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: 15 hours 37 min ago

Concurrent gallstone ileus and cholecystocolic fistula causing high volume diarrhoea

September 18, 2019 - 21:54
ANZ Journal of Surgery, EarlyView.

Caecal herniation and volvulus through the foramen of Winslow: a rare presentation

September 18, 2019 - 21:54
ANZ Journal of Surgery, EarlyView.

Sarcopenic obesity and post‐operative morbidity after pancreatic surgery: a cohort study

September 18, 2019 - 21:53

Significant variability exists in the sarcopenic indices. All three sarcopenic indices previously described failed to predict post‐operative morbidity. Sarcopenic obesity was the only predictor of post‐operative morbidity.


Abstract Background

Several indices of sarcopenia (SARC) exist in the literature, however, there is no consensus as to the best SARC index to predict post‐operative morbidity following pancreatic surgery.

Methods

A prospectively collected database was reviewed in a single institution including a total of 89 consecutive patients who had undergone pancreatic resection between 2015 and 2018.

Results

A total of 89 patients comprised the cohort. Seventy‐one percent (63/89) underwent pancreaticoduodenectomy. SARC was identified in 49 patients (55%) using psoas muscle index, 44 patients (49%) using the skeletal muscle index and 25 patients (28%) using the skeletal muscle attenuation. Post‐operative morbidity did not differ between SARC and non‐SARC (NSARC) patients using all three preoperative computed tomography measures (skeletal muscle index SARC 64%, 28/44, NSARC 64%, 29/45, P = 1.000; psoas muscle index SARC 63%, 31/49, NSARC 65%, 26/40, P = 0.810; skeletal muscle attenuation SARC 17/25, NSARC 40/64, P = 0.247). However, sarcopenic obesity was a significant independent risk factor for overall post‐operative morbidity on multivariate analysis (odds ratio 1.241 (SE 0.608), P = 0.041) with the highest specificity (81%).

Conclusion

Preoperative sarcopenic obesity can be an important independent predictor of post‐operative morbidity following pancreatic resection. There remains a need for standardization of SARC indices.

Evaluation of website information provided by paediatric surgery centres in Australia and New Zealand

September 15, 2019 - 00:39

This is the first study to evaluate the quality of paediatric surgical information provided in hospital websites within Australia and New Zealand. One‐third of centres do not have a hospital webpage. Our findings suggest that an improvement in internet presence of paediatric surgery in Australasia is needed.


Background

Hospital websites are an important source of information for patients, parents and healthcare providers. There are currently no standardized recommendations for the information provided on paediatric surgery websites. We aimed to assess the information available on each hospital website, in Australia and New Zealand, which provides paediatric surgical care.

Methods

Google search was performed of the 16 paediatric surgical centres in Australia and New Zealand to determine whether they had a hospital website and to assess its contents. The presence of patient fact sheets and clinical practice guidelines was recorded. Access to contact information, hospital Facebook page and Twitter handles were noted.

Results

We found that 11 (69%) centres had a specific paediatric surgical section to the hospital website, all provided contact information. Five centres (31%) had paediatric‐specific guidelines available for health professionals. Six websites (37.5%) provided health information sheets on common paediatric surgical conditions. Facebook and Twitter facilities were present on the majority of the websites (75%).

Conclusion

The internet presence of paediatric surgery in Australia and New Zealand is sparse. One‐third of centres do not have hospital web presence. The availability of clinical guidelines and patient information sheets on hospital websites is limited. Our findings would suggest that improvement and increase in the internet presence of paediatric surgery in Australia and New Zealand is needed.

Low recurrence of lung adenoid cystic carcinoma with radiotherapy and resection

September 15, 2019 - 00:39

Adenoid cystic carcinoma is a rare cause of thoracic malignancy, and the prognosis may depend on extent of surgical resection and adjuvant radiotherapy. Complete resection has low rates of local recurrence but is complicated by the involvement of central airways. Adjuvant radiotherapy is frequently recommended, but unproven. Our case series consolidates evidence that early radical resection and radiotherapy is associated with a low risk of local recurrence in patients with thoracic adenoid cystic carcinoma.


Background

Adenoid cystic carcinoma is a rare cause of thoracic malignancy, and the prognosis may depend on the extent of surgical resection and adjuvant radiotherapy. Complete resection has low rates of local recurrence but is complicated by the involvement of central airways. Adjuvant radiotherapy is frequently recommended but unproven.

