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: 1 hour 38 min ago

Change in serum albumin level predicts short‐term complications in patients with normal preoperative serum albumin after gastrectomy of gastric cancer

July 12, 2019 - 04:10
Background

The purpose of this study was to evaluate the correlation between serum albumin level change (ΔALB) and post‐operative complications in patients with normal preoperative serum albumin after gastrectomy of gastric cancer.

Methods

A total of 193 patients undergoing curative (R0) gastrectomy from September 2015 to May 2017 were enrolled in this study. The risk factors for predicting post‐operative complications were identified by univariate and multivariate analysis. The cut‐off value and diagnostic accuracy of ΔALB were measured by receiver operating characteristic curves. ΔALB was defined as: (albumin level before surgery − albumin on post‐operative day (POD) 1)/albumin level before surgery × 100%.

Results

A total of 60 patients (31.0%) had post‐operative complications. Our results showed that the cut‐off value of ΔALB was 19.0%. Using a cut‐off value of 19.0%, multivariate analysis identified that ΔALB was able to predict post‐operative complications as an independent factor (odds ratio 13.98, 95% confidence interval 6.048–32.32, P < 0.001). In addition, the area under the curve of ΔALB is higher than C‐reactive protein on POD 3 (0.773 versus 0633). Compared with patients with ΔALB <19.0%, patients with ΔALB ≥19.0% have higher risk of post‐operative complications suffered (62.3 versus 13.7%, P < 0.001) and longer post‐operative stay (22.1 ± 13.5 versus 17.5 ± 4.2, P < 0.001).

Conclusion

ΔALB acted as an independent predictor in short‐term complications for patients with normal preoperative serum albumin and its diagnostic accuracy was higher than C‐reactive protein on POD 3. It is promising to be a precise and straight predictor for incidence of post‐operative complications to patients with normal preoperative serum albumin.

Solo single‐incision laparoscopic cholecystectomy: a safe substitute for conventional laparoscopic cholecystectomy

July 11, 2019 - 00:19

We introduced solo single‐incision laparoscopic cholecystectomy technique using a laparoscopic scope holder, as a simple, fixed and easy‐to‐perform procedure for an unassisted surgeon. It is a feasible and safe procedure with shorter post‐operative hospital stay compared to conventional laparoscopic cholecystectomy.


Background

Despite the incremental application of single‐incision laparoscopic cholecystectomy (SILC), this procedure has technical difficulties, including physical disturbance and an unstable surgical view through the small incision; therefore, we introduce the solo SILC (S‐SILC) technique using a laparoscopic scope holder, as a simple, fixed and easy‐to‐perform procedure for an unassisted surgeon.

Methods

We performed a comparative analysis of S‐SILC (n = 566) and conventional three‐incision laparoscopic cholecystectomy (n = 874) performed from January 2013 to December 2016 at multiple centres.

Results

There was no significant difference of operative time between the two groups (P = 0.176); however, S‐SILC showed a higher incidence of intraoperative gallbladder perforation, especially in the initial period (17.0% versus 2.3%, P < 0.001); and shorter post‐operative hospital stay (3.3 ± 1.7 versus 1.9 ± 2.7 days, P < 0.001) than conventional three‐incision laparoscopic cholecystectomy. There were no significant differences in major post‐operative complications between the two groups (P = 0.909) and operation type (P = 0.971) was not a significant risk factor for major post‐operative complications in multivariate analysis.

Conclusion

S‐SILC is a feasible and safe procedure; however, careful selection of surgical candidates is necessary in the early period of the experience with this method.

Amputations in patients with diabetic foot ulcer: a retrospective study from a single centre in the Northern Territory of Australia

July 11, 2019 - 00:19

Diabetes‐related amputation rates are higher in the Northern Territory. Indigenous patients had higher amputation rates and were younger at the time of amputation. However, ethnicity is not an independent risk factor. The risk factors that were significant in multivariate analysis are all modifiable, indicating prevention and prompt treatment of diabetic foot disease is the key in reducing amputation rates.


Background

Lower extremity amputations (LEAs) in diabetic patients are common in the indigenous population. There is no published data from the Northern Territory.

