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: 40 min 44 sec ago

Clinical practice visits: a rapid review

September 15, 2019 - 00:39

Practice visits are a peer review activity where one or more healthcare providers visit the practice of another from the same field to provide constructive feedback. This rapid review aimed to determine the effectiveness of practice visits at improving practice quality and patient care.


Background

Practice visits are a peer review activity where one or more healthcare providers visit the practice of another in the same field. The purpose of this exercise is for visitors to observe and review a host’s practice in a non‐punitive manner and provide them with constructive feedback as required; ultimately to improve practice quality and patient care.

Methods

A rapid review of three biomedical databases was conducted to identify relevant literature published up until 9 April 2018. There were no limits placed on publication date or publication type. Two authors were responsible for study selection and data extraction using a priori inclusion criteria and extraction templates. Study details and key findings were reported narratively and in tables.

Results

A total of nine publications, reporting outcomes for eight study groups, were identified as eligible for inclusion in this rapid review. Of these eight, six were observational studies, one was a longitudinal study and one was a randomized controlled trial. Practice visits were considered useful in identifying areas of improvement in professional practice; however, the rate at which these improvements were elicited varied greatly between the included studies. Overall, both hosts and visitors gained insight from the practice visit process and in general their experiences were positive.

Conclusions

Based on the evidence provided by the included studies, recommendations for an effective practice visit can be made. Importantly, the poor quality and age of the literature from which these recommendations are based should be considered.

External fixation of unstable pelvic fractures: a systematic review and meta‐analysis

September 15, 2019 - 00:39

A descriptive meta‐analysis of pelvic external fixation to establish optimal fixation techniques and management of unstable pelvic fractures is provided. Outcomes of interest included fracture re‐displacement, complications, functional outcome scores, time to mobilization and removal of the external fixation device.


Background

Unstable pelvic fractures are typically caused by high‐impact trauma. Early stabilization is required to prevent further neurological or visceral injury, haemorrhage, reduce pain, infection and long‐term deformity and disability. The aim was to review the optimal external fixation techniques and management for unstable pelvic fractures.

Methods

A total of 28 studies were identified from the initial database search. Seventeen studies met our inclusion criteria – eight prospective cohorts, four retrospective cohorts and five in vitro studies. This equated to 539 patients and 38 cadaveric (in vitro) models.

Results

Type B and double vertical fractures have less re‐displacement (43.7% and 68.2% <5 mm, respectively) than Type C fractures (55.7% >15 mm) regardless of pin placement. Greater than 50% experience a complication with the most common being pin site infection (36%) and a trend towards increased infection with increasing pins was seen. Most can be managed with antibiotics alone (93%). A minimum time of 6–8 weeks in frame was required for definitive management of all fractures.

Conclusion

This review supports the use of supra‐acetabular pins over iliac crest pins to decrease re‐displacement, the least number of pins for the shortest amount of time and the largest size pin where possible. Type B fractures will generally have a better outcome than Type C fractures. Definitive management in a frame should be at least 8 weeks. Further studies directly comparing iliac crest and supra‐acetabular pin placement are recommended.

Glove change to reduce the risk of surgical site infection or prosthetic joint infection in arthroplasty surgeries: a systematic review

September 15, 2019 - 00:39
Background

Microbiological contamination of surgical gloves occurs during surgery, which may warrant glove change during orthopaedic surgeries. However, no systematic review of this topic has previously been published. Therefore, this review evaluated whether changing gloves during arthroplasty surgeries reduces the risk of surgical site infection/prosthetic joint infection (SSI/PJI) and the optimal frequency of glove change.

Methods

Search terms such as surgical gloves, surgical site infections, prosthesis‐related infections, arthroplasty were used, including Medical Subject Headings terms. Of the 89 articles screened, 12 articles were included for qualitative synthesis.

Results

No studies measured the direct effect of glove change on PJI rate. Therefore, microbiological contamination and perforation rate of gloves were used as surrogate outcomes. Eight studies evaluated microbiological contamination of surgical gloves, with rates ranging from 3.4 to 30%. Five contamination studies recommended changing gloves after draping and before handling implants. One randomized controlled trial also recommended changing gloves at least once an hour regardless of surgical stages. Five studies recommended changing gloves to prevent perforation, with recommendations ranging from 20 to 90 min. Furthermore, one study advised change of gloves after resection of bone and before implantation.

