical success was higher in those who were older or with diverticular related bleeding.

Clinical significance of serum transthyretin level in patients with hepatocellular carcinoma

March 14, 2018 - 09:56
Background

Although serum albumin has been reported to be useful as a prognostic biomarker for various malignancies, it is not suitable for prognosis of patients with hepatocellular carcinoma (HCC) due to impaired liver function. We aimed to determine whether serum transthyretin (TTR) level can be used as a novel prognostic biomarker.

Methods

Serum levels of TTR, as well as other nutritional and inflammatory parameters including angiogenic factors, were examined in 25 patients with HCC.

Results

The serum TTR levels exhibited a statistically significant inverse correlation with interleukin-6 (r = −0.412, P = 0.041), and showed statistically significant correlations with retinol-binding protein (r = 0.919, P < 0.001) and albumin (r = 0.442, P = 0.027). The patients with TTR <11.4 mg/dL (P = 0.012), those with ≥T2 (P = 0.011) and those with a retention rate of indocyanine green after 15 min ≥15.5 (P = 0.037) showed poorer prognoses than the counterparts of each parameter. The TTR level <11.4 mg/dL (hazard ratio: 4.837, 95% confidence interval: 1.118–20.926, P = 0.035) and ≥T2 (hazard ratio: 5.011, 95% confidence interval: 1.243–20.203, P = 0.023) were independent prognostic factors of HCC patients.

Conclusion

Serum TTR measurement can be useful for predicting the prognosis of patients with HCC.

Weight loss and retroperitoneal mass

March 14, 2018 - 09:56

Most effective pain-control procedure for open liver surgery: a network meta-analysis

March 14, 2018 - 09:56
Background

To determine the most effective pain-control procedure for open liver surgery through a network meta-analysis and provide a best developing direction in this field.

Methods

PubMed, Embase and Cochrane Library database were searched for randomized controlled trials up to 1 July 2016. We extracted data on post-operative pain score at the 4th–8th hour and 24th hour from studies that compared various pain-control strategies. Network meta-analysis was conducted in Aggregate Data Drug Information System software by evaluating the parametric pain score at rest and on movement. Cumulative probability value was utilized to rank the procedures under examination. The inconsistency would also be tested by node-splitting models.

Results

Twelve articles containing 661 patients were included. Intrathecal analgesia plus intravenous analgesia played the most effective role in pain controlling at post-operative 4–8 h (both at rest and on movement, P = 0.49 and P = 0.62, respectively) and at post-operative 24 h (both at rest and on movement, P = 0.46 and P = 0.29, respectively). Node-splitting models test revealed that no significant inconsistency existed in this research.

Conclusions

Intrathecal analgesia plus intravenous analgesia revealed the most effective clinical pain-control value for open liver surgery. More importantly, we believed that creating a better comprehensive and systematic combined pain-control procedure should be considered as the developing direction in this field.

Surgical versus non-surgical management of type B ankle fractures with minimal talar shift in adults: a systematic review

March 9, 2018 - 13:29
Background

This systematic review aims to determine the effectiveness of surgical and non-surgical management for the type B ankle fracture with minimal talar shift.

Methods

Two authors independently systematically searched the following databases: MEDLINE, EMBASE and CENTRAL. Only randomized controlled trials were included that evaluated surgical versus non-surgical management of type B ankle fracture with minimal talar shift in adults. Two authors independently performed study selection, risk of bias assessment and data extraction. Main outcomes extracted were general health and ankle function. Heterogeneity was assessed using I2 and chi-squared statistic. Data were pooled using fixed effect where appropriate.

Results

Two studies were included involving 241 patients. The pooled mean difference for the physical component score was 0.60 (95% confidence interval (CI): −1.62 to 2.82) non-significantly favouring surgical management. One study reported no significant difference in ankle function (mean difference: 3.20; 95% CI: −6.56 to 12.96) whilst the other reported a significant difference favouring non-surgical management (mean difference: 3.20; 95% CI: 0.44–5.96). Ankle function scores were not pooled due to heterogeneity. Meta-analysis showed that the surgical group was more likely to develop a minor infection (odds ratio: 12.46; 95% CI: 2.29–67.78) or undergo hardware removal (odds ratio: 4.40; 95% CI: 1.09–17.84). There was no significant difference in major infection between the two groups (odds ratio: 4.03; 95% CI: 0.44–36.65; favouring non-surgical management).

