ANZ Journal of Surgery

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Post-operative outcomes in older patients: a single-centre observational study

March 7, 2018 - 10:05
Background

Improved life-expectancies have seen increased rates of older patients undergoing surgery worldwide. These patients are at increased risk of post-operative complications. Australian evidence is limited regarding the association between age and post-operative outcomes, especially rapid response calls (RRCs) as indicators of adverse outcomes. The aim was to compare the post-operative outcomes of older patients (≥80 years) to younger patients. Specifically, 30-day in-hospital mortality; unplanned intensive care unit (ICU) admission; and RRC activation within 72 h post-operatively.

Methods

Single-centre retrospective observational study conducted over 12 months in a metropolitan Australian hospital. All adult patients (≥16 years) undergoing surgical procedures were included, excluding cardiac and obstetric/gynaecological surgeries. Patient co-morbidities were quantified using Charlson co-morbidity index (CCI) and American Society of Anesthesiologists physical status classification.

Results

Seven thousand four hundred and seventy-nine patients met inclusion criteria, 14.5% (n = 1086) aged ≥80 years. Most procedures (65%) were elective; and general surgical procedures were most common (24.2%). Compared to younger patients, older patients had significantly higher 30-day mortality (2.3% versus 0.2%; P < 0.001), increased post-operative RRC rates (7.3% versus 1.2%; P < 0.001), and unplanned ICU admissions (3.2% versus 1.6%; P < 0.001). Increasing age was associated with increased risk of post-operative RRC, unplanned ICU admission, and in-hospital mortality (all P < 0.01), with associations remaining significant after controlling for surgery type and CCI.

Conclusion

Older patients are at increased risk of adverse post-operative outcomes, including post-operative RRC, unplanned ICU admission, and mortality, especially if they underwent emergency procedures. This has implications for preoperative risk stratification and post-operative management. Incidence of post-operative RRCs may be an important indicator of post-operative care.

Prevention of peritoneal recurrence in high-risk colorectal cancer and evidence of T4 status as a potential risk factor

March 7, 2018 - 10:05

Peritoneal metastasis (PM) following primary resection of colorectal cancer is common. The combined use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy has significantly improved the survival outcome of patients with colorectal PM (CRPM). Diagnosing and treating early PM is essential as its extent is correlated with poorer outcomes. There are two novel therapies – second-look surgery and synchronous hyperthermic intraperitoneal chemotherapy – that are proposed to prophylactically treat or intervene early in the disease process to reduce the incidence and adverse outcomes associated with PM. These strategies are limited to patients at high risk of developing CRPM, including those that had synchronous PM or ovarian metastases resected at primary tumour removal, or a perforated primary tumour. The data on advanced primary tumour (T4) as a prognostic factor for PM after primary resection suggest that T4a tumours are prognostically worse than T4b. This literature review outlines the evidence, feasibility and safety regarding the pre-emptive treatments, as well as the relevance of T4a tumours as a risk factor for metachronous CRPM.

Gastrografin may reduce time to oral diet in prolonged post-operative ileus: a pooled analysis of two randomized trials

March 7, 2018 - 10:05
Background

Gastrografin has been suggested as a rescue therapy for prolonged post-operative ileus (PPOI) but trial data has been inconclusive. This study aimed to determine the benefit of gastrografin use in patients with PPOI by pooling the results of two recent randomized controlled trials assessing the efficacy of gastrografin compared to placebo given at time of PPOI diagnosis.

Methods

Anonymized, individual patient data from patients undergoing elective bowel resection for any indication were included, stoma closure was excluded. The primary outcome was duration of PPOI. Secondary outcomes were time to tolerate oral diet, passage of flatus/stool, requirement and duration of nasogastric tube, length of post-operative stay and rate of post-operative complications.

Results

Individual patient data were pooled for analysis (53 gastrografin, 55 placebo). Gastrografin trended towards a reduction in PPOI duration compared to placebo, respectively, median 96 h (interquartile range, IQR, 78 h) versus median 120 h (IQR, 84 h), however, this result was non-significant (P = 0.11). In addition, no significant difference was detected between the two groups for time to passage of flatus/stool (P = 0.36) and overall length of stay (P = 0.35). Gastrografin conferred a significantly faster time to tolerate an oral diet compared to placebo (median 84 h versus median 107 h, P = 0.04). There was no difference in post-operative complications between the two interventions (P > 0.05).

