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.
Updated: 18 hours 57 min ago

Primary duct closure combined with transcystic drainage versus T‐tube drainage after laparoscopic choledochotomy

August 5, 2019 - 00:12

Primary duct closure combined with transcystic drainage after laparoscopic choledochotomy is a simplified technique for external drainage of the biliary tract. The technique facilitates post‐operative channel decompression, examination and treatment. We can effectively prevent post‐operative complications, especially biliary leakage by this means. Furthermore, it provides a convenient means to treat remnant stones of the bile duct. Finally, compared with minimally invasive drainage using T‐tubes, cystic duct biliary drainage significantly shortens the time for patients to recover and resume normal activities.


Background

We compared the post‐operative course and final outcome of primary duct closure combined with transcystic drainage with those of T‐tube drainage.

Methods

We retrospectively analysed 112 consecutive patients treated with laparoscopic choledochotomy for common bile duct stones between February 2014 and December 2017. Primary closure with transcystic drainage was performed in 59 patients (group A), and laparoscopic choledochotomy with T‐tube drainage was performed in 53 (group B). The primary endpoints were morbidity, the bile drainage quantity, operative time, post‐operative stay, time until return to work and post‐operative complications.

Results

The operation was successfully completed in all patients. The return to work period in group A was significantly shorter than that in group B (7.25 ± 1.27 versus 46.47 ± 3.86 days, P < 0.05). The average daily drainage was not significantly different between the two groups (P > 0.05). There was no significant difference in the operation time (133.75 ± 14.51 versus 132.21 ± 12.71 min) and duration of hospital stay (5.15 ± 1.23 versus 5.94 ± 0.95 days) between the two groups (P > 0.05). Bile leakage was seen in one T‐tube removal patient. No complications were reported in group A. The patients were followed for 2 to 29 months (average: 10). Normal liver function and no stricture of the bile duct were detected with ultrasonography.

Conclusion

Primary closure of choledochotomy and subsequent transcystic drainage is a simple and less invasive procedure than T‐tube placement.

Laparoscopic versus open transverse‐incision right hemicolectomy: a retrospective comparison study

August 5, 2019 - 00:12

Data on 99 adult patients with right‐side colon cancer undergoing either laparoscopic or open transverse‐incision right hemicolectomy at two different university hospitals were retrospectively reviewed. The aim of this study was to compare the short‐ and long‐term outcomes of laparoscopic and transverse‐incision open approaches to right hemicolectomy. Our results suggest that laparoscopic right hemicolectomy when compared to the transverse‐incision open procedure may guarantee the same oncological radicality, but short‐term functional benefits are still unclear.


Background

The optimal surgical approach to right colon cancer is still under debate. The aim of the present study was to compare the short‐ and long‐term outcomes of laparoscopic and transverse‐incision open approaches to right hemicolectomy for colon cancer.

Methods

Data on 99 adult patients with right‐side colon cancer undergoing either laparoscopic or open transverse‐incision right hemicolectomy at two different university hospitals, between January 2013 and December 2016, were retrospectively reviewed. Data concerning patients’ characteristics, operative details and post‐operative recovery were retrieved from prospective databases and analysed.

Results

Forty‐nine subjects were operated on laparoscopically, while 50 through an open transverse incision. Operating time was significantly longer in the laparoscopic group compared with the open group (182 versus 105 min; P < 0.01). Patients treated laparoscopically had a shorter time to first bowel movement, while time to resume a normal diet and post‐operative length of hospital stay were comparable in between groups. The median number of lymph nodes harvested was higher in the laparoscopic group (25.6 versus 18.6; P < 0.01), but no significant difference in overall survival between groups was detected. At long‐term follow‐up, the incidence of incisional hernia was higher in the laparoscopic group as compared to the open group (24.5% versus 0%; P = 0.0002).

Conclusion

Our results show that laparoscopic right hemicolectomy when compared to the transverse‐incision open procedure may guarantee the same oncological radicality, but short‐term functional benefits are still unclear. Randomized control studies are warranted to better clarify the comparison of these two approaches for right‐sided colon cancers.