Conclusion

There was no significant difference in the general health outcome or ankle function for patients treated surgically versus non-surgically at 12 months. Further follow-up is needed to evaluate longer-term ankle function.

Radiotherapy for anal squamous cell carcinoma: must the upper pelvic nodes and the inguinal nodes be treated?

March 8, 2018 - 10:35
Background

Loco-regional failure is the predominant cause of death in anal squamous cell carcinoma. We assessed patterns of loco-regional recurrence to determine the impact of radiotherapy (RT) volumes on patient outcome.

Methods

Retrospective clinical study, including patients treated curatively with RT or chemo-radiotherapy between 1994 and 2007. RT fields/volumes were reviewed and compared with patterns of failure. Patients were classified as having whole pelvic radiotherapy (WPRT) if RT extended to L5/S1 or lower pelvic radiotherapy (LPRT) if it extended to the lower sacroiliac joints or below. Patients with negative inguinal nodes either underwent prophylactic inguinal radiotherapy (PIRT) or had inguinal observation (IO). Patterns of failure were compared.

Results

Twenty-seven patients (53%) had WPRT and 24 (47%) had LPRT. Forty-two patients had negative inguinal nodes: 29 (69%) had PIRT and 13 (31%) had IO. Median follow-up was 5.8 years. Twelve regional failures occurred in eight patients: three pelvic, one inguinal and four pelvic and inguinal. All patients with regional failure died of disease. Pelvic nodal failure was 7.7% in N0 and 33% in N1–3 patients (P = 0.012). There was no difference in pelvic regional failure between WPRT and LPRT (11% versus 16%, P = 0.64). There was only one possible regional failure above LPRT in this group (4%). Inguinal failure was 0% in the PIRT group compared with 23% in IO group (P = 0.009).

Conclusion

There was no difference in pelvic regional failure between WPRT and LPRT. LPRT is likely to be safe in N0 patients. Inguinal nodes should be treated in all patients.

Initial experience with robotic hepatectomy in Singapore: analysis of 48 resections in 43 consecutive patients

March 7, 2018 - 19:27
Background

Presently, the adoption of laparoscopic hepatectomy is rapidly increasingly worldwide. However, the application of robotic hepatectomy (RH) remains limited and its role remains undefined today.

Methods

A retrospective review of 43 consecutive patients who underwent RH at two institutions in the Singapore Health Services Group.

Results

Forty-three consecutive patients underwent 48 resections during the study period. Seven (16.3%) patients underwent major resections and seven (16.3%) underwent right posterior sectionectomies. Nineteen (44.2%) patients had tumours located in the difficult posterosuperior segments, five had multiple resections and three underwent repeat resections for recurrent tumours. RH was performed for malignant tumours in 32 (74%) patients and 16 (37.2%) had cirrhosis. Seven RH was performed with other concomitant procedures including three colectomies, three hilar lymphadenectomies and one portal vein ligation. The median operation time was 360 min (range 75–825) and the median blood loss was 300 mL (range 25–4500). There was one (2.3%) open conversion for bleeding. The median post-operative stay was 4 days (range 2–33) and there was one (2.3%) readmission. There was one (2.3%) major (>grade 2 morbidity) in a patient with concomitant anterior resection who underwent reoperation for anastomotic leak. There was no 90 day/in-hospital mortality. Comparison between RH for tumours in the anterolateral segments versus posterosuperior segments demonstrated no significant difference in perioperative outcomes.

Conclusion

Our initial experience demonstrated that RH is safe, feasible and associated with excellent post-operative outcomes. It can be performed successfully with low morbidity even for complex resections such as major hepatectomies, posterior sectionectomies, tumours in difficult posterosuperior segments and repeat liver resections.

Medicine in small doses

March 7, 2018 - 10:41