Methods

All patients with diabetic foot ulcer, presenting for the first time to the multi‐disciplinary foot clinic at Royal Darwin Hospital, between January 2003 and June 2015, were included. These patients were followed until 2017, or death. LEA rates over the follow‐up period and the risk factors were studied.

Results

Of the 513 included patients, 62.8% were males and 48.2% were indigenous. The majority (93.6%) had type 2 diabetes with median diabetes duration of 7.0 years (interquartile range 3–12). During the follow‐up period of 5.8 years (interquartile range 3.1–9.8), a total of 435 LEAs (16.6% major; 34.7% minor) occurred in 263 patients (mean age 57.0 ± 11.8 years). In multivariate analysis, the following variables were associated with LEAs (adjusted odds ratio (95% confidence interval)): prior LEA (4.49 (1.69–11.9)); peripheral vascular disease (2.67 (1.27–5.59)); forefoot ulcer (7.72 (2.61–22.7)); Wagner grade 2 (3.71 (1.87–7.36)); and Wagner grade 3 (17.02 (3.77–76.72)). Indigenous patients were 1.8 times more likely to have LEAs than non‐indigenous patients. Indigenous amputees were approximately 9 years younger than their non‐indigenous counterparts.

Conclusion

Half of patients presenting with diabetic foot ulcer had LEA during follow‐up. Prior LEAs, peripheral vascular disease, forefoot ulcers and higher Wagner grades were independent risk factors for LEA. Indigenous patients were at higher risk for LEAs and were younger at the time of amputation.

Is anticoagulation for venous thromboembolism safe for Asian elective neurosurgical patients? A single centre study

July 11, 2019 - 00:19

This is a study to determine the incidence of venous thromboembolic events in our Asian neurosurgical population and the risk of haemorrhage in these patients.


Background

The incidence of venous thromboembolism (VTE) in neurosurgical patients ranges 3–24%. VTE is potentially fatal, and prophylactic anticoagulation is recommended worldwide. However, anticoagulation poses a risk of haemorrhage, which can be devastating. We aim to determine the incidence of VTE and risk of haemorrhage following anticoagulation.

Methods

Between 1 May 2014 and 1 May 2016, all patients who underwent elective neurosurgery were recruited into our study. All patients had bilateral lower limb ultrasound to screen for deep vein thrombosis (DVT) between post‐operative days 3 and 7. These patients are also monitored for manifestations of pulmonary embolism (PE). If present, a computed tomography pulmonary angiogram will be performed. Patients with VTE will either receive conservative treatment or anticoagulation.

Results

During this period, 170 of 610 patients were included. Of the 170 patients, 17 patients (10.0%) developed DVT. Fifteen patients had cranial surgery and two patients had spinal surgery. Two patients (1.2%) developed PE and both patients had concurrent DVT. Of these 17 patients, nine patients received anticoagulation. Of these nine patients, six patients (66.7%) developed surgical site bleeding following anticoagulation and all of them required surgical intervention. Patients who were managed conservatively did not suffer haemorrhage.

Conclusion

Our results show an overall 10.0% incidence of DVT and 1.2% incidence of PE following elective neurosurgery within this Asian cohort of neurosurgical patients. There is also a high risk (66.7%) of significant surgical site bleeding following anticoagulation.

Impact of preoperative percutaneous transhepatic biliary drainage on post‐operative survival in patients with distal cholangiocarcinoma

July 7, 2019 - 21:52
Background

The aim of this study was to investigate the long‐term impact of the type of preoperative biliary drainage used for patients undergoing pancreatoduodenectomy for distal cholangiocarcinoma (DCC).

Methods

A total of 84 patients with DCC who underwent preoperative biliary drainage between June 2000 and December 2016 were divided into groups for whom percutaneous transhepatic biliary drainage (PTBD) (n = 24) or endoscopic biliary drainage (EBD) (n = 60) was used.

Results

The 5‐year overall survival in the PTBD group was significantly worse than that in the EBD group (16.7% versus 52.3%, P = 0.007). After propensity score matching (22 patients in each group), the 5‐year overall survival in the PTBD group was still worse than that in the EBD group (13.6% versus 61.2%, P = 0.003). Multivariate analysis revealed that PTBD was independent risk factor for both poor survival (P = 0.028) and peritoneal recurrence (P = 0.018). The incidence of multiple sites at initial recurrence tended to be higher in the PTBD group than in the EBD group (P = 0.080).

