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.
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Short‐ and long‐term outcomes of selective pelvic exenteration surgery in a low‐volume specialized tertiary setting

June 10, 2019 - 00:38

A retrospective review of consecutive patients who underwent pelvic exenteration surgery for rectal/anal carcinoma, or gynaecological malignancy at Royal Adelaide Hospital between June 2008 and September 2018. A total of 54 patients who underwent pelvic exenteration were included and short and long‐term outcomes of selective pelvic exenteration surgery were found to be acceptable in a low‐volume specialised tertiary setting with suitable multidisciplinary expertise.


Background

Most published data on pelvic exenteration comes from high‐volume quaternary units, with limited data available from outside of this setting. This study reports outcomes of selective pelvic exenteration performed in a low‐volume tertiary unit with multidisciplinary support.

Methods

A retrospective review of consecutive patients who underwent pelvic exenteration surgery for rectal/anal carcinoma, or gynaecological malignancy at Royal Adelaide Hospital between June 2008 and September 2018. Descriptive statistics and Kaplan–Meier analysis of 5‐year disease‐free and overall survival for patients treated with curative intent were performed.

Results

A total of 54 patients who underwent pelvic exenteration were included. Most patients presented with primary rectal adenocarcinoma, and posterior and total pelvic exenterations were the most common operations performed (>90%). Median total operating time was 323 min, median hospital stay was 15 days, and the readmission rate was 14.8%. The overall complication rate (per patient) was 70.4%, and the re‐intervention rate was 20.4%. Thirteen percent of patients required intensive care unit‐admission, and there was one postoperative death (1.9%). R0 resection margins were achieved in 81.5% of patients, with R1 and R2 margins in 13.0 and 5.6% of patients, respectively. Estimated 5‐year disease‐free survival was 38.8%, and 5‐year overall survival was 65.7%.

Conclusion

Short‐ and long‐term outcomes of selective pelvic exenteration surgery are acceptable in a low‐volume specialized tertiary setting with suitable multidisciplinary expertise. If the required expertise is not readily available, then outside referral is recommended.

Predicting non‐sentinel lymph node metastasis in Australian breast cancer patients: are the nomograms still useful in the post‐Z0011 era?

June 10, 2019 - 00:38

MD Anderson Cancer Centre nomogram showed the best performance to predict risk of non‐sentinel lymph node metastasis in an Australian breast cancer population.


Background

Axillary lymph node dissection (ALND) can be avoided in breast cancer patients with low‐volume disease in the sentinel lymph nodes (SLNs) according to Z0011 trial. We believe that nomograms developed for predicting non‐sentinel lymph node (NSLN) metastases can guide the axillary treatment in patients who do not fully match the criteria of Z0011 study. We identified risk factors and evaluated the performance of three nomograms to predict NSLN status in patients with positive SLNs.

Methods

Data from 526 breast cancer patients with positive SLNs who underwent ALND at two Australian hospitals from 2002 to 2015 were studied. Univariate and multivariate associations for NSLN metastasis were analysed. Predictive models evaluated were MD Anderson Cancer Centre (MDA), Helsinki University Hospital and Memorial Sloan Kettering Cancer Centre.

Results

Thirty‐nine per cent of patients demonstrated NSLN metastasis. The multivariate analysis identified extranodal extension (OR 3.2, 95% CI 2.07–4.80), tumour size >2 cm (OR 2.5, 95% CI 1.66–3.89), macrometastasis (OR 1.9, 95% CI 1.09–3.47), positive SLN ratio >0.5 (OR 1.7, 95% CI 1.16–2.60) and lymphovascular invasion (OR 1.6, 95% CI 1.09–2.44) as independent predictors for NSLN metastasis. MDA nomogram showed the best discrimination (area under the curve of 0.74) and a 9% false negative rate for predicted probability of NSLN metastasis ≤10%.

Conclusion

Our results suggest that presence of extranodal extension and tumour size >2 cm may influence the need of further axillary treatment. Conversely, ALND can be safety spared in low risk patients identified by MDA nomogram.

Solid pseudopapillary neoplasm of the pancreas in children: Hacettepe experience

June 10, 2019 - 00:38

Pseudopapillary neoplasm of the pancreas is quite uncommon in children. Surgical resection is the mainstay of management. Nineteen pediatric cases from our institution have been presented.


Background

Solid pseudopapillary neoplasm of the pancreas (SPNP) is mostly seen in young women in the second and third decades of life; it is quite uncommon in children. We aimed to review our institutional experience with SPNP in children.

