ANZ Journal of Surgery

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Syndicate content
Wiley Online Library : ANZ Journal of Surgery
Updated: 11 hours 6 min ago

Sentinel node biopsy for early breast cancer in Queensland, Australia, during 2008–2012

June 6, 2017 - 20:42
Background

Sentinel node biopsy (SNB) is now the standard of care for women with early-stage breast cancer. Despite lower morbidity than axillary lymph node dissection, widespread variation in SNB rates by non-clinical factors persists. We explored the factors associated with SNB usage and changes in those associations over time for recently diagnosed women.

Methods

We report here on a linked population-based cancer registry and hospital inpatient admission data set for 5577 women aged at least 20 years diagnosed with a first primary invasive early-stage node-negative breast cancer from July 2008 to 2012 in Queensland, Australia, who underwent breast cancer-related surgery within 2 years of diagnosis. Multivariate logistic regression was used to model predictors of SNB separately for 5172 women with ≤30 mm tumours and 405 with 31 to ≤50 mm tumours.

Results

Overall, 3972 (77%) women with ≤30 mm tumours and 221 (55%) of those with larger tumours underwent SNB. Usage increased over time for both cohorts but was consistently lower among those with larger tumours. A more recent diagnosis, having breast-conserving surgery, living in more accessible areas and attending a private or high-volume hospital independently increased the odds of SNB for both cohorts. There was no evidence that the geographical disparity had reduced over the study period for either cohort.

Conclusion

Geographical disparities to accessing SNB persist. Efforts to promote multidisciplinary care and facilitate education in healthcare changes through innovative solutions using emerging technologies as well as targeted research to identify the barriers to equitable access remain critical.

Effect of magnesium on arrhythmia incidence in patients undergoing coronary artery bypass grafting

May 22, 2017 - 15:55
Background

Cardiac arrhythmia after coronary artery bypass grafting (CABG) surgery is a common complication of cardiac surgery. The effect of serum magnesium, hypomagnesaemia treatment and prophylactic administration of magnesium in the development and prevention of arrhythmias is controversial and there are many different ideas. This study evaluates the therapeutic effects of magnesium in cardiac arrhythmia after CABG surgery.

Methods

The clinical trial enrolled 250 patients who underwent CABG. Based on the initial serum levels of magnesium, patients were divided into two groups: hypomagnesium and normomagnesium. Based on bioethics committee requirements, patients in the hypo-magnesium group received magnesium treatments until they attained normal magnesium blood levels. Both groups underwent CABG with normal blood levels of magnesium. After surgery, each group was randomly divided into two subgroups: one subgroup received a bolus dose of magnesium sulphate (30 mg/kg in 5 min) and the other subgroup received a placebo. Subgroups were under observation in the intensive care unit for 3 days and arrhythmias were recorded. Data from all four subgroups were analysed statistically and interpreted.

Results

The results of this study showed that the occurrence of arrhythmia was not significantly different among subgroups (P > 0.05). There was no significant relationship between blood levels of magnesium and arrhythmia during the 3 days post-surgery (P > 0.05).

Conclusion

The results of this study showed that magnesium sulphate administration did not significantly improve the incidence of arrhythmias in hypo- and normo-magnesium patients after CABG. There was no significant correlation between post-operative serum levels of magnesium and arrhythmia during 3 days.

Comparison of 5-year oncological outcomes of breast cancer based on surgery type

May 22, 2017 - 13:45
Background

A standardized classification system for breast surgery that incorporates oncoplastic techniques is needed. We classified the surgical techniques for breast cancer treatment into five groups according to the extent of surgery and reconstructive methods, i.e. conventional breast-conserving surgery, partial mastectomy with volume displacement, partial mastectomy with volume replacement, simple mastectomy and total mastectomy with immediate reconstruction. We then evaluated the oncological outcomes for each of the five groups.

Methods

We analysed clinical data and 5-year oncological results from patients with breast cancer who underwent breast surgery with reconstruction between 2008 and 2013. Local recurrence, distant metastasis and overall survival were investigated.