Conclusion

As microbiological contamination rates of gloves increase with duration of surgery, glove changes are recommended at least once per hour. Furthermore, gloves should be changed after draping, before handling implants and if visible perforation is seen to reduce contamination. Due to the lack of studies with SSI/PJI as primary outcomes, we cannot draw a definitive conclusion regarding the effectiveness of changing gloves in reducing the risk of SSI/PJI in arthroplasty.

Marked increase in the incidence of anterior cruciate ligament reconstructions in young females in New Zealand

September 15, 2019 - 00:39

We found a 120% increase in the incidence of anterior cruciate ligament reconstruction surgery in young females in New Zealand from 2000–2005 to 2013–2016. A higher proportion of anterior cruciate ligament reconstruction in New Zealand are now due to sport‐related causes, particularly netball, rugby and football. Injury prevention strategies should target these high‐risk groups, especially young females.


Abstract Background

Anterior cruciate ligament injuries cause significant morbidity, and may be increasing in incidence as participation in high‐risk sports increases. The aim of this study is to investigate the incidence of anterior cruciate ligament reconstruction (ACLR) surgery in New Zealand, and to analyse changes over time in demographic subgroups.

Method

Data were sourced from the Accident Compensation Corporation. Data relating to primary ACLRs performed from 2009 to 2016 were evaluated (n = 20 751). Baseline population estimates were obtained from national census data to calculate the incidence, and results were compared to previous data from 2000 to 2005 (n = 7375).

Results

The annual incidence of ACLR for 2009–2016 was 58.2 per 100 000 person‐years and was greater in males than in females (72.2 and 44.9, respectively). This represents a 58% increase when compared with the period 2000–2005 (36.9 per 100 000). The greatest increase was seen in females aged 15–19 years, with the incidence increasing by 120% in the last decade, compared with 53% in females aged 20–24 years. The percentage of injuries caused by sports changed from 65% over 2000–2005 to 76% over 2009–2016, with netball, rugby and football accounting for the highest number of injuries.

Conclusion

The incidence of ACLR procedures has increased markedly in New Zealand, and this increase was most pronounced in females aged 15–19 years. A greater proportion of procedures are now due to sport‐related injuries.

Distribution of lymph node metastasis and the extent of lymph node dissection in descending colon cancer patients

September 15, 2019 - 00:39

The optimal extent of lymph node dissection in patients with descending colon cancer is still debatable. This retrospective study evaluated lymph node metastasis of 118 descending colon cancer patients. Lymph nodes at the origin of the inferior mesenteric artery (IMA) showed no metastasis in any of the 26 patients who underwent high ligation of the IMA, and ligation of the IMA showed no prognostic benefit after propensity score matching.


Abstract Background

The optimal extent of lymph node dissection in patients with descending colon cancer is still debatable. We designed this study to evaluate the distribution of lymph node metastasis and the appropriate extent of lymph node dissection in descending colon cancer patients.

Methods

We retrospectively reviewed the medical records of 118 descending colon cancer patients without distant metastasis, who underwent curative resection between January 2004 and December 2014. The distribution of lymph node metastasis was evaluated, and prognostic factors were analysed.

Results

The median follow‐up period was 52 months (range 1–125 months). Twenty‐six (22.0%) patients underwent high ligation of the inferior mesenteric artery (IMA), whereas 92 (78.0%) patients underwent ligation of the left colic artery, saving the IMA. Lymph nodes at the origin of the IMA showed no metastasis in any of the 26 patients who underwent high ligation of the IMA. After propensity score matching, 3‐year disease‐free survival (80.4% versus 92.9%, P = 0.471) and 5‐year overall survival (81.8% versus 90.9%, P = 0.875) were not significantly different according to the type of IMA ligation.

Conclusion

In patients with descending colon cancer, there was no lymph node metastasis at the origin of the IMA, and ligation of the IMA showed no prognostic benefit.

Lymphopaenia in the diagnosis of paediatric appendicitis: a false sense of security?

September 15, 2019 - 00:39


Abstract Background

Appendicitis is a common indication for emergent surgery in children; however, it is a small proportion of presentations with abdominal pain. As viral illness is a common differential diagnosis, lymphopaenia is used by some as a predictor against appendicitis. Furthermore, neutrophil–lymphocyte ratio (NLR) has been found to predict appendicitis. We aimed to verify if lymphopaenia predicted against appendicitis in children.

