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: 10 hours 44 min ago

Complications of chest drain insertion in a patient with pleural plaques

June 10, 2019 - 00:38
ANZ Journal of Surgery, Volume 89, Issue 6, Page E250-E251, June 2019.

Jejunal diverticulitis secondary to enterolith: a case report

June 10, 2019 - 00:38
ANZ Journal of Surgery, Volume 89, Issue 6, Page E261-E262, June 2019.

Quick eating caused plastic bread bag clip ingestion and severe gastrointestinal bleed in young adult: a case report

June 10, 2019 - 00:38
ANZ Journal of Surgery, Volume 89, Issue 6, Page E256-E258, June 2019.

Laparoscopic distal pancreatectomy for intrapancreatic accessory spleen: a case report

June 10, 2019 - 00:38
ANZ Journal of Surgery, Volume 89, Issue 6, Page 781-782, June 2019.

Issue information ‐ TOC

June 10, 2019 - 00:38
ANZ Journal of Surgery, Volume 89, Issue 6, Page 620-623, June 2019.

Management of in‐transit melanoma metastases: a review

June 10, 2019 - 00:38

In‐transit metastases (ITM) of cutaneous melanoma are locoregional recurrences confined to the superficial lymphatics that occur in 3.4–6.2% of patients diagnosed with melanoma. ITM are a heterogeneous disease that poses a therapeutic dilemma. Patients may have a prolonged disease trajectory involving multiple or repeat treatment modalities for frequent recurrences. The management of ITM has evolved without the development of a standardized protocol. Owing to the variability of the disease course there are few dedicated clinical trials, with a number of key trials in stage III melanoma excluding ITM patients. Thus, there is a paucity of quality data on the efficacy of the treatment modalities available for ITM and even fewer studies directly comparing modalities. At present the mainstay of ITM treatment is surgical resection, with intralesional therapies, isolated limb infusion and radiotherapy utilized as second‐line measures. The developing role of targeted therapies and immunotherapy has yet to be explored completely in these patients. This review addresses the evidence base of the efficacy of the various treatment modalities available and those factors that have impacted their clinical uptake.

Mycobacterium ulcerans disease management in Australian patients: the re‐emergence of surgery as an important treatment modality

June 10, 2019 - 00:38

With the demonstration of the effectiveness of antibiotic treatment, the management of Mycobacterium ulcerans disease has changed from a predominantly surgically to a predominantly medically treated disease. However, research among Australian patients has revealed that antibiotic treatment alone is associated with prolonged wound healing times, high rates of treatment toxicity, and the potential for significant tissue destruction associated with severe paradoxical reactions. We present the current state of M. ulcerans management in Barwon Health, Australia, where a close working relationship exists between the Plastic Surgical and Infectious Diseases units. Here treatment has evolved based on nearly 20 years of experience gained from managing more around 600 patients from a M. ulcerans epidemic on the nearby Bellarine and Mornington Peninsulas. In our experience, surgery has re‐emerged to play an important role in the treatment of M. ulcerans in improving the rate of wound healing, minimizing antibiotic associated toxicity and preventing further tissue loss associated with severe paradoxical reactions. For selected small lesions surgery without antibiotics may also be an effective treatment option, however aggressive surgical resection of lesions with wide margins through uninvolved tissue should no longer be performed. Furthermore, extensive excisional surgery that will require the use of split skin grafts and vascularized tissue flaps to repair skin defects should be avoided if possible.

Predicting post‐operative pancreatic fistulae using preoperative pancreatic imaging: a systematic review

June 10, 2019 - 00:38
Background

Post‐operative pancreatic fistulae (POPF) remain a major contributor to morbidity and mortality following pancreatic resection. Evidence for preoperative prediction of POPF based on cross‐sectional imaging has not been systemically reviewed. This review aimed to determine whether preoperative imaging modalities can accurately predict the development of POPF.

Methods

A systematic review of major reference databases was undertaken, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) guidelines, up to May 2018.

