ANZ Journal of Surgery

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Syndicate content
Wiley Online Library : ANZ Journal of Surgery
Updated: 3 hours 52 min ago

The Australian laparoscopic radical prostatectomy learning curve

May 17, 2017 - 10:56
Background

International estimates of the laparoscopic radical prostatectomy (LRP) learning curve extend to as many as 1000 cases, but is unknown for Fellowship-trained Australian surgeons.

Methods

Prospectively collected data from nine Australian surgeons who performed 2943 consecutive LRP cases was retrospectively reviewed. Their combined initial 100 cases (F100, n = 900) were compared to their second 100 cases (S100, n = 782) with two of nine surgeons completing fewer than 200 cases.

Results

The mean age (61.1 versus 61.1 years) and prostate specific antigen (7.4 versus 7.8 ng/mL) were similar between F100 and S100. D'Amico's high-, intermediate- and low-risk cases were 15, 59 and 26% for the F100 versus 20, 59 and 21% for the S100, respectively. Blood transfusions (2.4 versus 0.8%), mean blood loss (413 versus 378 mL), mean operating time (193 versus 163 min) and length of stay (2.7 versus 2.4 days) were all lower in the S100. Histopathology was organ confined (pT2) in 76% of F100 and 71% of S100. Positive surgical margin (PSM) rate was 18.4% in F100 versus 17.5% in the S100 (P = 0.62). F100 and S100 PSM rates by pathological stage were similar with pT2 PSM 12.2 versus 9.5% (P = 0.13), pT3a PSM 34.8 versus 40.5% (P = 0.29) and pT3b PSM 52.9 versus 36.4% (P = 0.14).

Conclusion

There was no significant improvement in PSM rate between F100 and S100 cases. Perioperative outcomes were acceptable in F100 and further improved with experience in S100. Mentoring can minimize the LRP learning curve, and it remains a valid minimally invasive surgical treatment for prostate cancer in Australia even in early practice.

Modern cardiac surgery: the future of cardiac surgery in Australia

May 17, 2017 - 10:55

Cardiac surgery is a relatively young specialty and is undergoing many changes presently. The advent of catheter-based technology, minimally invasive surgery and better information regarding the roles of cardiac surgery in the management of common cardiac disease is changing the way we provide services. In Australia, attention must be turned to the way cardiac surgical services are provided to enable delivery of modern procedures. This has implications for the provision of training. We explore the face of modern cardiac surgery and how this may be taken up in Australia.

Subspecialty approach for the management of acute cholecystitis: an alternative to acute surgical unit model of care

May 17, 2017 - 10:55
Background

Acute cholecystitis is a common condition. Recent studies have shown an association between creation of an acute surgical unit (ASU) and improved outcomes. This study aimed to evaluate the outcomes of a subspecialty based approach to the management of acute cholecystitis as an alternative to the traditional ‘generalist’ general surgery approach or the ASU model.

Method

A 6-year retrospective analysis of outcomes in patients admitted under a dedicated upper gastrointestinal service for acute cholecystitis undergoing emergency laparoscopic cholecystectomy.

Results

Seven hundred emergency laparoscopic cholecystectomies were performed over this time. A total of 486 patients were available for analysis. The median time to operation was 2 days and median length of operation was 80 min. A total of 86.9% were performed during daylight hours. Eight cases were converted to open surgery (1.6%). Intra-operative cholangiography was performed in 408 patients. The major complication rate was 8.2%, including retained common bile duct stones (2.3%), sepsis (0.2%), post-operative bleeding (0.4%), readmission (0.6%), bile leak (2.1%), AMI (0.4%), unscheduled return to theatre (0.6%) and pneumonia (0.8%). There were no mortalities and no common bile duct injuries.

Conclusion

Over a time period that encompasses the current publications on the ASU model, a subspecialty model of care has shown consistent results that exceed established benchmarks. Subspecialty management of complex elective pathologies has become the norm in general surgery and this study generates the hypothesis that subspecialty management of patients with complex emergency pathologies should be considered a valid alternative to ASU. Access block to emergency theatres delays treatment and prolongs hospital stay.

