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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Tramadol as an adjunct to intra‐articular local anaesthetic infiltration in knee arthroscopy: a systematic review and meta‐analysis

August 5, 2019 - 00:12
Background

Arthroscopic knee surgery is a common technique used in Australia. Post‐operative pain is common and can lead to delayed discharge and impair early mobilization. Use of local anaesthesia can reduce pain while avoiding systemic side effects. This systematic review and meta‐analysis aimed to establish the use of tramadol as an adjunct to intra‐articular local anaesthetic infiltration in knee arthroscopy in the current literature.

Methods

Two independent reviewers performed a systematic search of four databases, where 24 articles were identified with six studies (four high‐quality and two low‐quality randomized controlled trials), with a total of 334 patients were included for analysis. RevMan 5.3 software (The Nordic Cochrane Centre, Copenhagen, Denmark) was used to perform the data analysis. The studies included focused on outcomes such as pain scores, breakthrough analgesia, total analgesia, time to discharge and adverse events related to the use of tramadol as an adjunctive therapy.

Results

This study found that using tramadol as an adjunct to intra‐articular local anaesthetic infiltration in arthroscopic knee surgery reduced post‐operative pain and increased time to breakthrough analgesia without an increase in side effects.

Conclusion

This meta‐analysis suggests that tramadol is an efficacious adjunct for use in intra‐articular local anaesthetic infiltration following arthroscopic knee surgery.

Volar locking plating versus percutaneous Kirschner wires for distal radius fractures in an adult population: a meta‐analysis

August 5, 2019 - 00:12
Background

This paper compares volar locking plates (VLPs) and percutaneous Kirschner wire (K‐wire) fixation for distal radius fractures in an adult population up to and beyond 12 months. The aim of this review is to compare functional and radiological outcomes along with complication rates. A meta‐analysis was performed to investigate this.

Methods

A systematic review and meta‐analysis was performed using the PRISMA guidelines. A search of major databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and CINAHL) was performed up to November 2017. Prospective and retrospective studies were included. Studies were assessed for quality using the Cochrane Risk of Bias tool. Meta‐analysis was performed using the ‘metafor’ package with R.

Results

A total of 14 studies (five randomized controlled trials and nine comparative studies) (n = 1535) were identified. Disabilities of the Arm, Shoulder and Hand (DASH) scores were statistically significant for VLP at all follow‐up intervals up to and beyond 12 months. Wrist movements were statistically significant for VLP at 6 weeks. Grip strength was significantly different favouring VLP at 12 months and final follow‐up. VLP provided better restoration of ulnar variance at 6 weeks, but overall radiological outcomes were similar. These results were not clinically significant. K‐wires were associated with an 18% higher risk of complication but the reoperation rate was higher for VLP (4.6% versus 3.2%).

Conclusions

This study demonstrates similar clinical functional and radiological outcomes for VLP and K‐wire fixation in the short and intermediate term. There is a higher rate of overall complication with K‐wires, but the increased risk of reoperation must be considered when planning surgical fixation of these fractures.

Change in serum albumin level predicts short‐term complications in patients with normal preoperative serum albumin after gastrectomy of gastric cancer

August 5, 2019 - 00:12
Background

The purpose of this study was to evaluate the correlation between serum albumin level change (ΔALB) and post‐operative complications in patients with normal preoperative serum albumin after gastrectomy of gastric cancer.

Methods

A total of 193 patients undergoing curative (R0) gastrectomy from September 2015 to May 2017 were enrolled in this study. The risk factors for predicting post‐operative complications were identified by univariate and multivariate analysis. The cut‐off value and diagnostic accuracy of ΔALB were measured by receiver operating characteristic curves. ΔALB was defined as: (albumin level before surgery − albumin on post‐operative day (POD) 1)/albumin level before surgery × 100%.

Results

A total of 60 patients (31.0%) had post‐operative complications. Our results showed that the cut‐off value of ΔALB was 19.0%. Using a cut‐off value of 19.0%, multivariate analysis identified that ΔALB was able to predict post‐operative complications as an independent factor (odds ratio 13.98, 95% confidence interval 6.048–32.32, P < 0.001). In addition, the area under the curve of ΔALB is higher than C‐reactive protein on POD 3 (0.773 versus 0633). Compared with patients with ΔALB <19.0%, patients with ΔALB ≥19.0% have higher risk of post‐operative complications suffered (62.3 versus 13.7%, P < 0.001) and longer post‐operative stay (22.1 ± 13.5 versus 17.5 ± 4.2, P < 0.001).