Australasian general surgical training and emergency medical teams: a review

August 5, 2019 - 00:12

Emergency medical teams (EMTs) have provided surgical care in sudden‐onset disasters in low‐ and middle‐income countries. General surgeons have been heavily involved in many EMTs due to their traditional broad set of surgical skills and experience. With the increased subspecialization of general surgical training in many high‐income countries, including Australia and New Zealand, finding general surgeons with adequately broad experience is becoming more challenging. Furthermore, it is now considered standard for EMTs deploying to a sudden‐onset disaster to have undergone credentialing, demonstrating sufficient training of their deployed members. The purpose of this review was to highlight the challenges and potential solutions facing those involved in training and recruiting general surgeons for EMTs in Australasia.

Primary splenic ectopic pregnancy: a case report

July 31, 2019 - 22:40
ANZ Journal of Surgery, EarlyView.

What is in the sac? Littré hernia

July 31, 2019 - 22:38
ANZ Journal of Surgery, EarlyView.

Sentinel lymph node biopsy in patients with malignant melanoma: analysis of post‐operative complications

July 31, 2019 - 22:38
Background

This study investigates the incidence of post‐operative complications and risk factors of sentinel lymph node biopsy (SLNB) in melanoma patients.

Methods

A retrospective cohort study was conducted at a single cancer institution on 408 consecutive SLNBs.

Results

Fifty‐five post‐operative complications occurred in 39 (9.5%) patients and included: wound infection in 24 (5.9%), seroma and lymphorrhea in 15 (3.7%), wound dehiscence in seven (1.7%), lymphocele in six (1.5%) and others in three (0.7%). Univariate analysis failed to identify possible risk factors (i.e. gender, age, lymph node region, number of excised lymph nodes, Breslow index, pT levels, comorbidities, length of surgery and hospital stay). Metastatic sentinel nodes occurred in four of 135 (3%) patients with thin melanoma (Breslow <1 mm) and in 68 of 262 (25.9%) patients with Breslow >1 mm.

Conclusion

For patients with thin melanoma in whom the incidence of lymph node metastasis is low, the reported post‐operative morbidity of almost 10% of SLNB highlights the need for careful patient selection.

Mucinous cystadenoma mimicking appendiceal mucocele

July 30, 2019 - 22:20
ANZ Journal of Surgery, EarlyView.

Meta‐analysis of unplanned readmission to hospital post‐appendectomy: an opportunity for a new benchmark

July 30, 2019 - 22:19
Background

Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. While many studies report readmission, a meta‐analysis of readmission post‐appendectomy has not been published. This meta‐analysis was undertaken to determine rates and predictors of hospital readmission following appendectomy and to potentially provide a metric benchmark.

Methods

An ethically approved PROSPERO‐registered (ID CRD42017069040) meta‐analysis following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines, using databases PubMed and Scopus, was undertaken for studies published between January 2012 and June 2017. Articles relating to outcomes and readmissions after appendectomy were identified. Those scoring >15 for comparative studies and >10 for non‐comparative studies, using Methodological Index for Non‐Randomized Studies criteria were included in the final analysis. The odds ratios (OR) using random‐effects, Mantel–Haenszel method with 95% confidence intervals (CI), were computed for each risk factor with RevMan5.

Results

A total of 1757 articles reviewed were reduced to 45 qualifying studies for a final analysis of 836 921 appendectomies. 4.3% (range 0.0–14.4%) of patients were readmitted within 30 days. Significant preoperative patient factors for increased readmission were diabetes mellitus (OR 1.93, CI 1.63–2.28, P < 0.00001), complicated appendicitis (OR 3.6, CI 2.43–5.34, P < 0.00001) and open surgical technique (OR 1.39, CI 1.08–1.79, P < 0.00001). Increased readmission was not associated with gender, obesity or paediatric versus general surgeons or centres.

Conclusion

This meta‐analysis identified that readmission is not uncommon post‐appendectomy, occurring in one in 25 cases. The mean readmission rate of 4.3% may act as a quality benchmark for improving emergency surgical care. Targeting high‐risk groups with diabetes or complicated appendicitis and increasing use of laparoscopic technique may help reduce readmission rates.

Widespread intraperitoneal hydatid cysts presenting with acute abdomen syndrome

July 30, 2019 - 22:19
ANZ Journal of Surgery, EarlyView.

Distal intestinal obstruction syndrome: an important differential diagnosis for abdominal pain in patients with cystic fibrosis

July 30, 2019 - 22:19

Distal intestinal obstruction syndrome (DIOS) is an important cause of obstructive symptoms in people with cystic fibrosis that must be differentiated from other causes of bowel obstruction. This review aims to highlight the clinical and pathophysiological features of DIOS, differentiate it from other causes of bowel obstruction and contrast management strategies. Improved knowledge of DIOS will help to facilitate appropriate recognition and permit optimal, multidisciplinary management of this cystic fibrosis complication.


