ANZ Journal of Surgery

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Syndicate content
Wiley Online Library : ANZ Journal of Surgery
Updated: 5 hours 20 min ago

Ischaemic colitis: uncertainty in diagnosis, pathophysiology and management

November 10, 2017 - 13:16

Ischaemic colitis is the most common form of gastrointestinal ischaemia, but may be confused with acute mesenteric ischaemia, inflammatory bowel disease or infectious colitis. This review article outlines the current classification, epidemiology and risk factors, as well as approaches about diagnosis and management to guide clinical practice. It also identifies areas for further research.

How should new orthopaedic implants be introduced: an example and recommendations for best practice

November 10, 2017 - 13:16

Continued advancements in orthopaedics have led to the development of many new implants; many of these are being utilized in clinical practice with little or no evidence base for their safety or effectiveness. Highly publicized failures in orthopaedic technology have led to an increased awareness of this issue in both medical and non-medical circles. In most cases, the significant harm caused to the public could have been avoided by the appropriately staged implementation of new implants. This review comments on the current literature regarding the optimal practice for the introduction of new orthopaedic technology. The authors’ experience with the failed ESKA Adapter Short-stem/Modular Hip is described; the methodology used for its evaluation is used as a basis to discuss what was successful about the process and also give warning on what could be improved upon. The ideal practice requires new orthopaedic implants to be evaluated by high-volume surgeons in specialist orthopaedic hospitals. These studies should include biomechanical studies, radiostereophotometric analysis, implant retrieval and outcome assessment. Results and complications should be reported early to the appropriate joint registry and regulatory body. Once a suitable evidence base has developed, the implant can be distributed into wider clinical practice or withdrawn. These recommendations aim to protect the patient and public from harm while allowing surgical innovation to still continue.

Lower risk of pelvic metalware infection with operative repair of concurrent bladder rupture

November 10, 2017 - 13:16
Background

Patients with traumatic bladder rupture frequently have associated pelvic fracture. With increasing numbers of pelvic fractures fixed internally, there are concerns that conservative management of bladder rupture may increase the risk of pelvic metalware infection. This study aims to determine if operative repair of bladder rupture in comparison to conservative management with catheter drainage alone is associated with a lower rate of infection of internal fixation device for concurrent pelvic fracture.

Methods

This is a retrospective cohort study of level IV evidence. From July 2001 through June 2013, 45 multi-trauma patients at a level 1 trauma centre were identified to have sustained bladder rupture with concurrent pelvic fracture requiring internal fixation. Clinicopathological data were extracted from the TraumaNET database, medical records and health-coding database. Patients were stratified into two retrospective cohorts, management with surgical repair and management with catheter drainage alone. Fischer's exact test was used to determine whether the rate of pelvic metalware infection was different in the two cohorts.

Results

Of the 45 patients, 13 had intraperitoneal bladder rupture, 28 had extraperitoneal bladder rupture and four had combined intra-extraperitoneal bladder rupture. The median age for this cohort was 31. Bladder rupture was surgically repaired in 36 patients and managed conservatively with catheter drainage in nine patients. The rate of pelvic internal fixation device infection was lower in patients managed with surgical repair compared with conservative management (5.6% versus 33.3%, P = 0.047).

Conclusion

Operative repair of bladder rupture is associated with a lower rate of pelvic orthopaedic hardware infection in the presence of concurrent pelvic fracture requiring internal fixation.

Safety of single-incision laparoscopic cholecystectomy for acute cholecystitis

November 10, 2017 - 13:16
Background

Single-incision laparoscopic cholecystectomy (SILC) is a common procedure performed worldwide. In this study, we evaluated the safety and efficacy of SILC for acute cholecystitis.

Methods

Patients who underwent SILC between September 2012 and December 2016 were retrospectively enrolled and divided into acute and chronic groups. Demographic, operative and outcome data were obtained by reviewing medical records, physical examination and telephone follow-up.