Tail gut cyst: an unusual case

May 17, 2017 - 10:55

Patterns of head and neck sarcoma in Australia

May 17, 2017 - 10:55
Background

Sarcomas affecting the head and neck often require complex management due to the combination of anatomic, aesthetic and oncological considerations. The incidence and patterns of presentation are poorly understood and have not been reviewed in the Australian population.

Method

This study sourced incidence and demographic data from the National Cancer Registry at the Australian Institute of Health and Welfare for the years 1982–2009 (corresponding to 97.3% of the Australian population). All cases of sarcoma, according to ICD-O-3 classification ((International Classification of Diseases for Oncology, 3rd edition), were assessed.

Results

A total of 3911 new cases of sarcoma affecting the head and neck were recorded during the period 1982–2009, including 1383, 2106 and 442 cases arising from skin, soft tissue and bone, respectively. The annual incidence rate of sarcomas affecting the head and neck was 1.59 per 100 000 population. The incidence of head and neck sarcoma rose substantially in older age groups (age 65 years and above) and was most common in male patients (69%). Malignant fibrous histiocytoma (MFH) was the most common pathology. There was an increase in incidence in skin-origin sarcoma in the head and neck, particularly affecting elderly males.

Conclusion

The incidence of head and neck sarcoma in Australia is higher than that reported for an equivalent European population. The increase in MFH arising from the skin in elderly male patients mirrors the patterns of common cutaneous malignancy, particularly melanoma, suggesting that ultraviolet radiation is an epidemiological factor. Management of head and neck sarcoma is complex and best managed in a specialist multidisciplinary environment.

Derivation and validation of the APPEND score: an acute appendicitis clinical prediction rule

May 17, 2017 - 10:55
Background

Although many clinical prediction rules (CPRs) for appendicitis exist, none have been developed for a New Zealand population presenting with right iliac fossa (RIF) pain. The aim of this study was to derive and validate an appendicitis CPR for our population.

Method

This is a retrospective review of all patients from December 2010 to February 2012 of at least 15 years of age presenting to the general surgery service with RIF pain. Patient data were divided into derivation and validation groups. Univariate and multiple regression analyses identified significant predictors of appendicitis which were used to construct a CPR. A retrospective validation study was then performed and the CPR was refined accordingly. Finally, the accuracy of the CPR was tested.

Results

The final components of the new CPR, the APPEND score, were Anorexia, migratory Pain, local Peritonism, Elevated C-reactive protein, Neutrophilia and male gender (Dude). This CPR has an area under the receiver operating characteristic curve of 0.84. The CPR can stratify patients into low, intermediate and high-risk groups which may standardize patient care and reduce the negative appendicectomy rate.

Conclusion

A new CPR for predicting appendicitis, in patients presenting with RIF pain, has been derived and validated for use in our population. A prospective study to further evaluate its performance is required.

Influence of primary site on metastatic distribution and survival in stage IV colorectal cancer

May 17, 2017 - 10:55
Background

To assess pattern distribution and prognosis of the three anatomical entities of metastatic colorectal cancer, and influence of treatment of metastases on survival.

Methods

Patients presenting with stage IV colorectal cancer (synchronous group), or who developed metastatic recurrence (metachronous group) after initial curative treatment between January 2005 and August 2015 were reviewed. Right sided (cecum to transverse colon), left sided (splenic flexure to sigmoid colon) and rectal cancers were identified. Distribution of metastases were noted as hepatic, lung or peritoneal.

Results

Of 374 patients, 276 were synchronous, 98 were metachronous. Metachronous group had a better 3-year survival (54%, 95% CI: 42–64 versus 33%, 95% CI: 27–39, log rank P = 0.0038). There were equal numbers of right (n = 119), left (n = 115) and rectal cancers (n = 140). Rectal cancers had a higher metastatic recurrence, yet demonstrated better 3-year survival (right colon 45%, 95% CI: 19–67, left colon 49%, 95% CI: 27–68, rectum 59%, 95% CI: 42–72, P = 0.39) due to higher proportions of metachronous patients undergoing treatment for metastases (40 versus 14%). Over half of all organ metastases spread to liver, with equal distribution from all three anatomical groups. Rectal cancers showed highest preponderance for lung metastases.

Conclusion

Rectal cancers have a higher chance of recurring, with a higher metastatic rate to the lung, yet demonstrate better survival outcomes in metastatic colorectal cancer, reflecting the benefit of intervention for metastases.