Methods

Hospital charts of children <18 years of age diagnosed to have SPNP were reviewed for demographic characteristics, presenting symptoms, diagnostic interventions, physical examination findings, radiological data, extent of disease, diagnostic and management strategies and final outcome.

Results

Nineteen cases were diagnosed as SPNP between 1992 and 2017 (female: male, 16:3; median age 13 years, range 8.5–16.5). The most common symptom was abdominal pain. Physical examination was normal in 12/19 cases. Three cases were diagnosed incidentally. The most common tumour localization was the head of the pancreas. Median tumour diameter was 5 cm (1.4–15). One patient had abdominal disseminated disease, and others had localized disease. Surgical interventions were enucleations in nine, distal pancreatectomies in four and total resection in two patients; three underwent no surgery following diagnosis. Only one patient received adjuvant chemotherapy and radiotherapy. One patient died, one was lost to follow‐up at 164 months and 17 were under follow‐up with no events at a median of 60 months (20–308 months).

Conclusion

In childen, SPNP demonstrates different clinical features. Complete resection is curative in most patients. In children, the optimal surgical strategy for SPNP is still debatable. Instead of radical resections, limited pancreatic resections, such as enucleations, with negative surgical margins should be attempted. For unresectable or recurrent tumours, cisplatin and 5‐FU‐based chemotherapy might be considered.

Outcomes of breast reconstruction in older women: patterns of uptake and clinical outcomes in a large metropolitan practice

June 10, 2019 - 00:38
Background

Older age is associated with lower rates of breast reconstruction (BR) following mastectomy. This study compared a range of factors in women aged 60 years and older who had received mastectomy and BR with those who received no BR (NBR).

Methods

An audit of 338 women aged 60 or over treated with mastectomy with (n = 86) or without (n = 252) BR for primary breast cancer from 2009 to 2016 was conducted. Demographic, tumour, treatment, comorbidity and surgical complication data were obtained from patient medical records.

Results

NBR patients were associated with older age (P ≤ 0.001), more comorbidities (P = 0.038) and more extensive disease (P = 0.001) than BR patients. Total number of complications was not significantly different between BR and NBR patients (P = 0.286), or the different types of BR (P = 0.697). BR patients had higher rates of unplanned returns to the operating theatre, particularly in the late post‐operative period (P = 0.025). Implant‐based reconstruction was associated with more unplanned operating theatre returns than autologous reconstruction in the late post‐operative period (P = 0.013).

Conclusion

Post‐mastectomy BR in elderly patients has a clinical complication profile similar to NBR patients. This audit found no clinical‐based reasons to not offer oncologically suitable and clinically fit elderly women the option of BR.

Quality of life after oncoplastic breast‐conserving surgery: a systematic review

June 10, 2019 - 00:38

The impact of oncoplastic breast‐conserving surgery compared to breast‐conserving surgery alone on quality of life is yet to be adequately investigated.


Background

Oncoplastic breast‐conserving surgery (OBCS) has gained increasing attention as a treatment option for early breast cancer patients, aiming to achieve the best possible breast symmetry with concomitant oncological safety. This paper aims to systematically review the current literature on patient quality of life (QoL) after OBCS compared with QoL after breast‐conserving surgery (BCS) alone.

Methods

MEDLINE via Ovid, CINAHL via EBSCO and PsycINFO via OvidSP were searched to retrieve all relevant studies. The reference lists of identified eligible studies were manually examined to search for additional eligible studies. The methodological quality of the included studies was assessed using the Critical Appraisal Skills Programme.

Results

A total of six articles met the inclusion criteria. Most of the studies used validated patient‐reported outcome measures for assessing QoL with good response rates. However, only one study was of sufficiently good quality to provide good evidence (P < 0.05) in favour of OBCS, while the remainder were of low to moderate quality with differences in outcomes that were not statistically significant.

Conclusion

The review found that the current evidence base is limited and not adequate enough to support or to reject the assumption that OBCS is associated with improved QoL when compared with QoL post‐BCS. However, the majority of studies show that OBCS is associated with a trend towards better patient QoL. The impact of OBCS on patient QoL needs to be more adequately investigated. Large prospective cohort studies to assess the impact of OBCS on QoL compared with QoL post‐BCS are strongly recommended.

Addressing the ethical grey zone in surgery: a framework for identification and safe introduction of novel surgical techniques and procedures

June 10, 2019 - 00:38

The introduction and uptake of new surgical techniques remains largely unregulated worldwide. Very few new surgical procedures are subject to rigorous safety evaluation when they are first used in humans, despite the potential for unforeseen harm to patients. This article addresses this important issue, and proposes a framework to help surgical departments and hospital administration to identify potentially harmful new techniques and presents a novel study design for introducing these techniques safely in a phase I context.


