ANZ Journal of Surgery

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Wiley Online Library : ANZ Journal of Surgery
Updated: 5 hours 22 min ago

Metastatic prostate cancer incidence in Australia after amendment to prostate-specific antigen screening guidelines

December 1, 2017 - 11:20
Background

To compare the incidence of newly diagnosed metastatic prostate cancer at an Australian facility pre- and post-publication of the United States Preventive Services Task Force (USPSTF) guidelines and subsequent amendment of the Royal Australian College of General Practitioners Preventive Activities in General Practice guidelines.

Methods

A retrospective analysis was undertaken by patients with newly diagnosed prostate cancer following transrectal ultrasound-guided biopsy between 2009 and 2014. Patients were divided into two even groups based on whether they had undergone their transrectal ultrasound biopsy pre- (2009–2011) or post- (2013–2014) publication of USPSTF guidelines. Metastatic disease was determined by computed tomography chest, abdomen, pelvis as well as nuclear medicine bone scan. A comparison in the incidence of newly diagnosed metastatic prostate cancer was made.

Results

A total of 130 patients were allocated into each group. In the pre-USPSTF group, 23 out of 130 patients had newly diagnosed metastatic prostatic cancer (17.7%). In the post-USPSTF group, 41 out of 130 (31.5%) had newly diagnosed metastatic prostate cancer (P < 0.05). The mean and median prostate-specific antigen was 15.9 and 9.4 (pre-guideline group) and 33.0 and 9.8 (post-guideline group), respectively (P = 0.02). The post-guidelines group had a higher incidence of low-grade disease (Gleason <7), a decreased incidence of intermediate grade disease (Gleason 7) and a relatively unchanged incidence in high-risk disease (Gleason >7).

Conclusion

The incidence of newly diagnosed metastatic prostate cancer nearly doubled in patients referred to our Urology Department post-release of the USPSTF guidelines.

Radical gastric cancer surgery results in widespread upregulation of pro-tumourigenic intraperitoneal cytokines

December 1, 2017 - 11:20
Background

Radical surgical resection is the mainstay of curative treatment for oesophagogastric malignancy. However, survival and recurrence rates remain poor. Theoretical data suggests that the inflammatory response to surgery can promote tumour recurrence. The local and systemic inflammatory response to radical oesophagogastric cancer surgery has not been fully characterized. We aimed to measure this response, particularly factors associated with tumour implantation.

Methods

Consecutive patients undergoing radical junctional or gastric cancer resection over 12 months were recruited. Repeated serum and adipose tissue were collected intra-operatively. Adipose tissue was collected adjacent and remote to the tumour, and cytokine messenger RNA (mRNA) expression was measured. Post-operatively, daily serum was collected for 7 days, and analysed for inflammatory cell profile and cytokine concentration.

Results

There were nine patients recruited (67.1 ± 2.1 years). mRNA expression of interleukin-6 (IL-6), CC-chemokine ligand-2 and IL-1β increased in adipose tissue intra-operatively (P < 0.05), equally both adjacent and remote from the tumour site. Serum IL-6 concentration increased from 23.3 pg/mL to 161.8 pg/mL intra-operatively (P < 0.05) before falling steadily to 35.7 pg/mL post-operatively (P < 0.05). Serum tumour necrosis factor-α was elevated throughout, and IL-1β levels were unaffected. Leukocyte and neutrophil populations increased, while T-cell and dendritic cell populations decreased intra-operatively (P < 0.05).

Conclusion

Radical surgery dramatically upregulates the expression of pro-tumourigenic cytokines in the peritoneum. There is also a marked systemic immune and inflammatory response to surgery, including downregulation of T-cell and dendritic cell populations. This offers two potential pathways that may facilitate tumour progression – local inflammation promoting peritoneal adherence and implantation, and secondary suppression of immunosurveillance due to circulating inflammatory response.

Factors influencing lymph node skip metastasis in colorectal cancer: a retrospective study

December 1, 2017 - 11:20
Background

The risk factors for lymph node skip metastasis (LNSM) have not been thoroughly clarified in patients with advanced colorectal cancer (CRC). This study aimed to identify the risk factors for LNSM in CRC patients who underwent laparoscopic radical resection with D3 lymphadenectomy.

