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: 22 hours 3 min ago

Gastroepiploic artery pseudoaneurysm: a rare cause of abdominal pain

September 12, 2019 - 19:09
ANZ Journal of Surgery, EarlyView.

Near‐infrared spectroscopy in the diagnosis of testicular torsion: valuable modality or waste of valuable time? A systematic review

September 12, 2019 - 03:33

Testicular torsion (TT) is a urological emergency that affects one in 4000 males younger than 25 years. Delays in the management of TT may result in testicular ischaemia, testicular necrosis, orchidectomy and infertility. This review assesses the validity of near‐infrared spectroscopy as a diagnostic tool in the assessment and diagnosis of TT.


Abstract Background

Testicular torsion (TT) is a urological emergency that affects one in 4000 males younger than 25 years. Delays in the management of TT may result in testicular ischaemia, testicular necrosis, orchidectomy and infertility. This review assesses the validity of near‐infrared spectroscopy (NIRS) as a diagnostic tool in the assessment and diagnosis of TT.

Methods

A systematic search of Cochrane Database of Systematic Reviews, EMBASE, Google Scholar, PubMed, Scopus and Web of Science databases was performed in January 2019 using specific search terms. Selected studies were ranked and evaluated using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines and the Quality Assessment of Diagnostic Accuracy Studies‐2 tool.

Results

A total of nine studies that included 253 subjects (88 animals and 165 humans) with a mean sample size of 28.1 (standard deviation 40.8) subjects were included. The mean difference in testicular tissue oxygen saturation between torsed and non‐torsed testes (Δ%StO2) were 45%, 42% (±5%), 26% and 5–18% in four animal studies and 2.0%, 3.0%, 6.7%, 6.8% and 23.0% in five human studies. The tissue oxygen saturation difference between contralateral healthy testes (controls) ranged from 1% to 10% in the five studies that alluded to this.

Conclusion

The current body of evidence does not support the use of NIRS in the work‐up of TT. Well‐designed clinical trials with large patient samples are required to determine whether NIRS may have some future role as a diagnostic modality in TT.

Clinical state of the paediatric acute scrotum in south‐eastern Victoria

September 11, 2019 - 20:04

This is a prospective study investigating delays in assessment and treatment of acute scrotal pain in children. We identify potential delays from the time of onset of the pain to seeking medical advice at different healthcare providers


Abstract Background

Acute scrotal pain is a common paediatric surgical presentation. Delays in treatment can result in testicular loss from torsion. It is unclear where delays occur. We aimed to investigate presentations with an acute scrotum to identify any potential areas of delay.

Methods

We conducted a prospective study (April 2017–November 2018) of paediatric patients (<18 years) presenting with acute scrotal pain. Data collected included: patient demographics, history/examination findings, mode of presentation, clinical timeline details and outcomes.

Results

A total of 107 acute scrotum presentations were identified: 58 (54.2%) testicular appendage torsion, 23 (21.5%) testicular torsion, 6 (5.6%) epididymo‐orchidits and 20 (18.7%) other diagnoses. Median age at presentation was 11 years (4 months–16 years). Fifty‐seven (53.3%) underwent emergency surgery, of whom 23 (40.4%) had testicular torsion, with 2 requiring orchidectomy. Median time from onset of symptoms to seeking medical opinion was 5.5 (0–135) h. Once assessed by a medical professional, the route to paediatric surgical review via general practitioner (GP) and local emergency department (ED) to paediatric ED was 4.84 (1.67–24.5) h; via GP to paediatric ED was 2.58 (0.75–25.5) h; via local ED to paediatric ED was 2.25 (1–7.75) h; and directly to paediatric ED was 0.45 (0–1.42) h.

Conclusion

Delays in assessment and treatment of acute scrotal pain occur from the time parents are aware of symptoms to seeking medical opinion. Education to increase awareness may reduce time delays. GPs should refer patients directly to a paediatric ED. Local EDs should manage paediatric cases as per the local surgeons' skill base.