The volume, cost and outcomes of pancreatic resection in a regional centre in New Zealand

May 15, 2017 - 10:42
Background

The frequency, costs and outcome of pancreatic resection (both pancreaticoduodenectomy and distal pancreatectomy) were reviewed in our own institution and correlated with regional population growth as well as national resection rates and locations.

Methods

Demographic, pathological and outcome data on pancreaticoduodenectomy and distal pancreatectomy were obtained from a prospectively maintained database for the years 2005–2009 and 2010–2014. During this period, the catchment population grew from 460 000 to 567 000. Costing information was obtained from the hospital-independent costing and coding committee, and the locations and rates of pancreatic resection were obtained by interrogating the national minimum dataset.

Results

A total of 41 pancreatectomies (29 pancreaticoduodenectomy, 12 distal pancreatectomy) were performed between 2005 and 2009, increasing to 84 pancreatectomies (55 pancreaticoduodenectomies, 27 distal pancreatectomies and two total pancreatectomies) between 2010 and 2014. This constituted one sixth of the national volume of pancreatic resections. There was no difference in patient demographics or indications for resection between the two time periods; however, portal vein resection was used more frequently in the second period. Margin positivity rate decreased (7 of 41 versus 8 of 84) and lymph node harvest increased (median 8 nodes versus median 15 nodes) between the two time periods. Overall 30-day mortality was 1.6%.

Conclusion

In New Zealand, regional rates of pancreatic resection reflect regional population demands, and institutional growth is driven by local population requirements. Institutional growth can be achieved with the maintenance of internationally accepted outcomes and quality indicators.

Lymph node dissection for Siewert II esophagogastric junction adenocarcinoma: a retrospective study of 136 cases

May 15, 2017 - 10:41
Background

To compare the lymph node dissection with the right transthoracic Ivor-Lewis (IL) procedure to that with the left transthoracic (LT) approach for Siewert type II adenocarcinoma of the esophagogastric (AEG) junction.

Methods

In this study, 136 patients with Siewert type II AEG who met the inclusion criteria underwent surgical resection were divided into the IL (47 cases) and LT (89 cases) groups. The number and frequency of the dissected lymph nodes in each station were compared between the two groups.

Results

The IL group had a longer proximal surgical margin (P = 0.000) and more total (P = 0.000), thoracic (P = 0.000), and abdominal lymph nodes (P = 0.000) dissected than the LT group. In general, the IL group had a higher dissection rate in each thoracic lymph node station (P < 0.05) than the LT group. The dissection rates of the hepatic artery, splenic artery and celiac trunk lymph nodes were higher in the IL group than in the LT group (P < 0.05). The lymph node metastasis rate was 78.7% in the IL group, higher than the 61.8% in the LT group (P = 0.045).

Conclusions

The right transthoracic IL procedure was demonstrated to be a better application than the LT approach for Siewert type II AEG in terms of the number and frequency of lymph node resections.

Risk factors for pedicled flap necrosis in hand soft tissue reconstruction: a multivariate logistic regression analysis

May 8, 2017 - 22:31
Background

Few clinical retrospective studies have reported the risk factors of pedicled flap necrosis in hand soft tissue reconstruction. The aim of this study was to identify non-technical risk factors associated with pedicled flap perioperative necrosis in hand soft tissue reconstruction via a multivariate logistic regression analysis.

Methods

For patients with hand soft tissue reconstruction, we carefully reviewed hospital records and identified 163 patients who met the inclusion criteria. The characteristics of these patients, flap transfer procedures and postoperative complications were recorded. Eleven predictors were identified. The correlations between pedicled flap necrosis and risk factors were analysed using a logistic regression model.

Results

Of 163 skin flaps, 125 flaps survived completely without any complications. The pedicled flap necrosis rate in hands was 11.04%, which included partial flap necrosis (7.36%) and total flap necrosis (3.68%). Soft tissue defects in fingers were noted in 68.10% of all cases. The logistic regression analysis indicated that the soft tissue defect site (P = 0.046, odds ratio (OR) = 0.079, confidence interval (CI) (0.006, 0.959)), flap size (P = 0.020, OR = 1.024, CI (1.004, 1.045)) and postoperative wound infection (P < 0.001, OR = 17.407, CI (3.821, 79.303)) were statistically significant risk factors for pedicled flap necrosis of the hand.