Results

There were 18 studies (2150 patients), seven used magnetic resonance imaging (MRI), five used computed tomography (CT) scans, four used transabdominal ultrasonography and one study each used MRI and CT and endoscopic ultrasonography elastography. All were retrospective, single‐centre studies. Intensity of the pancreas signal relative to the spleen, liver or muscle was commonly used. Other studies compared signal intensity between unenhanced and post‐contrast‐enhanced pancreas, apparent diffusion coefficient values comparing normal parenchyma to fibrosis, perfusion fraction (f) of intravoxel incoherent motion diffusion‐weighted imaging, or utilized a muscle‐normalized signal intensity curve with signal intensity ratio or directly assessed pancreatic volume and duct width. Shear wave velocity measurement on transabdominal ultrasonography may reflect pancreas tissue fibrosis or stiffness and predict POPF. Most parameters used to predict the development of POPF were based on identifying imaging features of a fatty or fibrotic pancreas and main pancreatic duct diameter.

Conclusion

A number of different and highly promising parameters have been used for preoperative prediction of POPF using ultrasound, MRI, CT or both. Large multicentre prospective studies are needed to determine which parameters most accurately predict POPF, using standardized definitions and methodology.

Role of nerve block as a diagnostic tool in pudendal nerve entrapment

June 10, 2019 - 00:38
Background

Pudendal nerve entrapment is a disabling condition which is difficult to diagnose and treat. Nantes criteria include the requirement of positive anaesthetic pudendal nerve block that is widely used to allow identification of patients likely to benefit from the definitive but invasive pudendal nerve release. This study aimed to determine if pudendal nerve blockade under general anaesthesia could diagnose and temporarily treat pudendal nerve entrapment in patients suffering from chronic pelvic/perineal pain and/or organ dysfunction.

Methods

This retrospective analysis of a prospectively maintained database examined the outcomes of all recipients of diagnostic pudendal nerve block in a quaternary referral centre between 2012 and 2017. Primary outcome was relief of perineal pain (transient or permanent). Secondary outcomes were demographics, referral patterns for definitive procedure and complication rates. Statistical analysis was performed using SPSS v 24.

Results

A total of 77 patients were included in the study. Mean age was 57.27 ± 13.55 years. Majority were females (n = 62, 80.5%). Relief of pain was experienced by 47 of 76 (68.1%) patients after initial injection. Complication rate of injection was 3.9% (n = 3) which in all cases was unilateral lower limb paraesthesia. Of the 37 patients (52.9%) referred, 20 underwent surgical decompression with 12 (60%) being successful.

Conclusion

Pudendal nerve injection is a safe and simple procedure that can provide accurate diagnosis and transient relief from this chronic and debilitating problem. This technique helps to isolate patients suitable for pudendal nerve decompression which offers high success rates.

Assessing adequacy of informed consent for elective surgery by student‐administered interview

June 10, 2019 - 00:38
Background

Studies show that patients often sign consent documents without fully comprehending the risks, benefits and potential complications. There is currently no Asian study performed analysing adequacy of informed consent. This study aims to assess adequacy of informed consent by evaluating patient understanding and retention of key information and complications pertaining to surgery via medical student‐administered interview.

Methods

A prospective study was performed on 48 patients undergoing groin hernia surgery, laparoscopic cholecystectomy and total thyroidectomy from 2017 to 2018 in a teaching hospital. Standardized assessment forms including major common complications and key details of the surgery were prepared. Structured one‐to‐one interviews between students and patients were performed and recorded on the morning of surgery.

Results

Although 93.8% of the patients claimed to have understood the information regarding their surgery, only 19.4%, 44.4% and 62.5% of the patients could actually recall the serious complications of groin hernia surgery, laparoscopic cholecystectomy and thyroidectomy, respectively. Elderly patients (>65 years) had poorer understanding of surgical procedure compared to the young (80% versus 100%, respectively, P = 0.008) with 26.7% of elderly patients claiming that they did not understand the indication for surgery. High satisfaction rates with this preoperative interview were reported by both patients and students (95.8% and 97.9%, respectively). Time interval from informed consent to surgery did not make any difference.

