ANZ Journal of Surgery

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Wiley Online Library : ANZ Journal of Surgery
Updated: 7 hours 10 min ago

Out-of-office hours’ elective surgical intensive care admissions and their associated complications

June 13, 2017 - 10:20
Background

The ‘weekend’ effect is a controversial theory that links reduced staffing levels, staffing seniority and supportive services at hospitals during ‘out-of-office hours’ time periods with worsening patient outcomes. It is uncertain whether admitting elective surgery patients to intensive care units (ICU) during ‘out-of-office hours’ time periods mitigates this affect through higher staffing ratios and seniority.

Methods

Over a 3-year period in Western Australia's largest private hospital, this retrospective nested-cohort study compared all elective surgical patients admitted to the ICU based on whether their admission occurred ‘in-office hours’ (Monday–Friday 08.00–18.00 hours) or ‘out-of-office hours’ (all other times). The main outcomes were surgical complications using the Dindo-Clavien classification and length-of-stay data.

Results

Of the total 4363 ICU admissions, 3584 ICU admissions were planned following elective surgery resulting in 2515 (70.2%) in-office hours and 1069 (29.8%) out-of-office hours elective ICU surgical admissions. Out-of-office hours ICU admissions following elective surgery were associated with an increased risk of infection (P = 0.029), blood transfusion (P = 0.020), total parental nutrition (P < 0.001) and unplanned re-operations (P = 0.027). Out-of-office hours ICU admissions were also associated with an increased hospital length-of-stay, with (1.74 days longer, P < 0.0001) and without (2.8 days longer, P < 0.001) adjusting for severity of acute and chronic illnesses and inter-hospital transfers (12.3 versus 9.8%, P = 0.024). Hospital mortality (1.2 versus 0.7%, P = 0.111) was low and similar between both groups.

Conclusion

Out-of-office hours ICU admissions following elective surgery is common and associated with serious post-operative complications culminating in significantly longer hospital length-of-stays and greater transfers with important patient and health economic implications.

Does the ileal brake mechanism contribute to sustained weight loss after bariatric surgery?

June 8, 2017 - 16:45

Bariatric surgery is currently the most effective strategy for treating morbid obesity. Weight regain following significant weight loss, however, remains a problem, with the outcome proportional to the period of follow-up. This review revisits a well-established physiological neurohormonally-mediated feedback loop, the so called ileal brake mechanism, with a special emphasis on the gut hormone peptide tyrosine tyrosine. The manuscript not only highlights the potential role of the ileal brake mechanism in weight loss and weight maintenance thereafter following obesity surgery, it also provides a compelling argument for using this appetite suppressing feedback loop to enable sustained long-term weight loss in patients undergoing surgery for morbid obesity.

It's worth the wait: optimizing questioning methods for effective intraoperative teaching

June 8, 2017 - 14:50
Background

The use of questioning to engage learners is critical to furthering resident education intraoperatively. Previous studies have demonstrated that higher level questioning and optimal wait times (>3 s) result in learner responses reflective of higher cognition and retention. Given the importance of intraoperative learning, we investigated question delivery in the operating room.

Methods

A total of 12 laparoscopic cholecystectomies were observed and recorded. All questions were transcribed and classified using Bloom's Taxonomy, a framework associated with hierarchical levels of learning outcomes. Wait time between question end and response was recorded.

Results

Six faculty attendings and seven house officers at our institution were observed. A total of 133 questions were recorded with an average number of questions per case of 11.2. The majority of questions 112 out of 133 (84%) were classified as Bloom's levels 1–3, with only 6% of questions of the highest level. The wait time before the resident answered the question averaged 1.75 s, with attendings interceding after 2.50 s. Question complexity and wait time did not vary based on resident postgraduate year level suggesting limited tailoring of question to learner.

Conclusions

Intraoperative questioning is not aligned with higher level thinking. The majority of questions were Bloom's level 3 or below, limiting the complexity of answer formulation. Most responses were given within 2 s, hindering opportunity to pursue higher-order thinking. This suggests including higher level questions and tailoring questions to learner level may improve retention and maximize gains. In addition, with attendings answering 20% of their own questions, increasing their wait time offers another area for teaching development.

Age 80 years and over is not associated with increased morbidity and mortality following pancreaticoduodenectomy

June 8, 2017 - 14:50
Background

Pancreaticoduodenectomy (PD) is associated with high morbidity, which is perceived to be increased in the elderly. To our knowledge there have been no Australian series that have compared outcomes of patients over the age of 80 undergoing PD to those who are younger.