Conclusions

PTBD should not be performed for patients undergoing pancreatoduodenectomy for DCC, except when EBD is contraindicated, as PTBD is significantly associated with shorter survival and peritoneal recurrence.

General Surgeons Australia's 12‐point plan for emergency general surgery

July 7, 2019 - 21:50

In the last decade, emergency general surgery in Australia and New Zealand has seen a transition from traditional on‐call system to the acute surgical unit model. The importance and growing demand for emergency general surgery resulted in the General Surgeons Australia's 12‐point plan for emergency surgery. This study aims to provide a descriptive review on the relevance of the 12‐point plan to the acute surgical unit model and review the current evidence to support this framework.


In the last decade, emergency general surgery (EGS) in Australia and New Zealand has seen a transition from the traditional on‐call system to the acute surgical unit (ASU) model. The importance and growing demand for EGS has resulted in the implementation of the General Surgeons Australia's 12‐point plan for emergency surgery. Since its release, the 12‐point plan has been used as a benchmark of a well‐functioning ASU, both locally and abroad. This study aims to provide a descriptive review on the relevance of the 12‐point plan to the ASU model and review the current evidence to support this framework. The review concludes that the establishment of the ASU model has met the aims set out by the Royal Australasian College of Surgeons for EGS. The 12‐point plan is relevant and has good evidence to support its framework.

Paediatric appendicitis: increased disease severity and complication rates in rural children

July 7, 2019 - 21:49

Appendicitis is an acutely time‐sensitive surgical pathology and it is plausible that those who have further to travel are at risk of worse outcomes. This study has demonstrated that residing in a rural location is associated with increased severity and increased number of complications in paediatric patients with acute appendicitis. Whilst increased perforation rates were seen in Māori children, ethnicity was not found as an independent risk factor associated with increased American Association for the Surgery of Trauma severity on multivariate analysis.


Background

Appendicitis is the most common surgical emergency affecting children. Rurality has been shown to be a predictor of worse surgical outcomes in patients with acute appendicitis compared to urban residents. There are no previously published studies investigating this in Australasia.

Methods

A 10‐year retrospective study of all patients aged ≤16 years who underwent an acute appendicectomy in Northland, New Zealand, was conducted. The cohort was identified by searching the hospital database for theatre events and admission diagnoses coded as appendicitis. Primary outcome of interest was the difference in the American Association for the Surgery of Trauma (AAST) anatomical severity grading of appendicitis and the Clavien–Dindo complication rate. The role of ethnicity was also examined.

Results

A total of 470 children underwent appendicectomy during this period. On multivariate analysis, increased AAST grade was twice as likely in rural patients (odds ratio 2.04). Post‐operatively, rural patients had higher Clavien–Dindo complication grade (P = 0.001), longer median length of stay and increased rates of intra‐abdominal collection (19% versus 4%; P = 0.018), 30‐day readmission (19% versus 4%; P = 0.020) and perforation (27% versus 19%; P = 0.031). Māori children had increased perforation rates (28.9% versus 19.0%; P = 0.014) but ethnicity was not found to be independently associated with increasing AAST grade.

Conclusion

Accounting for ethnicity, socio‐economic deprivation and age, we implicate rural patient status as being associated with increasing severity and complicated paediatric appendicitis. This work adds to the evolving description of inequities in rural health outcomes. Further prospective studies are needed to confirm these findings at a national level.

Accelerating the learning curve in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy using an external mentor model

July 7, 2019 - 21:49

The aim of this study was to describe early outcomes in the first 50 patients managed with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a newly established peritoneal malignancy centre in Sydney, Australia, under the guidance of an experienced peritoneal malignancy mentor. A total of 135 patients were referred and reviewed at the multidisciplinary team meeting with 50 (26 male) patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Of these 50 patients, 47 (94%) underwent complete cytoreduction while three (6%) had maximal tumour debulking surgery. Median length of hospital stay was 13 days (interquartile range 9.7–19.0). Six (12%) patients experienced a grade III or IV Clavien–Dindo complication. There was no 30‐day mortality.


Background

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an accepted therapeutic approach in selected patients with peritoneal malignancy. The aim of this study was to describe early outcomes in the first 50 patients managed with CRS and HIPEC in a newly established peritoneal malignancy centre in Sydney, Australia, under the guidance of an experienced peritoneal malignancy mentor.

