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: 19 hours 37 min ago

Cervical sympathetic schwannoma: a forgotten differential for Horner's syndrome

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

Opioid prescribing improvement in orthopaedic specialty unit in a tertiary hospital: a retrospective audit of hospital discharge data pre‐ and post‐intervention for better opioid prescribing practice

June 23, 2019 - 21:38

This study aimed to investigate the effects of an intervention focusing on better opioid prescription practice on an orthopaedic unit on discharge. Following a baseline audit of opioid prescribing practices, we delivered an intervention on how to improve opioid prescribing. Raised awareness across the organization and education for staff almost halved the post‐operative opioid prescription levels. This highlights the capacity for change in hospital departments and the ability to work towards safer prescribing of post‐operative opioid therapy.


Background

This study aimed to investigate the effects of an intervention focusing on better opioid prescription practice in a tertiary metropolitan hospital orthopaedic unit.

Methods

Following a previous audit of opioid prescribing in the orthopaedics unit, an intervention comprising the (i) Expert Advisory Group oversight of opioid prescribing, (ii) development of a prescription opioid guideline for various hospital contexts and (iii) a series of education sessions was undertaken to improve opioid prescription practice. A re‐audit was subsequently carried out to determine whether the intervention had had an impact on the previously audited orthopaedic unit.

Results

Each audit period was 6 months. There were 281 orthopaedic patients in the original audit (1 January 2017–30 June 2017) and 289 in the re‐audit (1 March 2018–31 August 2018). In both audits, a high proportion of patients were discharged to the community on opioids, 82.2% (n = 231) pre‐intervention and 79.6% (n = 230) post‐intervention. Statistically significant differences in opioid prescribing were found between audits, including: a reduction in the number of patients discharged on combination opioids from 71.4% to 45.7% (P < 0.001), a reduction in the provision of full pharmaceutical quantities of opioid on discharge from 29.4% to 6.1% (P < 0.001) and an increase in opioid weaning plans included in discharge summaries from 6.9% to 87.4% (P < 0.001).

Conclusion

Raised awareness across the organization and education for staff more than halved the post‐operative opioid prescription levels. This highlights the capacity for change in hospitals and the ability to work towards safer prescribing of post‐operative opioid therapy.

Carpal tunnel syndrome caused by space‐occupying lesion: case report

June 21, 2019 - 05:49
ANZ Journal of Surgery, EarlyView.

Rare case of internal hernia sac with Meckel's diverticulum

June 20, 2019 - 23:15
ANZ Journal of Surgery, EarlyView.

Short‐term outcomes of pancreaticoduodenectomy in the state of Victoria: hospital resources are more important than volume

June 20, 2019 - 23:14

The inpatient mortality associated with pancreaticoduodectomy in Victorian public hospitals is comparable to that seen in overseas studies. This study found a relationship between hospital resources and mortality. There does not seem to be a relationship between volume and short‐term outcomes.


Background

Pancreaticoduodenectomy (PD) is a high‐risk procedure. Australian hospitals perform a relatively low volume of PD. This study sought to gain an understanding of hospital volume and short‐term outcomes of the procedure in the Australian state of Victoria.

Methods

The Dr Foster Quality Investigator tool was used to interrogate the Victorian Admitted Episodes Database for the Australian Classification of Health Intervention code for PD (30584) from July 2010 to June 2016. The data set included patients from a peer group of 14 hospitals that included all the public hospitals performing PD during this period. Patient characteristics, inpatient mortality, 30‐day readmission rates and median length of stay were reported for each de‐identified hospital.

Results

There were 547 PD conducted over 6 years in 10 public hospitals. The median patient age was 65 years. Inpatient mortality was 2.7%. There was a significant risk adjusted difference in mortality between principal referral and other public hospitals. Annual hospital volume ranged from 3 to 20 PD, and there was no significant relationship between mortality, readmission rates or length of stay and hospital volume.

Conclusion

The inpatient mortality associated with PD in Victorian public hospitals is comparable to that seen in overseas studies. While hospital volume is relatively low, there does not seem to be a relationship between volume and short‐term outcomes. Variability between hospital peer groups suggests that resource availability is more important than volume. The development of a procedure specific registry would be useful to test the outcomes of this study and determine long‐term PD outcomes.

Unusual case of massive lower gastrointestinal bleeding in a young woman

June 20, 2019 - 23:14
ANZ Journal of Surgery, EarlyView.

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

June 20, 2019 - 23:14

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.

Incidence of delayed venous thromboembolic events in patients undergoing abdominal and pelvic surgery for cancer: a systematic review and meta‐analysis

June 18, 2019 - 19:30

Incidence of venous thromboembolism among patients who do not receive post‐hospital discharge venous thromboembolism prophylaxis at 3 months from surgery varies between 2.2% and 9.6%. Heterogeneity is explained by type of procedure performed.


Background

Incidence of venous thromboembolism (VTE) following discharge for abdominal cancer surgery is uncertain.