Conclusion

Understanding of information and key complications was generally low, especially in the elderly population. The structured preoperative interview achieved the dual goal of reinforcing patient gaps in knowledge and improving student communication skills.

Outcomes following radical cystectomy: a population‐based study from Queensland, Australia

June 10, 2019 - 00:38

This population‐based study of outcomes following radical cystectomy found 30‐ and 90‐day mortality was low. Some population sub‐groups, such as older patients are at heightened risk of post‐operative mortality. Regular monitoring of outcomes following oncologic surgery using quality indicators allows clinicians to reflect on practice and helps to identify areas for improvement.


Background

Radical cystectomy (RC) is a complex uro‐oncology surgical procedure with high surgical morbidity. We report on outcomes following RC for bladder cancer using a population‐based cohort of patients.

Methods

Patients receiving an RC from 2002 to 2016 were included and linked to their cancer‐related surgical procedures. Hospitals were categorized as high (>7 RCs/year) and low (≤7 RCs/year). Outcomes included 30‐ and 90‐day mortalities and 2‐year overall survival (OS). Multivariable logistic regression models were used to examine factors associated with the outcomes of interest. OS was estimated using the Kaplan–Meier survival function.

Results

During the 15‐year study period, 1230 patients underwent an RC for invasive bladder cancer. In‐hospital mortality was 1.1%, and 30‐ and 90‐day mortality was 1.4% and 2.9%, respectively. Both 30‐ and 90‐day mortalities were significantly higher for older versus younger patients (P = 0.01 and P < 0.001, respectively), and lymph node involvement was significantly associated with 90‐day mortality (P = 0.002). Patients treated more recently were about 80% less likely to die within 90 days. The 2‐year OS was 71.5%, with significant improvements observed over time (P < 0.001). While we found no evidence of a hospital‐volume relationship for post‐operative mortality or survival, patients treated in low‐volume compared to high‐volume hospitals were more likely to have surgical margin involvement (10.9% versus 7.1%, respectively, P = 0.03).

Conclusion

We observed low post‐operative mortality rates overall, with rates decreasing significantly over time. Some subgroups of patients experience poorer post‐operative outcomes. Reporting on post‐operative outcomes, and survival over time helps monitor clinical progress and identify areas for improvement.

Prolonged surgical duration, higher body mass index and current smoking increases risk of surgical site infection after intra‐articular fracture of distal femur

June 10, 2019 - 00:38

The incidence rate of surgical site infection (SSI) following surgery of a distal femur intra‐articular fracture is 4.0%. Open fracture, prolonged surgical duration, increased body mass index and current smoking were identified as independent risk factors associated with the SSI. Modification of these risk factors might be very difficult, but they do prove useful for preoperative counseling of patients and their relatives regarding their own risk profile of SSI, and the perioperative medical optimization.


Background

This study aimed to investigate incidence of surgical site infection (SSI) following the surgery of intra‐articular fractures of distal femur.

Methods

Between July 2014 and December 2017, inpatient medical records of consecutive patients who had intra‐articular fractures of distal femur treated by open reduction and plate/screw fixation were inquired to identify whether they had a SSI. After discharge, patients who had a SSI and were readmitted for treatment of SSI were also allocated to the case group. Univariate and multivariate logistic regression analyses were performed to determine whether some clinical factors were independently associated with SSI, after adjustment for confounding variables.

Results

During the study period, 434 patients were evaluated and 21 patients were confirmed to develop a SSI, indicating the accumulated incidence of 4.8% within 1 year. A total of six deep and 15 superficial SSIs were identified, with respective incidence being 1.4% and 3.4%. The most common causative pathogen was Staphylococcus aureus (8, 50.0%), followed by mixed bacteria (5, 31.3%). Open fracture, prolonged surgical duration, increased body mass index and current smoking were identified as independent risk factors for development of SSI (P < 0.05).

Conclusions

It should be noted that it was likely difficult to modify these risk factors, but they do prove useful for preoperative counselling of patients and their relatives regarding their own risk profile of SSI, and the perioperative medical optimization.