Methods

This is a retrospective review of a prospective maintained database of early outcomes in the first 50 patients who underwent CRS and HIPEC between April 2017 and April 2018 at a newly established peritoneal malignancy centre. Type of primary, surgery time, length of hospital stay, blood loss, peritoneal carcinomatosis index, completeness of surgery, complications, recurrence rate and 30‐day mortality were reviewed.

Results

A total of 135 patients were referred and reviewed at the multidisciplinary team meeting with 50 (26 male) patients undergoing CRS and HIPEC. Of these 50 patients, 47 (94%) underwent complete cytoreduction while three (6%) had maximal tumour debulking surgery. Tumour pathology was of appendix origin (44%) and colorectal peritoneal metastases (44%). Median surgical time was 7.4 h (interquartile range 5.7–10.0). Median length of hospital stay was 13 days (interquartile range 9.7–19.0). Six (12%) patients experienced a grade III or IV Clavien–Dindo complication. There was no 30‐day mortality.

Conclusion

This study reports the successful establishment of a peritoneal malignancy centre under the guidance of an experienced peritoneal malignancy mentor. The short‐term surgical outcomes observed in the first 50 cases are promising and comparable to other more experienced centres.

Outcome of a second hepatectomy in octogenarians with hepatocellular carcinoma recurrence: single centre's experience

July 7, 2019 - 21:49

Repeated hepatectomy for octogenarians have same positive influence on the prognosis in comparison to the young group.


Background

Physicians rarely select surgery a second time as the treatment for octogenarians with hepatocellular carcinoma (HCC) recurrence.

Methods

We encountered eight male and three female octogenarians underwent surgery a second time as the treatment for HCC recurrence (octo group). We studied these cases clinically and compared them with 25 younger people underwent surgery a second time (young group). All patients of octo group have resectable HCC according to the Japanese guideline, that is HCC patients with Child‐Pugh status A or B and who have solitary or only a few HCC nodules, in addition, no serious comorbidities, no serious dementia, a performance status of 0–1 and the will to receive hepatectomy.

Results

The average maximum tumour size at the first hepatectomy was significantly larger than that at the second hepatectomy (P < 0.05). The extent of the first hepatectomy was significantly greater than that of the second one (P < 0.05). There were no mortalities at either hepatectomy. The morbidities of the first and the second hepatectomies were 9.1% and 18.2%, respectively. All complications were bile leakage. Furthermore, there were no significant differences in the clinical features, including the prognosis, between the octo and young groups.

Conclusion

Selected octogenarians who received a second hepatectomy showed a relatively good post‐operative course after the first and second hepatectomies. Repeated hepatectomy for octogenarians seems to have same positive influence on the prognosis in comparison to the young group. But on the data analysed, we have not shown repeated hepatectomy is superior to non‐surgical treatments.

High efficacy and patient satisfaction with a nurse‐led colorectal cancer surveillance programme with 10‐year follow‐up

July 7, 2019 - 21:48

Nurse‐led surveillance after resection for colorectal cancer is valuable but requires validation. Results of the present study show high efficacy, high rates of patient satisfaction and appropriate clinical management.


Background

Surveillance after colorectal cancer resection remains contentious, and faces several contemporary issues. Patient‐centred care, intensive surveillance programmes and patient complexity increase the burden of surveillance on consultant‐led clinics. Recent years have seen reshaping of nursing roles to meet healthcare demand. Nurse‐led follow‐up after colorectal cancer has been piloted, but not validated. We report outcomes from a nurse‐led colorectal cancer surveillance clinic functioning in our institution since 2008, the longest term follow‐up in the published literature.

Methods

Included patients were surveilled through the clinic from 2008 to 2018 by credentialled nurses who performed history, examination and investigations as per the local protocol. Demographic, tumour‐related, outcome‐related and patient satisfaction data were extracted from a prospectively maintained database. Primary outcomes were compliance with surveillance protocol and patient satisfaction.

