ANZ Journal of Surgery

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

The volume, cost and outcomes of pancreatic resection in a regional centre in New Zealand

May 15, 2017 - 10:42
Background

The frequency, costs and outcome of pancreatic resection (both pancreaticoduodenectomy and distal pancreatectomy) were reviewed in our own institution and correlated with regional population growth as well as national resection rates and locations.

Methods

Demographic, pathological and outcome data on pancreaticoduodenectomy and distal pancreatectomy were obtained from a prospectively maintained database for the years 2005–2009 and 2010–2014. During this period, the catchment population grew from 460 000 to 567 000. Costing information was obtained from the hospital-independent costing and coding committee, and the locations and rates of pancreatic resection were obtained by interrogating the national minimum dataset.

Results

A total of 41 pancreatectomies (29 pancreaticoduodenectomy, 12 distal pancreatectomy) were performed between 2005 and 2009, increasing to 84 pancreatectomies (55 pancreaticoduodenectomies, 27 distal pancreatectomies and two total pancreatectomies) between 2010 and 2014. This constituted one sixth of the national volume of pancreatic resections. There was no difference in patient demographics or indications for resection between the two time periods; however, portal vein resection was used more frequently in the second period. Margin positivity rate decreased (7 of 41 versus 8 of 84) and lymph node harvest increased (median 8 nodes versus median 15 nodes) between the two time periods. Overall 30-day mortality was 1.6%.

Conclusion

In New Zealand, regional rates of pancreatic resection reflect regional population demands, and institutional growth is driven by local population requirements. Institutional growth can be achieved with the maintenance of internationally accepted outcomes and quality indicators.

Lymph node dissection for Siewert II esophagogastric junction adenocarcinoma: a retrospective study of 136 cases

May 15, 2017 - 10:41
Background

To compare the lymph node dissection with the right transthoracic Ivor-Lewis (IL) procedure to that with the left transthoracic (LT) approach for Siewert type II adenocarcinoma of the esophagogastric (AEG) junction.

Methods

In this study, 136 patients with Siewert type II AEG who met the inclusion criteria underwent surgical resection were divided into the IL (47 cases) and LT (89 cases) groups. The number and frequency of the dissected lymph nodes in each station were compared between the two groups.

Results

The IL group had a longer proximal surgical margin (P = 0.000) and more total (P = 0.000), thoracic (P = 0.000), and abdominal lymph nodes (P = 0.000) dissected than the LT group. In general, the IL group had a higher dissection rate in each thoracic lymph node station (P < 0.05) than the LT group. The dissection rates of the hepatic artery, splenic artery and celiac trunk lymph nodes were higher in the IL group than in the LT group (P < 0.05). The lymph node metastasis rate was 78.7% in the IL group, higher than the 61.8% in the LT group (P = 0.045).

Conclusions

The right transthoracic IL procedure was demonstrated to be a better application than the LT approach for Siewert type II AEG in terms of the number and frequency of lymph node resections.

Risk factors for pedicled flap necrosis in hand soft tissue reconstruction: a multivariate logistic regression analysis

May 8, 2017 - 22:31
Background

Few clinical retrospective studies have reported the risk factors of pedicled flap necrosis in hand soft tissue reconstruction. The aim of this study was to identify non-technical risk factors associated with pedicled flap perioperative necrosis in hand soft tissue reconstruction via a multivariate logistic regression analysis.

Methods

For patients with hand soft tissue reconstruction, we carefully reviewed hospital records and identified 163 patients who met the inclusion criteria. The characteristics of these patients, flap transfer procedures and postoperative complications were recorded. Eleven predictors were identified. The correlations between pedicled flap necrosis and risk factors were analysed using a logistic regression model.

Results

Of 163 skin flaps, 125 flaps survived completely without any complications. The pedicled flap necrosis rate in hands was 11.04%, which included partial flap necrosis (7.36%) and total flap necrosis (3.68%). Soft tissue defects in fingers were noted in 68.10% of all cases. The logistic regression analysis indicated that the soft tissue defect site (P = 0.046, odds ratio (OR) = 0.079, confidence interval (CI) (0.006, 0.959)), flap size (P = 0.020, OR = 1.024, CI (1.004, 1.045)) and postoperative wound infection (P < 0.001, OR = 17.407, CI (3.821, 79.303)) were statistically significant risk factors for pedicled flap necrosis of the hand.