How to do the bottle suction method for removal of a silicone gel breast implant

June 10, 2019 - 00:38

There is a growing prevalence of silicone breast implant rupture and need for removal. This article identifies a novel method of removing silicone gel breast implants which addresses issues identified with the current methods. Our technique is an efficient and effective method but most importantly complies to strict Therapeutic Goods Administration guidelines for equipment used in surgery.


Clinical clearance of the thoracic and lumbar spine: a pilot study

June 10, 2019 - 00:38

This pilot study was to test the feasibility and accuracy of a clinical decision tool focused towards clearance of the thoracolumbar spine during assessment of patients in the Emergency Department after trauma. In this pilot study, sensitivity of the clinical decision tool was 100% (95% confidence interval: 87.3–100%) for the detection of a thoracic or lumbar vertebral fracture.


Background

In patients who are awake with normal mental and neurologic status, it has been suggested that the thoracolumbar (TL) spine may be cleared by clinical examination, irrespective of the mechanism of injury. The aim of this pilot study was to test the feasibility and accuracy of a clinical decision tool focused towards clearance of the TL spine during assessment of patients in the emergency department after trauma.

Methods

A prospective interventional study was conducted at two major trauma centres. The intervention of a clinical decision tool for assessment of the TL spine was applied prospectively to all patients with subsequent imaging results acting as the comparator. The primary outcome variable was fracture of the thoracic or lumbar vertebra(e). The clinical decision tool was assessed using sensitivity and specificity for detecting a TL fracture and reported with 95% confidence intervals (CIs).

Results

There were 188 cases included for analysis that all underwent imaging of the thoracic and/or lumbar vertebrae. There were 34 (18%) patients diagnosed with fractures of the thoracic and/or lumbar vertebrae. In this pilot study, sensitivity of the clinical decision tool was 100% (95% CI 87.3–100%) and specificity was 37.0% (95% CI 29.5–45.2%) for the detection of a thoracic or lumbar vertebral fracture.

Conclusions

Feasibility of clinical clearance of the TL spine in two major trauma centres was demonstrated in a clinical study setting. Evaluation of this clinical decision tool in patients following blunt trauma, particularly in reducing imaging rates, is indicated using a larger prospective study.

Long‐term outcomes of surgical management of rectal prolapse

June 10, 2019 - 00:38

The studies on the repair of rectal prolapse have produced conflicting outcomes. This study reviewed the long‐term outcomes of abdominal and perineal approaches for the repair of rectal prolapse in a single colorectal unit.


Background

Various surgical options for rectal prolapse are available but none have been shown to be clearly superior. The aims of this study were to investigate the long‐term recurrence rate of a variety of surgical approaches, their associated morbidities and the types of reoperation used to treat recurrence.

Methods

A retrospective analysis was performed of all cases of rectal prolapse surgery within one colorectal surgical unit between January 2000 and June 2017. Abdominal approaches consisted of rectopexy (RP) and resection rectopexy (RRP); perineal approaches included perineal rectosigmoidectomy (PR) and Delorme's repair (DR). Complications were graded according to the Clavien–Dindo classification. The median follow‐up was 4.5 years (interquartile range 1.5–10.1, maximum 16.5). Statistical analysis was performed using Kaplan–Meier to determine recurrence rates.

Results

A total of 157 patients were included in the study. The numbers for each procedure were: DR (n = 55), RRP (n = 44), RP (n = 38) and PR (n = 20). The majority were females (94%). The perineal group were significantly older than the abdominal group (80 versus 67 years, P = 0.0001). At 5 years, the recurrence rates were 52%, 30%, 5% and 3% for DR, PR, RP and RRP, respectively. Morbidity was highest in PR (20%) followed by RRP (18%), RP (16%) and DR (7%) (n.s.). The overall morbidity rates for perineal group and abdominal group were 10.7% and 17.1%, respectively (n.s.).

Conclusion

Abdominal approaches have a significantly lower recurrence rate at 5 years but tend to be associated with higher morbidity.