Methods

This retrospective cohort study included a total of 167 consecutive patients who underwent laparoscopic radical resection with D3 lymphadenectomy for CRC between April 2005 and June 2017. The patients were sorted into the LNSM-positive (skip+ group) and LNSM-negative (skip− group) groups. Logistic regression was used to identify the risk factors for LNSM.

Results

Compared with the skip− group, the frequency of tumour size <5 cm, pT1-2 stage, and pN1 stage were significantly higher in the skip+ group (tumour size <5 cm: 68.8 versus 46.7%, P = 0.025; pT1-2 stage: 18.8 versus 4.4%, P = 0.012; pN1 stage: 78.1 versus 57.0%, P = 0.028), respectively. Multivariate logistic regression analysis revealed that pT1-2 stage (odds ratio (OR) = 4.3, 95% confidence interval (CI): 1.1–16.6, P = 0.034) and pN1 stage (OR = 2.6, 95% CI: 1.1–6.8, P = 0.047) were independent risk factors for LNSM.

Conclusions

pT1-2 stage and pN1 stage are significantly associated with LNSM. Radical D3 lymphadenectomy should remain standard practice for CRC.

Serial lipase for pancreatitis: not enough evidence

November 28, 2017 - 15:40
Background

Lipase is both a sensitive and specific marker for diagnosing pancreatitis. However, the benefit of serial lipase in both monitoring and defining prognosis remains undetermined. This systematic review was conducted to further evaluate this potential application. In addition, this review also looked into the benefits of serial lipase in the subgroup of traumatic pancreatitis.

Methods

PubMed, Cochrane Library and Google Scholar were systematically searched for related articles, between January 1995 and December 2015, according to Preferred Reporting Items for Systematic Reviews and Meta-analyses standards. Data was extracted and analysed by two authors.

Results

Seven studies were included in the final analysis: six retrospective and one prospective studies were identified. Five studies (all retrospective) concluded no benefits in serial lipase for prognostication, while two studies identified serial lipase as a beneficial prognostic factor for acute pancreatitis. Of the included studies, only two involved traumatic pancreatitis (both dedicated to the paediatric population).

Conclusion

The evidence supporting or opposing serial lipase as a prognostic factor for pancreatitis is weak and consists mainly of retrospective analyses. The only prospective data identified suggested benefits to serial lipase in prognosis. Further prospective studies evaluating the prognostic value of serial lipase in the adult population with both traumatic and non-traumatic pancreatitis are required given the paucity of available evidence.

Intravenous fluid therapy in acute pancreatitis: a critical review of the randomized trials

November 22, 2017 - 19:18
Introduction

Fluid management is a cornerstone of treatment in acute pancreatitis (AP).

Methods

Identification of existing randomized prospective trials of patients with AP, in which intravenous fluid management was a significant parameter in the experimental design, was undertaken using the PubMed and ENDOBASE databases.

Results

Included patients in the seven studies identified were on the whole very unwell with deaths occurring in six trials. Fluid regimens in AP included crystalloid alone, combinations of crystalloid and colloid and in two studies, plasma. In most studies, patients with premorbid major organ failure and advanced age were excluded. Study entry within 6 h of presentation occurred in three trials. Initial fluid administration rates varied from 1 to 2 mL/kg/h to 15 mL/kg/h. Rapid fluid rates were associated with increased morbidity and mortality except in one study in which a high fluid regimen (20 mL/kg bolus within 4 h of presentation followed by 3 mL/kg) led to a better clinical outcome than a more conservative regimen. Use of Ringer's lactate led to improved surrogate outcome markers compared to that of normal saline in one study. Administration of colloid as part of the fluid management was associated with lower morbidity and lower fluid requirements.

Conclusion

Rapid infusion of crystalloid very early in the course of AP may be beneficial but rapid infusion of fluid later in the course of the illness may be deleterious. Colloid administration and the use of Ringer's lactate solution in preference to normal saline may improve outcome.

Nonsteroidal anti-inflammatory drugs and anastomotic dehiscence after colorectal surgery: a meta-analysis

November 22, 2017 - 19:18
Background

Enhanced recovery after surgery protocols supports the post-operative use of nonsteroidal anti-inflammatory drugs (NSAIDs) to minimize the use of opioids. However, there is an increasing concern on the impaired wound healing of anastomosis associated with NSAID use, potentially causing a higher risk of anastomotic leakage. The aim was to conduct a meta-analysis to evaluate the association of NSAIDs with anastomotic leakage after colorectal surgery.