Conclusion

Gastrografin did not significantly reduce PPOI duration or length of stay after abdominal surgery, but did reduce time to tolerate a solid diet. Further studies are required to clarify the role of gastrografin in PPOI.

Outcomes of laparoscopic sleeve gastrectomy in Crohn's disease patients: an initial Australian experience

March 5, 2018 - 10:55
Background

Crohn's disease (CD) in association with obesity is becoming an increasing issue in Australia and worldwide. This report looks at outcomes for patients with CD undergoing laparoscopic sleeve gastrectomy.

Methods

This is a retrospective analysis of our database of patients undergoing laparoscopic sleeve gastrectomy from 2007 to 2016. Patients with concurrent CD were included.

Results

Eight patients with CD underwent laparoscopic sleeve gastrectomy with a mean preoperative body mass index of 43.8. There were no identified intraoperative or post-operative complications. The mean excess weight loss was 55.7% and 56.5% at 6 months and 1 year, respectively.

Conclusion

Laparoscopic sleeve gastrectomy can be achieved in CD patients. No complications and effective weight loss was observed in the eight reported patients.

Corrigendum

March 5, 2018 - 10:55

Accuracy of digital radiography: regional scaling factors for trauma

March 2, 2018 - 13:15
Background

Surgical planning in trauma is essential for optimal patient care and best patient outcomes. Digital radiography has improved the availability, convenience and access to radiographs worldwide as used in every trauma centre in Australia. One shortcoming, however, is the variability in magnification error associated with different anatomic regions. Accurate assessment of radiographs is paramount to proper surgical planning.

Methods

A retrospective review of 513 post-operative trauma radiographs of implants at a single centre, collected from January 2015 to August 2016, was measured by the four individual investigators. A comparison of the digital calliper reading with the known implant size, taken from operation reports and company implant data, was conducted. Magnification scales were created for different anatomic regions: femur, tibia, humerus, elbow, wrist and hand, foot and ankle.

Results

Precise regional scaling factors increase accuracy of digital radiography. Average magnification for hand, wrist, ankle and forearm is 5% (1–16%). Average magnification for foot, knee, tibia and elbow is 8% (3–11%). Humerus magnification is 10.3% (3–17%) and shoulder and femur approximately 15% (12–18%). Inter-rater Pearson's R reliability testing is 0.985–0.995 and intra-observer reliability is 0.998.

Discussion

Applying regional scaling factors improves accuracy of digital imaging, therefore improving clinical decision-making regarding fractures, distance from bony landmarks, component sizing and reduction assessment. Femoral and tibial fracture measurements with appropriate scaling factors allow the accurate estimation of nail diameter required for fixation and screw diameter for fragment fixation.

Corrigendum

March 1, 2018 - 11:44

Corrigendum

February 28, 2018 - 15:15

Soft tissue balancing in total knee arthroplasty using sensor-guided assessment: is there a learning curve?

February 19, 2018 - 12:55
Background

Sensor-guided assessment for soft tissue balance in total knee arthroplasty (TKA) has been reported to improve patient satisfaction and self-reported outcome scores. As more surgeons adopt this technology in TKA, we performed this study to identify if there is a learning curve with its use.

Methods

Analysis of a total of 90 consecutive cases was performed in this study. Initial and final intercompartmental pressure differences were recorded before and after knee ligament balancing. The first 45 patients (group 1) were compared to the last 45 patients (group 2) in terms of operative time and the final state of knee balance. A balanced knee was defined as pressure difference between medial and lateral compartments of ≤15 pounds.

Results

Group 1 had 10 unbalanced knees in the final pressure difference assessment, while all cases in group 2 were balanced (P < 0.001). There was no statistically significant difference in mean operative time between the two groups. A scatter plot of intercompartmental pressure difference identified that after 30 cases, the capacity to achieve knee ligament balance improved.

Conclusion

This study suggests that there is a learning curve with the use of sensor-guided assessment in TKA in achieving knee balance; however, the differences noted between initial and final groups were small and may not be of clinical significance.

Establishing a successful perioperative geriatric service in an Australian acute surgical unit

February 19, 2018 - 12:55
Background

The purpose of this study was to assess the impact of a perioperative geriatric service (PGS) in an acute surgical unit (ASU) on patient and organizational outcomes.

