ANZ Journal of Surgery

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Wiley Online Library : ANZ Journal of Surgery
Updated: 5 hours 22 min ago

Outcomes of percutaneous cholecystostomy and predictors of subsequent cholecystectomy

October 20, 2017 - 21:30
Background

The use of a percutaneous cholecystostomy (PC) in the management of severe acute cholecystitis is a well recognized alternative to acute cholecystectomy. The need for definitive surgical management remains controversial.

Methods

A retrospective analysis of hospital records at Nambour General Hospital between 2012 and 2016 was conducted and data relating to indications, demographics, comorbidities and outcomes were collected.

Results

Thirty PC patients (20 male and 10 female) were identified, with a mean age of 77 years (range 46–93). Thirteen proceeded to cholecystectomy, nine elective and four emergent. Mean time to operation was 97 days (range 1–480). Ten were performed laparoscopically with a complication rate of 23% (3/13). One patient in the operative group died. Seventeen patients did not proceed to cholecystectomy. Fifteen resolved and were discharged, and two died. Three of those discharged were readmitted with gallstone disease requiring treatment, one of which died. A total of 71% (12/17) of the non-operative group died and three of those had a cause of death related to gallstone disease. The operative group was younger (P = 0.01) and had a lower estimated mortality risk (P < 0.05). In this cohort, this translated to an overall survival benefit (P < 0.01).

Conclusion

Predictors of eventual cholecystectomy include younger age and lower estimated mortality risk. Patients who require a PC for the treatment of acute cholecystitis and subsequently go on to cholecystectomy can expect to have a favourable outcome.

Firework-related injury in the Top End: a 16-year review

October 18, 2017 - 15:45
Background

On July 1st on ‘Territory Day’, the public in the Northern Territory are permitted to purchase and operate consumer fireworks without a licence. Serious permanent injuries from fireworks are well described, leading to their banning in many other jurisdictions. This study describes those seriously injured by fireworks in the Top End of the Northern Territory, with the aim of identifying opportunities for prevention and harm minimization.

Methods

This is a retrospective audit of all admitted patients with an injury from fireworks at the Royal Darwin Hospital between 2000 and 2015. The variables collected included demographic data and the circumstances around injury (operator versus bystander, alcohol involvement and day of device operation). The consequences such as injuries, operating theatre visits, length of stay and outpatient visits are described.

Results

Fifty-five patients (including 17 children) suffered 67 injuries over the study period, resulting in 68 operating theatre visits, 322 hospital days and 380 outpatient appointments. Burns, hand and eye injuries predominate. Females (P = 0.000) and children (P = 0.029) were more likely to be injured as bystanders. Injuries on a day other than Territory Day were more likely to have alcohol involvement (P = 0.01), and occur in the operator (P = 0.017).

Conclusion

Consumer firework usage results in a small number of life altering injuries annually. Previous prevention campaigns focusing on device user safety should be expanded to include the safety of bystanders and children and reduce firework usage outside of the Territory Day.

Ethnic disparities in rates of publicly funded bariatric surgery in New Zealand (2009–2014)

October 18, 2017 - 15:45
Background

Publicly funded bariatric surgery in New Zealand (NZ) is steadily on the rise to meet the obesity epidemic. Ethnic disparities in obesity rates exist in NZ with Māori and Pacific people having three to five times higher rates than all other ethnic groups within NZ. Ethnic disparities in rates of bariatric surgery have been reported internationally. This research sought to describe rates of publically funded bariatric surgery by self-identified ethnicity in NZ.

Methods

Using reported census and hospitalization discharge data from Statistics NZ and the NZ Ministry of Health, we calculated estimate rates of publicly funded bariatric surgery in the morbidly obese population from June 2009 to July 2014.

Results

The average number of publicly funded bariatric procedures performed per 1000 morbidly obese patients from June 2009 to July 2014 was 3.0 for European, 1.4 for Māori and 0.7 for Pacific ethnicities.

Conclusion

While these data should be interpreted cautiously due to data limitations, the estimated rates may indicate that bariatric services are currently being provided inequitably across the major ethnic groups within NZ. We suggest that further studies should be performed to explore potential patient, healthcare provider and system-level factors that may contribute to ethnic disparities in the rates of publicly funded bariatric surgery in NZ.