Results

In total, 1435 patients were included in this study: 220 (15.3%) in the acute group and 1215 (84.7%) in the chronic group. The mean operative time was longer in the acute group than in the chronic group (44.7 ± 21.6 versus 32.8 ± 9.8 min; P < 0.001). Insertion of additional ports was performed in 17 patients: six in the acute group and 11 in the chronic group. Conversion to abdominal laparotomy was performed in eight patients: one in the acute group and seven in the chronic group. The mean post-operative hospital stay was 31.7 ± 20.4 h in the acute group and 27.7 ± 13.7 h in the chronic group. The complication rate was similar between the acute (n = 8, 3.6%) and chronic (n = 33, 2.7%) groups.

Conclusion

SILC does not increase the complication rate and is a safe and feasible technique for both chronic and acute cholecystitis.

Splenic vessel preservation versus splenic vessel resection in laparoscopic spleen-preserving distal pancreatectomy

November 10, 2017 - 13:16
Background

Laparoscopic spleen-preserving distal pancreatectomy for low-grade malignant pancreas tumours was recently demonstrated and can be performed with splenic vessel preservation (SVP) or splenic vessel resection (SVR). Whether one approach is superior to another is still a matter of debate.

Methods

A systematic literature search (PubMed, Embase, Science Citation Index, Springer-Link and Cochrane Central Register of Controlled Trials) was performed. Pooled intra- and post-operative outcomes were evaluated. Stratified and sensitivity analyses were performed to explore heterogeneity between studies and to assess the effects of the study qualities.

Results

A total of six studies were included. There was no significant difference for SVR and SVP in terms of overall post-operative complications and the pooled odds ratio (OR) was 0.87 (95% confidence interval (CI) 0.55–1.38, I2 = 25%). Meta-analysis on the pooled outcome of intraoperative operative time and blood loss favoured SVR; the mean differences were 18.64 min (95% CI 6.91–30.37 min, I2 = 21%) and 65.67 mL (95% CI 18.88–112.45 mL, I2 = 48%), respectively. Subgroup analysis showed a decrease incidences in perigastric varices (OR = 0.07, 95% CI 0.03–0.18, I2 = 29%) and splenic infarction (OR = 0.16, 95% CI 0.08–0.32, I2 = 0%) in SVP.

Conclusion

For selected patients who underwent laparoscopic spleen-preserving distal pancreatectomy, an increased preference for the SVP technique should be suggested considering its short-term benefits. However, in case of large tumours that distort and compress vessel course, SVR could be applied with acceptable splenic ischaemia and perigastric varices.

Reconstructive options for large back free flap donor sites

November 10, 2017 - 13:15
Background

Reconstruction of posterior thoracic and trunk defects can prove challenging even to the most seasoned surgeons. Many commonly used techniques for closing back defects include primary closure and split skin grafts. Often times, however, other techniques are needed in order to give the patient the best aesthetic and functional outcome. In this study, we focus on and evaluate donor site closure techniques for defects in the back created by harvesting scapular and parascapular flaps.

Methods

Twenty patients were operated on to remove pathologically diagnosed sarcomas using a wide local excision. The defects, ranging from 5 to 22 cm in width, were closed using donor flaps from the scapular/parascapular region. Nine donor sites were then closed primarily with wide undermining, while 11 donor sites were closed using multiple techniques, such as large transposition flaps, large rotation advancement flaps, keystone neurovascular island flaps, latissimus dorsi advancement flap and large Y-V advancement flaps.

Results

All recipient and donor flaps survived with good aesthetic and functional outcome. Patient satisfaction was high and only two of 20 donor site flaps required further surgery due to wound dehiscence. No other complications were seen during the follow-up period.

Conclusion

The proposed advanced techniques for donor site closure in back defects have shown that primary wound healing can be achieved with the use of a variety of different techniques and the avoidance of the complications of a skin graft.

Issue information - TOC

November 3, 2017 - 10:03

Unusual bony hernia

November 3, 2017 - 10:03

Issue information - JEB

November 3, 2017 - 10:03

Medicine in small doses

November 3, 2017 - 10:03

25, 50 & 75 years ago

November 3, 2017 - 10:03