Methods

Single centre retrospective cohort study. Inclusion criteria were patients over the age of 65 admitted to the ASU between January and June 2014 (pre-PGS) and 2015 (post-PGS). Chart reviews were performed to identify outcomes of interest including in-hospital morbidity and mortality, length of stay (LOS), 30-day representation and mortality.

Results

Geriatric admissions increased by 32% over the two study periods (154 pre-PGS and 203 post-PGS). Surgical intervention increased by 11% (P = 0.01). Significantly more medical complications (14% versus 33%, P < 0.001) were identified after the implementation of the PGS. Recognition of delirium in the over 80s also increased by 57%. Rate of surgical complications was unchanged over the study (28% pre-PGS and 34% post-PGS, P = 0.6). In-hospital (<1%, P = 0.5) and 30-day mortality (<1%, P = 0.6) remained low, as did 30-day representation (10% versus 8%, P = 0.5). A trend towards decreased LOS of 1 day was identified after the implementation of the PGS (P = 0.07).

Conclusion

This study demonstrated successful implementation of a PGS into an ASU. This multi-disciplinary approach has been effective in maintaining low numbers of surgical complications, in-hospital mortality, LOS and patient representations despite an increased number of medical complications. This likely reflects more timely recognition and intervention of medically unwell patients with the PGS.

Body weight change is unpredictable after total thyroidectomy

February 15, 2018 - 10:31
Background

There is a common perception that total thyroidectomy causes weight gain beyond expected age-related changes, even when thyroid replacement therapy induces a euthyroid state. The aim of this study was to determine whether patients who underwent total thyroidectomy for a wide spectrum of conditions experienced weight gain following surgery.

Methods

We retrospectively studied 107 consecutive total thyroidectomy patients treated between January 2013 and June 2014. Medical records were reviewed to determine underlying pathology, thyroid status, use of antithyroid drugs and preoperative weight. Follow-up data were obtained from 79 patients at least 10 months post-operatively to determine current weight, the type of clinician managing thyroid replacement therapy and patient satisfaction with post-thyroidectomy management.

Results

The cohort was 73% female, with a mean age of 55.8 ± 15.7 years and a mean preoperative weight of 78.8 ± 17.5 kg. Commonest pathologies were multinodular goitre, Graves' disease, thyroid cancer and Hashimoto's thyroiditis. Preoperatively, 63.2% of patients were hyperthyroid. Mean weight change at follow-up was a non-significant increase of 0.06 ± 6.9 kg (P = 0.094). Weight change was not significant regardless of preoperative thyroid function status. This study did not demonstrate any significant differences in clinical characteristics (including post-operative thyroid-stimulating hormone) between the group with >2% weight gain and those who did not.

Conclusions

This study did not reveal significant weight gain following thyroidectomy for a wide spectrum of pathologies. Specifically, preoperative hyperthyroidism, female gender and use of antithyroid medications do not predict weight gain after thyroid surgery.

Morbidity and mortality meetings: gold, silver or bronze?

February 12, 2018 - 12:31
Abstract Background

Morbidity and mortality (M&M) meetings contribute to surgical education and improvements in patient care through the review of surgical outcomes; however, they often lack defined structure, objectives and resource support. The aim of this study was to investigate the factors that impact the effective conduct of M&M meetings.

Methods

We conducted a rapid systematic literature review. Three biomedical databases (PubMed, the Cochrane Library and the University of York Centre for Reviews and Dissemination), clinical practice guideline clearinghouses and grey literature sources were searched from May 2009 to September 2016. Studies that evaluated the function of a hospital-based M&M process were included. Two independent reviewers conducted study selection and data extraction. Study details and key findings were reported narratively.

Results

Nineteen studies identified enablers, and seven identified barriers, to the effective conduct of M&M meetings. Enabling factors for effective M&M meetings included a structured meeting format, a structured case identification and presentation, and a systems focus. Absence of key personnel from meetings, lack of education regarding the meeting process, poor perceptions of the process, logistical issues and heterogeneity in case evaluation were identified as barriers to effective M&M meetings.

Conclusion

Taking steps to standardize and incorporate the enabling factors into M&M meetings will ensure that the valuable time spent reviewing M&M is used effectively to improve patient care.

Usefulness of Rapiplug in nipple reconstruction to improve nipple projection

February 9, 2018 - 14:57
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.