Methods

We searched MEDLINE and Embase for studies evaluating the incidence of VTE at 3 months from surgery. Studies indicating use of post‐hospital VTE prophylaxis were excluded. Two independent reviewers performed study selection, data abstraction and risk of bias. Random‐effects model was used to estimate pooled incidence, and weights were estimated using inverse variance method. Statistical heterogeneity was explored via subgroup analysis.

Results

Of 4215 abstracts retrieved, 11 reported the incidence of VTE at 3 months. There were three randomized trials (n = 520), one prospective cohort study (n = 284) and seven retrospective cohort studies (n = 65 308). VTE incidence among prospective studies was 9.6% (95% confidence interval (CI) 2.9–16.4), while for retrospective studies was 2.2% (95% CI 1.4–3.0). Heterogeneity was high (I 2 = 92% and 81%, respectively). The incidence of symptomatic VTE was 1.3% (95% CI 0.4–2.3) for prospective studies. VTE was diagnosed by screening venography in most of the prospective studies, whereas retrospective studies did not use a screening method. Subgroup analysis based on the type of organ surgery performed explained the heterogeneity.

Conclusions

VTE incidence following abdominal cancer surgery varies greatly depending on the study type, with differences largely explained by the method of assessment of VTE. The fact that VTE incidence among retrospective studies was closer to the incidence of symptomatic events (non‐screen detected) in the prospective studies, suggests that the screened events were mostly asymptomatic and their clinical significance is unclear.

Delivery of surgical care in Samoa: perspectives on capacity, barriers and opportunities by local providers

June 18, 2019 - 19:29
Background

The Pacific Island nation of Samoa faces a number of challenges in delivering surgical care. Our group aimed to identify the barriers and opportunities to improving the delivery of safe, affordable, timely surgical care in Samoa.

Methods

A mixed‐methods approach was undertaken. The quantitative analysis used a modified version of the World Health Organization Emergency and Essential Surgical Checklist while the qualitative methodology used semi‐structured interviews. Respondents were asked to share their views on the capacity, quality, accessibility and future directions of surgery in Samoa. Interviews were transcribed and analysed using open and axial coding techniques.

Results

Stakeholders had a positive outlook on the delivery of surgical care, but it was suggested that existing services were not meeting needs. Respondents cited limited access to equipment and resources, compounded by insufficient organizational and logistical infrastructure. Shortage of medical staff and retention was identified as a key issue. Shortcomings in primary care and poor health literacy were seen as significant barriers to accessing care.

Conclusion

Documenting locally identified barriers and solutions to surgical care in Samoa is an important first step towards the development of formal strategies for improving surgical services nationally.

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

June 18, 2019 - 02:24

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.

Fishbone bowel perforation mimicking acute diverticulitis: a diagnostic dilemma

June 18, 2019 - 01:35
ANZ Journal of Surgery, EarlyView.

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

June 18, 2019 - 01:32
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.

Transvaginal evisceration of small bowel

June 10, 2019 - 00:38
ANZ Journal of Surgery, Volume 89, Issue 6, Page 774-776, June 2019.

Absence of the common bile duct

June 10, 2019 - 00:38
ANZ Journal of Surgery, Volume 89, Issue 6, Page 782-784, June 2019.

Complicated appendicitis within an incisional hernia

June 10, 2019 - 00:38
ANZ Journal of Surgery, Volume 89, Issue 6, Page E270-E271, June 2019.

Fatal flaws in clinical decision making

June 10, 2019 - 00:38
Background

Clinical decision making is a core competency of surgical practice, involving a continuous and evolving process of data interpretation and evaluation. The aim of this article is twofold. First, to recognize patient deaths where a clinical incident arose following unsatisfactory clinical decision making, determining where in the clinical decision‐making process each failure occurred. Second, to discuss and explore individual incidents to provide lessons from which the surgical community can learn.

Methods

Using the Australian and New Zealand Audit of Surgical Mortality database, all deaths from 1 January 2015 to 31 December 2015 were analysed. All deaths in which the surgeon or assessor identified an aspect of patient management that was inadequate were recognized. Clinical incidents deemed by the assessor to be an area of concern or an adverse event were individually reviewed to determine if a clinical decision‐making incident (CDMI) occurred. CDMIs were categorized into various themes depending on the nature of the incident.

Results

A total of 3422 fully audited deaths occurred throughout the study period; from these cases, 226 individual CDMIs were identified. Decision to operate was the most commonly identified CDMI (n = 99, 43.8%), followed by diagnostic error (n = 49, 21.7%). The least common CDMI identified was inadequate post‐operative assessment (n = 14, 6.2%).

Conclusion

This paper demonstrates thought‐provoking examples of clinical decision‐making failure implicated in patient death. Clinical decision‐making failures most commonly occur around the decision to operate with increased discussion of complex cases possibly required. Further CDMI evaluation should be considered to complement more traditional methods of surgical mortality evaluation.