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: 14 hours 53 min ago

Evaluation of the smartphone for measurement of femoral rotational deformity

September 3, 2019 - 04:48

A patent measurement technique has been designed to assess femoral rotation deformation. The aim of this study was to investigate and assess its possibility and reliability.


Abstract Background

A novel measurement technique has been designed to assess femoral rotation deformation. The purpose of this study was to evaluate smartphone‐aided measurement, including measurement software, intra‐observer differences and the occurrence frequency of the unacceptable outliers.

Methods

Five positions (intact bone, external and internal rotations of 20° and 40° of the distal blocks after dividing the femoral shafts using a saw) were used in each of the five artificial femora. Guide wires were separately inserted into the proximal and distal ends of the model femora with a navigation system and the intersection angles between the guide wires were measured with a smartphone. The values obtained by two measurement software packages (Smart Tools and Super Swiss Army Knife) were compared with that measured on the overlapped computed tomography images.

Results

There were no significant differences between the intersection angles measured by smartphone and that measured on the overlapped images (P = 0.24). The mean absolute difference between pairs of measurements of the two software packages for all guide wire angles was 2.33 ± 2.34°, without statistically significant difference (P = 0.33). There was a significant correlation (r = 0.99) between the first and second (1 week apart) measurements with the same measurement tool. The values of offset capability index of the Smart Tools and the Super Swiss Army Knife measurement tools were 1.62 and 1.13, respectively.

Conclusion

Smartphone‐aided measurement technique could reliably assess femoral rotation deformation with more accurate angle measurement for software with zero calibration function.

Bilateral absence of the fibular artery: an unusual variation

September 3, 2019 - 04:47
ANZ Journal of Surgery, EarlyView.

Outcomes and learning curve for robotic‐assisted radical cystectomy: an Australian experience

September 3, 2019 - 04:46

In the largest Australian series of robotic‐assisted radical cystectomy, initial short‐term experience shows technical improvements along a learning curve and favourable perioperative and survival outcomes compared to open and robotic radical cystectomy series.


Abstract Background

This study aimed to describe perioperative, oncological and learning curve outcomes for robotic‐assisted radical cystectomy (RARC) across the first 100 cases performed by an Australian high‐volume, fellowship‐trained robotic surgeon.

Methods

A retrospective cohort study was performed on a consecutive group of 100 patients who underwent RARC between 2010 and 2016 in Brisbane, Australia. Perioperative, oncological and survival data were collected. Demographic, survival and learning curve analyses were performed in MedCalc.

Results

A total of 100 patients underwent RARC over the study period. Median operative time was 389 min, with a reduction in median times from 420 to 330 min when comparing the first 50 versus the second 50 patients (P < 0.001). Median estimated blood loss was 500 mL, while urinary diversion was performed extracorporeally in 20 patients, intracorporeally in 69 patients and using a hybrid technique in 11 patients. Median length of hospital stay was 11 days. Post‐operative complications occurred in 56% of patients (Clavien–Dindo classification I–II 32%, III–V 24%). Positive operative margins were 2% and median lymph node yield was 21 nodes. Overall recurrence‐free survival was 50.3 months.

Conclusion

Initial short‐term experience with RARC shows favourable outcomes with regard to operative, perioperative and pathological indicators compared to open radical cystectomy and other RARC series.

Changing trends in surgical management of renal tumours from 2000 to 2016: a nationwide study of Medicare claims data

September 3, 2019 - 04:46
Abstract Background

Guidelines recommend nephron sparing surgery where possible for patients with T1 renal tumours. The trends of nephron sparing surgery outside the USA are limited, particularly since the introduction of robotic‐assisted partial nephrectomy (RAPN). The aim of this study was to describe contemporary surgical management patterns of renal tumours in Australia according to Medicare claims data.

Methods

Claims data according to the Medicare Benefits Schedule on surgical management of renal tumours in adult Australians between January 2000 and December 2016 was collated. Analysis of absolute number, population‐adjusted rate and renal cancer‐adjusted rate of interventions according to age and gender were performed, as well as proportion of RAPN.

