ANZ Journal of Surgery

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Syndicate content
Wiley Online Library : ANZ Journal of Surgery
Updated: 1 hour 28 min ago

Long-term effectiveness of the preoperative smoking cessation programme at Western Health

July 22, 2017 - 14:41
Background

Smoking is associated with adverse effects in the perioperative period, including elevated risk of death. The perioperative period provides an opportunity to engage with patients who are smokers to encourage smoking cessation, often referred to as a ‘teachable moment’. We developed a smoking intervention model for the pre-admission clinic (PAC) at Western Health, Victoria, Australia. This case series aimed to assess the impact of the smoking intervention model, which is standard of care, on the participant's smoking habits over four time points.

Methods

We enrolled 50 consecutive participants for elective surgery who were smokers and had attended PAC at Western Health, Footscray. All smokers were offered a standard intervention package to address their smoking. Participants underwent a brief interview to elicit their current smoking behaviour on their day of surgery, 3 and 12 months post-operatively.

Results

We found a reduction at each time point post-intervention in the average number of cigarettes smoked per day by all participants with a 43% reduction at 12 months compared with PAC. We found that the number of participants who had quit increased at each time point, with 29% abstinent at 12 months post-operatively. At 12 months, we found 71% of participants had either quit or reduced the number of cigarettes smoked compared with the amount reported at PAC.

Conclusion

This study adds to the evidence that a simple intervention preoperatively can contribute to long-term changes in smoking behaviour.

Hartmann's reversal: a comparative study between laparoscopic and open approaches

July 21, 2017 - 17:05
Background

A reversal of Hartmann's procedure can be performed using either a laparoscopic or open approach. However, laparoscopic reversal (LR) of Hartmann's procedure is challenging. This study was designed to compare the results between open and laparoscopic approaches.

Methods

This was a retrospective study of prospectively collected data. We analysed 29 patients who received Hartmann's reversal at Korea University Anam Hospital between April 2007 and September 2014. All patients underwent either LR (n = 17) or open reversal (OR, n = 12).

Results

Patient characteristics were similar between the LR and OR groups. There was also no difference in mean operation time (212.5 versus 251.8 min), diversion ileostomy, length of hospital stay, postoperative analgesic days, time to diet resumption (3.9 versus 6.2 days) or complication rate. Although the time to resuming a solid diet was not different between the two groups (P = 0.053), bowel movement occurred faster in LR patients (LR versus OR, 1.8 versus 2.8 days, P = 0.020). Patients in the LR group also had less blood loss during surgery (114.1 versus 594.2 mL, P = 0.026). There were no mortalities in this study.

Conclusion

LR of Hartmann's procedure resulted in faster bowel function recovery than the open method. Laparoscopic approaches are feasible even for patients who received an open Hartmann's procedure.

Pre-hydrated sterile acellular dermal matrix allograft in breast reconstruction: review of a single unit's experience

July 20, 2017 - 20:12
Background

The acellular dermal matrix (Flex HD) (FHD) became available for use in Western Australia in 2014 to aid prosthetic breast reconstruction and this descriptive study aims to review and discuss a single institution's experience since its introduction.

Methods

By retrospective case note, review data were collected for all patients who underwent prosthetic breast reconstruction with the aid of FHD between January 2014 and August 2015 in our institution. Data on basic demographic parameters, risk factors, surgery-related factors, post-operative factors and follow-up information were collected. All complications were recorded and described in detail.

Results

FHD was used in 42 breast reconstructions in 26 patients. Procedure-related complications were seen in 26% (n = 11) of cases. A major complication requiring return to theatre was seen in 11% (n = 5) of cases. Cellulitis of the reconstructed breast (red breast syndrome) was seen in 16.67% (n = 7) cases. Overall implant loss was 2.4% (n = 1). Of the six possible risk factors for any complication, only current smoking was found to increase the risk of complications (odds ratio = 9.667, 95% confidence interval = 1.429–65.377).

Conclusion

FHD is associated with a relatively high overall complication rate. Use of this optional expensive material has to be carefully selected balancing its perceived advantages against this possible risk. The red breast syndrome merits further studies considering its frequent occurrence with FHD use.

Predictive factors for publication of abstracts at the Royal Australasian College of Surgeons Annual Scientific Congress

July 14, 2017 - 10:30
Background

A key metric of the research quality of medical conferences is the publication rate of abstracts. The study objective was to determine the publication rate of abstracts presented at the Royal Australasian College of Surgeons Annual Scientific Congress (RACS ASC) and to examine for any predictive factors associated with publication.