Methods

Retrospective review was conducted for all patients aged 15 years and under presenting with abdominal pain to our institution in 2017, and data including age, white cell count, neutrophil and lymphocyte count, NLR, C‐reactive protein and diagnosis of appendicitis were recorded. Statistical analysis was performed using Stata©. Receiver operating characteristic curves for various tests were formed and areas under curve (AUC) compared using regression, P < 0.05 was considered significant.

Results

A total of 1263 patients were presented, of whom 546 had their blood performed and were included, 86 had appendicitis and 460 did not. Neutrophilia was the best predictor for appendicitis (AUC = 0.86), significantly higher than NLR (0.81), P < 0.05. Lymphopaenia was a poor negative predictor of appendicitis (AUC = 0.46), and while isolated lymphopaenia was more predictive (AUC = 0.23) this was inferior to the positive prediction of neutrophilia, P < 0.05.

Conclusion

The value of isolated lymphopaenia to predict against appendicitis is largely accounted for inherently normal neutrophils, independently lymphopaenia has little value. NLR, while predictive, is a weaker predictor than neutrophilia.

Clinical role of frequency‐doubled double‐pulse neodymium YAG laser lithotripsy for removal of difficult biliary stones in laparoscopic common bile duct exploration

September 15, 2019 - 00:39

The optimal methods for patients with difficult biliary stones remain under debate. Laparoscopic common bile duct exploration combined with frequency‐doubled double‐pulse neodymium YAG laser lithotripsy appear to be effective and safe for the treatment of difficult biliary stones.


Background

The optimal methods for patients with difficult biliary stones remain under debate. The aim of this study was to evaluate the role of frequency‐doubled double‐pulse neodymium YAG (FREDDY) laser lithotripsy for removing difficult biliary stones during laparoscopic common bile duct exploration (LCBDE).

Methods

Between March 2013 and January 2015, 42 consecutive patients with difficult biliary stones who underwent LCBDE with FREDDY laser lithotripsy were included in this study. The clinical data of all patients were retrospectively collected and analysed.

Results

Bile ducts were completely cleared in all patients. The complications related to laser lithotripsy were not noted. A total of 38 patients (90.5%) underwent primary closure of common bile duct, and T‐tube drainage was applied to four patients (9.5%). No bile duct injury, bleeding and perforation were observed. There were no post‐operative surgery‐related deaths. Bile leakage occurred in four patients (9.5%) with primary closure procedure, and all of them were managed successfully with conservative therapy. The median follow‐up period was 42.8 months, with no evidence of bile duct stricture and stone recurrence in all patients.

Conclusions

The LCBDE combined with FREDDY laser lithotripsy appear to be effective and safe for the treatment of difficult biliary stones.

Surgical aortic valve replacement in Australia, 2002–2015: temporal changes in clinical practice, patient profiles and outcomes

September 15, 2019 - 00:39

Surgical aortic valve replacement is increasing and the predominant cardiothoracic procedure in Australia. There is a greater use of bioprosthetic aortic valves, a fall in 30‐day readmission but no change in mortality between 2002 and 2015.


Background

This study describes the temporal changes in risk profiles and outcomes among patients with aortic stenosis (AS) undergoing surgical aortic valve replacement (SAVR) in Australia between 2002 and 2015.

Methods

Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, we identified first‐recorded SAVR for AS over 14 years. Patients’ surgical risk profiles, procedures, 30‐day and 12‐month outcomes were summarized before and after the introduction of transcatheter aortic valve implantation in Australia, in 2008. We applied multivariable regression models to investigate the changes over time on risk‐adjusted 30‐day mortality, re‐hospitalization and 12‐month mortality.

Results

We identify a total of 18 147 patients with AS who underwent SAVR; mostly men (64%) with a mean age of 72 years. The proportion of major cardiac surgeries devoted to SAVR increased from 14% in 2002 to 20% in 2015. More SAVRs were performed electively (80% in 2002 versus 86% in 2015), and the recipients were at lower surgical risk (mean multi‐risk score 3.9% in 2002 versus 3.0% in 2015). The use of bioprosthetic aortic valves increased over time (67% in 2002 to 88% in 2015). We found no significant changes in 30‐day mortality, a significant decrease in 30‐day readmission and minor fluctuations in 12‐month mortality over the study period.

Conclusion

SAVR comprises an increasingly larger proportion of all adult cardiac surgeries in Australia. There has been a greater use of bioprosthetic aortic valves, a fall in 30‐day readmission but no significant changes in mortality.

