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.
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Epithelial tissue cut‐out following needle insertion into a joint: a potential complication during arthroscopy

April 30, 2019 - 01:16
Background

Knee arthroscopy is a common orthopaedic procedure and often involves insertion of a needle through skin into a joint. This needle insertion can create epithelial tissue cut‐outs possibly containing commensal bacteria that can be flushed into the joint, and potentially lead to post‐arthroscopy septic arthritis. This study aims to assess the frequency of epithelial tissue cut‐out creation on insertion of different needle sizes at different angles to the skin.

Methods

Using an ex‐vivo porcine limb tissue model, needles of various gauge (14–23G) were inserted at angles of 90, 60, 45 and 30° to the skin surface. Ten passes were undertaken at each angle. Needle lumen contents were then examined for solid tissue cut‐out.

Results

Two hundred and eighty needle passes were performed resulting in 70 tissue cut‐outs (25%) containing solid material. This was more common amongst lower gauge needles. 8 of the 70 (11.4%) tissue cut‐outs contained macroscopic evidence of epithelium. The overall rate of epithelial tissue cut‐out was 2.9%. The 23G needle had the lowest rate of tissue cut‐out creation, occurring twice out of 40 passes (P = 0.002). Neither of these contained macroscopic epithelial tissue.

Conclusion

Hypodermic needle insertion through skin into a joint can create epithelial tissue cut‐out. Epithelial tissue cut‐out occurs more frequently with use of lower gauge needles. This study suggests use of a 23G needle during arthroscopy, inserted either at 60 or 90° to the skin, to reduce epithelial tissue cut‐out and any potential contribution to post‐arthroscopy septic arthritis.

Safety of single‐anaesthetic versus staged bilateral primary total knee replacement: experience from the New Zealand National Joint Registry

April 30, 2019 - 01:16
Background

Surgical management options for bilateral knee osteoarthritis comprise staged or single‐anaesthetic bilateral total knee replacements (SABTKRs). We examined the New Zealand Joint Registry hypothesizing there would be no difference between these practices compared to unilateral total knee replacement (TKR) examining 30‐day mortality, all‐cause revision rate and function.

Methods

For this study, 84 946 primary TKRs were identified. We compared three groups: unilateral TKRs, all SABTKRs and all staged bilateral TKRs with intervals of 1 to 90 days, 91 days to 1 year and >1 year. Cumulative revision rates were calculated (Kaplan–Meier method). Mortality risks were compared to unilateral TKR and hazard ratios (HRs) calculated. Six‐month Oxford scores were compared using analysis of variance.

Results

Thirty‐day mortality for SABTKR was 0.219%: unilateral TKR 0.236% (HR 0.43; 95% confidence interval (CI) 0.38–0.48; P < 001). Staged TKR had lower mortality than unilateral TKR at three time interval groups unless performed within 90 days (adjusting for age and American Society of Anesthesiologists grade) TKR (<90 days HR 0.92; 95% CI 0.703–1.371; P = 0.915; 91–365 days HR 0.783; 95% CI 0.687–0.891; P < 0.001; >365 days HR 0.394; 95% CI 0.344–0.451; P < 0.001). Revision risk with SABTKR was lower at 0.43/100 component years (95% CI 0.37–0.49/100 component years) compared to unilateral 0.56/100 component years (95% CI 0.53–0.59; P < 0.05). Six‐month Oxford scores were superior in SABTKR versus unilateral TKR (38.6 (95% CI 38.2–39) versus 36.9 (95% CI 36.8–37.1); P < 0.001).

Conclusions

SABTKR is at least as safe as unilateral TKR or staged bilateral TKR in appropriately selected cases. Surgeons should wait at least 90 days before the second procedure.

Predictive energy equations are inaccurate for determining energy expenditure in adult burn injury: a retrospective observational study

April 30, 2019 - 01:16

Using indirect calorimetry (IC) to measure energy expenditure (EE) in adults with severe burn injury, this study found that prediction equations yielded clinically important overestimation of energy requirements compared with EE measured using IC. Measured EE correlated with day post‐burn (r = 0.42, P = 0.004), but not with % total body surface area (r = 0.02, P = 0.9). These results indicate the value of IC in determining EE in burn injury.