Methods

Abstracts presented at the RACS ASC from 2011 to 2013 were analysed. Abstract characteristics such as presentation format, study type, study design, study site, cohort size and author origin were recorded. Abstracts published were identified by a PubMed search using a strict algorithm. Univariate and multivariable logistic regressions were used to analyse for predictive factors of publication.

Results

Overall, 1438 abstracts were presented and 423 abstracts (29%) were published. The median time to publication was 15.2 months (interquartile range: 8–26) with 110 in Australasian journals (26%). The median number of citations for published abstracts was 6 (interquartile range: 2–16). After multivariable analysis, publication was significantly associated with prospective study design (odds ratio (OR) = 1.34, P = 0.02), multicentre study site (OR = 1.43, P = 0.02), cohort size ≥100 (OR = 2.00, P < 0.001) and New Zealand author origin (OR = 1.50, P = 0.01).

Conclusion

Our study demonstrates that less than one-third of abstracts presented at the RACS ASC are subsequently published in a peer-reviewed journal. Factors significantly associated with journal publication include prospective studies, multicentre study, a larger cohort size and New Zealand author origin. Advances in surgery may progress from the preliminary findings of conference abstracts. However only after the rigorous peer review offered by journal publication should changes in decision-making of patient care occur.

Impact of pre-operative health-related quality of life on outcomes after heart surgery

July 13, 2017 - 11:11
Background

Long-term improvement in health-related quality of life (HRQOL) is one of the most important outcomes of cardiac surgery. The aim of this study is to define the impact of perioperative patient and procedural variables on HRQOL dynamics, a year after cardiac surgery.

Methods

Consecutive patients undergoing elective on-pump cardiac surgery were enrolled in this prospective observational cohort study. Patients completed the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire a day before surgery and once again a year after surgery. The effect size method was used to determine whether treatment resulted in the improvement of HRQOL.

Results

A total of 67.3% of patients achieved long-term improvement in HRQOL. Significant negative association was identified between Physical and Mental Component Summary scores (PCS/MCS) and long-term outcomes. Pre-operative PCS were 40.7 ± 13.7 for improvers and 56.6 ± 14.4 for non-improvers; MCS were 45.8 ± 12.1 and 65.2 ± 13.7, respectively (P < 0.001 for all). There were no statistically significant differences in pre-operative risk factors, demographics, operative factors or post-operative variables between the two groups.

Conclusion

Among those completing this study, one in three patients did not experience long-term HRQOL improvements following cardiac surgery. Multivariate analysis confirmed that higher pre-operative PCS and MCS are independent predictors of worse HRQOL a year after surgery. Further research should focus on establishing the prevalence of this phenomenon worldwide and develop targeted interventions to improve long-term self-perceived quality of life for patients with relatively good pre-operative health.

Pathological prognostic factors of recurrence in early stage lung adenocarcinoma

July 13, 2017 - 11:11
Background

Histological heterogeneity is thought to be important for prognosis of lung adenocarcinoma. We investigated to determine pathological features with prognostic value for recurrence of early stage lung cancer.

Methods

A total of 368 patients who underwent curative surgical resection for early stage lung adenocarcinoma between 2009 and 2012 were enrolled. Pathologic characteristics including the presence of visceral pleural invasion, micropapillary patterns, aerogenous spread, lymphovascular invasion, perineural invasion and necrosis were examined. The correlations between pathological factors and clinical outcomes were analysed to determine prognostic significance.

Results

Mean follow-up was 43.0 months (±14.56, ranging from 0.0 to 73.9 months). Three-year overall survival was 95.2% and disease-free survival was 89.8%. The recurrence rate was 9.0% (33 patients) and the mortality rate was 6.0% (22 patients). The presence of a micropapillary pattern (P < 0.002), lymphatic invasion (P < 0.000), aerogenous spread (P < 0.000), vascular invasion (P = 0.036) and necrosis (P < 0.000) were negative prognostic factors of recurrence in univariate analysis. In multivariate analysis, only aerogenous spread had prognostic value (P = 0.020). The recurrence hazard ratio for the presence of aerogenous spread was 3.2 (95% confidence interval 1.20–8.47).

Conclusion

The presence of aerogenous spread was an independent pathological risk factor of recurrence in stage I lung adenocarcinoma. Micropapillary pattern had prognostic importance for recurrence in univariate analysis, but not in multivariate analysis.

Gender, ethnicity and smoking affect pain and function in patients with rotator cuff tears

July 13, 2017 - 11:11
Background

This study is a collation of baseline demographic characteristics of those presenting for rotator cuff repair in New Zealand, and exploration of associations with preoperative function and pain. Data were obtained from the New Zealand Rotator Cuff Registry; a multicentre, nationwide prospective cohort of rotator cuff repairs undertaken from 1 March 2009 until 31 December 2010.