Impact of a major sporting event on local orthopaedic service provision: Commonwealth Games 2018, Gold Coast, Australia

September 15, 2019 - 00:39
Background

The Gold Coast (Queensland, Australia) held the 2018 Commonwealth Games. Previous studies have focussed on the socio‐economic and employment impact of hosting a major sporting event; however, there is limited research available about the provision of medical recourses required of the host city.

Methods

Twelve weeks of data were retrospectively collected from the local health service to quantify the orthopaedic department workload for the period surrounding the 2018 Commonwealth Games. Data collected included referrals to Orthopaedic Fracture Outpatient clinic, theatre cases – emergency and category 1 (scheduled trauma) performed, and entries made into electronic medical records by the on‐call orthopaedic staff.

Results

A statistically significant increase was found for theatre cases performed during the Commonwealth Games (86 versus 71 cases per week, P = 0.033, 95% confidence interval 1.46–27.5). We found no statistically significant increase in Fracture Outpatient Clinic referrals or medical record entries between peri‐games and games periods (P = 0.149 and 0.699, respectively).

Conclusion

Based on our experience, orthopaedic departments should plan for an increase in operative intervention requirements of at least 20%, in consultation with other local services. Strategic use of pre‐existing resources and staff may be sufficient to address the increased workload during the event period.

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

September 15, 2019 - 00:39
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.

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

September 15, 2019 - 00:39
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.

Systematic mediastinal lymph node dissection outcomes and conversion rates of uniportal video‐assisted thoracoscopic lobectomy for lung cancer

September 15, 2019 - 00:39

>This study was performed to evaluate the systemic mediastinum lymph node dissection and conversive rate in uniportal video‐assisted thoracoscopic lobectomy for the treatment of non‐small‐cell lung cancer compared with three‐port video‐assisted thoracoscopic lobectomy, and the lymph node dissection of uniportal video‐assisted thoracoscopic lobectomy was the same as that of triportal video‐assisted thoracoscopic lobectomy, and there was no difference in the conversive rate.


Background

To evaluate the systematic mediastinal lymph node (LN) dissection outcomes and conversion rates of uniportal video‐assisted thoracoscopic surgery (UVATS).

Methods

Patients with non‐small‐cell lung cancer who underwent video‐assisted thoracoscopic surgery (VATS) and systematic mediastinal LN dissection between January 2015 and January 2017 were retrospectively reviewed. We categorized the patients into two groups according to the different surgical approaches. Patients' clinical data were collected and compared. The index of estimated benefit from LN dissection was used to evaluate the therapeutic value of LN dissection for each station.

Results

A total of 453 patients underwent VATS, including 197 patients in the UVATS group and 256 patients in the triportal VATS (TVATS) group. There were no significant differences in the 1‐, 2‐ and 3‐year survival rates of these two groups (P > 0.05). There were no statistically significant differences in the operative time, numbers and stations of LNs, numbers and stations of N2 LNs, conversion rate or postoperative complications. The UVATS group had less intraoperative blood loss, a shorter duration of hospital stay, less chest tube drainage and a shorter duration of chest tube drainage than the TVATS group (P < 0.05). The conversion rates in the UVATS and TVATS groups were 5.1% and 4.3%, respectively, and the difference was not significant. The same degree of LN sampling was achieved in both groups.

Conclusion

UVATS permits the same degree of LN sampling as TVATS without a difference in the conversion rate.

Impact of preoperative percutaneous transhepatic biliary drainage on post‐operative survival in patients with distal cholangiocarcinoma

September 15, 2019 - 00:39
Background

The aim of this study was to investigate the long‐term impact of the type of preoperative biliary drainage used for patients undergoing pancreatoduodenectomy for distal cholangiocarcinoma (DCC).

Methods

A total of 84 patients with DCC who underwent preoperative biliary drainage between June 2000 and December 2016 were divided into groups for whom percutaneous transhepatic biliary drainage (PTBD) (n = 24) or endoscopic biliary drainage (EBD) (n = 60) was used.

Results

The 5‐year overall survival in the PTBD group was significantly worse than that in the EBD group (16.7% versus 52.3%, P = 0.007). After propensity score matching (22 patients in each group), the 5‐year overall survival in the PTBD group was still worse than that in the EBD group (13.6% versus 61.2%, P = 0.003). Multivariate analysis revealed that PTBD was independent risk factor for both poor survival (P = 0.028) and peritoneal recurrence (P = 0.018). The incidence of multiple sites at initial recurrence tended to be higher in the PTBD group than in the EBD group (P = 0.080).