While the introduction of new surgical techniques can radically improve patient care, they may equally expose patients to unforeseen harms associated with untested procedures. The enthusiastic uptake of laparoscopic cholecystectomy in the early 1990s saw a dramatic increase in the rate of common bile duct injuries, and was described by Alfred Cuschieri as ‘the biggest unaudited free‐for‐all in the history of surgery’ due to ‘a lack of effective centralised control’. Whether a new surgical intervention is considered an acceptable ‘minor’ variation of an established procedure, or is sufficiently ‘novel’ to constitute experimentation on human subjects is often unclear. Furthermore, once a new technique is identified as experimental, there is no agreed protocol for safety evaluation in a first‐in‐human setting. In phase I (first‐in‐human) pharmacological trials only small, single arm cohorts of highly selected patients are enrolled in order to establish the safety profile of a new drug. This exposes only a small number of patients to the unknown or unforeseen risks that may be associated with a new agent, in a highly regulated and scientifically rigorous manner. There is no equivalent study design for the introduction of new and experimental surgical procedures. This article proposes a practical stepwise approach to the safe introduction of new surgical procedures that surgeons and surgical departments can adopt. It includes criteria for new surgical techniques which require formal prospective ethical evaluation, and a novel study design for conducting a safety evaluation at the ‘first in human’ stage.

Judgement: clinical decision‐making as a core surgical competency

June 10, 2019 - 00:38
ANZ Journal of Surgery, Volume 89, Issue 6, Page 760-763, June 2019.

Hospital volume versus outcome following oesophagectomy for cancer in Australia and New Zealand

June 10, 2019 - 00:38

A volume–outcome relationship was demonstrated for oesophagectomy for cancer in Australia and New Zealand, with overall better performance and lower perioperative mortality in hospitals performing 12 or more procedures each year. Co‐location of oesophagectomies to higher volume hospitals should be considered.


Background

Volume–outcome relationships for mortality following oesophagectomy have been demonstrated in Europe and the USA, but not in Australia or New Zealand. We determined whether higher volume hospitals achieve better outcomes following oesophagectomy in Australia and New Zealand.

Methods

Administrative data for hospitals contributing data to the Health Roundtable were analysed. Hospitals performing oesophagectomy for cancer from July 2008 to June 2015 were grouped according to mean annual caseload: low (1–5), medium (6–11) and high (12+) volume. Univariate and multivariable analyses determined the impact of volume on 30‐day and in‐hospital mortalities, length of hospital stay and mechanical ventilation following surgery.

Results

A total of 2252 patients underwent oesophagectomy in 65 hospitals. Sixty‐eight percent (n = 44) were low‐, 26% (n = 17) were medium‐ and 6% (n = 4) were high‐volume hospitals. Seven hundred and sixty‐two (34%) procedures were performed in low‐, 1042 (46%) in medium‐ and 448 (20%) in high‐volume hospitals. Overall in‐hospital mortality was 3.1% and 30‐day mortality was 2.1%. In‐hospital mortality was lowest in high‐volume hospitals; 1.6% versus 2.6% and 4.1% for low‐ and medium‐volume hospitals (P = 0.02). Surgery in high‐volume hospitals was shorter (32 min, P = 0.001), and patients were less likely to require post‐operative ventilation (16.7% versus 25.3% and 28.0%, P < 0.001), although patients requiring ventilation in high‐volume hospitals were ventilated for longer.

Conclusions

A volume–outcome relationship was demonstrated, with overall better performance in higher volume hospitals. Colocation of oesophagectomies to hospitals that can demonstrate appropriate caseload should be considered.

Portrayal of bariatric surgery in the New Zealand print news media

June 10, 2019 - 00:38

We aimed to explore the portrayal of bariatric surgery in the New Zealand media. The New Zealand media is a powerful tool that still bolsters binary perspectives of obesity and bariatric surgery, which may work against addressing the obesity epidemic.


Background

Bariatric surgery has become topical in the media worldwide, influencing wider societal attitudes towards obesity and obesity management. This study aims to explore the media portrayal of bariatric surgery in all print news articles published in New Zealand (NZ) over a decade.

Methods

An electronic search of two databases (Proquest Australia/NZ Newsstream and Newztext) and two NZ news media websites (Stuff and the NZ Herald) was performed to retrieve print news articles reporting stories, opinion pieces or editorials regarding bariatric surgery published between January 2007 to June 2017. Qualitative thematic analysis was performed on all included articles.