Methods

A total of 1383 patients were included in the study. This required complete demographic information, preoperative Flex-SF (functional score) and pain scores. Following univariate analysis, a multivariate model was used.

Results

The average age was 58 years (69% males and 11% smokers). New Zealand Europeans made up 90% and Maori 5%. The average preoperative Flex-SF was significantly lower (poorer function) in those over 65 years, females, smokers and Maori, in the non-dominant patients, using a multivariate model. Average preoperative pain scores were significantly worse (higher scores) in females, Maori, Polynesians, smokers, using a multivariate model.

Conclusion

This is the largest reported prospective cohort of patients presenting for rotator cuff surgery. Results can be used to understand the effect of rotator cuff tears on the different patients, for example Maori patients who are under-represented, present younger, with more pain and poorer function.

Suprascapular artery pseudoaneurysm

July 11, 2017 - 19:17

Fitness plus American Society of Anesthesiologists grade improve outcome prediction after endovascular aneurysm repair

July 10, 2017 - 18:05
Background

Although the American Society of Anesthesiologists (ASA) grade was established for statistical purposes, it is often used prognostically. However, older patients undergoing elective surgery are typically ASA III, which limits patient stratification. We look at the prognostic effect on early complications and survival of using ASA and self-reported physical fitness to stratify patients undergoing endovascular repair of abdominal aortic aneurysms.

Methods

Data were extracted from a trial database. All patients were assigned a fitness level (A (fit) or B (unfit)) based on their self-reported ability to walk briskly for 1 km or climb two flights of stairs. Fitness was used to stratify ASA III patients, with fitter patients assigned ASA IIIA and less fit patients ASA IIIB. Outcomes assessed included survival, reinterventions, endoleak, all early and late complications and early operative complications.

Results

A combined ASA/fitness scale (II, IIIA, IIIB and IV) correlated with 1- and 3-year survival (1-year P = 0.001, 3-year P = 0.001) and early and late complications (P = 0.001 and P = 0.05). On its own, ASA predicted early complications (P = 0.0004) and survival (1-year P = 0.01, 3-year P = 0.01). Fitness alone was predictive for survival (1-year P = 0.001, 3-year P = 0.001) and late complications (P = 0.009).

Conclusion

This study shows that even a superficial assessment of fitness is reflected in surgical outcomes, with fitter ASA III patients showing survival patterns similar to ASA II patients. Physicians should be alert to differences in fitness between patients in the ASA III group, despite similarities based on preexisting severe systemic disease.

Brain metastases from colorectal cancer: characteristics and management

July 8, 2017 - 09:55
Background

Brain metastases (BMs) are the most common intracranial neoplasms in adults, but they rarely arise from colorectal cancer (CRC). The objective of this study was to report an overview of the characteristics and current management of CRC BMs.

Methods

A systematic review on CRC BMs was performed using Medline database from 1983 to 2015. The search was limited to studies published in English. Review articles, not relevant case report or studies or studies relating to animal and in vitro experiments were excluded.

Results

BMs occurred in 0.06–4% of patients with CRC. Most BMs were metachronous and were associated with lung (27–92%) and liver (12–80%) metastases. Treatment options depended on the number of BMs, the general conditions of the patient and the presence of other metastases. Most frequent treatment was whole-brain radiotherapy (WBRT) alone (36%), with median overall survival comprised between 2 and 9 months. Median overall survival was better after surgery alone (from 3 to 16.2 months), or combined with WBRT (from 7.6 to 14 months). After stereotactic radiosurgery alone, overall survival could reach 9.5 months. Many favourable prognostic factors were identified, such as high Karnofsky performance status, low recursive partitioning analysis classes, lack of extracranial disease, low number of BMs and possibility to perform surgical treatment.

Conclusion

BMs from CRC are rare. In the presence of favourable prognostic factors, an aggressive management including surgical resection with or without WBRT or stereotactic radiosurgery can improve the overall survival.

Prognostic value of positron emission tomography/computed tomography for adjuvant chemotherapy of colon cancer

July 8, 2017 - 09:55
Background

To assess the prognostic value of preoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with high-risk stage II or stage III colon cancer who underwent FOLFOX chemotherapy.

Methods

The study included 166 patients with high-risk stage II or stage III colon cancer who received FOLFOX4 chemotherapy. Retrospective patient data were analysed including pathological stage, histology, disease-free survival (DFS) and the maximum standardized uptake value (SUVmax) of the primary tumour on 18F-fluorodeoxyglucose positron emission tomography/computed tomography. The primary end point was DFS.