Methods

We describe the technicalities of radical resection and adjuvant radiotherapy using the primary endpoint of local recurrence and secondary endpoints of locoregional (mediastinal) recurrence and distant metastasis. Resections were classed as microscopically and macroscopically clear (R0) or only macroscopically clear (R1).

Results

Twelve patients (eight males) diagnosed between 1999 and 2016, with an average age of 44 ± 12 years, were included. Six of these were operable (operative group), and six had non‐resectable lesions (radiotherapy group). In the operative group, three had tracheal disease and three had bronchial disease. Tracheal lesions underwent excision with tracheal anastomosis (all R1 resections). Main bronchial lesions underwent complete excision via pneumonectomy (two R0 and one R1 resections). All these patients received 50–60 Gray of adjuvant radiotherapy. At an average follow‐up of 6.1 ± 4.3 years, no patient had local recurrence, two had locoregional recurrence and four had distant metastasis. The radiotherapy group received 60–70 Gray as definitive therapy, and at an average follow‐up of 5.4 ± 4.2 years, three had locoregional recurrence and four had distant metastasis.

Conclusion

Our case series consolidates evidence that early radical resection and radiotherapy is associated with a low risk of local recurrence in patients with thoracic adenoid cystic carcinoma.

Analysis of portal vein thrombosis after liver transplantation

September 15, 2019 - 00:39
Background

Portal vein thrombosis (PVT) is one of the most deadly complications after orthotopic liver transplantation (OLT). This study aimed to identify risk factors and summarize the experience of PVT management after OLT.

Methods

The clinical data of 407 adult patients received OLT from July 2011 to December 2015 was retrospectively investigated.

Results

The incidence rate of PVT was 2.9% (12/407). Pre‐transplant PVT (P = 0.001), post‐operative transfusion of erythrocyte (P = 0.006) and platelet (P = 0.036) were significantly associated with PVT in the univariate analysis and the appearance of pre‐transplant PVT (P = 0.002, odds ratio 6.05) was the independent risk factor according to binary logistic regression. Among patients with PVT, three cases (3/12) received balloon dilation through selective catheterization of portal vein, five (5/12) received balloon‐expandable stent placement, three (3/12) received thrombectomy and surgical revascularization and one (1/12) received retransplantation. Six patients (6/12) died from various complications and the remaining six were followed up with normal liver function and patent portal vein.

Conclusions

The risk factors were pre‐transplant PVT and post‐operative transfusion of erythrocyte and platelet. To recipients with high risk, early diagnosis and prompt management of PVT are essential to improve prognosis.

Acute surgical unit improves outcomes in appendicectomy

September 15, 2019 - 00:39

The acute surgical unit dedicates an on‐site registrar, an on‐call consultant and an operating theatre to the task of managing emergency general surgery presentations, 24 h/day. In this single‐centre retrospective cohort study of 1214 patients undergoing appendicectomy, compared with the prior Traditional model, the acute surgical unit model was associated with more daytime operating, fewer complications and fewer open procedures.


Background

Few large Australian studies have explored the impact of acute surgical unit (ASU) model in appendicitis.

Methods

An ASU model commenced practice at our institution on 1 August 2012. In this retrospective cohort study, patients undergoing appendicectomy 2.5 years before (Traditional group) or after (ASU group) this date were compared. Primary outcomes were median length of stay, median time from emergency department referral to theatre start and proportion of cases performed in‐hours. Secondary outcomes were rates of complications, open appendicectomy, consultant scrubbed for procedure, intensive care unit admission and re‐presentation to emergency department within 30 days.

Results

After removing those with incomplete data, 1214 patients were enrolled; 465 in the Traditional group and 749 in the ASU group. There were no significant baseline differences between groups. Compared with the Traditional group, ASU patients had similar length of stay (1.81 versus 1.81 days; P = 0.54) and time to theatre (0.59 versus 0.56 days; P = 0.14), but a greater proportion of in‐hours operation (72% versus 79%; P = 0.014). The ASU group also experienced fewer complications (9% versus 6%; P = 0.031), fewer primary open (4% versus 1%; P < 0.0001) or conversion‐to‐open appendicectomies (6% versus 2%; P < 0.0005) and had superior rates of consultant scrubbed in theatre (21% versus 56%; P < 0.00001). Rates of intensive care unit admission (1% versus 1%; P = 0.72) and re‐presentation were unchanged (5% versus 5%; P = 0.46).