Subcutaneous neostigmine appears safe and effective for acute colonic pseudo‐obstruction (Ogilvie's syndrome)

June 10, 2019 - 00:38
Background

Intravenous neostigmine is a well‐established treatment for acute colonic pseudo‐obstruction (ACPO). Its use is hampered by the perceived requirement for continuous cardiac monitoring, and patients are often transferred to high‐dependency units for close observation during treatment. Subcutaneous neostigmine has the potential to minimize adverse cardiovascular effects while maintaining efficacy. This study aims to assess the safety of subcutaneous neostigmine on ward inpatients with ACPO monitored with standard nursing care.

Methods

This is a retrospective case series of 30 patients with ACPO who were treated with subcutaneous neostigmine between August 2008 and October 2012. Data were collected prospectively. All patients were diagnosed using clinical examination and radiology and were assessed for contraindications to neostigmine. Patients were treated on regular wards and monitored with standard nursing observations. The main outcomes were time to flatus and bowels working and complications.

Results

No serious complications such as clinically evident bradycardia were encountered. Ninety‐three percent of patients had clinically successful resolution of ACPO. Two patients (7%) developed caecal tenderness and proceeded to colonoscopic decompression, which was successful in both instances.

Conclusions

Subcutaneous neostigmine appears to be safe for the treatment of ACPO. No clinically evident serious adverse events occurred, meaning continuous cardiac monitoring as a routine may not be necessary. In our cohort, we achieved similar success rates compared with reported rates using intravenous neostigmine.

Outcomes of total hip arthroplasty surgery in heart and lung transplant recipients

June 10, 2019 - 00:38
Background

Traditionally, arthroplasty in heart and lung transplant patients has been undertaken to manage transplant‐related complications. More recently, arthroplasty is increasingly being performed for end‐stage osteoarthritis. This study reviewed short‐term outcomes and complications of total hip arthroplasty (THA) in heart and lung transplant recipients.

Methods

A retrospective cohort of heart and lung transplant recipients who underwent THA was identified using ICD‐10 coding. Post‐operative complications and hospital outcomes were collected using the patient medical record.

Results

Thirteen patients underwent 17 primary THA between 2008 and 2017, including five for osteoarthritis and 12 for femoral head avascular necrosis. Of the 13 patients, nine were bilateral sequential lung transplant recipients and four were orthotopic heart transplant recipients. The mean patient age was 61 years, with nine being male. Overall, five patients had one post‐operative complication with eight having two or more complications. Surgical complications included three intraoperative fractures, three patients with superficial infection and one with deep infection requiring surgery. Seven patients had significant bleeding requiring blood transfusion. Prosthetic dislocations occurred in two patients, with one patient requiring revision surgery (developing a joint infection). Other complications included one pulmonary embolism, two episodes of pneumonia and six episodes of acute kidney injury, whilst three patients developed post‐operative delirium. At 6‐week follow‐up, five patients had ongoing pain and seven had limitations with mobility. At 12‐month follow‐up, three patients reported ongoing pain.

Conclusion

Complications following THA after transplant are common. The risks and benefits of THA should be carefully considered preoperatively in this cohort.

Male urethral stricture disease in a regional centre: 10 years of experience

June 10, 2019 - 00:38
Background

Male urethral stricture disease is a challenging condition with a propensity for recurrence following endoscopic management. In recent years, earlier definitive urethral reconstruction has been advocated through international guidelines, prompted by series suggesting the underutilization of urethroplasty at rates of 0.6–0.8%. However, little local data exists to characterize our urethral stricture patients and we aimed to characterize the management of patients with urethral stricture disease presenting over a 10‐year period to a single regional centre.

Methods

Patients with urethral stricture disease and admitted to a regional health service were identified. Retrospective chart review was undertaken for patients detailing basic demographics, stricture characteristics, clinical management and follow up.