Results

There were recurrences in 29 of the 166 patients (17.4%). Measuring the area under the receiver operating characteristic curve, the cut-off value of SUVmax with maximum sensitivity and specificity was 10.95. Using the Kaplan–Meier method, the DFS of the patients categorized by SUVmax tended to differ (P = 0.055). In univariate analyses, the risk factors for DFS were age over 70 years, higher N stage and neural invasion. SUVmax ≤ 10.95 showed a tendency, but was not significant (P = 0.0604). In multivariate analyses, the risk factors for DFS were age over 70 and neural invasion.

Conclusions

The results of this study suggest that high fluorodeoxyglucose uptake of the primary mass in high-risk stage II and stage III colon cancer does not significantly correlate with DFS.

Emergency appendicectomy in Australia: findings from a multicentre, prospective study

July 8, 2017 - 09:55
Abstract Background

Emergency appendicectomy is the most common emergency surgical procedure performed in Australia. Despite this frequency, there is a relative paucity of contemporary, broad-based, local data that examine how emergency appendicectomies are currently performed and what are the outcomes from these operations.

Methods

A multicentre, prospective, observational study was performed. Patients were recruited by local investigators for a period of 2 months with 30-day follow-up. Patients were eligible for study inclusion if they underwent an emergency appendicectomy for suspected acute appendicitis. The primary outcome of the study was the negative appendicectomy rate (NAR), with secondary outcomes including 30-day complication rates, method of operation and conversion rates.

Results

A total of 1189 patients were recruited across 27 centres. The NAR across all centres was 19.0%. 98.2% of appendicectomies were performed with a laparoscopic-first approach. The rate of conversion from laparoscopy to open operation was 2.4%. 9.4% of patients were recorded as having one or more of the following complications: readmission (6.6%), surgical site infection (1.9%), intra-abdominal abscess (2.7%) or further intervention (1.5%). Patients who had an open operation had higher rates of readmission and surgical site infection.

Conclusion

The NAR found in this study is within the traditional measures of acceptance; however, this rate is high when measured against modern international benchmarks.

Adrenalectomy for incidentaloma: lessons learned from a single-centre series of 274 patients

July 8, 2017 - 09:55
Background

Adrenal incidentalomas are increasingly diagnosed and include a wide spectrum of lesions from benign adenomas to secreting or malignant lesions. The aim of the present study is to report a large single-institution experience of patients undergoing surgery for adrenal incidentaloma with particular attention to their diagnosis and post-operative course and the evolution of surgical practice over time.

Methods

From 1993 to 2013, 274 patients underwent adrenalectomy for incidentaloma. All patients underwent standardized clinical, hormonal and imaging assessments.

Results

Patients were mainly female (63.1%; n = 173), and the median age of patients was 56.5 years. After a complete hormonal evaluation, 47.9% (n = 129) of incidentalomas were classified as secreting tumours, including 24.4% (n = 67) subclinical cortisol-secreting adenomas and 18.9% (n = 52) pheochromocytomas. Adrenocortical carcinomas represented 9.5% (n = 26) of incidentalomas, and the risk of malignancy was significantly correlated with tumour size. The conversion rate after laparoscopic adrenalectomy (90.9%; n = 249) was 3.2% (n = 8). The overall morbidity rate was 13.9%, which included a 4.4% rate of severe morbidity (Clavien–Dindo ≥3). From 2008 onwards, there was a significant decrease (P < 0.001) in the use of surgical approaches for non-secreting adenomas.

Conclusion

After a complete work-up, half of the incidentalomas were classified as subclinical oversecreting adrenal lesions and 10% proved to be malignant adrenocortical carcinomas. The debatable use of surgical approaches for benign nonfunctioning adenomas significantly decreased over time.

Publication rate of General Surgery abstracts presented at the Royal Australasian College of Surgeons Annual Scientific Congress

July 6, 2017 - 21:31
Background

A commonly used metric for evaluating the quality and impact of presentations at a scientific meeting is the frequency with which the findings presented are published as full research papers in peer-reviewed journals. The purpose of this study was to determine the full article publication rates of abstract presentations for General Surgery and related sub-specialities at the Royal Australasian College of Surgeons Annual Scientific Congress (RACS ASC) from 2010 to 2014.

Methods

All General Surgical (including its sub-speciality groups) abstracts presented at the RACS ASC from 2010 to 2014 were identified from the ANZ Journal of Surgery. We determined the rates of full paper publication, time to publication, journals of publication and specialty rates of conversion. Full article publications were identified using the PubMed, MEDLINE and Google Scholar databases.