Background

Severe burn injuries are associated with hypermetabolism. This study aimed to compare the measured energy expenditure (mEE) with predicted energy requirements (pERs), and to correlate energy expenditure (EE) with clinical parameters in adults with severe burn injury.

Methods

Data were retrospectively analysed on 29 burn patients (median (interquartile range) age: 46 (28–61) years, % total body surface area burn: 37% (18–46%)) admitted to an intensive care unit. Indirect calorimetry was performed on 1–4 occasions per patient to measure EE. mEE was compared with pER calculated using four prediction equations. Bland–Altman and correlation analyses were performed.

Results

Mean ± SD mEE was 9752 ± 2089 kJ/day (143 ± 32% of predicted basal metabolic rate). Bland–Altman analysis demonstrated clinically important overestimation for three of the four prediction equations and wide 95% limits of agreement for all equations. Overestimation of EE was more marked early post‐burn. mEE correlated with day post‐burn (r = 0.42, P = 0.004) and number of operations prior to first EE measurement (r = 0.34, P = 0.016), but not with % total body surface area (r = 0.02, P = 0.9).

Conclusions

Patients with severe burn injury exhibit hypermetabolism. The observed poor agreement between pER and mEE at an individual level indicates the value of indirect calorimetry in determining EE in burn injury.

What is the functional result of a delayed coloanal anastomosis in redo rectal surgery?

April 30, 2019 - 01:16
Background

Delayed coloanal anastomosis (DCAA) may be used in patients with complex rectal conditions, such as chronic pelvic sepsis, low recto‐vaginal and recto‐vesical fistula; however, limited data are available. The aim is to report the morbidity and functional results of DCAA in redo rectal surgery.

Methods

All patients undergoing DCAA between January 2014 and August 2017 were retrospectively included. Success was defined as a functional anastomosis without stoma, evaluated using the Low Anterior Resection Syndrome (LARS) score and the Gastrointestinal Quality of Life Index (GIQLI) functional assessment tools.

Results

Of the 72 redo pelvic surgeries, 29 (40.3%) DCAA were performed over a 4‐year period. Indications for redo resection were chronic pelvic sepsis (n = 13, 44.8%), recto‐vaginal fistula (n = 11, 37.9%) and recto‐vesical fistula (n = 5, 17.2%). Mean interval period between the two procedures was 14 ± 3 days (8–21). Global major morbidity (Clavien‐Dindo III or IV) was seen in six patients (20.7%). Stoma closure was feasible for 22 (75.9%) patients after a median period of 78 days (interquartile range 61–98). The 6‐month success rate was 79.3%. Mean LARS was 28.8 ± 10.2 (3–41) (minor LARS) for 18 patients with no stoma at the end of follow‐up. LARS score was significantly better with a follow‐up >2 years (23.3 ± 12.2 versus 32.3 ± 7.9), P = 0.074. Mean GIQLI score was 79.2 ± 14.3 (48–98).

Conclusions

Transanal colonic pull through with delayed anastomosis for redo‐surgery in complex pelvic situations had low morbidity and avoided a permanent stoma in three out of four patients with an acceptable quality of life.

Propensity score‐matched analysis of early outcomes after laparoscopic‐assisted versus open pancreaticoduodenectomy

April 30, 2019 - 01:16
Background

Minimally invasive pancreaticoduodenectomy (PD) is a feasible option for periampullary tumours. However, it remains a complex procedure with no proven advantages over open PD (OPD). The aim of the study was to compare the outcomes between laparoscopic‐assisted PD (LAPD) and OPD using a propensity score‐matched analysis.

Methods

Retrospective review of 40 patients who underwent PD for periampullary tumours between January 2014 and December 2016 was conducted. The patients were matched 1:1 for age, gender, body mass index, Charlson comorbidty index, tumour size and haematological indices. Peri‐operative outcomes were evaluated.