Conclusion

ΔALB acted as an independent predictor in short‐term complications for patients with normal preoperative serum albumin and its diagnostic accuracy was higher than C‐reactive protein on POD 3. It is promising to be a precise and straight predictor for incidence of post‐operative complications to patients with normal preoperative serum albumin.

Solo single‐incision laparoscopic cholecystectomy: a safe substitute for conventional laparoscopic cholecystectomy

August 5, 2019 - 00:12

We introduced solo single‐incision laparoscopic cholecystectomy technique using a laparoscopic scope holder, as a simple, fixed and easy‐to‐perform procedure for an unassisted surgeon. It is a feasible and safe procedure with shorter post‐operative hospital stay compared to conventional laparoscopic cholecystectomy.


Background

Despite the incremental application of single‐incision laparoscopic cholecystectomy (SILC), this procedure has technical difficulties, including physical disturbance and an unstable surgical view through the small incision; therefore, we introduce the solo SILC (S‐SILC) technique using a laparoscopic scope holder, as a simple, fixed and easy‐to‐perform procedure for an unassisted surgeon.

Methods

We performed a comparative analysis of S‐SILC (n = 566) and conventional three‐incision laparoscopic cholecystectomy (n = 874) performed from January 2013 to December 2016 at multiple centres.

Results

There was no significant difference of operative time between the two groups (P = 0.176); however, S‐SILC showed a higher incidence of intraoperative gallbladder perforation, especially in the initial period (17.0% versus 2.3%, P < 0.001); and shorter post‐operative hospital stay (3.3 ± 1.7 versus 1.9 ± 2.7 days, P < 0.001) than conventional three‐incision laparoscopic cholecystectomy. There were no significant differences in major post‐operative complications between the two groups (P = 0.909) and operation type (P = 0.971) was not a significant risk factor for major post‐operative complications in multivariate analysis.

Conclusion

S‐SILC is a feasible and safe procedure; however, careful selection of surgical candidates is necessary in the early period of the experience with this method.

Amputations in patients with diabetic foot ulcer: a retrospective study from a single centre in the Northern Territory of Australia

August 5, 2019 - 00:12

Diabetes‐related amputation rates are higher in the Northern Territory. Indigenous patients had higher amputation rates and were younger at the time of amputation. However, ethnicity is not an independent risk factor. The risk factors that were significant in multivariate analysis are all modifiable, indicating prevention and prompt treatment of diabetic foot disease is the key in reducing amputation rates.


Background

Lower extremity amputations (LEAs) in diabetic patients are common in the indigenous population. There is no published data from the Northern Territory.

Methods

All patients with diabetic foot ulcer, presenting for the first time to the multi‐disciplinary foot clinic at Royal Darwin Hospital, between January 2003 and June 2015, were included. These patients were followed until 2017, or death. LEA rates over the follow‐up period and the risk factors were studied.

Results

Of the 513 included patients, 62.8% were males and 48.2% were indigenous. The majority (93.6%) had type 2 diabetes with median diabetes duration of 7.0 years (interquartile range 3–12). During the follow‐up period of 5.8 years (interquartile range 3.1–9.8), a total of 435 LEAs (16.6% major; 34.7% minor) occurred in 263 patients (mean age 57.0 ± 11.8 years). In multivariate analysis, the following variables were associated with LEAs (adjusted odds ratio (95% confidence interval)): prior LEA (4.49 (1.69–11.9)); peripheral vascular disease (2.67 (1.27–5.59)); forefoot ulcer (7.72 (2.61–22.7)); Wagner grade 2 (3.71 (1.87–7.36)); and Wagner grade 3 (17.02 (3.77–76.72)). Indigenous patients were 1.8 times more likely to have LEAs than non‐indigenous patients. Indigenous amputees were approximately 9 years younger than their non‐indigenous counterparts.

