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.
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Case of rectosigmoid carcinoma and incidental pelvic kidney

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

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

July 23, 2019 - 19:39

>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.

Regional versus metropolitan pancreaticoduodenectomy mortality in Australia

July 23, 2019 - 19:38

This retrospective, population‐based cohort study aims to determine if differences in the regional distribution of procedures or variation in regional mortality contributes to the variable pancreaticoduodenectomy outcomes between states and territories mortality in Australia.


Background

This retrospective, population‐based cohort study aims to determine if differences in the regional distribution of procedures or variation in regional mortality contributes to the variable pancreaticoduodenectomy (PD) mortality between Australian states and territories.

Methods

De‐identified procedural data from public hospitals between 1 July 2005 and 30 June 2015 from the Australian Institute of Health and Welfare were analysed. The regional distribution of procedures and variation in perioperative mortality rate (POMR) were investigated in New South Wales (NSW), Victoria and Queensland (QLD) using logistic regression analysis.

Results

NSW performed the highest proportion of city‐based procedures (93.8%) while QLD performed the highest proportion of regional procedures (15.3%). QLD demonstrated the lowest city mortality (1.9%) and lowest POMR overall (2.0%). City, regional and state‐wide mortality was highest in NSW (5.0%, 8.4% and 5.3%). No significant difference in POMR was demonstrated between regional and city hospitals in each of the states (P = 0.46) or across all states (P = 0.50).

Conclusion

This study demonstrates comparable regional PD distribution across Australia. The difference in PD POMR between city and regional areas was not found to be statistically significant. NSW exhibited the highest city, regional and overall PD POMR, potentially warranting further investigation.

Transhepatic gallbladder: an unusual variation

July 23, 2019 - 19:37
ANZ Journal of Surgery, EarlyView.

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

July 7, 2019 - 21:52
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

July 7, 2019 - 21:49

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

July 7, 2019 - 21:49

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.

Outcome of a second hepatectomy in octogenarians with hepatocellular carcinoma recurrence: single centre's experience

July 7, 2019 - 21:49

Repeated hepatectomy for octogenarians have same positive influence on the prognosis in comparison to the young group.


Background

Physicians rarely select surgery a second time as the treatment for octogenarians with hepatocellular carcinoma (HCC) recurrence.

Methods

We encountered eight male and three female octogenarians underwent surgery a second time as the treatment for HCC recurrence (octo group). We studied these cases clinically and compared them with 25 younger people underwent surgery a second time (young group). All patients of octo group have resectable HCC according to the Japanese guideline, that is HCC patients with Child‐Pugh status A or B and who have solitary or only a few HCC nodules, in addition, no serious comorbidities, no serious dementia, a performance status of 0–1 and the will to receive hepatectomy.

Results

The average maximum tumour size at the first hepatectomy was significantly larger than that at the second hepatectomy (P < 0.05). The extent of the first hepatectomy was significantly greater than that of the second one (P < 0.05). There were no mortalities at either hepatectomy. The morbidities of the first and the second hepatectomies were 9.1% and 18.2%, respectively. All complications were bile leakage. Furthermore, there were no significant differences in the clinical features, including the prognosis, between the octo and young groups.

Conclusion

Selected octogenarians who received a second hepatectomy showed a relatively good post‐operative course after the first and second hepatectomies. Repeated hepatectomy for octogenarians seems to have same positive influence on the prognosis in comparison to the young group. But on the data analysed, we have not shown repeated hepatectomy is superior to non‐surgical treatments.

High efficacy and patient satisfaction with a nurse‐led colorectal cancer surveillance programme with 10‐year follow‐up

July 7, 2019 - 21:48

Nurse‐led surveillance after resection for colorectal cancer is valuable but requires validation. Results of the present study show high efficacy, high rates of patient satisfaction and appropriate clinical management.


Background

Surveillance after colorectal cancer resection remains contentious, and faces several contemporary issues. Patient‐centred care, intensive surveillance programmes and patient complexity increase the burden of surveillance on consultant‐led clinics. Recent years have seen reshaping of nursing roles to meet healthcare demand. Nurse‐led follow‐up after colorectal cancer has been piloted, but not validated. We report outcomes from a nurse‐led colorectal cancer surveillance clinic functioning in our institution since 2008, the longest term follow‐up in the published literature.

Methods

Included patients were surveilled through the clinic from 2008 to 2018 by credentialled nurses who performed history, examination and investigations as per the local protocol. Demographic, tumour‐related, outcome‐related and patient satisfaction data were extracted from a prospectively maintained database. Primary outcomes were compliance with surveillance protocol and patient satisfaction.