Clinical predictors of small solitary hepatitis B virus‐related hepatocellular carcinoma microinvasion

September 11, 2019 - 20:03
Abstract Background

Microinvasion serves as a reliable indicator of poor prognosis after hepatectomy or transplantation for hepatocellular carcinoma (HCC). However, microinvasion is difficult to detect with current imaging modalities and is usually diagnosed histopathologically. The aim of this study is to identify the preoperative clinical predictors of microinvasion of small solitary hepatitis B virus (HBV)‐related HCC.

Methods

From January 2000 to December 2009, 110 patients with HBV‐related small primary solitary HCC (tumour diameter ≤3.0 cm) who underwent hepatectomy at Chinese PLA General Hospital were enrolled. The independent predictors of microinvasion, such as microvascular invasion and microscopic satellite nodules, were analysed. The prognosis of patients with microinvasion was compared with that of patients without microinvasion.

Results

Of the 110 patients, 31 (28.2%) exhibited microinvasion. Among them, 16 (51.6%) had microvascular invasion with microscopic satellite nodules, five (16.1%) had microscopic satellite nodules without microvascular invasion and 10 (32.3%) had microvascular invasion without microscopic satellite nodules. Two independent predictors of microinvasion were identified: serum alpha‐fetoprotein >20 ng/mL and a viral load of >104 copies/mL. Patients without microinvasion exhibited a significantly better prognostic outcome compared with those with microinvasion.

Conclusion

Regarding HBV‐related small HCC, patients presenting with alpha‐fetoprotein levels >20 ng/mL and a high viral load (HBV‐DNA >104 copies/mL) are at substantial risk for microinvasion.

Ten‐year evolution of a massive transfusion protocol in a level 1 trauma centre: have outcomes improved?

September 10, 2019 - 05:00
Abstract Background

We aimed to evaluate the evolution and implementation of the massive transfusion protocol (MTP) in an urban level 1 trauma centre. Most data on this topic comes from trauma centres with high exposure to life‐threatening haemorrhage. This study examines the effect of the introduction of an MTP in an Australian level 1 trauma centre.

Methods

A retrospective study of prospectively collected data was performed over a 14‐year period. Three groups of trauma patients, who received more than 10 units of packed red blood cells (PRBC), were compared: a pre‐MTP group (2002–2006), an MTP‐I group (2006–2010) and an MTP‐II group (2010–2016) when the protocol was updated. Key outcomes were mortality, complications and number of blood products transfused.

Results

A total of 168 patients were included: 54 pre‐MTP patients were compared to 47 MTP‐I and 67 MTP‐II patients. In the MTP‐II group, fewer units of PRBC and platelets were administered within the first 24 h: 17 versus 14 (P = 0.01) and 12 versus 8 (P < 0.001), respectively. Less infections were noted in the MTP‐I group: 51.9% versus 31.9% (P = 0.04). No significant differences were found regarding mortality, ventilator days, intensive care unit and total hospital lengths of stay.

Conclusion

Introduction of an MTP‐II in our level 1 civilian trauma centre significantly reduced the amount of PRBC and platelets used during damage control resuscitation. Introduction of the MTP did not directly impact survival or the incidence of complications. Nevertheless, this study reflects the complexity of real‐life medical care in a level 1 civilian trauma centre.

Clinicopathological factors associated with positive circumferential margins in rectal cancers

September 9, 2019 - 18:51

The incidence of advanced T3/T4 rectal cancers with positive circumferential resection margins after surgery in Western Sydney is significantly higher than recent national estimates. This may be exacerbated by failure to treat eligible patients with appropriate neoadjuvant therapy.


Abstract Background

Positive circumferential resections are associated with local disease recurrence and reduced survival in rectal cancer. We studied a cohort of consecutive rectal cancer resections to assess for clinicopathological differences and survival in patients with positive and negative circumferential margins.