Conclusions

PTBD should not be performed for patients undergoing pancreatoduodenectomy for DCC, except when EBD is contraindicated, as PTBD is significantly associated with shorter survival and peritoneal recurrence.

Paediatric appendicitis: increased disease severity and complication rates in rural children

September 15, 2019 - 00:39

Appendicitis is an acutely time‐sensitive surgical pathology and it is plausible that those who have further to travel are at risk of worse outcomes. This study has demonstrated that residing in a rural location is associated with increased severity and increased number of complications in paediatric patients with acute appendicitis. Whilst increased perforation rates were seen in Māori children, ethnicity was not found as an independent risk factor associated with increased American Association for the Surgery of Trauma severity on multivariate analysis.


Background

Appendicitis is the most common surgical emergency affecting children. Rurality has been shown to be a predictor of worse surgical outcomes in patients with acute appendicitis compared to urban residents. There are no previously published studies investigating this in Australasia.

Methods

A 10‐year retrospective study of all patients aged ≤16 years who underwent an acute appendicectomy in Northland, New Zealand, was conducted. The cohort was identified by searching the hospital database for theatre events and admission diagnoses coded as appendicitis. Primary outcome of interest was the difference in the American Association for the Surgery of Trauma (AAST) anatomical severity grading of appendicitis and the Clavien–Dindo complication rate. The role of ethnicity was also examined.

Results

A total of 470 children underwent appendicectomy during this period. On multivariate analysis, increased AAST grade was twice as likely in rural patients (odds ratio 2.04). Post‐operatively, rural patients had higher Clavien–Dindo complication grade (P = 0.001), longer median length of stay and increased rates of intra‐abdominal collection (19% versus 4%; P = 0.018), 30‐day readmission (19% versus 4%; P = 0.020) and perforation (27% versus 19%; P = 0.031). Māori children had increased perforation rates (28.9% versus 19.0%; P = 0.014) but ethnicity was not found to be independently associated with increasing AAST grade.

Conclusion

Accounting for ethnicity, socio‐economic deprivation and age, we implicate rural patient status as being associated with increasing severity and complicated paediatric appendicitis. This work adds to the evolving description of inequities in rural health outcomes. Further prospective studies are needed to confirm these findings at a national level.

Accelerating the learning curve in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy using an external mentor model

September 15, 2019 - 00:39

The aim of this study was to describe early outcomes in the first 50 patients managed with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a newly established peritoneal malignancy centre in Sydney, Australia, under the guidance of an experienced peritoneal malignancy mentor. A total of 135 patients were referred and reviewed at the multidisciplinary team meeting with 50 (26 male) patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Of these 50 patients, 47 (94%) underwent complete cytoreduction while three (6%) had maximal tumour debulking surgery. Median length of hospital stay was 13 days (interquartile range 9.7–19.0). Six (12%) patients experienced a grade III or IV Clavien–Dindo complication. There was no 30‐day mortality.


Background

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an accepted therapeutic approach in selected patients with peritoneal malignancy. The aim of this study was to describe early outcomes in the first 50 patients managed with CRS and HIPEC in a newly established peritoneal malignancy centre in Sydney, Australia, under the guidance of an experienced peritoneal malignancy mentor.

Methods

This is a retrospective review of a prospective maintained database of early outcomes in the first 50 patients who underwent CRS and HIPEC between April 2017 and April 2018 at a newly established peritoneal malignancy centre. Type of primary, surgery time, length of hospital stay, blood loss, peritoneal carcinomatosis index, completeness of surgery, complications, recurrence rate and 30‐day mortality were reviewed.

Results

A total of 135 patients were referred and reviewed at the multidisciplinary team meeting with 50 (26 male) patients undergoing CRS and HIPEC. Of these 50 patients, 47 (94%) underwent complete cytoreduction while three (6%) had maximal tumour debulking surgery. Tumour pathology was of appendix origin (44%) and colorectal peritoneal metastases (44%). Median surgical time was 7.4 h (interquartile range 5.7–10.0). Median length of hospital stay was 13 days (interquartile range 9.7–19.0). Six (12%) patients experienced a grade III or IV Clavien–Dindo complication. There was no 30‐day mortality.