Results

LAPD appeared to have a longer median operative time as compared to OPD (LAPD, 425 min (285–597) versus OPD, 369 min (260–500)) (P = 0.066). Intra‐operative blood loss was comparable between both groups. Respiratory complications were five times higher in the OPD group (LAPD, 5% versus OPD, 25%) (P = 0.077), while LAPD patients required less time to start ambulating post‐operatively (LAPD, 2 days versus OPD, 2 days) (P = 0.021). Pancreas‐specific complications and morbidity/mortality rates were similar.

Conclusion

LAPD is a safe alternative to OPD in a select group of patients for an institution starting out with minimally invasive PD, and can be used to bridge the learning curve required for total laparoscopic PD.

Quality improvement in surgery: introduction of the American College of Surgeons National Surgical Quality Improvement Program into New South Wales

April 30, 2019 - 01:16
Background

Quality improvement in surgery requires accurate, reliable, risk‐adjusted and comparative data. The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) takes reliable clinical data and provides risk‐adjusted comparisons with more than 800 hospitals. This paper describes the early outcomes of introducing this programme into New South Wales (NSW).

Methods

Four NSW hospitals formed a collaborative. Surgical clinical reviewers were trained and data collected. Risk‐adjusted reports were returned to individual hospitals and the NSW Collaborative.

Results

The results identified that the NSW Collaborative were outliers for the following causes of morbidity: urinary tract infections, surgical site infections, pneumonia and 30‐day readmissions.

Conclusion

We have shown that ACS‐NSQIP can be adapted to Australia and there is a plan to widen the programme in NSW.

Adverse impact of malnutrition markers on major abdominopelvic cancer surgery

April 30, 2019 - 01:16

This study examined the effect of pre‐operative malnutrition on major cancer surgery outcomes and found that malnourished individuals were more likely to experience a peri‐operative complication. We also showed that this risk is associated with the number of malnutrition indicators present.


Background

Malnutrition has been associated with adverse postoperative outcomes in a range of procedures but none have evaluated the interaction between clinical indicators of malnutrition. We aimed to comparatively evaluate how combinations of nutritional parameters impact postoperative outcomes amongst patients undergoing major cancer operations.

Methods

Major abdominopelvic cancer surgery cases (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, nephrectomy, pancreatectomy, pneumonectomy and prostatectomy) were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2007–2016. Malnutrition was defined by the presence of the following parameters: body mass index <18.5 kg/m2; preoperative serum albumin <3.0 g/dL or more than 10% weight loss in the last 6 months. Malnourished cases were matched with cases with satisfactory nutritional status using propensity scores. The primary outcome was the incidence of Clavien III–IV complications.

Results

Of the 30 207 cases included, 8.5% had at least one marker of malnutrition. The incidence of Clavien III–IV complications across all cases was 5.8%. In the matched cohort, malnourished cases had a higher rate of complications than those with adequate nutritional status (11.3% versus 9.6%, P = 0.018). A correlation was observed between the number of malnutrition markers possessed and the incidence of Clavien III–V complications. Cases with all three makers had the highest likelihood of experiencing a complication (odds ratio 5.47, 95% confidence interval 1.85–16.17).

Conclusion

Poor nutritional status confers an increased risk of major postoperative complications and being discharged to a facility in non‐upper gastrointestinal cancer patients. There was a correlation between the number of malnutrition parameters and the risk of complications.

Decreased total psoas muscle area after neoadjuvant therapy is a predictor of increased mortality in patients undergoing oesophageal cancer resection

April 30, 2019 - 01:16

The total psoas muscle area (TPA) has been used as a measurement of frailty and can be easily measured on computed tomography scans. In patients undergoing curative treatment for oesophageal cancer, there is a significant decrease in their TPA during their neoadjuvant therapy. A decrease of greater than 4% of their TPA is associated with high post‐operative mortality in these patients.


Background

Oesophagectomy for locally advanced cancer carries high rates of morbidity and mortality. Patients require a thorough risk assessment alongside preoperative counselling. Total psoas area (TPA) measurements have been used as a surrogate marker of sarcopenia to predict post‐operative complications in oesophageal cancer patients. No studies to date have determined whether there is an association between the proportion of TPA lost during neoadjuvant therapy and post‐operative outcomes.