Methods

Rectal cancers were identified from a retrospective histopathology database of colorectal resections performed at five western Sydney hospitals from 2010 to 2016. Univariate and multivariate analysis with binary logistic regression were performed on histopathology data matched with survival times from the New South Wales Registry of Births Deaths and Marriages.

Results

A total of 502 rectal cancer patients were identified including 66 (13.1%) with involved circumferential margins. Patients with positive and negative circumferential margins had a similar distribution of age, gender and use of neoadjuvant radiotherapy. Tumours with involved circumferential margin comprised 98.5% T3 and T4 disease of which 51.5% received neoadjuvant radiotherapy. These were significantly associated with metastatic disease, increasing tumour size, circumferential and perforated tumours on univariate analysis. Multivariate analysis identified abdomino‐perineal resection (odds ratio (OR) 3.35; P = 0.003), en‐bloc multivisceral resection (OR 2.56; P = 0.032), T4 stage (OR 6.99; P < 0.001), perineural (OR 5.61; P < 0.001) and vascular invasion (OR 2.46; P = 0.022) as independent risk factors. Five‐year survival was significantly worse for patients with involved circumferential margins (26% versus 69%; P < 0.001).

Conclusion

Circumferential margin status reflects not only technical success but also aggressive disease phenotypes which require adjuvant therapy. Further work is needed to determine whether omission of radiotherapy has had an effect on long‐term outcomes in some of our at‐risk patients.

Comparative study of outcomes for elderly hip fractures presenting directly to a referral hospital versus those transferred from peripheral centres

September 9, 2019 - 18:49
Abstract Background

The geography of rural Australia poses a myriad of logistical dilemmas, including the provision of timely access to emergency orthopaedic hip fracture surgery. Current guidelines support surgery within 48 h, and delays to transfer to a referral hospital may result in worse outcomes and increase mortality rates. The aim of this study was to examine the effect of transfer delays on the clinical outcomes of hip fractures in a rural setting.

Methods

We retrospectively reviewed 265 hip fracture patients who underwent surgical management between 2013 and 2015 at a rural referral hospital. Factors such as age, time to surgery, delay to surgery, preoperative clinical deterioration, preoperative transthoracic echocardiogram, American Society of Anesthesiologists class and 30‐day and 1‐year mortality rates were examined. Unadjusted odds ratios were calculated for statistically significant primary and secondary outcomes.

Results

The mean delay to transfer was 19.9 h. Patients were 6.76 times more likely to undergo surgery within 48 h if they presented to the referral hospital first. Surgery within 48 h was more likely in those who presented to the referral hospital first, had no preoperative transthoracic echocardiogram and did not experience a preoperative clinical deterioration. The 30‐day mortality rates were significantly higher in those who had surgery after 48 h or underwent a preoperative clinical deterioration.

Conclusion

Increased time to hip fracture surgery was associated with increased mortality rates. Transfer delays from a peripheral hospital had a significant bearing on time to surgery. Early transfer to a referral hospital is recommended.

Factors associated with the decision for operative versus conservative treatment of displaced distal radius fractures in the elderly

September 3, 2019 - 21:14
Abstract Background

The treatment of senile distal radius fractures had not been clearly defined. The objective of this study was to identify the factors associated with the decision for operative treatment of displaced distal radius fractures in patients aged over 55 years.

Methods

Data of 318 patients with displaced distal radius fractures were collected on patient‐, fracture‐ and surgeon‐related characteristics that were plausibly related to the decision for operation. Mean comparisons or chi‐squared test were used for univariate analysis of the above‐mentioned factors, and then multiple logistic regression was used to identify factors associated with the decision for operation.