Conclusion

This study reports the successful establishment of a peritoneal malignancy centre under the guidance of an experienced peritoneal malignancy mentor. The short‐term surgical outcomes observed in the first 50 cases are promising and comparable to other more experienced centres.

Increasing primary anastomosis rate over time for the operative management of acute diverticulitis

September 15, 2019 - 00:39

Primary anastomosis rates for the operative management of acute diverticulitis have increased over the study period in our institution. The primary anastomosis rates were higher if a colorectal surgeon performed the procedure.


Background

Over the past two decades, there has been mounting evidence that primary anastomosis (PA) is a safe alternative to Hartmann's procedure (HP) in acute diverticulitis. In addition, specialized colorectal surgeons are more likely to perform PA. This study aimed to analyse if this evidence has led to an increase in the rate of PA in a major tertiary institution over time.

Methods

A retrospective observational study of patients requiring operative management of acute diverticulitis from 1 January 2001 to 31 December 2015 at a tertiary teaching hospital.

Results

One hundred and eighteen patients underwent surgery for acute diverticulitis. Patients who failed initial conservative management were more likely to have PA (43% versus 21%, P = 0.044). There was no difference in medical or surgical complications, readmission rate or mortality between patients who had a PA compared with HP. Patients were more likely to have a PA if a colorectal surgeon was operating compared with a colorectal surgery fellow or general surgeon (36% versus 19% versus 10%, P = 0.039). In patients with modified Hinchey 0–2, there was an increased PA rate within the study period, 21%, 43%, 63% to 57% from the first to the fourth quartile of patients (P = 0.038).

Conclusions

The mounting evidence for the safety of performing PA has led to an increase in the PA rates for acute diverticulitis. Patients who were operated by a colorectal surgeon were more likely to have a PA. The morbidity and mortality were similar in patients who had PA compared with HP.

Progress towards near‐zero 90‐day mortality: 388 consecutive hepatectomies over a 16‐year period

September 15, 2019 - 00:39

This audit analyses 388 consecutive hepatectomies at The Queen Elizabeth Hospital between 2001 and 2016. Intraoperative mortality was 0.5% and 90‐day mortality was 2.3%. Hepatectomies can be performed safely with low mortality.


Background

Hepatectomy has been the gold standard procedure for curative treatment of benign and malignant hepatobiliary lesions for over a century. The aim of this study is to report on the 16‐year experience of a single institution.

Methods

All patients admitted to The Queen Elizabeth Hospital, South Australia, for a hepatectomy between 2001 and 2016 were included in this audit. Data regarding demographics, tumour type and operative outcomes were prospectively collected. To identify trends, patients were divided into four periods, each spanning 4 years (Period 1 = 2001–2004, Period 2 = 2005–2008, Period 3 = 2009–2012 and Period 4 = 2012–2016).

Results

Between 2001 and 2016, 388 consecutive patients (230 men; 158 women; mean age ± SD = 63.7 ± 13.0 years) underwent hepatectomy. From Periods 2 to 4, complex cases increased from 14.4% to 18.9%, and there was an increase in mean duration of operation time from 187.0 ± 60.6 to 217.3 ± 78.7 min. Length of hospitalization decreased from Periods 1 to 4 (12.2 ± 9.2 to 8.1 ± 5.6 days). Intraoperative and 90‐day mortalities were 0.5% and 2.3%, respectively. Length of stay, morbidity and 90‐day mortality were significantly affected by mass of resection.

Conclusion

Hepatectomy can be safely performed in a specialized Western centre with low mortality. Advances in health care have facilitated in shorter duration of hospitalization despite more frequent complex resections, operating on older patients and patients with worse American Society of Anesthesiologists scores, without increasing rates of mortality.

Elevated visceral fat area is associated with adverse postoperative outcome of radical colectomy for colon adenocarcinoma patients

September 15, 2019 - 00:39

This findings from this study indicated the potential predictive value of visceral fat area not body mass index or visceral fat area/subcutaneous fat area for postoperative complications, recovery and expenses. So, visceral fat area should be considered before surgery.


Objective

To assess the impact of visceral obesity quantified by preoperative computed tomography on short‐term postoperative outcomes compared with body mass index (BMI) in stage I–III colon adenocarcinoma patients.