Results

From January 2007 to December 2017, 252 articles related to bariatric surgery were published. Seven major themes emerged centred around barriers to accessing bariatric surgery, deficit attitudes towards obesity and social justice. These views were driven by articles that debated the limited number of publicly funded bariatric procedures offered in NZ. In addition, healthcare professionals used the media as a platform to challenge discriminatory attitudes towards obesity and bariatric surgery.

Conclusion

The NZ media is a powerful tool that still bolsters binary perspectives of obesity and bariatric surgery which may work against addressing the obesity epidemic.

Urethral syringocele: unseen but existing

June 10, 2019 - 00:38

This article summarizes our experience in urethral syringocele. It is the presentation, diagnosis and treatment to further clarify the importance of this rare diagnosis.


Background

Bulbourethral syringocele is an uncommon and under‐diagnosed condition most commonly seen in the paediatric population, although there is increasing recognition in adults. Due to the difficulty in diagnosis, we report our experience of urethral syringocele in a quaternary paediatric hospital, with differing presentations, diagnosis and treatment.

Methods

This is a retrospective review of seven cases of children over a period of 14 years, including their presentations, diagnosis, treatment and follow‐up. A review of the current literature is presented.

Results

The median age of these seven cases at presentation was 11 years (6 days to 16 years). Clinical features varied with age, with obstructive uropathy in a neonate, urinary tract infection in an infant, scrotal abscess in two children and lower urinary tract obstructive symptoms in three teenagers. Diagnostic voiding cystogram diagnosed the majority of syringoceles and two were seen on magnetic resonance imaging. Five boys underwent endoscopic transurethral deroofing and two children required transperineal marsupialization. Long‐term follow‐up showed all had complete resolution of symptoms.

Conclusion

Urethral syringocele presents from the neonatal period to late adolescence, with the presenting features reflective of age. Surgical management can be performed endoscopically or by open approach. Awareness of this condition and inclusion in the differential diagnosis, particularly in the setting of an atypical or recurrent scrotal abscess, could avoid a prolonged therapeutic course.

Cadaveric evaluation of sternal reconstruction using the pectoralis muscle flap

June 2, 2019 - 22:30

This is the first study examining the use of cadavers for the pectoralis major flap for sternal wound dehiscence.


Background

Deep sternal wound infection is a significant complication of open cardiac surgery associated with increased mortality and morbidity. The use of muscle flaps, such as the pectoralis major advancement flap, in deep sternal wound infection reconstruction reduces hospital stay and mortality. However, the lower end of the sternum is remote from the vascular supply and cover is therefore problematic in many cases.

Methods

This study aimed to determine the distance (cm) and surface area (cm2) of sternum covered when the pectoralis major muscle is sequentially dissected from the sternocostal origin and humeral insertion using 10 cadaveric specimens.

Results

The largest proportion of sternum was covered when both the origin and insertion were divided, allowing the flap to be islanded on its vascular pedicle. There was a statistically significant difference when the pectoralis major was divided from the origin and insertion compared to division of the origin alone (P < 0.01). The average area covered with sternocostal origin division alone was 55.43 cm2 compared to 85.36 cm2 after division of both the origin and insertion.

Conclusion

Division of both the sternocostal origin and humeral insertion of the pectoralis major muscle represents an effective means to increase sternal coverage. This study describes the average distance and area covered by sliding pectoralis major muscle advancement flaps. These measurements could better inform plastic surgeons when evaluating reconstructive options in sternal defects.

Reinforcing collaboration and teamwork: the role of team communication and training

June 2, 2019 - 22:29
ANZ Journal of Surgery, EarlyView.

Fresh frozen cadaver workshops for general surgical training

May 23, 2019 - 22:04
Background

The technical proficiency of a surgeon is intricately linked to training and experience. Reduction in working hours, decreased operating time and ethical imperatives to protect patients have all resulted in a decrease in hands‐on experience. The introduction of laparoscopic procedures has also decreased trainees' exposure to open operative procedures not routinely performed in the current era.

Methods

The Clinical Training and Evaluation Centre at The University of Western Australia introduced the Core Skills Workshop for general surgical trainees in 2007. The workshop provides cadaveric dissection time for a range of open procedures. We describe in this article the logistics of setting up and running a cadaveric workshop, the performance and report our trainees' evaluation of the workshop.

Results

The Clinical Training and Evaluation Centre has hosted 26 General Surgery Core Skills Workshops since 2007. There were 227 participants with 196 evaluations returned (response rate 86%). Feedback was strongly positive for the course meeting the participants' expectations as well as its contribution to their skillset. Participants value the use of cadavers and high instructor:student ratios along with performance of a large number of open procedures in the setting of a stress‐free workshop and looked forward to more similar courses in the future.