Results

Univariate analysis showed that age, osteoporosis, Charlson score, associated orthopaedic injuries requiring surgery, Orthopaedic Trauma Association (AO) and Fernandez classification, radial height, volar tilt, volar/dorsal comminution, ulnar variance, intra‐articular displacement/step‐off, associated distal radioulnar joint instability or radiocarpal joint dislocation and subspecialty of treating surgeons had statistically significant association with operative intervention. In the multivariate analysis, the predictors of operative intervention were younger patient age (P = 0.028), associated orthopaedic injuries requiring surgery (P = 0.020), higher AO classification (P = 0.037), higher Fernandez classification (P = 0.041), radial shortening >5 mm (P = 0.020), volar tilt > −10° (P = 0.020), volar/dorsal comminution (P = 0.020), ulnar variance >5 mm (P = 0.023), intra‐articular displacement/step‐off >2 mm (P = 0.004), associated distal radioulnar joint instability or radiocarpal joint dislocation (P = 0.047) and treatment by an upper extremity specialist (P = 0.038).

Conclusion

The decision for surgery was predominantly influenced by the characteristics and severity of the fracture. Patients' age and treatment by an upper extremity specialist were also significant factors associated with a higher likelihood of operative intervention.

Assessment of hospital characteristics associated with improved mortality following complex upper gastrointestinal cancer surgery in Queensland

September 3, 2019 - 21:14

Post‐operative mortality is lower following oesophagectomy and pancreaticoduodenectomy performed in high‐volume (six or more procedures annually) when compared with low‐volume centres, regardless of hospital service capability.


Abstract Background

High hospital‐volume and service capability are associated with improved mortality following complex cancer surgery. Using a population‐based study in Queensland, we assessed differences in mortality following oesophagectomy and pancreaticoduodenectomy, comparing high‐ and low‐volume hospitals stratified by service capability.

Methods

Data on all patients undergoing oesophagectomy and pancreaticoduodenectomy for cancer in Queensland between 2001 and 2015 were obtained from the Queensland Oncology Repository. Hospital service capability was defined using the 2015 Australian Institute of Health and Welfare hospital peer groupings. Hospitals were grouped into ‘high‐volume (≥6 oesophagectomies or pancreaticoduodenectomies annually) with high service capability'; ‘low‐volume (<6) with high service capability' and ‘low‐volume with low service capability'. Multivariate Poisson models were used to estimate differences in 30‐ and 90‐day mortality between hospital groups adjusting for age, sex, socioeconomic status, Charlson and American Society of Anesthesiologists scores, chemotherapy, radiotherapy, stage and time‐period.

Results

For oesophagectomy, adjusted 90‐day mortality was higher in low‐volume compared with high‐volume hospitals, regardless of service capability (low‐volume, high service: incident rate ratio (IRR) 3.86, 95% confidence interval (CI) 1.74–8.57; low‐volume, low service: IRR 3.40, 95% CI 1.16–10.00). For pancreaticoduodenectomy, mortality was higher in low‐volume compared with high‐volume centres regardless of service capability: 30‐day mortality (low‐volume, high service: IRR 2.32, 95% CI 1.07–5.03; low‐volume, low service: IRR 3.92, 95% CI 1.45–10.61); 90‐day mortality (low‐volume, high service: IRR 2.36, 95% CI 1.29–4.30; low‐volume, low service: IRR 3.32, 95% CI 1.64–6.71).

Conclusion

High hospital resection volumes are associated with lower post‐operative mortality following oesophagectomy and pancreaticoduodenectomy regardless of hospital service capability. This data supports centralization of these procedures to high‐volume centres.

Top 100 most frequently cited papers in liver cancer: a bibliometric analysis

September 3, 2019 - 21:14

We analyse the 100 most cited papers in liver cancer. These 100 most cited papers reflect major advances and a number of hot topics of liver cancer during the recent decades.


Abstract Background

Bibliometric analysis has become popular in recent years, and increasingly more articles focusing on a particular disease are being published. The present study was performed to analyse the 100 most frequently cited papers in liver cancer (LC).

Methods

We searched the Thomson Reuters Web of Science database on 14 July 2018 to identify all potential manuscripts for this study. The search terms were ‘liver cancer’ and its synonyms. Manuscripts were listed in descending order by the total citations (TCs), and the 100 most frequently cited papers were identified and analysed by topic, journal, author, year and institution.