Conclusion

Half of patients presenting with diabetic foot ulcer had LEA during follow‐up. Prior LEAs, peripheral vascular disease, forefoot ulcers and higher Wagner grades were independent risk factors for LEA. Indigenous patients were at higher risk for LEAs and were younger at the time of amputation.

Is anticoagulation for venous thromboembolism safe for Asian elective neurosurgical patients? A single centre study

August 5, 2019 - 00:12

This is a study to determine the incidence of venous thromboembolic events in our Asian neurosurgical population and the risk of haemorrhage in these patients.


Background

The incidence of venous thromboembolism (VTE) in neurosurgical patients ranges 3–24%. VTE is potentially fatal, and prophylactic anticoagulation is recommended worldwide. However, anticoagulation poses a risk of haemorrhage, which can be devastating. We aim to determine the incidence of VTE and risk of haemorrhage following anticoagulation.

Methods

Between 1 May 2014 and 1 May 2016, all patients who underwent elective neurosurgery were recruited into our study. All patients had bilateral lower limb ultrasound to screen for deep vein thrombosis (DVT) between post‐operative days 3 and 7. These patients are also monitored for manifestations of pulmonary embolism (PE). If present, a computed tomography pulmonary angiogram will be performed. Patients with VTE will either receive conservative treatment or anticoagulation.

Results

During this period, 170 of 610 patients were included. Of the 170 patients, 17 patients (10.0%) developed DVT. Fifteen patients had cranial surgery and two patients had spinal surgery. Two patients (1.2%) developed PE and both patients had concurrent DVT. Of these 17 patients, nine patients received anticoagulation. Of these nine patients, six patients (66.7%) developed surgical site bleeding following anticoagulation and all of them required surgical intervention. Patients who were managed conservatively did not suffer haemorrhage.

Conclusion

Our results show an overall 10.0% incidence of DVT and 1.2% incidence of PE following elective neurosurgery within this Asian cohort of neurosurgical patients. There is also a high risk (66.7%) of significant surgical site bleeding following anticoagulation.

General Surgeons Australia's 12‐point plan for emergency general surgery

August 5, 2019 - 00:12

In the last decade, emergency general surgery in Australia and New Zealand has seen a transition from traditional on‐call system to the acute surgical unit model. The importance and growing demand for emergency general surgery resulted in the General Surgeons Australia's 12‐point plan for emergency surgery. This study aims to provide a descriptive review on the relevance of the 12‐point plan to the acute surgical unit model and review the current evidence to support this framework.


In the last decade, emergency general surgery (EGS) in Australia and New Zealand has seen a transition from the traditional on‐call system to the acute surgical unit (ASU) model. The importance and growing demand for EGS has resulted in the implementation of the General Surgeons Australia's 12‐point plan for emergency surgery. Since its release, the 12‐point plan has been used as a benchmark of a well‐functioning ASU, both locally and abroad. This study aims to provide a descriptive review on the relevance of the 12‐point plan to the ASU model and review the current evidence to support this framework. The review concludes that the establishment of the ASU model has met the aims set out by the Royal Australasian College of Surgeons for EGS. The 12‐point plan is relevant and has good evidence to support its framework.

Carbapenem sparing in the management of post‐transrectal prostate biopsy bacteraemia

August 5, 2019 - 00:12
Background

Sepsis following transrectal ultrasound (TRUS)‐guided prostate biopsy is a major complication. With the emergence of multidrug‐resistant organisms, empirical use of carbapenem antibiotics has been increasing. This study, conducted in the Illawarra Shoalhaven Local Health District (ISLHD), Australia, quantifies how much we can spare carbapenem use.

Methods

A retrospective audit of patients who underwent TRUS prostate biopsy and were admitted post‐operatively with proven bacteraemia between January 2007 and April 2016.

Results

Of 2719 TRUS procedures, 50 (1.84%) cases had bacteraemia. The most common isolate was Escherichia coli in 44 of 50 (88%) of which six of 50 (12%) were extended‐spectrum beta‐lactamase (ESBL)‐producing. Sixteen different empirical antimicrobial regimens were used, to which 42 of 50 (84%) of isolates were susceptible. Eight (16%) isolates were resistant to the chosen empiric combination, with five switched over to appropriate treatment once antimicrobial sensitivity results became available. Empirical carbapenem was utilized in 12 of 50 (24%) patients with only two of the ESBL isolates covered. A further 10 of 50 patients received carbapenems during their admission. Carbapenems could have been avoided in 18 of 22 (82%). A total of 86% of organisms (n = 43) were susceptible to the combination of amoxicillin–clavulanate and gentamicin.