Results

In total, 1469 patients had 1504 breast surgeries performed with a mean follow-up of 72.40 ± 16.76 months. There were 35 cases (2.3%) of locoregional recurrence and 85 cases (5.7%) of distant metastasis, and the 5-year overall survival rate was 98.6%. No statistically significant differences were observed in local recurrence, distant metastasis or death among the five surgical technique groups (P = 0.218, 0.518 and 0.450, respectively).

Conclusion

Oncological outcomes among all patients and within each surgical technique group were excellent during the 5-year follow-up period. No significant differences in oncological results were observed among the five surgical technique groups.

Medial sural artery perforator free flap for the reconstruction of leg, foot and ankle defect: an excellent option

May 17, 2017 - 10:56
Background

The defects over the leg, foot and ankle are best covered with a thin pliable flap. The use of muscle flap for the reconstruction of these defects leaves a grafted, aesthetically inferior result. The medial sural artery perforator (MSAP) free flap gives a thin pliable tissue for the reconstruction with better aesthesis.

Methods

The study design was retrospective case analysis over a period of 2 years. All the patients who underwent flap for leg, foot and ankle defect reconstruction in the form of MSAP free flap were included in the study. The flap characteristics and aesthesis were assessed along with the patient satisfaction. The flap complication and donor site morbidity were also analysed.

Results

A total of seven MSAP free flaps were done for leg, foot and ankle reconstruction. The mean flap size was 14.29 × 6.6 cm and mean pedicle length was 9.71 cm. One flap had venous congestion post-operatively resulting in marginal flap loss. All the flaps had acceptable aesthesis with good patient satisfaction. There was donor site morbidity in two patients, in the form of wound dehiscence.

Conclusion

MSAP free flap is a reliable choice for leg, foot and ankle defect reconstruction.

Predict pancreatic fistula after pancreaticoduodenectomy: ratio body thickness/main duct

May 17, 2017 - 10:56
Background

The occurrence of post-operative pancreatic fistula (POPF) after pancreaticoduodenectomy is a challenging issue. The aim was to identify variables on preoperative computed tomography (CT) scan, useful to predict clinically significant POPF (grades B–C) after pancreaticoduodenectomy.

Methods

Patients presented POPF after pancreaticoduodenectomy were included from two tertiary referral centres. B/W ratio was defined by ratio of pancreas body thickness (B) to main pancreatic duct (W). The predictive parameters of POPF on CT scan were assessed with a receiving operator characteristics (ROC) curve and intrinsic characteristics.

Results

Between 2010 and 2013, 186 patients who underwent pancreaticoduodenectomy were included. POPF occurred in 25% of them, and was clinically significant in 13%. After univariate analysis, endocrine tumours (P = 0.03), main pancreatic duct size (P < 0.01) and B/W ratio (P = 0.04) were significantly associated with POPF. ROC curve showed a greater area under curve for B/W ratio (0.68) than for main pancreatic duct size (0.33). A 3.8 threshold displayed 80 and 51% for sensibility and specificity, respectively, and a negative predictive value of 94%. A B/W ratio >3.8 increased the rates of post-operative haemorrhage (odds ratio = 4.3 (1.4–13.2), P = 0.01), and reintervention (odds ratio = 3.4 (1.2–9.6), P = 0.02).

Conclusions

B/W ratio superior to 3.8 assessed on preoperative CT scan may be an easy tool to predict clinically significant POPF after pancreaticoduodenectomy.

The Australian laparoscopic radical prostatectomy learning curve

May 17, 2017 - 10:56
Background

International estimates of the laparoscopic radical prostatectomy (LRP) learning curve extend to as many as 1000 cases, but is unknown for Fellowship-trained Australian surgeons.

Methods

Prospectively collected data from nine Australian surgeons who performed 2943 consecutive LRP cases was retrospectively reviewed. Their combined initial 100 cases (F100, n = 900) were compared to their second 100 cases (S100, n = 782) with two of nine surgeons completing fewer than 200 cases.