Methods

Clinical data and imaging of patients who underwent neoadjuvant therapy followed by open two‐stage oesophagectomy between January 2008 and April 2018 were analysed retrospectively. Patients who did not undergo restaging computed tomography scan prior to surgery were excluded from the study. The TPA was measured on two cross‐sectional slices at L4 on computed tomography scans pre‐ and post‐neoadjuvant therapy.

Results

A total of 53 patients who met inclusion criteria were identified. The mean loss of TPA was 7.3%. Patients who had a decrease of TPA of more than 4% had significantly increased 30‐day mortality compared to those who lost 4% or less (24% versus 0%, P = 0.02). Patients aged over 65 years who also had a loss of TPA >4% had significantly increased 30‐day mortality (37% versus 2.9%, odds ratio 19, P = 0.008).

Conclusion

A decrease in TPA of >4% is associated with a significantly higher risk of post‐operative mortality in patients undergoing neoadjuvant therapy followed by oesophagectomy. Measuring the loss of TPA during neoadjuvant treatment could be a novel aid to preoperative risk assessment.

Outcomes of paediatric septic arthritis of the hip and knee at 1–20 years in an Australian urban centre

April 30, 2019 - 01:16

Septic arthritis in children is a joint threatening condition with potentially severe consequences, however, long‐term outcome data is lacking. This study examines 1–20‐year outcomes following septic arthritis of hip and knee joints in children in an Australian population. Results show that 1–20‐year outcomes for the majority of patients following septic arthritis of the hip and knee are excellent with early joint irrigation and intravenous antibiotics.


Background

Septic arthritis in children is a joint threatening condition with potentially severe consequences; however, long‐term outcome data is lacking. This study aims to determine 1–20‐year outcomes following septic arthritis of hip and knee joints in children in an Australian population.

Methods

All paediatric patients with septic arthritis of the hip or knee from 1995 to 2015 treated at our Australian institution were retrospectively assessed. Clinical features, treatment and investigation results were recorded. Long‐term functional and radiological outcomes, infection recurrence and reoperation rate at final follow‐up (mean 8.5 years, range 1.0–20.3; hip versus mean 7.7 years, range 1.1–20.3; knee) were recorded.

Results

Sixty‐four patients (37 hip, 27 knee) met inclusion criteria. Fifty‐two patients (81.3%) attended follow‐up. No mortalities or late infection recurrence occurred. Three patients (1; hip versus 2; knee) had a later operation. Median Oxford scores were excellent (48; hip versus 48; knee); however, a significant proportion had a degree of impaired function (31.3%; hip versus 42.1%; knee). Radiological outcomes were excellent in knees more commonly than hips (81.3%; hip versus 100%; knee).

Conclusions

Outcomes at 1–20 years for the majority of patients following septic arthritis of the hip and knee are excellent with early joint irrigation and intravenous antibiotics. Our results demonstrate a significant proportion of patients following septic hip arthritis have mild to moderately poor functional and radiological outcomes. Those with septic knee arthritis demonstrated universally excellent radiological outcomes and mild functional impairment in approximately one‐third of cases.

Sentinel lymph node biopsy in clinically node‐negative Merkel cell carcinoma: the Westmead Hospital experience

April 30, 2019 - 01:16
Background

Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous malignancy with a propensity to metastasize to regional lymph nodes. Sentinel lymph node biopsy (SLNB) in patients with clinically node‐negative MCC has been utilized to identify patients with subclinical nodal metastases. This study aims to review the accuracy of SLNB in MCC and to evaluate the impact of SLNB on management.

Methods

Patients with clinically node‐negative MCC who underwent SLNB were identified from a prospective database of patients treated at the Westmead Hospital, Sydney, between 1998 and 2017. Data from these patients were reviewed and analysed.

Results

Forty‐one patients were identified: 28 men and 13 women, median age 70 years. Median duration of follow‐up was 27 months. Sixteen (39%) patients had a positive SLNB and all underwent nodal treatment which consisted of radiotherapy (n = 13), completion lymphadenectomy and adjuvant radiotherapy (n = 2), and completion lymphadenectomy alone (n = 1). Following negative SLNB, 24 of 25 patients did not undergo further nodal treatment. The false‐negative rate was 16% as three patients developed in‐field nodal recurrence subsequent to a negative SLNB. At last follow‐up, 29 patients had no evidence of disease, six were alive with disease and three had died from other causes. Three SLN‐positive patients have died of MCC.