Trends in non-lactation breast abscesses in a tertiary hospital setting

October 18, 2017 - 15:45
Background

The aim of this paper was to retrospectively review non-lactation breast abscesses treated in Princess Alexandra Hospital over a 10-year period and to illustrate the trends in size, risk factors, microbiological profile and management.

Methods

A computerized search of the medical records was undertaken to identify all adult patients with a diagnosis of breast abscesses during June 2005–June 2015. Patients concurrently breastfeeding were excluded. A retrospectively review of the clinical records was performed.

Results

Eighty-five abscesses were identified in 77 patients. The median patient age was 45 years and 93.7% were females. Smoking and diabetes mellitus were associated with a longer inpatient hospital stay. There was a significant difference in microbiology of abscesses in relation to size. Smaller abscesses (≤3.0 cm) predominantly had mixed anaerobes (54%), whereas larger abscesses had a dominance of Staphylococcus aureus (29%) and other aerobic microbes (33%) (P < 0.05). Seven percent of all abscesses had methicillin-resistant S. aureus. Flucloxacillin was prescribed solely in majority of the cases (45%) with addition of suitable mixed anaerobic cover in 12% cases. Of the 85 abscesses, 58.8% were managed non-operatively with antibiotics ± percutaneous drainage. Percutaneous aspiration had a shorter inpatient stay compared with patients who underwent operative management.

Conclusion

This represents the first Australian study solely analysing non-lactation breast abscess. Size was correlated significantly to characteristic bacteriology and empiric therapy should include both aerobic and anaerobic cover. The majority of non-lactation breast abscesses can be managed non-operatively with a combination of antibiotics and percutaneous aspiration.

Rare case of Bouveret syndrome

October 13, 2017 - 17:25

Laparoscopic ventral hernia repair using only 5-mm ports

October 13, 2017 - 14:35
Background

The technique of laparoscopic ventral hernia repair has been evolving since it was first described over 20 years ago. We report a new technique where polyester mesh was back loaded through a 5-mm port site, coming into contact with the skin. This avoids the need for any 10–12-mm ports.

Methods

A prospective database of laparoscopic ventral hernia repairs was examined. A single surgeon performed 344 laparoscopic ventral hernia repairs using this technique over 60 months. Follow-up was conducted by both clinical and independent phone review. Surgical technique: Laparoscopic access was achieved via a 5-mm optical port, adding two, or occasionally three, 5-mm extra ports. Hernia contents were reduced and the extra-peritoneal fat excised; 5-mm tooth graspers were placed through the lateral port and then in a retrograde fashion through the uppermost port. The port was removed, and the mesh pulled back into the abdominal cavity and positioned with a minimum of 3-cm overlap. The mesh was fixed using absorbable tacks and sutures.

Results

Most patients had primary umbilical hernias. There was one case of mesh infection due to enteric organisms. This occurred in a patient undergoing repair of a stoma site hernia, resulting from a Hartmann's procedure for perforated diverticulitis. There was no other evidence of acute or chronic mesh infection despite cutaneous contact with the mesh. In this series, there was an overall hernia recurrence rate of 2.4%.

Conclusion

Laparoscopic ventral hernia repair using only 5-mm ports is a safe, effective technique with no extra risk of infection.

Littoral cell angioma of spleen

October 12, 2017 - 08:51

Hepatic cystic echinococcosis in Australia: an update on diagnosis and management

October 12, 2017 - 08:51
Background

Echinococcosis is an uncommonly encountered zoonotic disease caused by the taeniid Echinococcus. The only endemic species in Australia, Echinococcus granulosus, forms cysts in the liver in 70% of cases. The aim of this study was to review the literature to provide an evidence-based narrative update on the diagnosis and management of hepatic cystic echinococcosis in Australia.

Methods

We reviewed the literature, utilizing multiple research databases and citation tracking. Original research and review articles examining the diagnosis and management of hydatid disease in adults, published prior to 2016 and in the English language were included in our review.