Results

The mean age (61.1 versus 61.1 years) and prostate specific antigen (7.4 versus 7.8 ng/mL) were similar between F100 and S100. D'Amico's high-, intermediate- and low-risk cases were 15, 59 and 26% for the F100 versus 20, 59 and 21% for the S100, respectively. Blood transfusions (2.4 versus 0.8%), mean blood loss (413 versus 378 mL), mean operating time (193 versus 163 min) and length of stay (2.7 versus 2.4 days) were all lower in the S100. Histopathology was organ confined (pT2) in 76% of F100 and 71% of S100. Positive surgical margin (PSM) rate was 18.4% in F100 versus 17.5% in the S100 (P = 0.62). F100 and S100 PSM rates by pathological stage were similar with pT2 PSM 12.2 versus 9.5% (P = 0.13), pT3a PSM 34.8 versus 40.5% (P = 0.29) and pT3b PSM 52.9 versus 36.4% (P = 0.14).

Conclusion

There was no significant improvement in PSM rate between F100 and S100 cases. Perioperative outcomes were acceptable in F100 and further improved with experience in S100. Mentoring can minimize the LRP learning curve, and it remains a valid minimally invasive surgical treatment for prostate cancer in Australia even in early practice.

Modern cardiac surgery: the future of cardiac surgery in Australia

May 17, 2017 - 10:55

Cardiac surgery is a relatively young specialty and is undergoing many changes presently. The advent of catheter-based technology, minimally invasive surgery and better information regarding the roles of cardiac surgery in the management of common cardiac disease is changing the way we provide services. In Australia, attention must be turned to the way cardiac surgical services are provided to enable delivery of modern procedures. This has implications for the provision of training. We explore the face of modern cardiac surgery and how this may be taken up in Australia.

Subspecialty approach for the management of acute cholecystitis: an alternative to acute surgical unit model of care

May 17, 2017 - 10:55
Background

Acute cholecystitis is a common condition. Recent studies have shown an association between creation of an acute surgical unit (ASU) and improved outcomes. This study aimed to evaluate the outcomes of a subspecialty based approach to the management of acute cholecystitis as an alternative to the traditional ‘generalist’ general surgery approach or the ASU model.

Method

A 6-year retrospective analysis of outcomes in patients admitted under a dedicated upper gastrointestinal service for acute cholecystitis undergoing emergency laparoscopic cholecystectomy.

Results

Seven hundred emergency laparoscopic cholecystectomies were performed over this time. A total of 486 patients were available for analysis. The median time to operation was 2 days and median length of operation was 80 min. A total of 86.9% were performed during daylight hours. Eight cases were converted to open surgery (1.6%). Intra-operative cholangiography was performed in 408 patients. The major complication rate was 8.2%, including retained common bile duct stones (2.3%), sepsis (0.2%), post-operative bleeding (0.4%), readmission (0.6%), bile leak (2.1%), AMI (0.4%), unscheduled return to theatre (0.6%) and pneumonia (0.8%). There were no mortalities and no common bile duct injuries.

Conclusion

Over a time period that encompasses the current publications on the ASU model, a subspecialty model of care has shown consistent results that exceed established benchmarks. Subspecialty management of complex elective pathologies has become the norm in general surgery and this study generates the hypothesis that subspecialty management of patients with complex emergency pathologies should be considered a valid alternative to ASU. Access block to emergency theatres delays treatment and prolongs hospital stay.

Tail gut cyst: an unusual case

May 17, 2017 - 10:55

Patterns of head and neck sarcoma in Australia

May 17, 2017 - 10:55
Background

Sarcomas affecting the head and neck often require complex management due to the combination of anatomic, aesthetic and oncological considerations. The incidence and patterns of presentation are poorly understood and have not been reviewed in the Australian population.