Conclusion

Although the rates of bacteraemia with ESBL‐producing organisms post‐TRUS biopsy are increasing, use of carbapenem‐free combination antimicrobials as empirical therapy appears to be safe and effective in our setting. Clinicians can utilize local resistance patterns to inform targeted and appropriate therapy for septic patients.

Assessment of haemorrhoidal artery network using Doppler‐guided haemorrhoidal artery ligation for haemorrhoids and pathogenesis implications

August 5, 2019 - 00:12

The aim of the study was to record the exact position of the distal branches of the superior rectal artery during Doppler‐guided haemorrhoidal artery ligation‐rectoanal repair procedures for haemorrhoids. Number of distal branches of the superior rectal artery is lower at the posterior midline than in the other segments of the lower rectum. This is evidence of the vascular deficiency at the posterior pole of the anal canal that might explain the pathogenesis of anal fissures.


Background

Some authors, either with anatomical studies or Doppler laser flowmetric investigations have shown the blood flow to the posterior midline of the anus to be potentially deficient. This relative local ischaemia might explain pathogenesis of anal fissure, which is often located posteriorly. The aim of this study was to record the exact position of the distal branches of the superior rectal artery during Doppler‐guided haemorrhoidal artery ligation‐rectoanal repair (HAL‐RAR) procedures with special reference to posterior distribution of the arteries.

Methods

All consecutive patients with symptomatic haemorrhoids who were treated with the HAL‐RAR procedure between February 2008 and February 2014 in a single institution were included in the study. Number and position of Doppler‐guided ligations were prospectively collected. Pearson's chi‐squared test was used to compare artery locations.

Results

A total of 150 patients (75 women) with symptomatic haemorrhoids were included in the study. Median age was 53 years (range 23–83). A median of 10 ligations were placed per patient (range 3–18). A significantly lower number of cumulative arterial ligations was recorded in the posterior position (88 ligations overall, P = 0.025).

Conclusions

The number of distal branches of the superior rectal artery that have been localized by the Doppler‐guided HAL‐RAR technique is lower at the posterior midline than in the other segments of the lower rectum. This is another evidence of the vascular deficiency at the posterior pole of the anal canal that might explain the pathogenesis of the anal fissure.

Dermal regeneration template and vacuum sealing drainage for treatment of traumatic degloving injuries of upper extremity in a single‐stage procedure

August 5, 2019 - 00:12

Use of dermal regeneration template and vacuum sealing drainage in a single‐stage procedure is an effective method for reconstruction of traumatic degloving injuries of upper extremity. This prospective case series study demonstrated the safety and efficacy of Pelnac for the treatment of traumatic degloving injuries of upper extremity.


Background

This study aimed to assess the efficacy and safety of a single‐stage procedure using single‐layer Pelnac and defatted avulsed skin for the management of degloving injuries of the forearm and hand.

Methods

This is a prospective study conducted from March 2013 to May 2017. A total of 15 consecutive patients with degloving injuries of the forearm and hand were treated with a single‐stage procedure using single‐layer Pelnac and defatted avulsed skin as a split‐thickness skin graft. Post‐operatively, scheduled follow‐up was conducted.

Results

The overall ‘take’ rate of the Pelnac dermal template and the skin graft was 85–100%. No infections, haematoma or seroma were observed during hospitalization and after discharge. At the final follow‐up, patients’ subjective satisfaction with the aesthetic appearance of the grafted areas was, on average, 71.0 (SD 8.0, range 55–92). The Vancouver Scar Scale value was 2.1 (SD 1.8, range 1.0–5.5), representing a good result. The response of ‘normal or near normal’ to the sensory recovery was obtained for 13 patients and ‘slight loss’ for two patients. The average Disabilities of the Arm, Shoulder and Hand score was 21.2 (SD 13.5, range 0–53), and most patients (14/15) regained the ability to perform the daily activities without pain or restriction by tissue adhesion.