Results

A total of 1386 abstracts were identified, of which 356 (26%) were converted to full paper publications. The number of abstracts presented annually increased from 206 in 2010 to 386 in 2014, but the percentage of abstracts converted to full paper publications did not follow any temporal trend. The majority (74%) of full papers were published within 2 years of the abstract presentation.

Conclusion

In total, 26% of General Surgery abstracts presented at the RACS ASC from 2010 to 2014 were converted to full paper publications. This could provide a baseline against which to judge the quality of presentations at other national General Surgical congresses, as well as at future RACS ASC meetings.

Extravasation injury in a paediatric population

July 6, 2017 - 21:31
Background

Extravasation occurs when a drug is inadvertently administered outside of the vein. Depending on the substance involved, this may lead to tissue necrosis with significant long-term morbidity. Children, particularly neonates, are particularly susceptible to extravasation with up to 70% of children in neonatal intensive care unit having some form of extravasation injury. These injuries are commonly referred to plastic surgeons for ongoing management.

Methods

We prospectively collected information on all extravasation injuries referred to the plastic surgery department in a children's hospital over an 18-month period. Data collected included the agent involved in the extravasation, treatment and outcomes.

Results

In total, there were 43 extravasation injuries recorded on the hospital risk management system during the period of this study. All of these were referred to the plastic surgery team for ongoing management. Five patients (11%) underwent washout of their injuries. Three patients (7%) suffered injuries, which led to significant tissue necrosis, delayed healing and prolonged morbidity.

Conclusion

Smaller infants, particularly those being cared for in an intensive care setting, are at increased risk for extravasation injury. Early referral and treatment of high-risk extravasation injuries may reduce the incidence of tissue loss and morbidity.

Impact of an acute surgical unit on patient outcomes in South Australia

July 6, 2017 - 21:31
Background

Compared with traditional (Trad) systems of managing emergency surgical presentations, the acute surgical unit (ASU) model provides an on-site registrar, on-call surgeon and dedicated emergency theatre, 24 h/day. To date, there have been no Australasian ASU studies of >3000 patients, nor from South Australia.

Methods

A retrospective historical control study compared the outcomes of adults admitted to the Lyell McEwin Hospital in the Trad (1 February 2010 to 31 July 2012) and ASU periods (1 August 2012 to 31 January 2015), who underwent an emergency general surgical procedure.

Results

A total of 4074 patients met inclusion criteria; 1688 and 2386 patients during the Trad and ASU periods, respectively. The cohorts were not significantly different in median age, gender or American Society of Anesthesiologists scores. Compared with the Trad period, improved median time from emergency department referral to theatre start (19.4 h versus 17.9 h, P < 0.0001) and median length of stay (2.32 days versus 2.06 days, P < 0.0001) were observed during the ASU period. The proportion of procedures performed in-hours was similar (77.9% versus 79.6%, P = 0.18). Secondary outcomes of rates of intensive care unit admission, emergency department representation within 30 days, in-hospital mortality and 1-year all-cause mortality were unchanged.

Conclusion

Institution of an ASU was associated with decreased time from referral to theatre and reduced length of stay. The proportion of cases performed in-hours did not change. This may be related to the high Trad period rate and increased workload. These findings represent the largest Australasian study of an ASU and support the current model of care.

Predictive factors for lymph node metastasis in early gastric cancer with signet ring cell histology: a meta-analysis

July 6, 2017 - 21:30
Abstract Background

Less invasive surgery is widely used in the treatment of early gastric cancer; however, no definite guidelines exist regarding indications for less invasive surgery to treat early gastric cancer with signet ring cell histology. The aim of this study was to identify risk factors for lymph node metastasis (LNM) in early signet ring cell carcinoma (SRC). An extensive search of PubMed, Embase and the Cochrane library was performed for pertinent articles involving early SRC and LNM.

Methods

Eligible data (gender, depth of invasion, lymphovascular invasion, size, ulceration, macroscopic type and location) were extracted from the included studies and systematically reviewed via a meta-analysis. Review Manager version 5.3 was used to perform the data processing. The Newcastle–Ottawa Scale was utilized to evaluate the quality of the included articles.

Results

Fourteen studies were included in the final analysis. After meta-analysis, female gender, submucosal invasion, lymphovascular invasion and size >20 mm were associated with LNM in early SRC.

Conclusion

Four variables were identified as risk factors for LNM in early SRC. The significance of the results of the present study should be further confirmed in more early SRC patients for future clinical use.