Conclusion

SLNB has a high rate of positivity and can improve the accuracy of staging and prognostication in MCC, and guide management. The relatively low risk of a false‐negative SLNB justifies close observation in SLNB‐negative patients.

How to do a laparoscopic high left colectomy with complete mesocolic excision and central vascular ligation for splenic flexure cancer

April 30, 2019 - 01:16

Due to a lack of a standardized surgical approach in splenic flexure cancer, we consider useful to present a how to do it material on laparoscopic high left colectomy with complete mesocolic excision and central vascular ligation for this type of tumours.


Clinical efficacy of middle pancreatectomy contrasts distal pancreatectomy: a single‐institution experience and review of literature

April 30, 2019 - 01:16

The middle pancreatectomy is a safe and feasible surgical method. It can well preserve the endocrine and exocrinosity function of pancreas and improve the quality of patient's life.


Background

We aim to analyse the difference of clinical efficacy between middle pancreatectomy (MP) and distal pancreatectomy (DP).

Methods

A retrospective study was used to analyse 39 cases of MP and 52 cases of DP from the Department of Hepatopancreatobiliary Surgery of the Affiliated Hospital of Qingdao University from February 2007 to December 2016. Furthermore, we identify randomized controlled trials or strictly designed clinical controlled trials on MP and DP. We performed a meta‐analysis of the final included studies using RevMan 5.3 software to illustrate the differences in efficacy between MP and DP.

Results

In the MP group, the operation time and diet start time were significantly longer than DP group. However, there was no significant difference in serious complications including clinically significant pancreatic fistula (grades B and C), delayed gastric emptying, reoperative and mortality. Furthermore, compared with DP, patients in MP group could benefit from long‐term post‐operative exocrine and endocrine function. Finally, we performed a meta‐analysis including 14 studies with a total of 1104 patients and proved that the pancreatic fistula rate, endocrine and exocrine function were significantly different in the two groups.

Conclusion

The MP is a safe and feasible surgical method. It can well preserve the endocrine and exocrine function of pancreas and improve the life quality of patients.

Treatment of colonoscopic perforation: outcomes from a major single tertiary institution

April 30, 2019 - 01:16

A study over 13 years (2003–2015) was carried out which identified patients who had a colonoscopic perforation and were subsequently managed by the colorectal unit at a single tertiary referral centre. Main outcomes were time of diagnosis, modality of management, time to theatre, length of stay, cost of admission and complications.


Background

The use of colonoscopy has been increasing in Australia. This case series describes management and outcomes of colonoscopic perforation managed by a single tertiary referral unit.

Methods

An analysis of 13 years (2003–2015) of prospectively collected data on patients who had a colonoscopic perforation and were managed by the colorectal unit at a single tertiary referral centre was performed. Main outcomes were time of diagnosis, modality of management, time to theatre, length of stay, cost of admission and complications.

Results

Sixty‐two patients had perforations (median age of 69 years). Thirty‐eight (61.2%) patients had their colonoscopy performed in another institution. The incidence rate decreased to 0.37 perforations per 1000 colonoscopies within Western Health. Overall, diagnostic colonoscopies accounted for 56% of perforations and perforations were likely to occur in the left colon (P = 0.006). Fifty‐one (82%) patients underwent surgery during their admission, with 24% of these being laparoscopic procedures. An earlier diagnosis was associated with significantly less intra‐abdominal contamination. Gross peritoneal contamination was more likely to be associated with the decision to form a stoma (37%, n = 19, P = 0.04). Thirty‐day mortality was 1.6% (n = 1).

Conclusions

Colonoscopic perforations occur in experienced hands and may have serious implications. We demonstrated a difference in patterns of injury between therapeutic and diagnostic colonoscopies. Those who have an earlier diagnosis are less likely to have severe intra‐abdominal contamination requiring a stoma formation.