Conclusion

This single‐stage procedure represents an effective technique for the management of degloving injuries of the forearm and hand and should be considered an alternative to other reconstructive procedures.

T‐tube‐free single‐incision laparoscopic common bile duct exploration plus cholecystectomy: a single centre experience

August 5, 2019 - 00:12

A cohort of patients with the diagnosis of common bile duct stones and treated with T‐tube‐free single‐incision common bile duct exploration plus laparoscopic cholecystectomy by conventional instruments was retrospectively analysed. By long‐term follow‐up, these patients achieved great therapeutic effects. We concluded that: in selected cases, T‐tube‐free trans‐umbilical single‐port laparoscopic common bile duct exploration plus laparoscopic cholecystectomy is feasible and safe for experienced surgeons, and can achieve similar therapeutic effects as common laparoscopic common bile duct exploration procedures.


Background

The present study aimed to explore the indications and feasibility of T‐tube‐free trans‐umbilical single‐incision laparoscopic common bile duct exploration (SILCBDE) plus laparoscopic cholecystectomy (LC) for treating choledocholithiasis.

Methods

Patients hospitalized in the Second Affiliated Hospital (Shengjing Hospital) of China Medical University from January 2010 to January 2017 with the diagnosis of common bile duct stones and treated with T‐tube‐free trans‐umbilical single‐incision LC plus common bile duct exploration were retrospectively analysed.

Results

A total of 37 male/female choledocholithiasis patients (mean age 65 years, range 29–86) were treated with T‐tube‐free trans‐umbilical SILCBDE plus LC. No intraoperative complication or conversion to open surgery occurred in any of the cases. The mean operative time was 99.8 min (range 84–125) for endoscopic nasobiliary drainage group (n = 6), 113.8 min (range 70–150) for endoscopic retrogradebiliary drainage group (n = 2), 131.1 min (range 75–161) for pigtail J‐tube group (n = 24), 113.7 min (range 100–150) for primary closure group (n = 5). The mean post‐operative hospital stay length was 5.5 days (range 4–7) for endoscopic nasobiliary drainage group, 12.5 days (range 10–15) for endoscopic retrogradebiliary drainage group, 6.5 days (range 4–10) for J‐tube group, 5.8 days (range 4–9) for primary closure group. Pancreatitis, bile leakage and peritonitis were not presented in any of the group. After 17–101 months follow‐up, three patients presented recurrent common bile duct stones.

Conclusion

In selected cases, T‐tube‐free trans‐umbilical SILCBDE plus LC is feasible and safe for experienced surgeons, and can achieve similar therapeutic effects as common LC plus common bile duct exploration procedures.

Residual cancerous lesion and vein tumour thrombus identified intraoperatively using a fluorescence navigation system in liver surgery

August 5, 2019 - 00:12
Aim

The main aims of this study are to investigate the clinical application value of using indocyanine green fluorescence imaging for ensuring complete resection of tumour tissue during hepatectomy and to evaluate the diagnostic efficacy of near‐infrared (NIR) fluorescence imaging system using indocyanine green in hepatectomy.

Methods

After undergoing liver resection at the Affiliated Hospital of Southwest Medical University from July 2017 to May 2018, 35 eligible patients were included in this study. The liver surface and resection margin were intraoperatively assessed by intraoperative ultrasonography and NIR fluorescence imaging, after intravenous administration of indocyanine green (0.5 mg/kg) 72–96 h prior to surgery. The intraoperative observations were compared with the pathological findings in the liver.

Results

In the 35 patients, a total of 53 lesions were found, of which 42 were malignant lesions. The analysis results showed that the sensitivity and accuracy of detection using NIR fluorescence imaging were significantly higher than with intraoperative ultrasonography (P < 0.05). However, there was no difference between contrast‐enhanced helical computed tomography and NIR fluorescence imaging in finding lesions (P > 0.05). In addition, 11 new suspicious lesions were detected only by NIR fluorescence imaging in the liver surface and resection margin during surgery, four of which were hepatocellular carcinoma. We also detected four vein tumour thrombi using the NIR fluorescence navigation system.