Methods

A literature search was conducted using the MEDLINE, PubMed, Cochrane Library and Clinicaltrial.gov. Studies identified were appraised with standard selection criteria. Data points were extracted and meta-analysis was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Results

Seventeen studies comprising of 26 098 patients were examined. The analysis of all studies showed a significantly lower rate of anastomotic dehiscence in the no-NSAID group (pooled odds ratio (OR) = 2.00, 95% confidence interval (CI) = 1.48–2.71, P < 0.00001). The analysis of randomized controlled trials (RCTs) demonstrates similar dehiscence rates between both groups (P = 0.17). In subgroup analysis, non-selective NSAIDs was associated with a higher risk of anastomotic dehiscence (pooled OR = 2.02, 95% CI = 1.62–2.50, P < 0.00001). However, there was no difference in the incidence of anastomotic leakage between no-NSAID group and selective NSAID group (P = 0.05).

Conclusion

Use of NSAIDs after colorectal surgery may be associated with a higher risk of anastomotic leakage. It is important to balance between the benefits of faster post-operative recovery and potential adverse effects of NSAIDs. Selective NSAIDs may be safer than non-selective ones. More RCTs are warranted to further evaluate the relationship between anastomotic leakage and use of NSAIDs, especially selective ones.

Comparison of three fixation methods in treatment of tibial fracture in adolescents

November 21, 2017 - 18:12
Background

Tibial fractures are the most common musculoskeletal injury in adolescents. The optimal management of tibial fractures in adolescents is controversial. In this study, we compared the outcomes including complications of three fixation methods in tibial fractures of adolescents and explored the factors associated with the complications.

Methods

A retrospective cohort study about 83 diaphyseal tibial fractures in 79 children and adolescents, who were treated with plate fixation (PF), elastic stable intramedullary nail fixation (ESINF), or external fixation (EF), was conducted. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in accordance with the length of the hospital stay, time to union, and complication rates including many factors.

Results

The mean age of the patients was 13.4 years, and their mean weight was 44.2 kg. There was a loss of reduction in two of 33 fractures treated with ESINF and four of 13 treated with EF (P < 0.001). At the time of final follow-up, three patients (two treated with EF and one treated with ESINF) had ≥2.0 cm of shortening. Four of the 32 patients (33 fractures) treated with ESINF underwent a reoperation (two due to loss of reduction and one each because of delayed union and nonunion). Six patients treated with EF required a reoperation (four due to loss of reduction, one for malunion and one for replacement of a pin complicated by infection). Two fracture treated with PF required refixation attributing to nonunion and malunion. A multivariate analysis with adjustment for baseline differences showed that EF was associated with a 7.56-times (95% confidence interval 3.74–29.87) greater risk of loss of reduction and/or malunion than ESINF.

Conclusions

All three treatments had satisfactory outcomes, and EF was correlated with the highest rate of complications in our series of adolescents treated with a tibial fracture. However, we cannot currently recommend that all fractures might be suitable for ESINF. The choice of fixation will remain influenced by surgeon preference in term of expertise and experience, patient and fracture characteristics, and patients and family preferences.

Systematic review of disparities in surgical care for Māori in New Zealand

November 18, 2017 - 15:05
Background

Health equity for Indigenous peoples in the context of surgery has recently become topical amongst surgeons in Australasia. Health inequities are amongst the most consistent and compelling disparities between Māori and New Zealand Europeans (NZE) in New Zealand (NZ). We aimed to investigate where ethnic disparities in surgical care may occur and highlight some of the potential contributing factors, over all surgical specialties, between Māori and NZE adults in NZ.

Methods

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A series of electronic searches were performed in Medline, Embase, PubMed and CINAHL.

Results

Ten studies met the inclusion criteria. All studies employed a range of indicators for surgical care including receipt of surgery following diagnosis, delays to treatment and post-operative morbidity and mortality. Disparities in the receipt of surgical treatment for several cancers were observed for Māori and remained after adjustment for socioeconomic variables and extent of disease. Māori were more likely to experience delays in treatment and referral to other medical specialties involved in their care.

Conclusion

Despite the significant variation in the types of diseases, procedures and indicators of surgical care of the included studies, consistent findings are that disparities in different aspects of surgical care exist between Māori and NZE in NZ. This review highlights the need to better quantify the important issue of health equity for Māori in surgery given the lack of studies over the majority of surgical specialties.