Conclusion

In our institution, the introduction of an ASU model was associated with more in‐hours operations and safer care for patients undergoing appendicectomy.

Establishing content validity and fidelity of a novel paediatric intussusception air enema reduction simulator

September 15, 2019 - 00:39
Background

Intussusception is a common, potentially life‐threatening paediatric condition. Non‐operative treatment with an air enema has been established as the clinical gold standard. There is no validated model for the training of this procedure. Our aim was to produce a novel air enema reduction simulator and validate its use as a training tool.

Methods

A low‐cost paediatric intussusception air enema simulator was created. It was designed to include essential key clinical procedural steps. Participants included both procedural experts and novices from the Departments of Paediatric Radiology and Surgery. The simulator was assessed for face and content validity and its physical, conceptual and experiential fidelity by a structured questionnaire using a 5‐point Likert's scale. Statistical analysis included a t‐test, and a P‐value of <0.05 was considered significant.

Results

Twenty‐four clinicians completed the simulation activity (expert: 13 and novices: 11). All experts had performed a minimum of 40 clinical procedures, and 46% had performed >50 procedures. All scores were favourable in all domains for face and content validity: 3.5 (physical appearance), 3.3 (insertion of the tube and taping), 3.1 (holding of the buttocks) and 3.5 (performing the air enema). The simulator also scored highly with fidelity assessment; visual 3.5, conceptual 3.4. There was no difference in procedural confidence with experts (3.8 versus 3.6, P = 0.28), but there was for novices (1.0 versus 2.9, P = 0.0002).

Conclusions

This low‐cost air enema reduction simulator for intussusception has an excellent educational potential for use in a training program in a tertiary centre, as well as, resource‐constrained environments.

Comparing the sterility and visibility of surgical marking pens available in Australia

September 15, 2019 - 00:39

This is an unblinded, prospective cohort study assessing the sterility and visibility of surgical marking pens. Photographs of the pen marks were taken before and after wash with surgical prep solutions to analyse ink visibility during surgery. The pen tips were swabbed for culture.


Background

Surgical site marking is an important safety procedure prior to surgery. Visibility of pen marks is affected by surgical wash which increases the risk of wrong‐site surgery. Additionally, multiple patient contact with a single pen is a potential source of bacterial transmission. In this study we compare pens commonly used for surgical marking in Australia.

Methods

We conducted an unblinded, prospective cohort study comparing 12 marking pens. Six volunteers' thighs were marked with each pen. Standardized photographs were taken before and after wash with four prep solutions. Ink visibility was analysed using grayscale images, comparing the pen mark tone before and after wash. The pen tips were swabbed for culture.

Results

Red tinted 2% chlorhexidine gluconate (w/v) with 70% isopropyl alcohol (v/v) was shown to reduce pen mark visibility significantly more than the other solutions used. The Pentel N50 permanent marker and Aspen WriteSite Plus were least affected by wash. No pen tip cultured any bacteria.

Conclusions

When marking the correct site for surgery, we recommend the use of either the Pentel N50 permanent marker or Aspen Writesite Plus pen. A 2‐min interval between patient contact limits bacterial transmission.

Outcomes from cytoreduction and hyperthermic intraperitoneal chemotherapy for appendiceal epithelial neoplasms

September 15, 2019 - 00:39

Cytoreductive surgery with HIPEC for PMP and other appendiceal neoplasms is safe and effective. Despite carrying some morbidity, it offers very good 5 year, overall and recurrence‐free survival.


Background

Appendiceal epithelial neoplasms are rare cancers. Management of peritoneal disease from appendiceal neoplasms has historically been with debulking surgery. In recent decades, the advent of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has become the standard of care. Here, we report our single institution 10‐year experience with CRS and HIPEC for appendiceal neoplasms.

Methods

This is a retrospective review from 1 January 2008 to 1 June 2017 of all patients undergoing CRS and HIPEC for appendiceal neoplasms. Institutional ethics approval was granted for this project.

Results

One hundred and seventy‐two patients underwent 208 CRSs during this time. Overall, 83.72% of patients had one CRS and HIPEC procedure. Pseudomyxoma peritonei from a perforated appendiceal mucinous neoplasm accounted for 67.9% of cases. The median peritoneal carcinomatosis index (PCI) was 14, with complete cytoreduction achieved in 74.2% of patients. Fifty‐four percent of patients had at least one complication, with one (0.5%) peri‐operative mortality in our cohort. For the entire cohort, the median overall survival was 104 months and a 5‐year survival of 75%. In those having a complete cytoreduction, 5‐year survival was 90%, with a median disease free interval of 63 months. PCI and completeness of cytoreduction were independent predictors of overall survival.