Conclusions

The NIR fluorescence navigation system enables the identification of small tumours, residual cancer tissues in resection margin and venous tumour embolies in real time and enhances the accuracy and integrity of liver resection.

Reduced post‐operative urinary tract infection using the National Surgical Quality Improvement Program

August 5, 2019 - 00:12

This study is a prospective assessment of the incidence of post‐operative urinary tract infections (UTI) using the American College of Surgeons National Safety and Quality Program. It demonstrates the previously unknown and unacceptably high incidence of post‐operative UTI in our general surgical patients followed by the significant improvement after the implementation of a program to reduce post‐operative UTI.


Background

The incidence of post‐operative urinary tract infection (UTI) is frequently unknown or underestimated. Failure to recognize a clinical problem results in no action occurring to improve outcomes. The aims of this study were firstly to define the incidence of post‐operative UTI in general surgery patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS‐NSQIP). Secondly to design and implement an intervention to reduce the incidence of post‐operative UTI and assess the extent of improvement.

Methods

ACS‐NSQIP data were collected and analysed from June 2015 to June 2016 and reported in the Semi Annual Report (SAR). A quality improvement programme was designed and implemented to manage the high incidence of UTI. The outcomes were assessed by the subsequent ACS‐NSQIP SAR.

Results

The SAR in 2016 reported that Nepean Hospital as a significant outlier with an incidence of post‐operative UTI of 3.62% (odds ratio 2.21, confidence limits 1.51–3.44, P < 0.001). A hospital‐wide policy for catheter insertion in surgical patients was developed including: education, workshops, accreditation for aseptic technique for catheter insertion, reduced rates of insertion, reduced duration of use and improved catheter care. There was a significant improvement in the incidence of UTI (1.21%) reported by the 2018 SAR (odds ratio 1.01, confidence limits 0.64–1.60, P = 0.68).

Conclusions

ACS‐NSQIP identified a 2.2‐fold increased risk of post‐operative UTI. There was no increased risk of UTI after the programme to reduce UTI was introduced.

Cadaveric evaluation of sternal reconstruction using the pectoralis muscle flap

August 5, 2019 - 00:12

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

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page 957-961, July/August 2019.

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

August 5, 2019 - 00:12

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.

Intraoperative detection of aberrant biliary anatomy via intraoperative cholangiography during laparoscopic cholecystectomy

August 5, 2019 - 00:12

Intraoperative cholangiography (IOC) is widely used as an adjunct to laparoscopic cholecystectomy, but there is still no worldwide consensus on the value of its routine use. The purpose of this study was to assess the adequacy of and the reporting of 300 IOCs during laparoscopic cholecystectomy. Aberrant right sectoral ducts were identified in 15.2% of the complete IOCs, and 2.6% demonstrated left sectoral or confluence anomalies. Only 20.4% of these were reported intraoperatively. Surgeons generally demonstrate biliary anatomy well on IOC, but reporting of sectoral duct variation can be improved.


Background

Laparoscopic cholecystectomy (LC) is the standard of treatment for symptomatic cholelithiasis. Although intraoperative cholangiography (IOC) is widely used as an adjunct to LC, there is still no worldwide consensus on the value of its routine use. Anatomical studies have shown that variations of the biliary tree are present in approximately 35% of patients with variations in right hepatic second‐order ducts being especially common (15–20%). Approximately, 70–80% of all iatrogenic bile duct injuries are a consequence of misidentification of biliary anatomy. The purpose of this study was to assess the adequacy of and the reporting of IOCs during LC.

Methods

IOCs obtained from 300 consecutive LCs between July 2014 and July 2016 were analysed retrospectively by two surgical trainees and confirmed by a radiologist. Biliary tree anatomy was classified from IOC films as described by Couinaud (1957) and correlated with documented findings. The accuracy of intraoperative reporting was assessed. Biliary anatomy was correlated to clinical outcome.

Results

A total of 95% of IOCs adequately demonstrated biliary anatomy. Aberrant right sectoral ducts were identified in 15.2% of the complete IOCs, and 2.6% demonstrated left sectoral or confluence anomalies. Only 20.4% of these were reported intraoperatively. Bile leaks occurred in two patients who had IOCs (0.73%) and two who did not (7.4%).