Suspended animation: the past, present and future of major cardiothoracic trauma

November 18, 2017 - 15:05

About 50% of the trauma victims die at the scene mostly because of exsanguinating haemorrhage. Most trials of resuscitation fail in face of the ongoing bleeding. Ongoing research/studies to save these victims by inducing rapid hypothermia using cardiopulmonary bypass as an emergency initial measure along with delayed resuscitation show improved outcomes. A comprehensive review of this research and analysis of studies showed that rapid induction of hypothermia within 5 min of cardiac arrest is associated with better survival and improved neurological outcome. This led us to conclude that suspended animation is a lifesaving modality for the treatment of trauma victims, otherwise hurtling towards certain death. This should be integrated into regular clinical practice. The US Food and Drug Administration has given its approval for clinical trials on such an intervention.

Supraclavicular flap repair in the free flap era

November 17, 2017 - 19:42
Background

Supraclavicular flap (SCF) repair is widely reported in head and neck surgery in select patients and defects. The authors’ objective is to present our series of 30 patients who underwent SCF repair for varying defects and to review the scope and outcome of SCF repair in the literature.

Methods

The authors contributed primary evidence of 30 cases of SCF repair. Our outcomes are compared with those reported in the last 5 years’ literature; 33 articles published between January 2012 and January 2017 that present original clinical experience of 528 SCFs.

Results

SCF is suitable for a wide variety of oral cavity, pharyngeal, skull base and cutaneous defects. Consistent with our experience, SCF is highly reliable even in previously irradiated or dissected necks, so long as the supraclavicular artery is intact. Our case series shows minor complications in 3/30 (10%) and flap loss in 1/30 (3.3%) cases. The literature reports a similar rate of complete flap failure of 3.4% and a slightly higher average minor complication rate of 24.6%.

Conclusion

We add our experience of 30 cases of SCF repair to the international literature. We experienced a complication rate lower than the reported average, and maintain that the SCF is an excellent reconstructive option in patients with previously irradiated necks or comorbidities that affect microvasculature and anaesthetic resilience.

Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue

November 17, 2017 - 19:40
Background

Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico-legal ramifications. Further, well-documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met.

Method

We undertook an audit of Urology and General Surgery operation notes handwritten by junior doctors and surgical trainees in a tertiary teaching hospital over a month period both in 2014 and 2015. Individual operative notes were assessed for quality based on parameters described by the Royal College of Surgeons of England guidelines.

Results

Based on the Royal College of Surgeons of England guidelines, a significant proportion of analysed surgical operative notes were incomplete, with information pertaining to the time of surgery, name of anaesthetist and deep vein thrombosis prophylaxis in particular being recorded less than 50% of the time (22.42, 36.36 and 43.03%, respectively).Overall, 80% compliance was achieved in 14/20 standards and 100% compliance was attained in only one standard.

Conclusions

The quality of surgical operation notes written by junior doctors and trainees demonstrated significant deficiencies when compared against a set standard. There is a clear need to educate junior medical staff and to provide systems and ongoing education to improve quality. This would involve leadership from senior staff, ongoing audit and the development of systems that are part of the normal workflow to improve quality and compliance.

Development of a surgical trainer assessment questionnaire

November 14, 2017 - 08:30
Background

The assessment of surgical trainees has become well-established in practice; however, this is not yet the case for surgical trainers. The aim of this study was to develop a trainer assessment questionnaire (OxTrAQ) based on the 12 key trainer attributes identified by a previous systematic review, to then explore this questionnaire's potential domains and test its reliability.

Methods

The OxTrAQ was piloted at two surgical training centres in two surgical sub-specialities. At each centre, every trainee assessed every trainer while under their clinical supervision.

Results

Internal consistency (Cronbach's alpha) was calculated for this 12-item questionnaire as 0.958. Factor analysis revealed two domains which accounted for 77.997% of the variance; these were the general domain (nine items) and the independence domain (three items). Inter-observer reliability was shown by the intraclass correlation coefficients (ICCs) (average measures) for the overall OxTrAQ score, general domain score and independence domain score which were 0.951, 0.945 and 0.955 for centre 1 and 0.857, 0.819 and 0.883 for centre 2, respectively. Intra-observer reliability was shown by the ICCs (average measures) for the overall OxTrAQ score, general domain score and independence domain score which were 0.925, 0.913 and 0.940, respectively. Construct validity was demonstrated by a high correlation (Spearman rho = 0.886, P = 0.019) between trainer scores and the scores predicted by the trainers themselves.