Conclusion

Our results demonstrate that CRS and HIPEC for appendiceal neoplasms are safe and effective. Despite carrying some morbidity, it offers patients an excellent disease free and overall survival.

Complete resection of colorectal cancer with ovarian metastases combined with chemotherapy is associated with improved survival

September 15, 2019 - 00:39
Background

Ovarian metastases (OM) from colorectal cancer (CRC) are uncommon, and data about optimal management are lacking. The aim of this study was to examine the management and outcomes of patients with OM from CRC.

Methods

A retrospective review of records of patients with a histopathological diagnosis of OM from CRC who were treated at Christchurch Hospital between 1 January 2000 and 31 December 2016. Data related to presentation, clinicopathological characteristics, treatment and outcomes were recorded. The primary outcomes were overall survival and disease‐free survival.

Results

Thirty‐one patients were identified (median age 55 years, range 28–77), with a median follow‐up of 23 months (range 3–84 months). Abdominal pain was the most common presenting symptom (22 patients). Synchronous OM occurred in 22 patients, 14 patients had bilateral ovarian involvement. Twenty‐one patients received adjuvant chemotherapy. R0 resection was achieved in 14 patients. For all patients the 5‐year disease‐free and overall survival were 11% and 12%, respectively, while 5‐year overall survival for R0 resections was 30%. Improved median survival was associated with negative colon resection margins (26.7 months versus 7.8 months, P = 0.03), R0 resection (30.5 months versus 23.5 months, P = 0.04), and use of adjuvant chemotherapy (28.8 months versus 8.2 months, P < 0.0001); however, on multivariate analysis adjuvant chemotherapy was the only independent factor associated with improved prognosis (P = 0.01).

Conclusions

OM from CRC are uncommon and carry a poor prognosis. Improved survival was associated with complete surgical resection of the primary tumour and metastatic disease in combination with systemic chemotherapy.

Time is of the essence: evaluation of emergency department triage and time performance in the preoperative management of acute abdomen

September 15, 2019 - 00:39

Time is of the essence: Evaluation of emergency department triage and time performance in the pre‐operative management of acute abdomen.


Background

Acute abdomen is a time‐critical condition, which requires prompt diagnosis, initiation of first‐line preoperative therapy and expedient surgical intervention. The earliest opportunity to intervene occurs at presentation to the emergency department triage. The aim of this audit was to evaluate the relationship between emergency triage and time performance measures in the preoperative management of abdominal emergencies.

Methods

Retrospective audit of time performance measures of key clinical events from emergency triage. Patient characteristics, elapsed time from triage to commencement of fluid resuscitation, intravenous antibiotics and emergency surgery and post‐operative outcomes were obtained from review of operative medical records data over a 1‐year duration.

Results

There was variability in triage allocation of patients with acute abdomen requiring urgent surgery. Category 3 was the most commonly assigned triage category (65.6%). The majority of patients (94.8%) had initial clinical assessment within the National Emergency Access Target ‘4‐hour’ rule, and 41.7% seen within 1‐h from triage. Despite this, in cases of intra‐abdominal sepsis, there was nearly a fourfold elapsed time for first dose intravenous antibiotics, beyond the 1‐h recommendation in the Sepsis Kills pathway. There was non‐significant trend in faster overall time performances with successive higher triage category allocation.

Conclusion

This study highlights an opportunity to consider alternative triage methods or fast‐track of patients with acute abdomen to promote early surgical assessment, resuscitation, antibiotic therapy and definitive intervention.

Stereotactic body radiation therapy for early hepatocellular carcinoma: a retrospective analysis of the South Australian experience

September 15, 2019 - 00:39

This article provides the first Australian data on the emerging technique of stereotactic body radiation therapy for small hepatocellular carcinoma. It deals with a common scenario for hepatobiliary and transplant surgeons, when small and curable HCCs cannot be either resected or ablated.


Background

Stereotactic body radiation therapy (SBRT) is an emerging treatment option for liver tumours unsuitable for established curative treatment such as ablation or surgery. The aim of the study is to evaluate the efficacy and safety of SBRT in the treatment of small hepatocellular carcinoma (HCC) in South Australia.