As life expectancy for those with cystic fibrosis (CF) now exceeds 40 years of age, adult hospitals away from specialized CF services are being exposed more frequently to people with acute complications of CF. Well‐known manifestations of CF include pulmonary disease and pancreatic insufficiency with malabsorption. However, a less well‐known entity is distal intestinal obstruction syndrome (DIOS), which is an important cause of obstructive symptoms in people with CF that must be differentiated from other causes of bowel obstruction. However, one confounding factor is that adults with CF may have elements of both DIOS and mechanical bowel obstruction due to adhesions from previous operations. A recent tragic outcome in a young adult with CF highlights the need for all doctors, both junior and senior, especially those who are not directly involved in day‐to‐day CF care, to understand the features of DIOS and the appropriate management, which differs from that of a mechanical bowel obstruction. This review aims to highlight the clinical and pathophysiological features of DIOS, differentiate it from other causes of bowel obstruction and contrast management strategies. Improved knowledge of DIOS will help to facilitate appropriate recognition and permit optimal, multidisciplinary management of this CF complication.

Predicting the prognosis of undifferentiated pleomorphic soft tissue sarcoma: a 20‐year experience of 266 cases

July 30, 2019 - 22:19
Background

Undifferentiated pleomorphic sarcoma (UPS) is a rare malignant tumour of mesenchymal origin, which was conceived following re‐classification of malignant fibrous histiocytoma (MFH). The objective of this study is to determine prognostic factors for the outcome of UPS, following multi‐modal treatment.

Methods

Data of UPS tumours from 1996 to 2016 were collected, totalling 266 unique UPS patients. Median follow‐up was 7.8 years. All tumours were retrospectively analysed for prognostic factors of the disease, including local recurrence (LR) and metastatic disease (MD) at diagnosis, tumour size, grade, location and depth, patient age, adjuvant therapy and surgical margin. Overall survival (OS), post‐treatment LR and metastatic‐free survival were assessed as outcomes.

Results

The 5‐ and 10‐year OS rates for all ages were 60% and 48%, respectively, with a median survival time of 10.1 years. Multivariate analysis revealed that the adverse prognostic factors associated with decreased OS were older age (P < 0.001; hazard ratio 1.03) and MD at diagnosis (P = 0.001; 2.89), with upper extremity tumours being favourable (P = 0.043; 2.30). Poor prognosis for post‐operative LR was associated with older age (P = 0.046; 1.03) and positive surgical margins (P = 0.028; 2.68). Increased post‐treatment MD was seen in patients with large tumours (5–9 cm (P < 0.001; 4.42), ≥10 cm (P < 0.001; 6.80)) and MD at diagnosis (P < 0.001; 3.99), adjuvant therapy was favourable, shown to reduce MD (P < 0.001; 0.34).

Conclusions

UPS is a high‐grade soft tissue sarcoma, for which surgery striving for negative margins, with radiotherapy, is the treatment of choice. Older age, lower extremity location, MD at presentation, large size and positive surgical margins, were unfavourable.

Implementation of electronic health records systems in surgical units and its impact on performance

July 30, 2019 - 22:17
Background

Electronic health records (EHR) systems have been utilized in New South Wales for more than a decade; however, there is no agreement as to what clinical benefits they provide. This study aims at determining whether the introduction of EHR systems resulted in changes in documentation quality and other markers of clinical performance such as post‐operative length of stay (PO LOS), use of imaging modality, rates of readmission and morbidity.

Methods

A before and after study was conducted utilizing both written and electronic patient documentation in a single surgical ward. Patients who underwent appendicectomy at Blacktown Hospital had inpatient documentation collated at three distinct time‐points. Documentation was then assessed against the QNOTE assessment criteria. Other markers of clinical performance assessed included PO LOS, ultrasound use, computed tomography use, rate of readmission, rate of morbidity and rate of positive histological findings.

Results

There was a significant (P = 0.001) improvement in QNOTE score between group 1 (6 months prior to the implementation of EHR) and group 3 (12 months after the implementation of EHR) of 9 points. PO LOS was reduced following the implementation of EHR from 1.94 to 1.37 days (P = 0.001).