Results

A total of 138 patients were included in the analysis. Mean time in surveillance was 25.4 months. Surveillance investigation protocol compliance was 97.4% overall. Five recurrences (3.6%) were detected during surveillance. In patients who developed recurrence, protocol compliance was 100%, and no clinical features of recurrence were newly found when patients were reviewed by a consultant surgeon. All recurrences during surveillance were detected by nursing staff. Response rate to the patient satisfaction survey was 90%. 96.3% of patients reported receiving adequate explanation regarding cancer surveillance and nurse‐led care. 90.7% of patients rated the clinic as ‘excellent’ and 9.3% as ‘good’.

Conclusion

Our results show a high level of efficacy and patient satisfaction associated with a nurse‐led colorectal cancer surveillance clinic over a prolonged time period, the longest in the published literature.

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

July 4, 2019 - 21:14

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.

Does indocyanine green improve the evaluation of perfusion during laparoscopic colorectal surgery with extracorporeal anastomosis?

July 4, 2019 - 21:14

While technically easy to perform indocyanine green perfusion testing does not appear to add additional information in the setting of laparoscopic segmental colonic resection with extracorporeal anastomosis and result from such studies should be interpreted with a degree of caution.


Background

There has been recent interest in indocyanine green (ICG) to assess anastomotic perfusion in colorectal surgery. We describe our experience using ICG when performing laparoscopic segmental colorectal resections with extracorporeal anastomotic technique and a highly standardized approach for clinically assessing blood flow.

Methods

We recruited 20 consecutive patients to undergo segmental laparoscopic resection and determined an appropriate point to transect mesentery proximally confirming pulsatile arterial flow at this level. Once confirmed, we did a further perfusion study using ICG to ascertain if this would change intraoperative decision‐making.

Results

Twenty segmental colonic resections were assessed in nine female and 11 male patients aged 26–91 years. ICG administration was safe with no adverse outcomes documented. ICG demonstrated anastomotic perfusion in all cases. We observed no cases wherewith pulsatile blood flow at the cut edge of the mesentery, ICG showed inadequate perfusion at this level. We did find in 25% of cases ICG showed perfusion beyond the cut edge of the mesentery to a distance of up to 2.5 cm.

Conclusion

ICG perfusion is safe and straightforward to carry out. However, when pulsatile arterial bleeding is demonstrated clinically it does not add anything to assessment of perfusion in our study. Furthermore, in 25% of cases perfusion can be demonstrated beyond the cut edge of the mesentery up to a distance of 2.5 cm. This raises the possibility that an organ well perfused with ICG may have less than ideal blood flow when assessing for this with a view to constructing an anastomosis.

Systematic scoping review of enhanced recovery protocol recommendations targeting return of gastrointestinal function after colorectal surgery

July 4, 2019 - 21:14
Background

Post‐operative ileus (POI) and delayed return of gastrointestinal (GI) function are common complications after colorectal surgery. There is a lack of uniformity in enhanced recovery protocols (ERPs) with regards to interventions used to target these complications. This systematic review aims to categorize and summarize management recommendations available from published ERPs.

Methods

A systematic search of Ovid MEDLINE, Embase, Cochrane Library and PubMed databases was performed from January 1990 to May 2018. All studies publishing enhanced recovery or fast‐track or multimodal pathway protocols for colorectal surgery in their full‐text were included. Data on interventions aimed at reducing the duration of POI were extracted, as well as references quoted to support specific interventions.

Results

Of 481 manuscripts screened, 37 published ERPs were identified from 37 studies (18 cohort, seven historical‐control, five guidelines, four randomized controlled trials, one randomized controlled trial protocol, one case series and one narrative review). The most commonly recommended interventions were magnesium‐based laxatives (18 of 37, 48.6%), chewing gum (13 of 37, 35.1%), Alvimopan (6 of 37, 16.2%), lactulose (4 of 37, 10.8%), neostigmine (2 of 37, 5.4%) and bisacodyl (2 of 37, 5.4%). Geographical trends were noted for the various interventions, but high‐quality evidence was only referenced to support the use of Alvimopan.

Conclusion

ERP recommendations specific to interventions targeting POI and return of GI function are varied. While laxatives are the most commonly recommended intervention, there is only weak evidence reported to support this practice.

Rare presentation of a tailgut cyst

July 4, 2019 - 19:55
ANZ Journal of Surgery, EarlyView.

Inferior load generated by preloaded versus manually loaded haemorrhoid banding devices: the effect of ‘creep relaxation’

July 4, 2019 - 19:53

Ligature bands from pre‐loaded haemorrhoid banding devices suffer age‐related deterioration in load generated. This could result in higher rates of recurrence.


Background

The efficacy of rubber band ligation of haemorrhoids relies on the load generated on haemorrhoidal tissue by bands as they return to their preformed shape after being deployed. ‘Preloaded’ haemorrhoid banding devices are widely available, but the effect of the resultant prolonged stretch on bands while stored in this manner has never been examined by comparing these to manually loaded devices, which are stretch immediately prior to being deployed. A difference could have clinical relevance, potentially resulting in a higher rate of clinical failure. The present study aimed to investigate any difference in load generated by preloaded versus manually loaded devices.