Results

We retrieved 235 687 papers from the Web of Science database. The TC of the 100 most frequently cited papers in LC ranged from 612 to 5358. The 100 papers were published in 31 journals and came from nine countries. The University of Barcelona published the highest number of papers and had the most TC. Ten authors published more than one paper. Treatment of LC was the most widely studied topic. A significant correlation was found between the journal's 2017 impact factor and the TC (P = 0.003).

Conclusion

We assessed the landmark papers in the field of LC. These 100 most frequently cited papers reflect major advances and several hot topics in LC during the recent decades. Our study is of great value for young investigators, provides insights into the trends of LC and can guide directions for future academic research.

Modifiable risk factors for multidrug‐resistant Gram‐negative infection in critically ill burn patients: a systematic review and meta‐analysis

September 3, 2019 - 21:14

We conducted a meta‐analysis combining data from 11 studies to identify modifiable risk factors for multidrug‐resistant Gram‐negative infection in a burn intensive care unit. Risk factors included antibiotic exposures and hospital interventions. Cephalosporins and carbapenems posed the highest antibiotic risks while urinary and arterial catheters posed the highest hospital intervention risks.


Abstract Background

We conducted a systematic review and meta‐analysis to identify potentially modifiable risk factors for multidrug‐resistant Gram‐negative colonization or infection in critically ill burn patients.

Methods

A systematic search was conducted of PubMed, Embase, CINAHL, Web of Science and Central (Cochrane). Risk factors including antibiotic use and hospital interventions were summarized in a random‐effects meta‐analysis. Risk of publication bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation method and funnel plots.

Results

A total of 11 studies met the inclusion criteria. We identified several potentially modifiable risk factors and were able to grade their importance based on effect size. Related to prior antibiotic exposure, extended‐spectrum cephalosporins (pooled odds ratio (OR) 7.00, 95% confidence interval (CI) 2.77–17.67), carbapenems (pooled OR 6.65, 95% CI 3.49–12.69), anti‐pseudomonal penicillins (pooled OR 4.23, 95% CI 1.23–14.61) and aminoglycosides (pooled OR 4.20, 95% CI 2.10–8.39) were most significant. Related to hospital intervention, urinary catheters (pooled OR 11.76, 95% CI 5.03–27.51), arterial catheters (pooled OR 8.99, 95% CI 3.84–21.04), mechanical ventilation (pooled OR 5.49, 95% CI 2.59–11.63), central venous catheters (pooled OR 4.26, 95% CI 1.03–17.59), transfusion or blood product administration (pooled OR 4.19, 95% CI 1.48–11.89) and hydrotherapy (pooled OR 3.29, 95% CI 1.64–6.63) were most significant.

Conclusion

Prior exposure to extended‐spectrum cephalosporins and carbapenems, as well as the use of urinary catheters and arterial catheters pose the greatest threat for infection or colonization with multidrug‐resistant Gram‐negative organisms in the critically ill burn patient population.

Acute surgical experience of Australian general surgical trainees

September 3, 2019 - 21:14

A de‐identified summary of general surgical trainee logbook data was obtained from General Surgeons Australia, over a 6‐year period (2009–2014). Case volumes in operative and non‐operative acute surgical cases were analysed over this time, encompassing 5307 individual logbooks. The acute surgical case experience of general surgical trainees has not declined according to this research, but should continue to be monitored in view of the changing scope of general surgical practice.


Abstract Background

A principle of Australian general surgical training is exposure to a variety of operative and clinical experiences. These are potentially being impacted upon by expanding post‐fellowship training positions, mandatory reduced working hours, and advances in non‐operative care. This study aims to report the recent acute surgical experience of Australian general surgical trainees.

Methods

A de‐identified summary of general surgical trainee logbook data was obtained from General Surgeons Australia, over a 6‐year period (2009–2014). Case volumes in operative and non‐operative acute surgical cases were analysed, encompassing 5307 individual logbooks from 12 consecutive training terms.