Results

A total of 138 patients were included in the analysis. Mean time in surveillance was 25.4 months. Surveillance investigation protocol compliance was 97.4% overall. Five recurrences (3.6%) were detected during surveillance. In patients who developed recurrence, protocol compliance was 100%, and no clinical features of recurrence were newly found when patients were reviewed by a consultant surgeon. All recurrences during surveillance were detected by nursing staff. Response rate to the patient satisfaction survey was 90%. 96.3% of patients reported receiving adequate explanation regarding cancer surveillance and nurse‐led care. 90.7% of patients rated the clinic as ‘excellent’ and 9.3% as ‘good’.

Conclusion

Our results show a high level of efficacy and patient satisfaction associated with a nurse‐led colorectal cancer surveillance clinic over a prolonged time period, the longest in the published literature.

Carbapenem sparing in the management of post‐transrectal prostate biopsy bacteraemia

July 4, 2019 - 21:15
Background

Sepsis following transrectal ultrasound (TRUS)‐guided prostate biopsy is a major complication. With the emergence of multidrug‐resistant organisms, empirical use of carbapenem antibiotics has been increasing. This study, conducted in the Illawarra Shoalhaven Local Health District (ISLHD), Australia, quantifies how much we can spare carbapenem use.

Methods

A retrospective audit of patients who underwent TRUS prostate biopsy and were admitted post‐operatively with proven bacteraemia between January 2007 and April 2016.

Results

Of 2719 TRUS procedures, 50 (1.84%) cases had bacteraemia. The most common isolate was Escherichia coli in 44 of 50 (88%) of which six of 50 (12%) were extended‐spectrum beta‐lactamase (ESBL)‐producing. Sixteen different empirical antimicrobial regimens were used, to which 42 of 50 (84%) of isolates were susceptible. Eight (16%) isolates were resistant to the chosen empiric combination, with five switched over to appropriate treatment once antimicrobial sensitivity results became available. Empirical carbapenem was utilized in 12 of 50 (24%) patients with only two of the ESBL isolates covered. A further 10 of 50 patients received carbapenems during their admission. Carbapenems could have been avoided in 18 of 22 (82%). A total of 86% of organisms (n = 43) were susceptible to the combination of amoxicillin–clavulanate and gentamicin.

Conclusion

Although the rates of bacteraemia with ESBL‐producing organisms post‐TRUS biopsy are increasing, use of carbapenem‐free combination antimicrobials as empirical therapy appears to be safe and effective in our setting. Clinicians can utilize local resistance patterns to inform targeted and appropriate therapy for septic patients.

Increasing primary anastomosis rate over time for the operative management of acute diverticulitis

July 4, 2019 - 21:14

Primary anastomosis rates for the operative management of acute diverticulitis have increased over the study period in our institution. The primary anastomosis rates were higher if a colorectal surgeon performed the procedure.


Background

Over the past two decades, there has been mounting evidence that primary anastomosis (PA) is a safe alternative to Hartmann's procedure (HP) in acute diverticulitis. In addition, specialized colorectal surgeons are more likely to perform PA. This study aimed to analyse if this evidence has led to an increase in the rate of PA in a major tertiary institution over time.

Methods

A retrospective observational study of patients requiring operative management of acute diverticulitis from 1 January 2001 to 31 December 2015 at a tertiary teaching hospital.

Results

One hundred and eighteen patients underwent surgery for acute diverticulitis. Patients who failed initial conservative management were more likely to have PA (43% versus 21%, P = 0.044). There was no difference in medical or surgical complications, readmission rate or mortality between patients who had a PA compared with HP. Patients were more likely to have a PA if a colorectal surgeon was operating compared with a colorectal surgery fellow or general surgeon (36% versus 19% versus 10%, P = 0.039). In patients with modified Hinchey 0–2, there was an increased PA rate within the study period, 21%, 43%, 63% to 57% from the first to the fourth quartile of patients (P = 0.038).

Conclusions

The mounting evidence for the safety of performing PA has led to an increase in the PA rates for acute diverticulitis. Patients who were operated by a colorectal surgeon were more likely to have a PA. The morbidity and mortality were similar in patients who had PA compared with HP.

Does indocyanine green improve the evaluation of perfusion during laparoscopic colorectal surgery with extracorporeal anastomosis?

July 4, 2019 - 21:14

While technically easy to perform indocyanine green perfusion testing does not appear to add additional information in the setting of laparoscopic segmental colonic resection with extracorporeal anastomosis and result from such studies should be interpreted with a degree of caution.


