ANZ Journal of Surgery

Syndicate content ANZ Journal of Surgery
Table of Contents for ANZ Journal of Surgery. List of articles from both the latest and EarlyView issues.
Updated: 10 hours 22 min ago

Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue

March 3, 2019 - 21:54
Background

Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico‐legal ramifications. Further, well‐documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met.

Method

We undertook an audit of Urology and General Surgery operation notes handwritten by junior doctors and surgical trainees in a tertiary teaching hospital over a month period both in 2014 and 2015. Individual operative notes were assessed for quality based on parameters described by the Royal College of Surgeons of England guidelines.

Results

Based on the Royal College of Surgeons of England guidelines, a significant proportion of analysed surgical operative notes were incomplete, with information pertaining to the time of surgery, name of anaesthetist and deep vein thrombosis prophylaxis in particular being recorded less than 50% of the time (22.42, 36.36 and 43.03%, respectively).Overall, 80% compliance was achieved in 14/20 standards and 100% compliance was attained in only one standard.

Conclusions

The quality of surgical operation notes written by junior doctors and trainees demonstrated significant deficiencies when compared against a set standard. There is a clear need to educate junior medical staff and to provide systems and ongoing education to improve quality. This would involve leadership from senior staff, ongoing audit and the development of systems that are part of the normal workflow to improve quality and compliance.

Role of interleukin‐17 in the pathogenesis of perianal abscess and anal fistula: a clinical study on 50 patients with perianal abscess

March 3, 2019 - 21:54
Background

To investigate the role of interleukin (IL)‐17 in tissue and peripheral blood of perianal abscess and anal fistula.

Methods

Patients with primary perianal abscess (n = 50) admitted to Jinhua Municipal Central Hospital between March 2003 and August 2004 were enrolled. Fifty patients with mixed haemorrhoids, who showed no perianal abscess or anal fistula, were also recruited as the control. After surgery, patients were followed up for 6 months. Protein and gene expression of IL‐17 was determined in surgically harvested anal tissues and peripheral blood, respectively. The relationship between IL‐17 and clinical pathological features were analysed.

Results

As shown by immunohistochemistry of anorectal tissues, the positive rate of IL‐17 protein was higher in the perianal abscess group than in the control group. In patients with perianal abscess, the expression of IL‐17 significantly correlated with the diameter of the abscess (P = 0.013), the wound surface healing time (P = 0.010) and the progression into anal fistula (P = 0.003). For the gene expression of IL‐17 in peripheral blood cells, the level was significantly higher in patients with perianal abscess comparing to the control group (0.4350 ± 0.1190 versus 0.1785 ± 0.1230, P ≤ 0.001). Comparing to the recovery group, patients with their perianal abscess progressed to anal fistula showed higher levels of IL‐17 gene expression (P = 0.014).

Conclusions

Expression of IL‐17 was increased in the anorectal tissues and peripheral blood of patients with perianal abscess and anal fistula. IL‐17 may play an important role in the pathogenesis of perianal abscess and anal fistula.

Loop ileostomy reversal after laparoscopic versus open rectal resection

March 3, 2019 - 21:54
Background

One of the potential advantages of laparoscopic abdominal surgery is in reducing the development of adhesions, making later surgery easier. The purpose of this study is to determine whether using the laparoscopic versus open approach for a rectal resection with a diverting ileostomy affects the speed and safety of subsequent ileostomy reversal.

Methods

This is a retrospective study using patients who underwent ileostomy reversal following a rectal cancer resection with curative intent with a diverting ileostomy at the University Hospital Geelong between January 2006 and June 2017. Demographic information, operative technique and histological staging for the initial resection were recorded. Theatre time and complication rates for the ileostomy reversal were also recorded.

Results

A total of 82 patients were included in this study (22 had laparoscopic resections as the primary operation, 50 had open resections and 10 had laparoscopic converted to open resections). The three groups were similar in age, body mass index, American Society of Anesthesiologists score and proportion undergoing chemoradiotherapy. Median (range) theatre time for ileostomy reversal was 118 (50–200) min after a laparoscopic resection, 80 (30–360) min after a laparoscopic converted to open resection and 65 (50–160) min after an open resection (P = 0.009). Complication rates after ileostomy reversal were similar between the three groups (P = 0.97).