Results

There was a mean of 112.2 ± 6.8 total major operative cases per trainee per term. There was an increase in case volumes reported from terms 1–8 (from 102.1 to 122.9), with the most recent reported volume being 117.8 cases per trainee in term 12. The total major operative primary operator rate increased from 35.5% in term 1 to 40.6% in term 8, with the most recent reported rate being 41.8% in term 12. Open and laparoscopic colorectal case volumes have remained stable. Operative trauma case volumes have increased.

Conclusion

The acute surgical operative case experience of general surgical trainees has not declined. However, it should continue to be monitored in view of the changing scope of surgical practice.

Demonstration of superficial venous dominance in the deep inferior epigastric perforator flap

September 3, 2019 - 21:14
ANZ Journal of Surgery, EarlyView.

Biomechanical performance of an intramedullary Echidna pin for fixation of comminuted mid‐shaft clavicle fractures

September 3, 2019 - 21:14

The aim of this study was to evaluate the biomechanical performance of clavicles repaired using a novel intramedullary Echidna pin device and the Knowles pin. The Echidna pin features retractable spines that engage with the bone to minimize migration and facilitate ease of device removal. The is device, which exhibits greater bending strength and pull‐out strength than that of the Knowles pin, may produce a more stable clavicle fracture reduction compared to that of commercially available threadless intramedullary pins.


Abstract Background

Surgical fixation of comminuted mid‐shaft clavicle fractures commonly employs intramedullary devices; however, pins with smooth surfaces are prone to migration, whilst threaded pins can be challenging to remove post‐operatively. The aim of this study was to evaluate the biomechanical performance of fractured clavicles repaired using a novel intramedullary Echidna pin device and a non‐threaded Knowles pin. The Echidna pin features retractable spines that engage with the bone to minimize migration and facilitate ease of device removal.

Methods

A total of 28 cadaveric clavicle specimens were harvested and a mid‐shaft wedge‐shaped osteotomy was performed to simulate a comminuted butterfly fragment. Specimens were allocated randomly to either the Echidna pin or Knowles pin fracture repair groups. Following surgery, eight specimens in each group underwent 200 cycles of four‐point bending, whilst six specimens in each group underwent torsional testing and pull‐out. Cyclic construct bending stiffness, torsional stiffness and ultimate strength were recorded.

Results

Echidna pin intramedullary repair constructs showed significantly greater bending stiffness (mean difference 0.55 N.m/°, 95% confidence interval −0.96, −0.14, P = 0.01) and pull‐out strength (mean difference 146.03 N, 95% confidence interval 29.14, 262.92, P = 0.019) in comparison to Knowles pin constructs. There was no significant difference in torsional stiffness between Echidna pin and Knowles pin repair constructs (P > 0.05).

Conclusion

The intramedullary Echidna pin device, which exhibits greater bending strength and pull‐out strength than that of the Knowles pin, may produce a more stable clavicle fracture reduction compared to that of commercially available threadless intramedullary pins.

Early laparoscopic cholecystectomy by a dedicated emergency surgical unit confers excellent outcomes in acute cholecystitis presenting beyond 72 hours

September 3, 2019 - 21:14

Laparoscopic cholecystectomy performed in patients with acute cholecystitis after 72 h of symptom onset by a dedicated surgical unit can have good outcomes


Abstract Background

Early laparoscopic cholecystectomy (ELC) within 72 h of symptom onset is preferred for management of acute cholecystitis (AC). Beyond 72 h, acute‐on‐chronic fibrosis sets in rendering surgery challenging. This study aims to compare the outcomes of ELC for AC within and beyond 72 h of symptom onset by a dedicated acute surgical unit.

Methods

This is a single‐centre retrospective study of 217 patients with AC who underwent ELC by an acute surgical unit from January 2017 to August 2018. Outcomes collected include post‐operative morbidity, length of hospitalization and operation duration. A subgroup analysis for the same outcomes was performed for elderly patients.