Endocuff Vision‐assisted colonoscopy: a randomized controlled trial

April 30, 2019 - 01:16

This is a brief paper looking at the benefit of capped devices for improving the efficiency of colonoscopy. Polyp detection can reduce the incidence of interval colorectal cancer. This is a randomized controlled trial comparing the benefit of Endocuff Vision versus standard colonoscopy.


Background

Adenoma detection rate (ADR) has shown to be an independent predictor, to reduce the rate of interval colorectal cancer. Endocuff Vision is a relatively new device that has shown promise to improve the ADR. The primary objective was to conduct a randomized controlled trial to compare Endocuff Vision‐assisted colonoscopy (EVAC) with standard colonoscopy (SC). The primary outcome of the study is ADR and the secondary outcomes are caecal intubation rate, terminal ileum intubation rate, scope withdrawal time, quality of bowel preparation and adverse events.

Methods

A randomized controlled trial was performed to compare EVAC versus SC. All patients who presented to the endoscopy suite at the Queen Elizabeth Hospital were assessed for eligibility. Patients were recruited from 15 June 2016 to 20 January 2017. A total of 360 patients were included; 40 were excluded. The patients were randomized using block randomization; 138 patients were recruited to SC and 182 to EVAC.

Results

A total of 231 polyps were retrieved during the study period. Polyp detection rate (PDR) was high in both groups: 53% in the EVAC group versus 41.1% in SC. This was statistically significant with a P‐value of 0.035. ADR was similarly high in both groups: 36.81% in EVAC group versus 28.99% in SC group. ADR did not reach statistical significance.

Conclusions

EVAC does improve the PDR. Though the ADR did not reach statistical significance, there is a trend towards improved adenoma detection and there is statistical significance in the overall PDR.

Oncoplastic partial breast reconstruction improves patient satisfaction and aesthetic outcome for central breast tumours

April 30, 2019 - 01:16

Lumpectomy for centrally located tumors has a high risk for breast deformity. Oncoplastic partial breast reconstruction can be done at the time of lumpectomy. It shows clear advantages, both for patient satisfaction and aesthetic outcome.


Background

Patients with centrally located tumours involving the nipple–areolar complex (NAC) who undergo breast‐conserving treatment (BCT) are at high risk for breast deformity and asymmetry. Immediate oncoplastic breast reconstruction (OBR) can have a favourable impact on surgical outcome.

Methods

We retrospectively compared aesthetic outcomes and patient satisfaction among women treated with NAC lumpectomy and immediate OBR with patients treated with BCT alone. Aesthetic outcome was evaluated by independent observers, and patient satisfaction was assessed by the BREAST‐Q questionnaire.

Results

A total of 24 patients were studied, 12 in each group. Demographics and oncological staging were similar in both groups, apart from mean age, hypertension and tumour size/lumpectomy weight. Patients in the OBR group had higher scores for aesthetic outcome and a higher degree of patient satisfaction from the surgical outcome compared to the patients in the BCT‐alone group.

Conclusions

The immediate OBR approach in the treatment of centrally located tumours with NAC resection has clear advantages over BCT alone. This approach should be considered for and offered to suitable patients.

Impact of public–private partnership on a regional colonoscopy service

April 30, 2019 - 01:16

Wait‐times for both specialist outpatient assessment and colonoscopy have been significantly reduced through the introduction of a unique public–private partnership in the Greater Geelong area, resulting in more timely access for public patients and improved compliance with the new guidelines.


Background

A public–private partnership for endoscopy was introduced in Geelong where there was no capacity for public hospital endoscopy lists to expand. This paper presents the impact of this partnership on colonoscopy services.

Methods

Data were collated from prospectively maintained databases. Wait‐times to outpatient appointments, colonoscopy and follow‐up were analysed between July 2015 and June 2017 allowing for a 12‐month period of analysis before and after the initiation of the contract. Data are presented as medians (interquartile range).