Methods

Patients who underwent PD between January 2008 and November 2015 were identified from a prospectively maintained database.

Results

A total of 165 patients underwent PD of whom 17 (10.3%) were aged 80 or over. The pre-operative health status, according to American Society of Anesthesiologists class was similar between the groups (P = 0.420). The 90-day mortality rates (5.9% in the elderly and 2% in the younger group; P = 0.355) and the post-operative complication rates (64.7% in the elderly versus 62.8% in the younger group; P = 0.88) were similar. Overall median length of hospital stay was also similar between the groups, but older patients were far more likely to be discharged to a rehabilitation facility than younger patients (47.1 versus 12.8%; P < 0.0001). Older patients with pancreatic adenocarcinoma (n = 10) had significantly lower median survival than the younger group (n = 69) (16.6 versus 22.5 months; P = 0.048).

Conclusion

No significant differences were seen in the rate of complications following PD in patients aged 80 or over compared to younger patients, although there appears to be a shorter survival in the elderly patients treated for pancreatic cancer. Careful selection of elderly patients and optimal peri-operative care, rather than age should be used to determine whether surgical intervention is indicated in this patient group.

Impact of atrial fibrillation on long-term survival following oesophagectomy: a 21-year observational study

June 8, 2017 - 14:50
Background

Post-operative atrial fibrillation (AF) is a common complication of oesophagectomy and thought to signal a complicated post-operative course. AF is associated with prolonged admissions, increased healthcare costs and inpatient mortality. However, the impact of post-operative AF on long-term outcomes remains uncertain.

Methods

Patients undergoing open Ivor-Lewis oesophagectomy from 1994 to 2014 at Palmerston North Hospital, New Zealand, were retrospectively evaluated. Demographic, perioperative and tumour variables were collected. Regression models were used to identify independent predictors of AF and assess post-discharge survival following oesophagectomy.

Results

In total, 89 patients were included. New-onset AF developed post-operatively in 27 patients (30%). Median follow-up was 6.3 years. Logistic regression identified volume of intravenous fluid in the first 24 h post-operatively as a predictor of AF. Post-discharge survival was predicted by AF occurrence (hazard ratio (HR): 2.99, 95% confidence interval (CI): 1.37–6.53, P = 0.006), preoperative chemoradiotherapy (HR: 0.43, 95% CI: 0.20–0.91, P = 0.03), 1–4 positive lymph nodes (HR: 2.29, 95% CI: 1.06–4.96, P = 0.04), ≥5 positive nodes (HR: 2.95, 95% CI: 1.25–6.94, P = 0.01) and year of operation from 2008 to 2014 (HR: 0.30, 95% CI: 0.12–0.75, P = 0.01).

Conclusion

Post-operative AF was associated with poorer long-term survival following oesophagectomy in this cohort. Further research should evaluate the influence of AF on cardiovascular and oncological outcomes following oesophagectomy.

Index cholecystectomy in a rural hospital: it can be done

June 7, 2017 - 10:20
Background

Index cholecystectomy (IC) refers to an operation during a patient's first hospital admission with symptomatic gallstone (GS) disease. There are proven reductions in cost, hospital bed days and GS-related complications while awaiting elective surgery. IC has not been universally adopted, particularly in smaller centres where logistics can present a barrier. The aim of this paper is to describe the introduction of routine IC at Hastings Hospital and the effects in terms of waiting time until surgery; GS-related re-presentations and complications while awaiting surgery; operative complications and overall hospital stay.

Methods

Data were collected for all patients who underwent cholecystectomy in the year following the introduction of IC (2015/2016). The results were compared with data from the year 2009/2010.

Results

A total of 259 cholecystectomies were performed over the 2015/2016 study period compared with 186 in the 2009/2010 study period. The IC rate increased from 9.89% in 2009 to 75.4% in 2015 (P < 0.001). The incidence of GS pancreatitis whilst waiting for surgery reduced from six in 2009 compared with one in 2015 (P = 0.046). The operative complications were similar in both groups. Total hospital stay was also similar.

Conclusion

The study shows that it is possible to perform IC in a rural setting reducing complications of waiting and in particular, rates of GS-related pancreatitis were significantly reduced. It can be done safely with an accommodating acute on-call system.

25, 50 & 75 years ago

June 6, 2017 - 21:42

Issue information - JEB

June 6, 2017 - 21:42

Issue information - TOC

June 6, 2017 - 21:42

Medicine in small doses

June 6, 2017 - 21:42