Background

There has been recent interest in indocyanine green (ICG) to assess anastomotic perfusion in colorectal surgery. We describe our experience using ICG when performing laparoscopic segmental colorectal resections with extracorporeal anastomotic technique and a highly standardized approach for clinically assessing blood flow.

Methods

We recruited 20 consecutive patients to undergo segmental laparoscopic resection and determined an appropriate point to transect mesentery proximally confirming pulsatile arterial flow at this level. Once confirmed, we did a further perfusion study using ICG to ascertain if this would change intraoperative decision‐making.

Results

Twenty segmental colonic resections were assessed in nine female and 11 male patients aged 26–91 years. ICG administration was safe with no adverse outcomes documented. ICG demonstrated anastomotic perfusion in all cases. We observed no cases wherewith pulsatile blood flow at the cut edge of the mesentery, ICG showed inadequate perfusion at this level. We did find in 25% of cases ICG showed perfusion beyond the cut edge of the mesentery to a distance of up to 2.5 cm.

Conclusion

ICG perfusion is safe and straightforward to carry out. However, when pulsatile arterial bleeding is demonstrated clinically it does not add anything to assessment of perfusion in our study. Furthermore, in 25% of cases perfusion can be demonstrated beyond the cut edge of the mesentery up to a distance of 2.5 cm. This raises the possibility that an organ well perfused with ICG may have less than ideal blood flow when assessing for this with a view to constructing an anastomosis.

Systematic scoping review of enhanced recovery protocol recommendations targeting return of gastrointestinal function after colorectal surgery

July 4, 2019 - 21:14
Background

Post‐operative ileus (POI) and delayed return of gastrointestinal (GI) function are common complications after colorectal surgery. There is a lack of uniformity in enhanced recovery protocols (ERPs) with regards to interventions used to target these complications. This systematic review aims to categorize and summarize management recommendations available from published ERPs.

Methods

A systematic search of Ovid MEDLINE, Embase, Cochrane Library and PubMed databases was performed from January 1990 to May 2018. All studies publishing enhanced recovery or fast‐track or multimodal pathway protocols for colorectal surgery in their full‐text were included. Data on interventions aimed at reducing the duration of POI were extracted, as well as references quoted to support specific interventions.

Results

Of 481 manuscripts screened, 37 published ERPs were identified from 37 studies (18 cohort, seven historical‐control, five guidelines, four randomized controlled trials, one randomized controlled trial protocol, one case series and one narrative review). The most commonly recommended interventions were magnesium‐based laxatives (18 of 37, 48.6%), chewing gum (13 of 37, 35.1%), Alvimopan (6 of 37, 16.2%), lactulose (4 of 37, 10.8%), neostigmine (2 of 37, 5.4%) and bisacodyl (2 of 37, 5.4%). Geographical trends were noted for the various interventions, but high‐quality evidence was only referenced to support the use of Alvimopan.

Conclusion

ERP recommendations specific to interventions targeting POI and return of GI function are varied. While laxatives are the most commonly recommended intervention, there is only weak evidence reported to support this practice.

Rare presentation of a tailgut cyst

July 4, 2019 - 19:55
ANZ Journal of Surgery, EarlyView.

Inferior load generated by preloaded versus manually loaded haemorrhoid banding devices: the effect of ‘creep relaxation’

July 4, 2019 - 19:53

Ligature bands from pre‐loaded haemorrhoid banding devices suffer age‐related deterioration in load generated. This could result in higher rates of recurrence.


Background

The efficacy of rubber band ligation of haemorrhoids relies on the load generated on haemorrhoidal tissue by bands as they return to their preformed shape after being deployed. ‘Preloaded’ haemorrhoid banding devices are widely available, but the effect of the resultant prolonged stretch on bands while stored in this manner has never been examined by comparing these to manually loaded devices, which are stretch immediately prior to being deployed. A difference could have clinical relevance, potentially resulting in a higher rate of clinical failure. The present study aimed to investigate any difference in load generated by preloaded versus manually loaded devices.

Methods

A preloaded and a manually loaded device were selected for comparison. Each type was measured on a testing rig. The device type, load generated by each band and the time to expiry were recorded.