Results

A total of 1300 colonoscopies were done between July 2015 and June 2016 compared to 2114 colonoscopies (P < 0.01) after the initiation of the public–private contract; 1073 (51%) colonoscopies were done on private contract. Prior to public–private contract, 41% patients waited more than 120 days from first presentation to healthcare services to diagnostic colonoscopy, this decreased to 19% after. Improvements were seen in both the waiting time for outpatient consultation (reduced from 92 days (39–136) prior to July 2016 to 73 days (32–122); P < 0.01) after) and the time taken from consultation to colonoscopy (from 125 days (70–207) to 36 days (21–159); P < 0.01) for category 1 patients.

Conclusion

Wait‐times for both specialist outpatient assessment and colonoscopy have been significantly reduced through the introduction of a unique public–private partnership in the Greater Geelong area, resulting in more timely access for public patients and improved compliance with new guidelines.

Computed tomography colonography: a retrospective analysis of outcomes of 2 years experience in a district general hospital

April 30, 2019 - 01:16

Computed tomography colonography is as efficacious as optical colonoscopy for colorectal cancer and polyp detection. The rate of colorectal cancer and polyp detection in this study was 2% and 8%, respectively. The rate of biopsy proven cancer was 10% following a suspicious colonogram. With our ageing population, it is acceptable that computed tomography colonography is increasingly used as a first line investigation in select patients.


Background

Colonoscopy is the gold‐standard investigation for direct luminal visualization of the large bowel. Studies have shown the efficacy of computed tomography colonography (CTC) is equivalent to colonoscopy in both cancer and polyp detection.

Methods

A retrospective review of patients undergoing CTC from January 2013 to October 2014 was performed. Patient demographics, indication for investigation, computed tomography findings, optical colonoscopy findings and histology results were recorded.

Results

Seven hundred and fifty‐eight CTC were performed. Three hundred and seventeen patients were male (42%) and 441 (58%) were female. Endoscopy was advised in 209 cases. One hundred and twenty (16%) were deemed suspicious for cancer of whom 96 (80%) had optical colonoscopy. A total of 12 colorectal cancers were detected. Potential polyps were noted in 58 cases (8%). Forty‐four patients underwent endoscopy (75%) and 17 polyps confirmed (38%). Two patients had foci of invasive cancer histologically. Significant extracolonic findings were identified in 60%, including five cases of gastric carcinomas. The most common other findings were gallstones and hernias.

Conclusion

The rate of colorectal cancer detection in this study was 2%. The rate of biopsy proven cancer was 10% following a suspicious colonogram. Endoscopic correlation was not obtained in 20% of cases of radiological suspicion. CTC is as efficacious as optical colonoscopy for colorectal cancer and polyp detection.

Anatomic symmetry of anterolateral thigh flap perforators: a computed tomography angiographic study

April 30, 2019 - 01:16

This study assesses the symmetry of anterolateral thigh flap vasculature using computed tomography angiography in order to guide flap harvest, especially if no perforators are identified initially. Results show that while average vessel size and location appear similar, there does not appear to be symmetry in the number of perforators. Surgical exploration of the contralateral thigh in an absence of perforators should be considered.


Background

The anterolateral thigh flap is a workhorse reconstructive flap. Versatility in design is a key strength but perforator anatomy can be variable. Inability to locate perforators prompts consideration of contralateral thigh exploration. However, such exploration would be futile if the absence of perforators proves symmetrical. This study assesses the symmetry of anterolateral thigh flap vasculature using computed tomography angiography (CTA).

Methods

A retrospective analysis of 20 bilateral thigh CTAs was performed. Each limb was assessed for number, course, location and size of perforators. Only vessels >0.5 mm in size at origin were included. Location was standardized between patients using perforator distance/thigh length ratio. Results were analysed using Wilcoxon signed‐rank test.

Results

In each thigh, the average number of perforators was 3.58 and average perforator distance/thigh length ratio was 0.358 ± 0.08. Between both limbs of the same patient, the mean difference in number of perforators was 0.55 (P = 0.002), and difference in average perforator size was 0.3 mm (P < 0.001). Average perforator location differed by a mean of 3% of thigh length (P < 0.001) between thighs.