Methods

In this retrospective study, 107 patients treated with radical colectomy for stage I–III colon adenocarcinoma were classified as obese or non‐obese by computed tomography‐based measures or BMI (obese: BMI ≥28 kg/m2, visceral fat area (VFA) to subcutaneous fat area ratio (V/S) ≥0.4, and VFA ≥100 cm2). Clinical variables, operation time, estimated blood loss, pathologic stage, histologic grade, postoperative complications, postoperative stay and hospitalization expenses were compared.

Results

Obese patients by VFA were more likely to have higher postoperative complication rate (32.9 versus 11.8%, P = 0.021), have longer operation time (184.6 ± 49.5 versus 163.1 ± 44.1 min, P = 0.033), postoperative stay (15.21 ± 7.59 versus 12.29 ± 5.40 days, P = 0.047) and cost more ($10 758.7 ± 3271.7 versus $9232.0 ± 2994.6, P = 0.023) than non‐obese.

Conclusion

Visceral obesity graded by VFA is associated with increased postoperative morbidity, operation time, postoperative stay and hospitalization expenses for colon adenocarcinoma patients and may be superior to BMI or V/S for the prediction of colon surgery.

Reduction in hospital admissions with an early computed tomography scan: results of an outpatient management protocol for uncomplicated acute diverticulitis

September 15, 2019 - 00:39
Background

There is increasing evidence that uncomplicated acute diverticulitis (UAD) can be safely and effectively managed as an outpatient. The aim of the current study was to evaluate if an early computed tomography (CT) scan in the emergency department (ED) can reduce the number of hospital admissions when UAD is diagnosed, without compromising patient safety.

Methods

A protocol was introduced in 2015, whereby patients with suspected diverticulitis receive a CT scan on presentation to the ED and be considered for discharge home on oral antibiotics if UAD is confirmed. A retrospective analysis of a prospectively collected database was conducted for all patients presenting to the ED with acute diverticulitis over a 4‐year period: 2 years prior (May 2013–April 2015; pre‐protocol) and 2 years after implementation of the protocol (May 2015–April 2017; post‐protocol).

Results

A total of 1147 patients presented to the ED, who were diagnosed with diverticulitis, and UAD was confirmed in 552 patients. There was a significant decrease in hospital admissions for UAD in the post‐protocol group from 93% to 39% (P < 0.0001) and in the total number of hospital admission days from 602 to 370 (P < 0.0001). There was no increase in representations between both periods (7% versus 6%; P = 0.49).

Conclusion

Definitive diagnosis by early CT scan in the ED decreased the admission rate for UAD by more than 50%, and significantly reduced the total number of hospital days without resulting in an increase in representations. UAD can safely and effectively be treated in an outpatient setting leading to a reduction in the burden on the health system.

Necrotizing myositis: highlighting the hidden depths – case series and review of the literature

September 14, 2019 - 23:30

Necrotizing myositis is a potentially life‐threatening emergency encountered by surgeons from differing specialties. Initial absence of cutaneous signs and symptoms coupled with delayed recognition commonly result in higher rates of morbidity and mortality. We report four cases of necrotizing myositis, in previously healthy males, treated in separate units and a comprehensive review of literature to aid better management of this rare but catastrophic condition.


Abstract Background

Necrotizing myositis (NM) is a life‐threatening emergency. It causes focal muscle necrosis without abscess formation or extensive involvement of the overlying fascia and soft tissue. It is a clinical diagnosis requiring a high index of clinical suspicion. Usual presentation can readily be mistaken to represent more benign pathologies such as muscular injury, viral myopathy or deep venous thrombosis. The clinical course following initial misdiagnosis is rapid deterioration into profound sepsis and progressive multiorgan failure. Prompt treatment is associated with favourable outcomes, but early diagnosis is challenging due to initial absence of cutaneous signs and symptoms. Delayed referral to surgeons with appropriate expertise results in higher morbidity and mortality. The cornerstones to treatment are complete surgical debridement, intensive care management and accurate antimicrobial therapy.

Methods

We report four cases of NM demonstrating classical scenarios of initial misdiagnosis, delays in referral and review by an experienced surgeon. A review of the current literature to aid with overall management is also included.

Results

Review of literature that revealed the most common presentation was antecedent prodromal flu‐like symptoms followed by rapidly progressing focal muscle pain. Patients were initially misdiagnosed followed by rapid deterioration into profound sepsis before surgical opinion was obtained.

Conclusion

NM is a rare and potentially fatal disease that must be considered in the differential diagnoses of the young, healthy patient with acute limb pain and fever. A high index of suspicion will facilitate earlier management and reduce morbidity and mortality.