Results

We identified 360 patients with median age 69 years (interquartile range 56–77). A total of 191 (53%) presented with lower urinary tract symptoms, 122 (34%) urethral strictures were incidental, and 13% presented in urinary retention. Bulbar urethral strictures were the commonest strictures at 40% with most being spontaneous or idiopathic (67%). A total of 339 patients had treatment during their first admission, 48% of patients had subsequent treatment on a second episode, and over 20% had a third or subsequent treatment. Only 21 (5.8%) underwent urethroplasty. Urethral dilatation and optical urethrotomy were most commonly performed (54%). With follow up 19 months (interquartile range 2–56), 205 (57%) were voiding, 38 (11%) were performing intermittent catheterization, and 59 were catheterized permanently.

Conclusion

Definitive urethral reconstruction appears underutilized in our cohort of patients. A high proportion of incidentally presenting urethral strictures emphasizes the importance of wider education to optimize patient outcomes.

Rural Emergency Laparotomy Audit

June 10, 2019 - 00:38

Emergency laparoscopy/laparotomy is associated with high levels of mortality. The aim of this multicentre prospective study was to determine whether outcomes following emergency laparoscopy/laparotomy in rural and regional South Australian hospitals were comparable to those reported in the National Emergency Laparotomy Audit and Perth Emergency Laparotomy Audit.


Background

Emergency laparoscopy/laparotomy is associated with high levels of mortality. The aim of this study was to determine whether outcomes following emergency laparoscopy/laparotomy in rural and regional South Australian hospitals were comparable to those reported in the National Emergency Laparotomy Audit and Perth Emergency Laparotomy Audit.

Methods

A prospective multicentre audit of patients who undergo emergency laparoscopy/laparotomy. Participating hospitals included Mount Gambier and Districts Health Service, Whyalla Hospital and Riverland General Hospital. Inclusion and exclusion criteria were identical to the National Emergency Laparotomy Audit. A modified dataset for patients was collected if patients were up‐transferred to another hospital prior to operative management. Data collected included patient demographics, operative management, adherence to processes of care and outcomes.

Results

Data were collected for a total of 58 cases. Fifty‐one of these had emergency laparoscopy/laparotomy in a rural or regional hospital and seven were transferred in the preoperative period. The median Portsmouth‐Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity predicted 30‐day post‐operative mortality was 3.5%. One hundred percent of patients (51 out of 51) had a consultant anaesthetist and surgeon present in the operating theatre. There were no deaths reported within the 30‐day post‐operative period.

Conclusion

Outcomes following emergency laparoscopy/laparotomy in rural and regional South Australian hospitals are comparable to those reported in the National Emergency Laparotomy Audit and Perth Emergency Laparotomy Audit.

Predictive model of heterotopy in Meckel's diverticulum in children

June 10, 2019 - 00:38

Retrospective analysis on a population of children with Meckel's diverticulum was performed. Statistical analysis of certain factors resulted in the creation of a classification and regression tree that might be considered useful, especially for the group of surgeons who follow the practice not to resect an uncomplicated Meckel's diverticulum found incidentally during surgery for different morbidities.


Background

The presence of heterotopic tissue in Meckel's diverticulum (MD) increases the incidence of future complications. Based on this concept, this study aimed to detect clinical and morphological parameters able to predict the probability of heterotopy in incidentally discovered uncomplicated MD and to develop a risk‐based classification tool.

Methods

The clinical records of 146 patients who underwent MD resection were reviewed. MD complications (bleeding, inflammation, perforation or involvement in pathological processes such as intussusception) and MD dimensions (width, length and the product width × length) were evaluated in association with heterotopy. Regression analysis was used to explore the discrete effect of clinically relevant parameters, which were subsequently combined in a Classification and Regression Tree.

Results

The probability of heterotopy was higher in complicated MDs. The width of the base of the MD and the product width × length were also significant predictors of heterotopy. A stepwise combination (Classification and Regression Tree model) of (i) uncomplicated macroscopic presentation, (ii) width <2.5 cm, (iii) age <10 years and (iv) product width × length <4 cm2 resulted in a null probability of heterotopy in our study group.

Conclusion

The combination of MD‐related clinical and morphological parameters using advanced statistical tools may assist in estimating the probability of heterotopy. This may be applied in incidentally discovered uncomplicated MDs during abdominal surgery for other morbidities. Prospective studies are required to confirm our findings and test the practical usefulness of the classification tool developed here.