Conclusion

Soft tissue defect site, flap size and postoperative wound infection were risk factors associated with pedicled flap necrosis in hand soft tissue defect reconstruction.

Management of recurrent bleeding after pancreatoduodenectomy

May 8, 2017 - 15:39
Background

Re-bleeding after management of a first haemorrhage following pancreatic surgery is an ever-present danger and often presents diagnostic and management dilemmas.

Methods

All cases of post-pancreatectomy haemorrhage (PPH) following pancreatoduodenectomy were identified from a tertiary referral, clinical database (April 2004–April 2013). Only those suffering a second re-bleeding episode were included in the final case notes review.

Results

A total of 301 patients underwent pancreatoduodenectomy during the study period (most common indication: pancreatic adenocarcinoma; 49.5%). Twenty-two (7.3%) patients suffered a PPH (five early). Of these cases, three suffered a re-bleeding event (one mortality). Endoscopy, interventional radiology and surgery were employed in each case.

Conclusion

PPH presents major clinical challenges and is associated with significant morbidity and mortality. Early detection of the site and type of bleeding are critical and multimodal therapy is usually required. Interventional radiology techniques are making a major contribution to overall management.

Australian validation of the Cancer of the Prostate Risk Assessment Post-Surgical score to predict biochemical recurrence after radical prostatectomy

May 4, 2017 - 19:46
Background

The Cancer of the Prostate Risk Assessment Post-Surgical (CAPRA-S) score is a simple post-operative risk assessment tool predicting disease recurrence after radical prostatectomy, which is easily calculated using available clinical data. To be widely useful, risk tools require multiple external validations. We aimed to validate the CAPRA-S score in an Australian multi-institutional population, including private and public settings and reflecting community practice.

Methods

The study population were all men on the South Australian Prostate Cancer Clinical Outcomes Collaborative Database with localized prostate cancer diagnosed during 1998–2013, who underwent radical prostatectomy without adjuvant therapy (n = 1664). Predictive performance was assessed via Kaplan–Meier and Cox proportional regression analyses, Harrell's Concordance index, calibration plots and decision curve analysis.

Results

Biochemical recurrence occurred in 342 (21%) cases. Five-year recurrence-free probabilities for CAPRA-S scores indicating low (0–2), intermediate (3–5) and high risk were 95, 79 and 46%, respectively. The hazard ratio for CAPRA-S score increments was 1.56 (95% confidence interval 1.49–1.64). The Concordance index for 5-year recurrence-free survival was 0.77. The calibration plot showed good correlation between predicted and observed recurrence-free survival across scores. Limitations include the retrospective nature and small numbers with higher CAPRA-S scores.

Conclusions

The CAPRA-S score is an accurate predictor of recurrence after radical prostatectomy in our cohort, supporting its utility in the Australian setting. This simple tool can assist in post-surgical selection of patients who would benefit from adjuvant therapy while avoiding morbidity among those less likely to benefit.

The ties that bind: what's in a title?

May 4, 2017 - 19:46
Background

Many Australian and New Zealand surgeons use the title ‘Mister’ rather than ‘Doctor’, a practice dating back to traditions established over 600 years ago. The Royal Australasian College of Surgeons is currently undergoing a period of critical self-reflection, embodied by its ‘Respect’ campaign. Active measures to embrace diversity and encourage women into surgery are underway.

Methods

This paper reviews the historical basis to the use of gendered titles and their current use amongst fellows. De-identified demographic data from the college register of active fellows was searched by self-identified title, country or state, and gender. Data were further reviewed by surgical sub-specialty and year of fellowship.

Results

The college dataset suggests that there is significant variance in the preference for gendered titles, determined predominantly by geography rather than specialty. The highest use of gendered titles (by male and female surgeons) was in Victoria/Tasmania (58% male, 22% female) and New Zealand (81% male, 17% female). By contrast, only 2% of female surgeons in other states elected a gendered title (Miss/Mrs/Ms).

Conclusion

Surgery is the only profession that continues to use gendered titles. As the College of Surgeons moves towards greater equity and diversity, consideration should be given to phasing out the use of gendered titles, which serve to divide rather than unite our profession.