Conclusions

Fresh frozen cadaver workshops are of value in the face of current surgical training challenges in providing an efficient, effective and safe environment.

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

May 21, 2019 - 22:54

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.

Resectable recurrent colorectal liver metastasis: can radiofrequency ablation replace repeated metastasectomy?

May 15, 2019 - 01:13

As far as we know, this article is the first to compare the clinical results of radiofrequency ablation (RFA) versus repeated surgery for resectable colorectal liver metastases recurrence. We found that recurrence occurred more frequently and in shorter interval after RFA, especially in patients with tumor size >3 cm. Liver resection and percutaneous RFA achieved similar overall survival.


Background

Percutaneous radiofrequency ablation (RFA) is used as a first‐line treatment for colorectal liver metastases that recur after first liver resection in our institution. We aim to evaluate its therapeutic efficacy compared to repeated surgical resection.

Methods

A retrospective review was performed in 104 patients treated with curative intent for resectable recurrent colorectal liver metastases.

Results

Sixty‐one patients underwent RFA and 43 patients underwent surgery. The overall recurrence rates were 82% in the RFA group and 65.1% in the resection group (P = 0.05). The local recurrence rate on a lesion‐basis was markedly higher after RFA than that after resection (16.7% versus 7.3%, P = 0.04). The difference remained significant in patients with a maximum lesion diameter >3 cm (24.5% versus 7.6%, P = 0.01). RFA treatment was independently associated with recurrence on multivariate analyses (P = 0.01). 69.7% of RFA patients and 42.6% of surgery patients with intrahepatic recurrence were amenable to repeated local treatment (P = 0.05), leading to the equivalent actuarial 3‐year progression free survival rates (RFA: 29.1% versus Resection: 33.1%, P = 0.48) and 5‐year overall survival rates in the two treatment groups (RFA: 33% versus Resection: 28.4%, P = 0.36).

Conclusions

Surgery remains the treatment of choice for resectable recurrence. RFA may offer similar benefit in selected patients.

Response of the Australian Medical Services to restoration of mobile warfare on the Western Front in 1918 (part I)

May 14, 2019 - 22:00

On 21 March 1918, after nearly 4 years of static warfare on the Western Front, German forces launched a massive offensive from the Hindenburg Line against a depleted British Fifth Army. Elite storm troops smashed through British forward and battle zone positions and advanced more than 17 miles in 2 days. By 5 April, the Germans were outside the town of Villers‐Bretonneux, 40 miles from their starting position and 15 miles from the railway junction of Amiens. This paper examines the response of Australian Medical Services to the restoration of mobile warfare and explains the measures that were put in place to deal with the evacuation of casualties.


On 21 March 1918, after nearly 4 years of static warfare on the Western Front, German forces launched a massive offensive from the Hindenburg Line against a depleted British Fifth Army. Elite storm troops smashed through British forward and battle zone positions and advanced more than 17 miles in 2 days. By 5 April, the Germans were outside the town of Villers‐Bretonneux, 40 miles from their starting position and 15 miles from the railway junction of Amiens. This paper examines the response of the Australian Medical Services to the restoration of mobile warfare and explains the measures that were put in place to deal with the evacuation of casualties.

Response of the Australian Medical Services to restoration of mobile warfare on the Western Front in 1918 (part II)

May 14, 2019 - 22:00

On 4 July 1918, at the Battle of Hamel, Australian Medical Services used a Field Ambulance Resuscitation Team for the first time, delivering life‐saving blood transfusion and early definitive surgery to badly wounded soldiers very soon after their wounds had been inflicted. During the closing months of the war, many lives and limbs were saved by early resuscitation and effective surgery, an achievement which stands out in marked contrast to the situation in 1914, when inadequate resuscitation, outdated surgical methods and appalling delays in delivering treatment resulted in great numbers of unnecessary deaths.


On 4 July 1918, at the Battle of Hamel, the Australian Medical Services used a Field Ambulance Resuscitation Team for the first time, delivering life‐saving blood transfusion and early definitive surgery to badly wounded soldiers very soon after their wounds had been inflicted. During the closing months of the war, many lives and limbs were saved by early resuscitation and effective surgery, an achievement that stands out in marked contrast to the situation in 1914, when inadequate resuscitation, outdated surgical methods and appalling delays in delivering treatment resulted in great numbers of unnecessary deaths.

Life‐threatening gastrointestinal bleeding from a giant ileal lipoma

May 14, 2019 - 03:35
ANZ Journal of Surgery, EarlyView.