Results

A total of 137 haemorrhoid bands were tested: 66 preloaded and 71 manually loaded. There was a statistically significant overall reduction in load generated by preloaded versus manually loaded devices (284.0 versus 272.1 g, mean difference −11.9 g, 95% confidence interval −17.5 to −6.3 g, P = 0.0001). Adjusted for time, the load generated by preloaded bands fell 3.7 g (95% confidence interval 2.7–4.8, P < 0.001) for each month closer to the expiry date.

Conclusions

The load generated by haemorrhoid bands from preloaded devices is lower and deteriorates significantly towards their expiry date compared with bands from manually loaded devices. This is mostly likely due to their storage in a stretched state. This should be considered by clinicians when using haemorrhoid banding devices.

Assessment of haemorrhoidal artery network using Doppler‐guided haemorrhoidal artery ligation for haemorrhoids and pathogenesis implications

July 1, 2019 - 22:29

The aim of the study was to record the exact position of the distal branches of the superior rectal artery during Doppler‐guided haemorrhoidal artery ligation‐rectoanal repair procedures for haemorrhoids. Number of distal branches of the superior rectal artery is lower at the posterior midline than in the other segments of the lower rectum. This is evidence of the vascular deficiency at the posterior pole of the anal canal that might explain the pathogenesis of anal fissures.


Background

Some authors, either with anatomical studies or Doppler laser flowmetric investigations have shown the blood flow to the posterior midline of the anus to be potentially deficient. This relative local ischaemia might explain pathogenesis of anal fissure, which is often located posteriorly. The aim of this study was to record the exact position of the distal branches of the superior rectal artery during Doppler‐guided haemorrhoidal artery ligation‐rectoanal repair (HAL‐RAR) procedures with special reference to posterior distribution of the arteries.

Methods

All consecutive patients with symptomatic haemorrhoids who were treated with the HAL‐RAR procedure between February 2008 and February 2014 in a single institution were included in the study. Number and position of Doppler‐guided ligations were prospectively collected. Pearson's chi‐squared test was used to compare artery locations.

Results

A total of 150 patients (75 women) with symptomatic haemorrhoids were included in the study. Median age was 53 years (range 23–83). A median of 10 ligations were placed per patient (range 3–18). A significantly lower number of cumulative arterial ligations was recorded in the posterior position (88 ligations overall, P = 0.025).

Conclusions

The number of distal branches of the superior rectal artery that have been localized by the Doppler‐guided HAL‐RAR technique is lower at the posterior midline than in the other segments of the lower rectum. This is another evidence of the vascular deficiency at the posterior pole of the anal canal that might explain the pathogenesis of the anal fissure.

Does the form of venous thromboembolism prophylaxis following primary total knee arthroplasty alter the rate of early reoperation or revision surgery?

June 24, 2019 - 21:29

Does the form of venous thromboembolism prophylaxis following primary total knee arthroplasty alter the rate of early reoperation or revision surgery: a systematic review and qualitative analysis.


Background

Currently there is significant variation in the management of venous thromboembolism prophylaxis following total knee arthroplasty (TKA). Excessive wound ooze and bleeding is thought to increase a patient's risk of haematoma formation and possible infection. We evaluated the rate of unexpected reoperation in the perioperative period in patients who received aspirin, rivaroxaban or enoxaparin following primary TKA.

Method

A systematic literature search was conducted in MEDLINE, CENTRAL and Embase to identify patients who underwent primary TKA. Two researchers independently reviewed the references identified in the literature search. The final 11 studies included for review were published between 1996 and 2016.

Results

There was a higher rate of reoperation in patients treated with aspirin following TKA when compared to enoxaparin and rivaroxaban in the perioperative period. Of the 5141 patients treated with enoxaparin, 11 (0.21%) required reoperation; of the 2764 patients treated with rivaroxaban, 12 (0.43%) required reoperation; and of the 228 patients treated with aspirin, seven (3.07%) required reoperation. The average time to follow‐up in the 11 studies was 55 days, ranging from 30 to 180 days post‐operatively.

Conclusion

There was a higher rate of reoperation in patients treated with aspirin following TKA when compared to enoxaparin and rivaroxaban in the perioperative period. While there is extensive data on the safety and efficacy of these medications following joint arthroplasty, improved reporting of surgically relevant outcomes are needed to assist both the surgeon and patient in clinical decision‐making.