Methods

A preloaded and a manually loaded device were selected for comparison. Each type was measured on a testing rig. The device type, load generated by each band and the time to expiry were recorded.

Results

A total of 137 haemorrhoid bands were tested: 66 preloaded and 71 manually loaded. There was a statistically significant overall reduction in load generated by preloaded versus manually loaded devices (284.0 versus 272.1 g, mean difference −11.9 g, 95% confidence interval −17.5 to −6.3 g, P = 0.0001). Adjusted for time, the load generated by preloaded bands fell 3.7 g (95% confidence interval 2.7–4.8, P < 0.001) for each month closer to the expiry date.

Conclusions

The load generated by haemorrhoid bands from preloaded devices is lower and deteriorates significantly towards their expiry date compared with bands from manually loaded devices. This is mostly likely due to their storage in a stretched state. This should be considered by clinicians when using haemorrhoid banding devices.

Does the form of venous thromboembolism prophylaxis following primary total knee arthroplasty alter the rate of early reoperation or revision surgery?

June 24, 2019 - 21:29

Does the form of venous thromboembolism prophylaxis following primary total knee arthroplasty alter the rate of early reoperation or revision surgery: a systematic review and qualitative analysis.


Background

Currently there is significant variation in the management of venous thromboembolism prophylaxis following total knee arthroplasty (TKA). Excessive wound ooze and bleeding is thought to increase a patient's risk of haematoma formation and possible infection. We evaluated the rate of unexpected reoperation in the perioperative period in patients who received aspirin, rivaroxaban or enoxaparin following primary TKA.

Method

A systematic literature search was conducted in MEDLINE, CENTRAL and Embase to identify patients who underwent primary TKA. Two researchers independently reviewed the references identified in the literature search. The final 11 studies included for review were published between 1996 and 2016.

Results

There was a higher rate of reoperation in patients treated with aspirin following TKA when compared to enoxaparin and rivaroxaban in the perioperative period. Of the 5141 patients treated with enoxaparin, 11 (0.21%) required reoperation; of the 2764 patients treated with rivaroxaban, 12 (0.43%) required reoperation; and of the 228 patients treated with aspirin, seven (3.07%) required reoperation. The average time to follow‐up in the 11 studies was 55 days, ranging from 30 to 180 days post‐operatively.

Conclusion

There was a higher rate of reoperation in patients treated with aspirin following TKA when compared to enoxaparin and rivaroxaban in the perioperative period. While there is extensive data on the safety and efficacy of these medications following joint arthroplasty, improved reporting of surgically relevant outcomes are needed to assist both the surgeon and patient in clinical decision‐making.

Investigation and surgical treatment of a superior vena cava lipoma

June 23, 2019 - 21:40
ANZ Journal of Surgery, EarlyView.

Diagnostic accuracy of procalcitonin for the early diagnosis of anastomotic leakage after colorectal surgery: a meta‐analysis

June 23, 2019 - 21:39
Background

Anastomotic leakage (AL) is a dreaded complication following colorectal surgery. Procalcitonin is one of many biomarkers studied and research has suggested that it has improved accuracy for the diagnosis of AL compared with other inflammatory biomarkers such as C‐reactive protein. This meta‐analysis was conducted to evaluate the accuracy of procalcitonin in the early diagnosis of AL following colorectal surgery.

Methods

MEDLINE, Embase and PubMed were searched for studies evaluating procalcitonin in the context of AL following colorectal surgery in the elective setting. The literature was reviewed using the Preferred Reporting Items for Systematic Review and Meta‐Analysis (PRISMA) statement. Quality of the studies was assessed using the Quality Assessment Diagnostic Accuracy Studies (QUADAS)‐2 tool. Meta analyses were conducted using area under the receiver operating characteristic curves for day 3, 4 and 5 post‐surgery as a diagnostic test to detect AL.

Results

A total of eight studies were analysed. Results showed that the highest diagnostic accuracy for procalcitonin is on day 5 post surgery. The reported optimal cut‐off values ranged from 0.25 to 680 ng/mL from postoperative day 3 to 5, with reported negative predictive values ranging from 95% to 100%, and positive predictive values of up to 34%. The highest area under the receiver operating characteristic curve was 0.88 on postoperative day 5.

Conclusion

Procalcitonin is a useful negative test for AL following elective colorectal surgery. However, as an isolated test, it is not useful in detecting AL.

Post‐surgical pyoderma gangrenosum of the breast: a diagnostic dilemma?

June 23, 2019 - 21:38
ANZ Journal of Surgery, EarlyView.