ANZ Journal of Surgery

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What is the non-inflammed appendix?

March 7, 2018 - 10:41

25, 50 & 75 years ago

March 7, 2018 - 10:41

Issue information - TOC

March 7, 2018 - 10:41

Development of a pelvic exenteration service at a tertiary referral centre

March 7, 2018 - 10:06
Background

Over one-third of primary rectal cancers are locally advanced at diagnosis, and local recurrence of rectal cancer occurs at a rate of 3–10% following primary curative resection. Extended resectional surgery, including pelvic exenteration, is the only proven therapy with curative potential in the treatment of these cancers along with many other pelvic malignancies. A microscopically clear resection margin (R0 resection) is the predominant prognostic factor affecting overall and disease-free survival. The extent and complexity of surgery required to achieve an R0 resection is associated with significant risk of morbidity and mortality. The aim of this paper is to show that pelvic exenterations can be performed with acceptable oncological and safe perioperative results in an appropriately resourced specialist centre.

Methods

Data was collected retrospectively for 61 consecutive patients treated between June 2012 and February 2017. This included patient demographics, tumour characteristics, operative, clinical and histological data, length of hospital stay, morbidity and mortality data.

Results

A total of 61 patients underwent surgery. Median age was 57 years (range 27–78 years). Median length of stay was 41 days (range 6–288 days). Median operative time was 624 min (range 239–1035 min); 30-day mortality was 3.3% (n = 2). Resection rates were 91.5% – R0, 6.8% – R1 and 1.7% – R2 resections. Histologically, 86.9% – adenocarcinomas, 3.3% – squamous cell carcinomas and 9.8% – represented by leiomyosarcoma, melanoma, myxoid chondrosarcoma, non-neoplastic processes and undifferentiated carcinoma.

Conclusion

Our experience confirms that radical resectional pelvic surgery can be safely performed with acceptable results during the establishment phase of a dedicated tertiary service.

Addressing social influences reduces antibiotic duration in complicated abdominal infection: a mixed methods study

March 7, 2018 - 10:06
Background

Antimicrobial therapy for intra-abdominal infections is often inappropriately prolonged. An intervention addressing factors influencing the duration of intravenous antibiotic use was undertaken. This study reports the antibiotic prescribing patterns before and after the intervention and a qualitative analysis of the experience of the intervention.

Methods

Quantitative: A retrospective audit of patients with complicated intra-abdominal infection before and after a multifaceted persuasive intervention was performed. Qualitative: Semi-structured interviews were performed to evaluate which elements of the intervention were perceived to be effective.

Results

An intervention including collaborative inter-specialty and inter-professional educational meetings, and education of all professional streams was undertaken. Quantitative: Twenty-three patients before and 22 patients after the intervention were included. The total duration of antibiotics decreased significantly following the intervention (9.2 versus 6.6 days P = 0.02). The duration of intravenous antibiotics did not change significantly (5.4 versus 4.5 days, P = 0.06). Qualitative: Eighteen health-care professionals participated. Thematic analysis indicated that a collaborative approach between senior surgical and infectious disease specialists in the pre-intervention stage led to perceived ownership and leadership of the intervention by the surgical team, which was thought critical to the success of the intervention. Conversely, the ability of nurses and pharmacists to influence antibiotic practice was considered limited and a poster promoting the intervention was perceived as ineffective.

Conclusion

Consultant leadership and specialty ownership of the process were perceived to be critical in the success of the intervention. Antibiotic stewardship programs which address social factors may have greater efficacy to optimize antimicrobial prescribing.

Laparoscopic repair of large hiatal hernias: clinical outcomes of 10 years

March 7, 2018 - 10:06
Background

Whilst laparoscopic repair is the most common surgical procedure for the treatment of large hiatal hernias, knowledge of long-term outcomes (>10 years) is scarce. The aim of this study was to evaluate the long-term results following this approach, in particular the hernia recurrence rate and the impact of repair on quality of life (QoL).

Methods

Patients were identified from a prospective database. A standardized questionnaire was used to assess symptoms and a barium swallow radiograph was performed to determine anatomy. A validated QoL measure, Gastrointestinal Quality of Life Index (GIQLI) was also applied to all patients.

Results

Of the 69 eligible patients, clinical follow-up was available for 54 patients (78.3%). Follow-up ranged from 72 to 185 (median: 114) months. Post-operative heartburn and dysphagia were significantly improved, with 45 patients (83%) reporting a good or excellent result. Contrast radiology in 35 patients (65%) revealed recurrence in 12 patients (34%). Fifty-four patients answered the GIQLI questionnaire. The mean GIQLI score was 117 (61–136). Patients with objectively documented anatomic recurrence had a QoL index of 92 (61–121) compared to an index of 122 (77–136, P < 0.01) in the non-recurrent hernia group.

Conclusions

At mean 114 months follow-up, laparoscopic repair of large hiatal hernias achieves effective and durable relief of symptoms, and most patients are satisfied with the outcome.

Neurological injuries from skateboards in paediatric and adolescent populations: injury types and severity

March 7, 2018 - 10:06
Background

Skateboarding is a popular recreation among children and adolescents. Injuries that result in presentation to emergency departments are varied including head injuries. The study aims to assess the type and severity of neurological damage to the brain and spine in children from injuries incurred while using a skateboard.

Methods

After obtaining Ethics approval, a retrospective case review was performed of all admissions to all Brisbane, Australia public hospital neurosurgery departments of children 18 years and less who experienced injuries to the brain and spine for the years 2010–2014.

Results

There were 51 skateboard-related admissions over the study period of which 94% were male. The mean age was 14.3 years. The Injury Severity Score (ISS) ranged from 1 to 38 with a mean of 11.4. A total of 70.5% of the ISS scores fell within the minor or moderate categories and 29.5% fell within the serious and severe categories. There were no ISS scores in the critical category. A total of 16 skull vault fractures and 14 skull base fractures were recorded. There were 13 extradural haematomas of which five were evacuated by craniotomy and one of whom experienced hemiplegia. There was a spinal cord injury with paraplegia. A range of other neurological complications occurred. There were no deaths.

Conclusion

Uncommon but serious neurological morbidity accompanies skateboard use. Concerns remain about the level of helmet use and choice of unsafe locations for skateboarding.

Snapshot of trauma laparotomy deaths in Queensland

March 7, 2018 - 10:06
Background

Trauma remains the most frequent cause of death for patients under 35 years of age. Head injury and catastrophic haemorrhage account for the majority of early deaths. A trauma laparotomy is often necessary to arrest haemorrhage.

Methods

All patients who died in Queensland hospitals between 2011 and 2016 having had a trauma laparotomy were identified from the Queensland Audit of Surgical Mortality.

Results

About 69.0% of the 84 deaths were male with a median age of 47.6 years. About 64.3% of deaths occurred within the first 2 days following trauma. Mechanism of injury was typically road traffic accident (77.4%). Sixteen patients underwent a non-therapeutic laparotomy. Following peer-review, different management was recommended for only three patients.

Conclusion

This group of patients who died in the setting of a trauma laparotomy received high quality trauma care. Ongoing education is needed as some non-therapeutic laparotomies may be avoidable.