Conclusion

This study demonstrated that following the implementation of EHR system in an inpatient surgical ward, notation quality improved. It was also found that the implementation of EHR was associated with a decrease in PO LOS.

Danger of sandwiches: accidental bread clip ingestion requiring small bowel resection

July 30, 2019 - 19:40
ANZ Journal of Surgery, EarlyView.

Novel approach to a hepatic foreign body using a $5.50 magnet

July 30, 2019 - 19:39
ANZ Journal of Surgery, EarlyView.

Radiographic severity of knee osteoarthritis and its relationship to outcome post total knee arthroplasty: a systematic review

July 23, 2019 - 22:28

This systematic review of available research indicates that total knee arthroplasty for osteoarthritis improves pain, function and satisfaction, particularly in those with more severe preoperative radiological knee osteoarthritis.


Background

Up to 20% of patients are dissatisfied after total knee arthroplasty (TKA). There are many contributing factors. The relationship between preoperative osteoarthritis (OA) severity and outcome post TKA remains unclear. This review explores the relationship between preoperative OA severity with patient reported pain, function and satisfaction post TKA.

Methods

A pre‐registered systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Major databases were searched until September 2017. We included studies assessing adults undergoing TKA for OA. Minimum follow‐up was 6 months. Methodological quality assessment was conducted using the Newcastle‐Ottawa Scale.

Results

Twenty cohort studies with 7478 patients were included. There were 16 good, one fair and three poor quality studies. Knee OA was most commonly reported according to the Kellgren and Lawrence tool. Ten studies showed statistically significant pain outcomes for those with worse preoperative OA. This was supported by meta‐analysis of the Knee Society Score pain change scores to final follow‐up for those with Kellgren and Lawrence grade 4 OA. Six studies showed statistically significant results for various aspect of functional recovery, although meta‐analysis of Knee Society Score function change scores identified no difference. Meta‐analysis of final follow‐up pain and function scores alone yielded no significant difference. Patients with more severe preoperative OA were more likely to be satisfied. There were no studies demonstrating that less severe OA resulted in better pain, function or satisfaction.

Conclusion

Review of available research indicates that TKA for OA improves pain, function and satisfaction. Those with more severe preoperative radiological knee OA benefit most.

Superficial acral fibromyxoma in unusual location: a case report

July 23, 2019 - 19:40
ANZ Journal of Surgery, EarlyView.

Effect of preoperative psychological interventions on elective orthopaedic surgery outcomes: a systematic review and meta‐analysis

July 23, 2019 - 19:40

Although multiple prospective trials have been published on preoperative psychological interventions in elective orthopaedics, findings have been mixed. A systematic review and meta‐analysis of pooled data from existing literature was performed, demonstrating a small, significant beneficial effect of these interventions on acute post‐operative anxiety and long‐term mental quality of life.


Background

Orthopaedic surgery is largely successful; however, a proportion of patients are dissatisfied and report pain and poor function. Psychological factors have been shown to influence orthopaedic surgical outcomes. This systematic review and meta‐analysis investigates the types and effectiveness of preoperative psychological interventions in elective orthopaedic surgery.

Methods

A registered systematic review (PROSPERO CRD42017073833) was performed on literature (1960–January 2018) using eight databases. Prospective controlled clinical trials involving adult and adolescent elective orthopaedic surgery were included. Interventions examined included relaxation, cognitive behavioural therapy, hypnosis, emotional counselling and mixed psychotherapies; general procedural education was excluded. Outcomes extracted included pain, anxiety, quality of life and disability.

Results

A total of 19 studies met the inclusion criteria (n = 1893 patients). Meta‐analyses were performed for pain, anxiety and quality of life. Analysis did not find enough evidence to confirm reduction in post‐operative pain (seven studies, 666 patients; g = −0.15 (95% CI −0.42, 0.13), P = 0.305). Pooled data from six studies on acute post‐operative anxiety (589 patients) showed a moderate statistically significant benefit (g = −0.26 (−0.49, −0.03), P = 0.024). There was an improved quality of life (mental component) at longer term follow‐up (g = 0.25 (0.02, 0.49), P = 0.034).

Conclusions

These studies provide evidence that psychological interventions have a positive effect on anxiety in the acute post‐operative period, and on mental components of quality of life at longer term follow‐up.