Conclusion

While average vessel size and location appear similar, there does not appear to be symmetry in the number of perforators. Surgical exploration of the contralateral thigh in an absence of perforators should be considered. In patients where abnormal anatomy is expected, mapping with CTA could be considered to reduce morbidity associated with unsuccessful surgical exploration and dissection.

Association of preoperative total lymphocyte count with prognosis in resected left‐sided pancreatic cancer

April 30, 2019 - 01:16

Immunologic factor plays an important role in predicting the oncologic outcome of patients in left‐sided pancreatic cancer. Preoperative total lymphocyte at diagnostic stage is simple, and good prognostic factor in left‐sided pancreatic cancer.


Background

Immunologic factors such as neutrophil‐lymphocyte ratio and platelet‐lymphocyte ratio play an important role in predicting the oncologic outcome of patients in pancreatic ductal adenocarcinoma (PDAC). It is hypothesized that host immunity represented by total lymphocyte count at diagnostic stage would influence oncologic outcome in left‐sided PDAC.

Methods

Between January 1992 and August 2017, total of 112 patients who underwent distal pancreatectomy for left‐sided PDAC were included and analysed.

Results

At the time of the diagnosis, total lymphocyte count at diagnosis of left‐sided PDAC was 1.8 ± 0.7 103/μL (mean value ± standard deviation). Among different cut‐off values, 1.7 showed most powerful significant differences in long‐term oncologic outcomes. The patients with preoperative lymphocyte count (≤1.7) was associated with early recurrence (median 8.4 months versus 18.1 months, P = 0.011) and shorter survival (median 18.6 months versus 35.9 months, P = 0.028). Patients with preoperative total lymphocyte count over 1.7 showed higher white blood cell count (P < 0.001), platelet count (P = 0.039), neutrophil count (P = 0.004) and monocyte count (P = 0.001). However, more interestingly, neutrophil‐lymphocyte ratio (P < 0.001) and platelet‐lymphocyte ratio (P < 0.001) were found to be significantly higher in those with total lymphocyte count less than 1.7. Lymphocyte to monocyte ratio was inversely related to preoperative total lymphocyte count (P < 0.001). Only age was identified to be significantly different (P = 0.007). However, other clinicopathological parameters generally known to be related to tumour aggressiveness, were not different between two groups.

Conclusion

In conclusion, preoperative total lymphocyte at diagnostic stage is simple, and good prognostic factor in left‐sided pancreatic cancer.

Significance of drain fluid amylase check on day 3 after pancreatectomy

April 30, 2019 - 01:16

The present study analysed the risk factors and predictors of pancreatic fistulae, and confirmed the significance of drain fluid amylase among various factors identified. On the basis of these results, we tried to evaluate the practical clinical applicability of drain fluid amylase and obtain appropriate baseline values.


Background

The occurrence of pancreatic fistulae (PF) after pancreatectomy is the main cause of prolonged hospital stay, delayed chemotherapy, poor quality of life and post‐operative death. The surgical drainage after pancreatectomy can induce ascending infection, early removal is recommended if the possibility of PF is low. The present study analysed the risk factors and predictors of PF, and confirmed the significance of drain fluid amylase concentration (DFA, U/L) among various factors identified. On the basis of these results, we tried to evaluate the practical clinical applicability of DFA and obtain appropriate baseline values.

Methods

From January 2014 to December 2017, 117 patients underwent major pancreatectomy with pylorus‐preserving pancreatoduodenectomy, Whipple procedure, subtotal pancreatectomy or distal pancreatectomy. This study retrospectively collected and analysed demographics, pathological results and prognoses of these patients.

Results

Multivariate analysis indicated that the DFA obtained on day 3 after surgery (DFA 3) was the only predictor of PF with statistical significance (P < 0.001). Of all the factors tested, area under the curve was highest for DFA 3 (0.89). In addition, of all the factors tested, DFA 3 with a cut‐off value of 1004 U/L had the best sensitivity (92%) and specificity (82%).

Conclusions

DFA 3 of a cut‐off value of 1004 U/L might be determined to be the best predictor of PF, and early removal of the surgical drain could be considered if DFA (1004 U/L) is lower than the cut‐off value at 3 days after surgery.