Conclusions

The OxTrAQ is a simple trainer assessment questionnaire which has demonstrated both high inter- and intra-observer reliability.

Current evidence for the use of N-acetylcysteine following liver resection

November 14, 2017 - 08:30
Background

N-acetylcysteine (NAC) has many uses in medicine; notable in the management of paracetamol toxicity, acute liver failure and liver surgery. The aim of this review was to critically appraise the published literature for the routine use of NAC in liver resection surgery.

Methods

An electronic search was performed of EBSCOhost (Medline and CINAHL database), PubMed and the Cochrane Library for the period 1990–2016. MeSH headings: ‘acetyl-cysteine’, ‘liver resection’ and ‘hepatectomy’ were used to identify all relevant articles published in English.

Results

Following the search criteria used, three articles were included. Two of these studies were randomized controlled trials. All the studies collated data on morbidity and mortality. All three studies did not show a significant difference in overall complications rates in patients that underwent hepatic resection that had NAC infusion compared with patients that did not. In one study, NAC administration was associated with a higher frequency of grade A post-hepatectomy liver failure. In another study, a significantly higher incidence of delirium was observed in the NAC group, which led to the trial to be terminated early.

Conclusion

The current published data do not support the routine use of NAC following liver resection.

Carotid endarterectomy: the change in practice over 11 years in a stroke centre

November 14, 2017 - 08:30
Background

Recent research evidence has impacted the practice of carotid endarterectomy (CEA). We aim to characterize changes in the practice and outcome of CEA over time in a single large-volume stroke centre.

Methods

All patients who underwent CEA from 2004 to 2014 and carotid angioplasty and stenting (CAS) from 2003 to 2008 at an Australian metropolitan tertiary stroke centre hospital were included. Clinical data were analysed to identify time trends in choice of intervention, patient selection, preoperative imaging utilization, surgical timing and outcome.

Results

There were 510 CEAs performed during 2004–2014 and 95 CASs during 2003–2008. The proportion of patients undergoing CEA compared to CAS increased from 60% to 90% from 2004 to 2008 (P < 0.001). CAS patients were more likely to have cardiac co-morbidities. From 2004 to 2014, the proportion of CEA patients aged ≥80 years increased (P = 0.001) and the proportion of asymptomatic patients decreased (P = 0.003) over time. Median time from symptom onset to surgery decreased from 52 days (Q1: 25, Q3: 74) in 2004 to 8 days (Q1: 5, Q3: 37) in 2014 (P < 0.001). Use of preoperative ultrasonography decreased whilst CT angiography and the number of imaging modalities applied to each patient increased over time (P < 0.001). Overall, 5.9% of CEAs were complicated by death, stroke or acute myocardial infarction with no significant change over time.

Conclusion

The trends in CEA practice at our centre align with international trends and guidelines. This study provides a representative indicator of Australian hospital practice, and illustrates how evidence from research is translated into clinical care.

Impact of web-based clinical practice guidelines on paediatric fracture clinics

November 13, 2017 - 10:52
Background

In an effort to standardize management and reduce over-treatment of uncomplicated paediatric fractures, the Victorian Pediatric Orthopaedic Network and the Royal Children's Hospital, Melbourne, created publically available web-based paediatric fracture pathways. The aim of this study was to determine the impact of web-based fracture pathways on the clinic volume at a tertiary-care paediatric fracture clinic.

Methods

A comparative retrospective review was performed at a large, urban, tertiary-care children's hospital. Fracture clinic data from two 12-week periods before and after implementation of the fracture pathways were compared. For each study period, data collected included: total number of emergency department visits, number of fracture clinic visits, number of fracture clinic visits for patients that presented with upper extremity fractures for which web-based fracture pathways were available, number of radiology department visits for X-rays, and number of fracture clinic visits for patients requiring orthopaedic intervention in the operating room (closed or open reductions).

Results

The number of fracture clinic visits for patients with upper extremity fractures decreased 12% post-pathway implementation, from 954 visits to 842 visits. The number of radiology department visits for patients with upper extremity fractures decreased 24% post-pathway implementation, from 714 to 544 visits.

Conclusion

The implementation of web-based fracture pathways for upper extremity paediatric fractures was associated with a decrease in clinic resource utilization at a tertiary-care children's hospital.