Conclusion

Ileostomy reversal took longer to perform if the primary rectal resection was performed laparoscopically.

Topical haemostatic powder as a novel endoscopic therapy for severe colonic diverticular bleeding

March 3, 2019 - 21:54
Background

Although most diverticular bleeding resolve spontaneously, up to 30% can bleed torrentially, necessitating angioembolization, endoscopic or surgical intervention. Non‐contact endoscopic therapies, such as topical haemostatic powders, do not require precise targeting and are attractive because identification of specific culprit diverticulum is difficult. While their use in non‐variceal upper gastrointestinal bleeding is well established, its role in lower gastrointestinal bleeding remains unclear. We used topical Hemospray in a novel setting of severe diverticular bleeding, evaluating its efficacy in achieving haemostasis, reducing re‐bleeding and the need for re‐intervention.

Methods

Consecutive patients from a tertiary colorectal unit who underwent colonoscopy and Hemospray for severe diverticular bleeding from November 2016 to October 2017 were included. Hemospray was endoscopically applied to colonic segments with major stigmata of recent haemorrhage.

Results

Ten patients had a median time to colonoscopy of 22 h (range: 8–54) from admission. Median of 3.5 units (range: 0–10) of packed cells were transfused pre‐endoscopy. All achieved immediate haemostasis without further haemodynamic instability or re‐bleeding. No endoscopic, radiological or surgical re‐intervention was required. Patients were fit for discharge within a median of 3 days (range: 2–7) following Hemospray. There were no morbidities, mortalities or readmissions for diverticular bleeding after a median follow‐up of 9.5 months (range: 3–16).

Conclusion

This feasibility study shows that topical haemostatic powders can offer a safe and effective therapeutic endoscopic option in severe diverticular bleeding with high haemostatic rate. Prospective controlled trials are required to establish its efficacy compared to conventional therapy.

Usefulness of Rapiplug in nipple reconstruction to improve nipple projection

March 3, 2019 - 21:54
Background

The final stage of breast reconstruction after mastectomy for breast cancer is nipple reconstruction. However, a consistent and reliable method resulting in the most ideal aesthetic results has yet to be clarified. This study analysed the long‐term outcomes of nipple reconstruction using Rapiplug.

Methods

Forty‐one patients who underwent immediate breast reconstruction after mastectomy between January 2014 and February 2017 were enrolled. Nipple reconstruction was performed with C‐V flap and Hammond flap, and hat‐shaped Rapiplug was implanted at the flap core. Nipple projection and width were measured and nipple reduction rates were calculated immediately after and at 3, 6, and 12 months after surgery. Patient satisfaction was surveyed at the 12‐month follow‐up and compared with patient characteristics and other variables.

Results

Forty‐one nipple reconstructions were performed in 41 patients. Most post‐operative adverse events were resolved with conservative management, and revision was performed in only one case. The mean nipple projections were 8.9 ± 1.8, 7 ± 1.8, 5.6 ± 1.6 and 4.9 ± 1.6 mm immediately, and 3, 6 and 12 months after surgery, respectively, and the mean reduction rate of nipple size with reference to the size immediately after surgery was 22.2%, 37.2% and 44.7% at 3, 6 and 12 months after surgery, respectively. Patient satisfaction was 82.9% in overall outcome, and 85.3% of projection was good or excellent.

Conclusion

Rapiplug can improve the long‐term preservation of nipple projection after nipple reconstruction and is considered to be consistent and reliable with good aesthetic outcomes and no severe complications.

Early outcomes of two‐stage minimally invasive oesophagectomy in an Australian institution

March 3, 2019 - 21:54
Background

Minimally invasive oesophagectomy (MIO) has a steep learning curve. We report our outcomes of a standardized 25 mm circular‐stapled anastomosis using a trans‐orally placed anvil (Orvil™). The objective of this study is to report the initial experience of introducing two‐stage MIO to an Australian tertiary health service.

Methods

We describe our consecutive case series of all MIOs performed from a prospectively maintained database. We assessed the morbidity and mortality of MIO at our institution. We compared our first 30 cases to the second cohort of 32 cases.