Conclusion

Surgeons generally demonstrate biliary anatomy well on IOC but reporting of sectoral duct variation can be improved. Further research is needed to determine whether anatomical variation is related to ductal injury.

Colorectal cancer in young patients: a retrospective cohort study in a single institution

August 5, 2019 - 00:12

Young onset colorectal cancer is on the rise, with a disproportionate increase in incidence among young people. This retrospective cohort study of young patients undergoing colonoscopy shows an incidence rate greater than the age‐standardized incidence rate of colorectal cancer in Australia. Patients found to have malignancy were symptomatic and thus investigation should be offered early to young patients presenting with any warning symptoms. Flexible sigmoidoscopy may be an appropriate alternative to awaiting colonoscopy and lead to earlier diagnosis.


Background

Young onset colorectal cancer is on the rise, with a disproportionate increase in incidence among young people, both in Australia and internationally. Current national guidelines for bowel cancer screening in average risk individuals include only patients greater than 50 years of age. It is well recognized that colorectal cancer is a highly treatable malignancy when detected at an early stage, and timely diagnosis yields a greater than 90% chance of cure and survival. The aims of this study were to define the clinical presentations leading to colonoscopy in young patients and assess the incidence of malignancy in this group.

Methods

This is a retrospective cohort study including all patients ≤35 years of age without any baseline indication for early bowel cancer surveillance that underwent colonoscopy at Caboolture Hospital from January 2017 to April 2018.

Results

A total of 224 patients underwent colonoscopy in the study period. A total of 210 (93.8%) had symptoms including rectal bleeding (51.7%), altered bowel habit (25.9%), abdominal pain (10.3%) and symptomatic anaemia (6.7%) prior to colonoscopy. Two cases of invasive adenocarcinoma were identified (0.89%, P < 0.01), both of which were symptomatic and were defined as stage IIIB disease on histopathology.

Conclusion

In a theoretically low‐risk population, the incidence of malignancy was nearly 1%. More advanced disease at diagnosis may be due to a delay in investigating these patients due to an overall low suspicion of cancer in young individuals. As such, investigation should be offered early to young patients presenting with any warning symptoms.

Do we need to scan the whole neuraxis for coexistent abnormalities in children with surgically treated occult spinal dysraphism?

August 5, 2019 - 00:12

Cranial pathologies rarely coexisted with spina bifida occulta, while spinal abnormalities frequently accompany to this malformation. Therefore, we strongly suggest the radiological screening of whole spinal axis in occult spinal dysraphism, yet the necessity of cranial imaging was suspicious according to our results.


Background

Spina bifida occulta (SBO) is generally known as a benign isolated entity; however, there are ambiguous approaches for neuroaxial screening in cases of symptomatic SBO among institutions. This study aims to demonstrate the infrequency of cranial anomalies associated with symptomatic SBO and inquire the necessity of cranial radiological surveillance in those patients.

Methods

Between 2012 and 2016 pediatric patients who were surgically treated in our clinic due to symptomatic SBO were retrospectively evaluated. All radiological findings in craniospinal evaluation were documented.

Results

There were 76 patients with mean age of 5.3 years (range 2 months to 17 years), and female predominance (53 female and 23 male patients). Of those, 64 patients had whole neuroaxis investigation including cranial imaging. Among 64 patients with cranial screening, only two patients had occipital encephalocele and posterior fossa arachnoid cyst. There was neither hydrocephalus nor Chiari malformation in our case series.

Conclusions

We detected high number of additional spinal abnormalities accompanying to symptomatic SBOs, whereas cranial findings rarely coexisted with them. Therefore, we strongly suggest the radiological screening of whole spinal axis in occult spinal dysraphism with significant spinal findings. On the other hand, cranial imaging as a part of neuraxis screening in cases of symptomatic SBOs is not required in all cases; however, it can be done in selected patients where clinically indicated.

How to do it: a modified transabdominal wall approach for direct external iliac artery access during endovascular thoracic aneurysm repair

August 5, 2019 - 00:12

We describe the combined application of a transabdominal wall sheath tunnel, ‘pre‐close’ purse‐string sutures and manual external support of the iliac artery to facilitate introduction of an 18F sheath for endovascular exclusion of a 6‐cm thoracic aortic aneurysm.