Results

Ultrasound is the gold-standard screening test, whilst computed tomography has a role in emergency presentations and screening for multi-organ involvement. Magnetic resonance imaging is the preferred second-line imaging and better demonstrates biliary involvement. Medical therapy or PAIR (percutaneous aspiration, irrigation with scolicide and re-aspiration) may be appropriate in selected cases; however, surgery remains the definitive treatment for active, large (>5 cm), symptomatic or complicated cysts. A variety of surgical techniques have been described, including conservative, radical and minimally invasive procedures. There is currently no consensus approach; surgical modality should be tailored to patient factors, relevant anatomy, local facilities and surgeons’ expertise.

Conclusion

Diagnosis and therapy in hepatic hydatid cysts have been significantly advanced by imaging, interventional radiology and surgical approaches in recent years. Surgery remains the mainstay of treatment for large, active, complicated or symptomatic hepatic hydatid cysts.

Revision gastric bypass after laparoscopic adjustable gastric band: a 10-year experience at a public teaching hospital

October 12, 2017 - 08:50
Background

In Australia, there is limited access to public revisional bariatric procedures. However, the need for such procedures is rising. We investigated the safety and efficacy of band-to-bypass procedures in our experience at a public teaching hospital over a period of 10 years.

Methods

Using a prospectively maintained bariatric surgical database, we analysed 91 consecutive planned band-to-bypass procedures from 2007 to November 2016. All patients had prior laparoscopic adjustable gastric bands removed and formation of Roux-en-Y gastric bypass, in one or two stages. Primary outcomes were 30-day complication rate and excess weight loss from 12 months. The impact of fellows as primary operators on these outcomes was assessed.

Results

Eighty-two patients met the inclusion criteria. Seventy-one (84.5%) were females. Mean age was 48.8 years (SD: 8.85). Immediate post-operative complications included six (7.3%) patients with gastrojejunostomy leak, three of whom required conversion to laparotomy, with one mortality (1.22%). Fifty-two patients had follow-up of 1 year or more (median: 2.36, range: 1–9.24). Mean excess weight loss at the end of follow-up was 52.79% (SD: 46.46). Twenty-eight (34.14%) cases were performed primarily by a fellow under the guidance of an experienced bariatric surgeon, with equivalent results.

Conclusion

Revisional band-to-bypass in the public setting is an effective but complex procedure associated with morbidity. Some risk may be ameliorated by development of selection criteria to exclude certain high-risk groups. We hope discussion amongst other bariatric groups will further refine this approach.

Effect of a See and Treat clinic on skin cancer treatment time

October 12, 2017 - 08:50
Background

Many plastic surgery departments in Australasia have experienced increasing referrals for management of skin lesions. This has driven a demand for new strategies to decrease patient waiting time and administrative costs. The aim of this study was to determine if a purpose-built See and Treat skin cancer clinic could provide a faster skin cancer treatment pathway with comparable clinical outcomes and acceptability to patients.

Methods

This was a prospective observational study of patients treated through the See and Treat clinic with a retrospective control cohort. The prospective ‘See and Treat’ cohort included a consecutive series of 106 patients, while the retrospective cohort included a consecutive series of 200 patients. Patient demographics, time from referral to surgery and operative measures were analysed. One hundred patients in the prospective cohort completed an anonymous satisfaction survey regarding their treatment.

Results

The average time from referral to surgery was reduced from 121 days in the retrospective cohort to 60 days in the See and Treat cohort (P < 0.001). Rates of complete excision of malignant and premalignant lesions were not different between the two groups, being 93% (178/191) and 91% (76/84), respectively (P = 0.609). Ninety-five percent (95/100) of patients were satisfied with their See and Treat experience overall.

Conclusion

We show that a considerable reduction in the time between referral and surgery can be achieved through a See and Treat clinic without compromise of the success of surgical treatment. Moreover, such a treatment pathway has been shown to be acceptable, and largely preferable, to patients.

Laparoscopic pancreaticoduodenectomy in Brisbane, Australia: an initial experience

October 12, 2017 - 08:50
Background

The role of minimally invasive approach for pancreaticoduodenectomy has not yet been well defined in Australia. We present our early experience with laparoscopic pancreaticoduodenectomy (LPD) from Brisbane, Australia.