Results

There were 62 two‐stage MIOs performed from 2011 to 2015. The average age was 65 years. Median length of stay was 13 days (5–72 days). Median number of total lymph nodes was 14. Conversion occurred in three patients (5%). Major morbidity was 45%. Delayed gastric emptying 6% (n = 4), pneumonia 6% (n = 4), chyle leak 6% (n = 4), pulmonary embolus 2% (n = 1) and grade II or III anastomotic leak 5% (n = 4). One conduit ischaemia (2%) required reoperation and formation of oesophagostomy. There was one post‐operative death within 30 days. There were five post‐oesophagectomy hiatal hernias requiring re‐operation (8%). There was a significant improvement in operative time (minutes) from the first to second cohort 588 versus 464 (P‐value 0.01).

Conclusion

The introduction of two‐stage MIO to the Australian setting can be safely instituted. Our unit was still within a learning curve after 30 cases.

Surveillance colonoscopies frequently booked earlier than the National Health and Medical Research Council guidelines: findings of a single centre audit

March 3, 2019 - 21:54
Background

To assess the adherence rate of surveillance colonoscopy booking intervals to recommended National Health and Medical Research Council guidelines at The Queen Elizabeth Hospital, Adelaide, Australia.

Methods

Patients on The Queen Elizabeth Hospital colorectal unit surveillance colonoscopy waiting list were included in this audit. Patient demographics, colonoscopy findings, follow‐up plans and pathology results were analysed. Patients were categorized as normal/non‐neoplastic finding, low‐risk adenomas, high‐risk adenomas, personal history of colorectal cancer (CRC) and family history of CRC. Booked colonoscopy within 2 months of guideline recommended interval was considered correct.

Results

A total of 467 patients were included (59.1% male; mean age 60 years). Two hundred and fifty‐one (53.7%) patients had an incorrect surveillance colonoscopy booking. Twenty‐seven patients with a normal/non‐neoplastic previous colonoscopy not requiring surveillance colonoscopy were incorrectly booked for a colonoscopy. For the 222 patients booked incorrectly and requiring surveillance colonoscopy, 88.7% were early and 11.3% were late. The proportions of incorrect bookings were highest in the low‐risk finding (66.1%) and history of CRC (67.6%) groups. For the 186 patients requiring a 3‐year surveillance interval, 38.7% were booked incorrectly. For the 197 patients requiring a 5‐year surveillance interval, 63.5% were booked incorrectly, of which 99.2% were early. More 5‐year surveillance interval patients were booked at 3 years (n = 79), than at the correct interval of 5 years (n = 72).

Conclusion

Adherence to the National Health and Medical Research Council guidelines for surveillance colonoscopy is poor. The majority of deviations represent early follow‐up, which is most common among patients with low‐risk findings or history of CRC. There is a tendency towards 3‐year surveillance among low‐risk patients.

Does meeting the Milan criteria at the time of recurrence of hepatocellular carcinoma after curative resection have an impact on prognosis?

March 3, 2019 - 21:54
Background

The survival outcomes of recurrent hepatocellular carcinoma (HCC) after curative resection remain unclear due to lack of clear basis for the selection of treatment option. We investigated overall survival (OS) after intrahepatic recurrence and re‐recurrence free survival (rRFS) of the patients with recurrent HCC, and whether Milan criteria (MC) status at resection and recurrence impacts on OS and rRFS.

Method

We enrolled 959 patients who experienced recurrence after primary hepatic resection for HCC. We divided the cohort into four groups according to MC at two periods: IN‐rIN MC (HCC within MC at the time of resection‐recurrence within MC), IN‐rOUT MC (HCC within MC at the time of resection‐recurrence outside MC), OUT‐rIN MC (HCC outside MC at the time of resection‐recurrence within MC), and OUT‐rOUT MC (HCC outside MC at the time of resection‐recurrence outside MC).

Results

In the entire cohort, 1‐, 3‐, and 5‐year OS after recurrence was 81.0%, 55.7%, and 45.8%, respectively, while rRFS was 63.7%, 46.1%, and 42.0%, respectively. The IN‐rIN MC group had the best outcomes (5‐year OS and rRFS, 54.5% and 45.7%, respectively). The IN‐rOUT and OUT‐rIN MC groups had better 5‐year OS outcomes than the OUT‐rOUT MC group (46.5%, 38.6%, and 24.8%, respectively; P < 0.05). However, 5‐year rRFS did not differ among the three groups (37.5%, 36.6%, and 31.9%, respectively; P > 0.05).