Results

Of the 217 patients, 88 were operated within 72 h of symptom onset while 129 were operated beyond 72 h. Twenty‐six patients received ELC after 7 days. There was no occurrence of bile duct injury. There was no statistical difference in conversion rates, wound infections and post‐operative collections. Patients receiving ELC beyond 72 h had longer duration of operation (125.4 versus 116 min, P = 0.035) and length of hospitalization (4.59 versus 3.09 days, P = 0.001) without increase in morbidity. Patients older than 75 years had a higher incidence of post‐operative collection (P < 0.001).

Conclusion

Patients with AC undergoing ELC by a dedicated acute surgical unit can have good outcomes even beyond 72 h of symptom onset. Meticulous haemostasis should be performed for the elderly subgroup of patients.

Systemic predictors of adverse events in a national surgical mortality audit: analysis of peer‐review data from Australia and New Zealand Audit of Surgical Mortality

September 3, 2019 - 21:13

Examination of the Australia and New Zealand Audit of Surgical Mortality database has revealed systemic or organizational predictors of adverse events that may have implications for quality improvement at an institutional or jurisdictional level. The extent to which these associations are due to the peer‐review process itself should be the focus of further research.


Abstract Background

Peer review of surgical deaths can identify deficits in individual and systemic delivery of healthcare, ultimately informing quality improvement.

Methods

From 2008 to 2016, cases reported to the Australia and New Zealand Audit of Surgical Mortality were analysed. Variables associated with peer‐judged adverse events were sought.

Results

Of 21 045 cases evaluated, 24.8% incurred at least one adverse event judgement. The proportion of cases with reported adverse event significantly decreased over time. Following adjustment for demographic and clinical characteristics, significant negative patient‐related associations were advanced age, greater American Society of Anesthesiologists grade, and neurological and malignant comorbidities. Significant associations were also found with systemic or organizational factors, including state/territory, surgical specialty and hospital regionality.

Conclusion

Examination of this peer‐reviewed database revealed systemic or organizational predictors of adverse events that may have implications for quality improvement at an institutional or jurisdictional level. The extent to which these associations are due to the peer‐review process itself should be the focus of further research.

Common bile duct stones with situs inversus totalis

September 3, 2019 - 21:13
ANZ Journal of Surgery, EarlyView.

Evaluation of the smartphone for measurement of femoral rotational deformity

September 3, 2019 - 04:48

A patent measurement technique has been designed to assess femoral rotation deformation. The aim of this study was to investigate and assess its possibility and reliability.


Abstract Background

A novel measurement technique has been designed to assess femoral rotation deformation. The purpose of this study was to evaluate smartphone‐aided measurement, including measurement software, intra‐observer differences and the occurrence frequency of the unacceptable outliers.

Methods

Five positions (intact bone, external and internal rotations of 20° and 40° of the distal blocks after dividing the femoral shafts using a saw) were used in each of the five artificial femora. Guide wires were separately inserted into the proximal and distal ends of the model femora with a navigation system and the intersection angles between the guide wires were measured with a smartphone. The values obtained by two measurement software packages (Smart Tools and Super Swiss Army Knife) were compared with that measured on the overlapped computed tomography images.

Results

There were no significant differences between the intersection angles measured by smartphone and that measured on the overlapped images (P = 0.24). The mean absolute difference between pairs of measurements of the two software packages for all guide wire angles was 2.33 ± 2.34°, without statistically significant difference (P = 0.33). There was a significant correlation (r = 0.99) between the first and second (1 week apart) measurements with the same measurement tool. The values of offset capability index of the Smart Tools and the Super Swiss Army Knife measurement tools were 1.62 and 1.13, respectively.

Conclusion

Smartphone‐aided measurement technique could reliably assess femoral rotation deformation with more accurate angle measurement for software with zero calibration function.

Bilateral absence of the fibular artery: an unusual variation

September 3, 2019 - 04:47
ANZ Journal of Surgery, EarlyView.