Method

This study sourced incidence and demographic data from the National Cancer Registry at the Australian Institute of Health and Welfare for the years 1982–2009 (corresponding to 97.3% of the Australian population). All cases of sarcoma, according to ICD-O-3 classification ((International Classification of Diseases for Oncology, 3rd edition), were assessed.

Results

A total of 3911 new cases of sarcoma affecting the head and neck were recorded during the period 1982–2009, including 1383, 2106 and 442 cases arising from skin, soft tissue and bone, respectively. The annual incidence rate of sarcomas affecting the head and neck was 1.59 per 100 000 population. The incidence of head and neck sarcoma rose substantially in older age groups (age 65 years and above) and was most common in male patients (69%). Malignant fibrous histiocytoma (MFH) was the most common pathology. There was an increase in incidence in skin-origin sarcoma in the head and neck, particularly affecting elderly males.

Conclusion

The incidence of head and neck sarcoma in Australia is higher than that reported for an equivalent European population. The increase in MFH arising from the skin in elderly male patients mirrors the patterns of common cutaneous malignancy, particularly melanoma, suggesting that ultraviolet radiation is an epidemiological factor. Management of head and neck sarcoma is complex and best managed in a specialist multidisciplinary environment.

Derivation and validation of the APPEND score: an acute appendicitis clinical prediction rule

May 17, 2017 - 10:55
Background

Although many clinical prediction rules (CPRs) for appendicitis exist, none have been developed for a New Zealand population presenting with right iliac fossa (RIF) pain. The aim of this study was to derive and validate an appendicitis CPR for our population.

Method

This is a retrospective review of all patients from December 2010 to February 2012 of at least 15 years of age presenting to the general surgery service with RIF pain. Patient data were divided into derivation and validation groups. Univariate and multiple regression analyses identified significant predictors of appendicitis which were used to construct a CPR. A retrospective validation study was then performed and the CPR was refined accordingly. Finally, the accuracy of the CPR was tested.

Results

The final components of the new CPR, the APPEND score, were Anorexia, migratory Pain, local Peritonism, Elevated C-reactive protein, Neutrophilia and male gender (Dude). This CPR has an area under the receiver operating characteristic curve of 0.84. The CPR can stratify patients into low, intermediate and high-risk groups which may standardize patient care and reduce the negative appendicectomy rate.

Conclusion

A new CPR for predicting appendicitis, in patients presenting with RIF pain, has been derived and validated for use in our population. A prospective study to further evaluate its performance is required.

Influence of primary site on metastatic distribution and survival in stage IV colorectal cancer

May 17, 2017 - 10:55
Background

To assess pattern distribution and prognosis of the three anatomical entities of metastatic colorectal cancer, and influence of treatment of metastases on survival.

Methods

Patients presenting with stage IV colorectal cancer (synchronous group), or who developed metastatic recurrence (metachronous group) after initial curative treatment between January 2005 and August 2015 were reviewed. Right sided (cecum to transverse colon), left sided (splenic flexure to sigmoid colon) and rectal cancers were identified. Distribution of metastases were noted as hepatic, lung or peritoneal.

Results

Of 374 patients, 276 were synchronous, 98 were metachronous. Metachronous group had a better 3-year survival (54%, 95% CI: 42–64 versus 33%, 95% CI: 27–39, log rank P = 0.0038). There were equal numbers of right (n = 119), left (n = 115) and rectal cancers (n = 140). Rectal cancers had a higher metastatic recurrence, yet demonstrated better 3-year survival (right colon 45%, 95% CI: 19–67, left colon 49%, 95% CI: 27–68, rectum 59%, 95% CI: 42–72, P = 0.39) due to higher proportions of metachronous patients undergoing treatment for metastases (40 versus 14%). Over half of all organ metastases spread to liver, with equal distribution from all three anatomical groups. Rectal cancers showed highest preponderance for lung metastases.

Conclusion

Rectal cancers have a higher chance of recurring, with a higher metastatic rate to the lung, yet demonstrate better survival outcomes in metastatic colorectal cancer, reflecting the benefit of intervention for metastases.