Conclusion

Survival after first recurrence following curative primary resection for HCC was affected by MC at both time of resection and recurrence. Both the IN‐rOUT and OUT‐rIN MC groups with similar survival outcomes can be saved via curative treatment.

Audit of 117 otoplasties for prominent ear by one surgeon using a cartilage‐cutting procedure

March 3, 2019 - 21:54
Background

The plethora of surgical procedures for prominent ear correction reflects lack of satisfaction with outcomes achieved. This paper describes a cartilage‐cutting otoplasty procedure and reports an audit of its outcomes.

Methods

Discharge coding was used to retrospectively identify patients who had undergone the otoplasty of interest at Middlemore Hospital, Auckland, during the 5 years from March 2010 to the end of February 2015. Hospital records were accessed. Demographic, procedure and patient satisfaction data were recorded and analysed (PASW/SPSS Statistics 18.0). Chi‐square test and t‐test were used to assess associations, with significance accepted at two‐sided P < 0.05.

Results

Sixty‐four patients underwent the specified otoplasty (54.7% females: mean age 9.5 years (standard deviation, SD: 4.2; range: 4–20)), of whom 93.8% had bilateral procedures with mean surgical time of 61 min (SD: 14; range: 34–94). This was significantly shorter (P < 0.001) than for bilateral surgeries by all other techniques and surgeons in the review period. None of the 117 procedures of interest subsequently had suture extrusion or revision surgery. Mean time from surgery to satisfaction determination was 993 days (SD: 521; range: 111–1850) for 43 (67.2%) patients. 23.3% believed that there had been aesthetically insignificant partial recurrence of prominence, typically of one ear only. This was insufficient for all but one patient to consider repeat otoplasty. Surgery outcome was rated ‘very satisfactory’ and ‘satisfactory’ by 90.7% and 9.3% of patients/parents, respectively. All would recommend the surgery to others.

Conclusion

With infrequent complications and recurrence requiring revision, and without long‐term reliance on sutures, the otoplasty reported is time‐efficient, safe and generates high patient satisfaction.

Influence of liver fibrosis on prognosis after surgical resection for resectable single hepatocellular carcinoma

March 3, 2019 - 21:54
Background

Surgical resection (SR) is recommended for single hepatocellular carcinoma (HCC) in patients with well‐preserved liver function. However, unexpected liver fibrosis sometimes found at the SR which leads to a poor outcome. This study investigated the influence of liver fibrosis on prognosis after SR for HCC.

Methods

A total of 189 patients with Child‐Turcotte‐Pugh grade A who underwent curative SR for a single HCC <5 cm were evaluated. Patients were assigned to two groups based on the degree of fibrosis (mild or severe), as determined by histological evaluation.

Results

Severe fibrosis was present in 49 patients (25.9%); these patients had greater posthepatectomy liver failure (P = 0.000) and HCC recurrence (P = 0.016). Severe liver fibrosis (hazard ratio (HR) = 1.849, 95% confidence interval (CI) 1.191–2.869; P = 0.006), microvascular invasion (HR = 1.854, 95% CI 1.183–2.906; P = 0.007), and poor histologic grade (HR = 2.097, 95% CI 1.230–3.574; P = 0.007) were related to HCC recurrence.

Conclusion

Severe fibrosis can be found even in patients with well‐preserved liver function and it leads to poorer early post‐operative and late oncologic outcomes, therefore it should be considered before therapeutic decision making of HCC.

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

March 3, 2019 - 21:54
Background

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

Methods

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

Results

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

Conclusion

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

How to do laparoscopic associating liver partition with portal vein ligation for staged hepatectomy

March 3, 2019 - 21:54
ANZ Journal of Surgery, Volume 89, Issue 3, Page 255-256, March 2019.

Does knee position during wound closure alter patella height following total knee arthroplasty?

March 3, 2019 - 21:54

The aim of the study was to evaluate the effect of knee position during surgical closure of capsule, and skin on patella tendon length after total knee arthroplasty. Small but statistically significant differences were identified between flexion and extension groups initially postoperatively but this effect was not sustained at 12 months.


Background

Patella infera is a known complication of total knee arthroplasty, and the method of soft tissue closure is a possible contributing factor. The aim of our study was to evaluate the effect of knee position during surgical closure of capsule, subcutaneous tissue and skin on patella tendon length after total knee arthroplasty.