Conclusion

Soft tissue defect site, flap size and postoperative wound infection were risk factors associated with pedicled flap necrosis in hand soft tissue defect reconstruction.

Management of recurrent bleeding after pancreatoduodenectomy

May 8, 2017 - 15:39
Background

Re-bleeding after management of a first haemorrhage following pancreatic surgery is an ever-present danger and often presents diagnostic and management dilemmas.

Methods

All cases of post-pancreatectomy haemorrhage (PPH) following pancreatoduodenectomy were identified from a tertiary referral, clinical database (April 2004–April 2013). Only those suffering a second re-bleeding episode were included in the final case notes review.

Results

A total of 301 patients underwent pancreatoduodenectomy during the study period (most common indication: pancreatic adenocarcinoma; 49.5%). Twenty-two (7.3%) patients suffered a PPH (five early). Of these cases, three suffered a re-bleeding event (one mortality). Endoscopy, interventional radiology and surgery were employed in each case.

Conclusion

PPH presents major clinical challenges and is associated with significant morbidity and mortality. Early detection of the site and type of bleeding are critical and multimodal therapy is usually required. Interventional radiology techniques are making a major contribution to overall management.

Australian validation of the Cancer of the Prostate Risk Assessment Post-Surgical score to predict biochemical recurrence after radical prostatectomy

May 4, 2017 - 19:46
Background

The Cancer of the Prostate Risk Assessment Post-Surgical (CAPRA-S) score is a simple post-operative risk assessment tool predicting disease recurrence after radical prostatectomy, which is easily calculated using available clinical data. To be widely useful, risk tools require multiple external validations. We aimed to validate the CAPRA-S score in an Australian multi-institutional population, including private and public settings and reflecting community practice.

Methods

The study population were all men on the South Australian Prostate Cancer Clinical Outcomes Collaborative Database with localized prostate cancer diagnosed during 1998–2013, who underwent radical prostatectomy without adjuvant therapy (n = 1664). Predictive performance was assessed via Kaplan–Meier and Cox proportional regression analyses, Harrell's Concordance index, calibration plots and decision curve analysis.

Results

Biochemical recurrence occurred in 342 (21%) cases. Five-year recurrence-free probabilities for CAPRA-S scores indicating low (0–2), intermediate (3–5) and high risk were 95, 79 and 46%, respectively. The hazard ratio for CAPRA-S score increments was 1.56 (95% confidence interval 1.49–1.64). The Concordance index for 5-year recurrence-free survival was 0.77. The calibration plot showed good correlation between predicted and observed recurrence-free survival across scores. Limitations include the retrospective nature and small numbers with higher CAPRA-S scores.

Conclusions

The CAPRA-S score is an accurate predictor of recurrence after radical prostatectomy in our cohort, supporting its utility in the Australian setting. This simple tool can assist in post-surgical selection of patients who would benefit from adjuvant therapy while avoiding morbidity among those less likely to benefit.

The ties that bind: what's in a title?

May 4, 2017 - 19:46
Background

Many Australian and New Zealand surgeons use the title ‘Mister’ rather than ‘Doctor’, a practice dating back to traditions established over 600 years ago. The Royal Australasian College of Surgeons is currently undergoing a period of critical self-reflection, embodied by its ‘Respect’ campaign. Active measures to embrace diversity and encourage women into surgery are underway.

Methods

This paper reviews the historical basis to the use of gendered titles and their current use amongst fellows. De-identified demographic data from the college register of active fellows was searched by self-identified title, country or state, and gender. Data were further reviewed by surgical sub-specialty and year of fellowship.

Results

The college dataset suggests that there is significant variance in the preference for gendered titles, determined predominantly by geography rather than specialty. The highest use of gendered titles (by male and female surgeons) was in Victoria/Tasmania (58% male, 22% female) and New Zealand (81% male, 17% female). By contrast, only 2% of female surgeons in other states elected a gendered title (Miss/Mrs/Ms).

Conclusion

Surgery is the only profession that continues to use gendered titles. As the College of Surgeons moves towards greater equity and diversity, consideration should be given to phasing out the use of gendered titles, which serve to divide rather than unite our profession.

Table of contents

May 4, 2017 - 08:58

Medicine in small doses

May 4, 2017 - 08:58

Shoulder to knee: lessons learnt

May 4, 2017 - 08:58