Methods

Retrospective review in a prospectively collected database of patients undergoing LPD between 2006 and 2016 was performed. Patients who underwent a hybrid LPD (HLPD) mobilization approach and resection followed by open reconstruction and totally LPD (TLPD) approach were included in this study. Operative characteristics, perioperative outcomes, pathological and survival data were collected.

Results

Twenty-seven patients underwent LPD including 17 HLPD (63%) and 10 TLPD (37%) patients. HLPD patients were mostly converted to open for planned reconstruction or vascular resection. With increasing experience, more TLPDs were performed, including laparoscopic anastomoses. Median operating time was 462 min (504 min for TLPD). Median length of hospital stay was 10 days. Histology showed 21 invasive malignancies, two neuroendocrine tumours, two intraductal papillary mucinous neoplasms and two benign lesions. Median nodal harvest was 22. Margin negative resection was achieved in 84% of patients. Twenty-two percent of patients developed a Grade 3/4 complication, including 19% clinically significant pancreatic fistula. There was one perioperative mortality (4%) due to pancreatic fistula, post-operative haemorrhage and sepsis.

Conclusions

LPD is a technically challenging operation with a steep learning curve. The early oncological outcomes appear satisfactory. It remains to be determined whether the minimally invasive approach to pancreaticoduodenectomy offers benefits to patients

Review of appendicectomies over a decade in a tertiary hospital in New Zealand

October 10, 2017 - 12:21
Background

Acute appendicectomy is the most common emergency operation for patients with abdominal pain. In the last decade, computed tomography (CT) scans have increasingly been used to aid in the diagnosis in order to reduce the negative appendicectomy rate. The aim of this study was to evaluate our institution's negative appendicectomy rate and the use of pre-operative imaging.

Methods

A retrospective review was undertaken for all adult patients (>16 years), who underwent an appendicectomy on emergency basis in the years 2004, 2009 and 2014. Cases were identified from the hospital electronic theatre record system. Data were also obtained from the patients records and laboratory reports.

Results

A total of 874 patients were included, 227 in 2004, 308 in 2009 and 339 in 2014. The negative appendicectomy rate was 29.1% in 2004, 20.1% in 2009 and 19.5% in 2014 (P = 0.014). Negative appendicectomies were more common in women (P = <0.001), patients between the ages of 16–30 years (P = <0.001) and were associated with low inflammatory markers (median white cell count of 10.2, C-reactive protein of 8, P = <0.001). The use of CT scan prior to operation increased between 2009 and 2014 (34 (11.0%) versus 64 (18.9%), P = <0.001).

Conclusion

Though the number of appendicectomies being performed in our institution has increased over the last decade, the negative appendicectomy rate remains fairly static and the increased use of CT scans did not further decrease the proportion of negative appendicectomies between 2009 and 2014.

Natural history of endoscopically detected hiatus herniae at late follow-up

October 10, 2017 - 12:20
Background

Hiatus herniae are commonly seen at endoscopy. Many patients with a large hiatus hernia are endoscoped for symptoms associated with the hernia and many of these will progress to surgical treatment. However, little is known about the natural history of small to medium size hiatus herniae, and their risk of progressing to a larger hernia requiring surgery. This study aims to determine the need for subsequent surgery in these patients.

Methods

A retrospective audit of the endoscopy database at Flinders Medical Centre and the Repatriation General Hospital in Adelaide, South Australia for the 2-year period 2002–2003 was performed to identify all patients with a hiatus hernia. Patients under the age of 65 and with a sliding hiatus hernia <5 cm in length were selected for this study, and sent a questionnaire which determines the long-term (>10 years) outcome of these herniae.

Results

Small- to medium-sized hiatus herniae (<5 cm length) were found at 10% of endoscopies performed. In this group, 38% had reflux as the indication for endoscopy. 1.5% subsequently progressed to anti-reflux surgery or hiatus hernia repair. Thirty-nine percent reported being on proton pump inhibitors for symptom control. No patients required emergency surgical repair of their hiatus hernia.

Conclusion

While patients with small- to medium-sized sliding hiatus hernia commonly have symptomatic reflux, an acute problem requiring emergency surgery is unlikely over long-term follow-up.