Methods

A three arm retrospective cohort study was conducted in a single institution over a 3‐year period; 75 patients were divided, by surgeon preference, into three groups (Flexed, Extended and Hybrid) of 25 patients. All groups had standardized prosthesis, intraoperative and postoperative protocols, and differed in knee position at closure. Patellar tendon length was assessed radiologically using Insall Salvati ratio (ISR) and modified Insall Salvati ratio, with a 12‐month follow‐up. Intraclass correlation coefficients were used to assess intraobserver variability.

Results

There was a small but significant difference in preoperative to initial postoperative ISR change between Flexed and Extended groups (Extended group mean ISR change = −0.05; t = −2.31, P = 0.025, independent samples t‐test), which was not sustained at 12 months. The incidence of patella infera was similar in Flexed and Extended groups at 12 months with only one case seen in the Hybrid group.

Conclusion

Our study suggests that knee position during soft tissue closure does not have a sustained impact on patella tendon length after knee replacement. A small but statistically significant reduction in patella height was found in the Extended group initially after surgery but this effect was not sustained at 12 months.

Rates and outcomes of total knee replacement for rheumatoid arthritis compared to osteoarthritis

March 3, 2019 - 21:54

This study shows that the use of primary total knee replacement (TKR) for rheumatoid arthritis (RA) is declining. The rate of revision after TKR in RA patients is lower than those with osteoarthritis, but patients with RA are at increased risk of infection, particularly the male group. For patients diagnosed with RA undergoing TKR, the rate of revision varies with gender but not with age.


Background

Total knee replacement (TKR) has been shown to perform differently in patients with rheumatoid arthritis (RA) when compared to osteoarthritis (OA). In this study, we compare the survivorship between these two groups and examine patient and prosthesis factors that impact the revision rate.

Methods

All RA and OA patients undergoing TKR in Australia from 1 September 1999 to 31 December 2016 were included. Revision rates were assessed using Kaplan–Meier estimates of survivorship. The cumulative percent revision analysed age, gender, prosthesis constraint and revision for infection.

Results

There were 541 744 TKR procedures performed including 7542 patients with RA. RA declined as the primary diagnosis from 2.4% of all TKR in 2003 to 0.9% in 2016. Male sex was an independent revision risk in RA patients (hazard ratio (HR) = 1.66, P < 0.001) and OA patients (3.5 years+: HR = 1.09 (1.04–1.15), P < 0.001). Male RA patients had a higher revision rate for infection than females (HR = 3.14, P < 0.001). Females with RA had a lower cumulative percent revision compared to OA females, but males showed no difference between diagnoses. Revision in RA patients was not influenced by age. Compared to OA, RA patients had a decreased revision rate for those aged <65 years, but not for patients aged ≥65 years.

Conclusion

The rate of revision after TKR in RA patients is lower than those with OA, but patients with RA are at increased risk of infection, particularly the male group. Prosthesis constraint had no influence on revision rate. Mortality in those undergoing TKR with RA was higher than in those with OA.

Combined use of Kirschner wires and hinged external fixator for capitellar and trochlear fractures: a minimum 24‐month follow‐up

March 3, 2019 - 21:54
Background

Open reduction and internal fixation is the adequate treatment for capitellar and trochlear fractures. Given the low incidence of this type of fractures, it is difficult to constitute a universally accepted method for fixation. Thus, we hypothesised that combined use of Kirschner wires (K‐wires), absorbable rods and sutures for fixation and post‐operative hinged external fixator for early rehabilitation exercise can restore elbow joint function well.

Methods

This retrospective study included 20 patients with a mean age of 48.3 (range 16–76) years. According to the Dubberley classification, fractures were classified on plain radiographs, computed tomography images and intra‐operative findings. All patients were evaluated by the range of motion of the elbow and the Broberg‐Morrey score.

Results

All fractures had healed without non‐union, and the average time was 13.6 (range 8–17) weeks. The mean follow‐up was 42.5 (range 24–80) months. The mean flexion was 117.1° (range 90°–135°), and the mean extension was 17.5° (range 0°–45°). The mean pronation was 74.4° (range 45°–85°), and the mean supination was 84.3° (range 60°–90°). The average Broberg–Morrey score was 86.2 (range 68–98) points with 10 excellent, 7 good and 3 fair results.