Methods

From 2014 to 2018, 13 HCC patients were treated with SBRT. Eligibility criteria for SBRT included: unsuitable for standard curative therapies (resection or percutaneous ablation), lack of complete response to prior transarterial chemoembolization, Child–Pugh classification ≤B7, tumours ≤5 cm and minimum of up to 6 months follow‐up post‐SBRT. The prescribed radiation dose was determined by liver function with doses ranging from 40 to 45 Gy in three or five fractions. Records for all patients were reviewed, and treatment response was scored according to the modified response evaluation criteria in solid tumours. Toxicity was graded according to the Common Terminology Criteria for Adverse Events version 4.0.

Results

The median follow‐up time was 22.7 months, and the median tumour size was 40 mm. The 1 year local control was 92.3%, recurrence‐free survival was 67.7% and overall survival was 86.4% at end of study. Three patients underwent liver transplant. No grade ≥3 non‐haematological toxicities were observed. One patient experienced acute grade ≥3 haematological toxicity.

Conclusion

SBRT is a safe, effective and non‐invasive alternative treatment option for patients with small HCCs, unsuitable for standard, evidence‐based therapies and lacking complete response to transarterial chemoembolization. Randomized controlled trials are required to further investigate the role of SBRT in HCC.

Weekend effect: analysing temporal trends in solid organ donation

September 15, 2019 - 00:39

We aimed to characterize the effect of weekend referral on organ donation by retrospectively reviewing all New South Wales Organ and Tissue Donation Service logs from 2010 to 2016. Donation rates were no lower for weekend compared to weekday referrals (adjusted OR 1.17; 95% CI 0.95, 1.44), hence the donation pathway operates consistently throughout the week.


Background

Research suggests patients treated over weekends experience poorer outcomes. Only one US‐based study explored this weekend effect in organ donation, specifically the kidney discard rate. In Australia potential donors are referred to a donation service, and donation proceeds if family consent is granted and the donor is deemed medically suitable to donate. Organ procurement occurs when utilization is almost certain hence discard rates are much lower than in the USA. We aimed to characterize the effect of weekend referral on organ donation in Australia.

Methods

We retrospectively reviewed all New South Wales Organ and Tissue Donation Service logs from 2010 to 2016. Our primary outcome was progression to organ procurement, and secondary outcomes were family consent and meeting medical suitability thresholds. We used logistic regression with random effects adjusting for clustering of referral hospitals.

Results

Of 3496 potential donors referred for consideration, 694 (20%) progressed to organ procurement. There were fewer referrals on weekends (average 415 versus 588 for weekdays). However, donation rates were no lower for weekend compared to weekday referrals (adjusted OR 1.17; 95% CI 0.95, 1.44). Family consent (adjusted OR 1.20; 95% CI 1.00, 1.44) and medical suitability (adjusted OR 1.15; 95% CI 0.96, 1.38) were not lower for weekend compared to weekday referrals. Similar results were found for all sensitivity analyses conducted.

Conclusions

In Australia, the donation pathway operates consistently throughout the week, with donation no less likely to proceed on weekends and holidays. This finding contrasts with findings in the USA.

Re: Comparison of outcomes between hip fracture patients with concurrent upper limb injuries and patients with an isolated hip fracture

September 15, 2019 - 00:39
ANZ Journal of Surgery, Volume 89, Issue 9, Page 1173-1173, September 2019.

Adhesional small bowel obstruction following robotic pelvic surgery: challenges in management and outcome improvement

September 15, 2019 - 00:39
ANZ Journal of Surgery, Volume 89, Issue 9, Page 1174-1175, September 2019.

Posterior retroperitoneoscopic approach is feasible in selected patients requiring revision adrenal surgery

September 15, 2019 - 00:39
ANZ Journal of Surgery, Volume 89, Issue 9, Page 1175-1176, September 2019.

Response to Re: Comparison of outcomes between hip fracture patients with concurrent upper limb injuries and patients with an isolated hip fracture

September 15, 2019 - 00:39
ANZ Journal of Surgery, Volume 89, Issue 9, Page 1173-1174, September 2019.

American Society of Anesthesiologists score cannot be suitable for high‐risk criteria

September 15, 2019 - 00:39
ANZ Journal of Surgery, Volume 89, Issue 9, Page 1174-1174, September 2019.

Re: Selective cholecystectomy: using an evidence‐based prediction model to plan for cholecystectomy

September 15, 2019 - 00:39
ANZ Journal of Surgery, Volume 89, Issue 9, Page 1175-1175, September 2019.