Conclusion

K‐wires, absorbable rods and sutures combined with hinged external fixator are feasible for fixation of capitellar and trochlear fractures. However, due to the absence of a control group (such as Herbert screw fixation), comparative studies are still needed to demonstrate the safety and reliability of K‐wires for fixation.

Robotic‐assisted ventral hernia repair with surgical mesh: how I do it and case series of early experience

March 3, 2019 - 21:54

Robotic‐assisted ventral hernia repair (rVHR) may afford benefits of the laparoscopic approach while facilitating a more robust and less painful repair. We describe our rVHR technique and report on our series of 50 patients and early experience, showing that rVHR can be performed safely with good patient outcomes. We demonstrate a team approach to achieving a safe transition to new technology.


Background

Laparoscopic ventral hernia repair provides several benefits over the open approach. Intraperitoneal surgical mesh placement without fascial defect closure is associated with increased seroma formation and other adverse hernia‐site outcomes. Transfascial sutures and tacs for fascial closure and surgical mesh fixation are associated with greater post‐operative pain. Robotic‐assisted ventral hernia repair (rVHR) may afford benefits of the laparoscopic approach while facilitating a more robust and less painful repair.

Methods

Consecutive patients managed by rVHR from May 2015 to August 2018 were identified from a prospectively maintained robotic database. Retrospective review of this data was performed.

Results

Fifty patients underwent rVHR during the study period. Median body mass index was 31 (interquartile range (IQR) 29–34). Forty‐eight had previous abdominal surgery. Forty‐seven hernias were midline and three were lateral. Regarding hernia width, 15 were <4 cm wide, 32 were 4–10 cm and three were >10 cm. Median total anaesthetic time, docking time and surgical console time were 214 min (IQR 182–252), 5 min (IQR 4–8) and 144 min (IQR 104–174), respectively. No major intra‐operative complications occurred. No documented cases of adhesional complications or chronic post‐operative pain have occurred. To date, two recurrences have occurred in our series. Median length of hospital stay was 3 days (IQR 2–4).

Conclusion

We describe our rVHR technique and report on our series and early experience, showing that rVHR can be performed safely with good patient outcomes. We demonstrate a team approach to achieving a safe transition to new technology.

Lack of online video educational resources for open colorectal surgery training

March 3, 2019 - 21:54

Open surgery presents obstacles to distance learning as methodologies used to record the surgeon's point of view in open surgery remain limited. There are limited resources available online for open colorectal surgery videos. Open surgery videos have a higher number of views compared to laparoscopic surgery.


Background

Video recordings of open surgical procedures could provide a method for enhancing surgical education, analysing operative performance and presenting cases to a wider audience of surgeons. The aim of this pilot study was to systematically search the World Wide Web to determine the availability of open surgery videos and to evaluate their potential training value in terms of the educational content presented.

Methods

A broad search for open right hemicolectomy videos was performed on the three most used English language internet search engines (Google.com, Bing.com and Yahoo.com). All videos of open right hemicolectomy with an English language title were included. Laparoscopic surgery, single‐incision laparoscopic surgery and robotic‐ and hand‐assisted surgery videos were excluded, as were videos from fee charging websites.

Results

A total of 31 relevant websites were identified and 21 open surgery videos were finally included. The characteristics of the patients were presented only in four (19%) videos. A video commentary was present in 12 cases (57.1%) and this was in English language in 11. The median number of views per month was 84.1.

Conclusions

Open surgery videos have a significantly higher number of views per month compared to laparoscopic surgery videos, but current methodologies used to record and render the surgeon's point of view in open operative surgery remain limited.

Clinical value of preoperative CA19‐9 levels in evaluating resectability of gallbladder carcinoma

March 3, 2019 - 21:54
Background

This study evaluated the predictive ability of preoperative carbohydrate antigen 19‐9 (CA19‐9) level in assessing tumour resectability in patients with gallbladder carcinoma (GBC).

Methods

We retrospectively analysed preoperative serum levels of CA19‐9 in 292 patients with potentially resectable GBC between January 2000 and March 2016 in our institution. All final diagnoses were confirmed by pathological examination. The optimal cut‐off point of the CA19‐9 for predicting resectability was determined by the receiver operating characteristic curve. The univariate analysis and multivariate Cox regression model were applied to assess the relationship between the parameters to resectability.

Results

A total of 292 patients with surgical treatment were included, of whom 195 were identified as curative resection (R0 resection), 69 were classified as R1/2 resection and the remaining 28 patients were operated on with palliative surgery. The receiver operating characteristic curve analysis calculated the best CA19‐9 cut‐off point of 98.91 U/mL in the prediction of resectability. Meanwhile, the sensitivity, specificity, positive predictive value and negative predictive value were 76.3%, 70.8%, 85.7% and 56.5%, respectively. In the multivariate logistic regression analysis, CA19‐9 >98.91 U/mL (odds ratio (OR) 6.339, 95% confidence interval (CI) 3.562–11.284, P < 0.001), tumour located on hepatic side (OR 1.787, 95% CI 1.022–3.123, P = 0.042) and advanced American Joint Committee on Cancer stage (OR 2.156, 95% CI 1.180–3.940, P = 0.013) were independent determinants of resectability in patients diagnosed as GBC.

Conclusion

Preoperative CA19‐9 predicts resectability in patients with radiological resectable GBC. Increased preoperative CA19‐9 is related to poor resectability rate.

Prospective randomized comparative study of pigtail catheter drainage versus percutaneous needle aspiration in treatment of liver abscess

March 3, 2019 - 21:54
Background

This prospective randomized comparative study is designed to compare outcomes of ultrasonography‐guided pigtail catheter drainage (PCD) and needle aspiration for the treatment of liver abscesses in terms of days to achieve clinical improvement, 50% reduction in cavity size and duration of hospital stay.

Methods

This is a hospital‐based comparative study conducted in SMS Hospital, Jaipur, India, from May 2015 to May 2017. Sample size was calculated to be 95 subjects in each of the two groups at α error of 0.05 and power of 80%. Independent t‐test was used for statistical analysis.

Results

A total of 190 patients of liver abscess were included in this study and we treated 95 patients with percutaneous needle aspiration (PNA) and remaining patients with PCD along with systemic antibiotics. Mean time for clinical improvement in PNA group (6.96 ± 1.33 days) was higher as compared to PCD group (4.22 ± 1.25 days). The mean time for reduction of cavity size to 50% of original size in PNA group (7.05 ± 1.25 days) was higher as compared to PCD group (4.43 ± 1.27 days). Mean hospital stay of patients in PNA group (12.9 ± 4.02 days) was higher as compared to PCD group (11.44 ± 4.15 days).

Conclusion

Percutaneous catheter drainage is a better modality as compared to PNA especially in larger abscesses which are partially liquefied.

Initial experience with robotic pancreatic surgery in Singapore: single institution experience with 30 consecutive cases

March 3, 2019 - 21:54
Background

Presently, the worldwide experience with robotic pancreatic surgery (RPS) is increasing although widespread adoption remains limited. In this study, we report our initial experience with RPS.

Methods

This is a retrospective review of a single institution prospective database of 72 consecutive robotic hepatopancreatobiliary surgeries performed between 2013 and 2017. Of these, 30 patients who underwent RPS were included in this study of which 25 were performed by a single surgeon.

Results

The most common procedure was robotic distal pancreatectomy (RDP) which was performed in 20 patients. This included eight subtotal pancreatectomies, two extended pancreatecto‐splenectomies (en bloc gastric resection) and 10 spleen‐saving‐RDP. Splenic preservation was successful in 10/11 attempted spleen‐saving‐RDP. Eight patients underwent pancreaticoduodenectomies (five hybrid with open reconstruction), one patient underwent a modified Puestow procedure and one enucleation of uncinate tumour. Four patients had extended resections including two RDP with gastric resection and two pancreaticoduodenectomies with vascular resection. There was one (3.3%) open conversion and seven (23.3%) major (>Grade II) morbidities. Overall, there were four (13.3%) clinically significant (Grade B) pancreatic fistulas of which three required percutaneous drainage. These occurred after three RDP and one robotic enucleation. There was one reoperation for port‐site hernia and no 30‐day/in‐hospital mortalities. The median post‐operative stay was 6.5 (range: 3–36) days and there were six (20%) 30‐day readmissions.

Conclusion

Our initial experience showed that RPS can be adopted safely with a low open conversion rate for a wide variety of procedures including pancreaticoduodenectomy.