Results

Between 2000 and 2016, the rate of partial nephrectomy (PN) increased while radical nephrectomy (RN) remained stable (PN: 0.87–4.16, RN: 6.52–6.70 per 100 000 population). Since 2015, PN has become more common than RN in patients aged 25 to 44 years (0.98 versus 0.95 procedures per 100 000 population). Renal cancer‐adjusted rate exhibited a trend towards increasing utilization of PN and reduced RN across all age groups. An increase in overall surgical treatment was observed (25%–41%), mainly due to increased treatment of patients older than 75 years. The proportion of RAPN was seen to rapidly increase (4.7% in 2010 to 58% in 2016).

Conclusions

Treatment utilization for renal masses has markedly changed in Australia according to Medicare claims. PN is increasingly replacing RN in younger patients, and older patients are receiving more surgical treatment. The impact of increased RAPN utilization is yet to be determined.

Incidental abdominal heterotaxy syndrome

September 3, 2019 - 04:46
ANZ Journal of Surgery, EarlyView.

Do Indigenous patients in Australia's Northern Territory present with more advanced colorectal cancer? A cohort study based on registry data

August 28, 2019 - 22:10

Previous studies have shown that Indigenous Australians in the Northern Territory have allowed survival from, and present at a later stage with colorectal cancer than non‐Indigenous Australians. This study shows that a later stage of presentation is no longer present, implying that other factors such as treatment complaint or comorbidity may be responsible for the continued survival disparity.


Background

Previous studies show that Indigenous Australians (IndA) of the Northern Territory (NT) present later and have lower survival for colorectal cancer (CRC) compared with non‐Indigenous (NI) Territorians. This study compared the odds of presenting with advanced‐stage CRC between IndA and NI adjusted for demographic, histopathological and surgical features.

Methods

A cohort study of NT Cancer Registry (NTCR) CRC cases from 2005 to 2014. All (667) persons notified to the NTCR with a new diagnosis of CRC were included, of which 504 had sufficient data for analysis. The NTCR was used for case identification and linked to available hospital clinical data. The principal exposure was IndA compared with NI and the principal outcome was odds of presenting with advanced‐stage tumour (III and IV) compared with early‐stage (I and II). Univariable and multivariable logistic regression were performed on all relevant variables.

Results

Univariable logistic regression found no difference in the odds of advanced CRC between IndA and NI (odds ratio (OR) 0.99, 95% confidence interval (CI) 0.56–1.76, P = 0.982). This effect remained insignificant adjusted for the effects of sex, tumour position, remoteness and time period (OR 0.85, 95% CI 0.47–1.55, P = 0.606) and when adjusted for tumour grade, lympho‐vascular invasion, lymph node harvest and emergency status (OR 1.39, 95% CI 0.64–3.03, P = 0.401).

Conclusions

In distinction from previous studies, there was no evidence that IndA of the NT presented with later stage CRC in 2005–2014. Other factors (incomplete treatment or comorbidity) may be responsible for the continued observed survival disparity.

Colo‐pleural fistula: a rare complication of bariatric surgery

August 27, 2019 - 02:19
ANZ Journal of Surgery, EarlyView.

Laparoscopic totally extra‐peritoneal groin hernia repair with self‐gripping polyester mesh: a series of 780 repairs

August 27, 2019 - 02:19

Laparoscopic inguinal hernia repair using polyester self‐gripping mesh may reduce chronic pain by avoiding fixation. We present a large series (2011–2017) of 780 repairs using this technique with a chronic pain rate of 1.67% and four recurrences (0.51%) (follow‐up was up to 4.4 years).


Background

Laparoscopic groin hernia repair is an increasingly common procedure with benefits of reduced post‐operative pain and infection. Post‐operative chronic pain remains an ongoing concern in about 10% of patients. Parietex ProGrip™, a polyester self‐gripping mesh, has a theoretical benefit of avoiding tacks for mesh‐fixation. This case series reflects our long‐term experience of this technique.

Methods

We conducted a retrospective case series from November 2011 to December 2017. Patients were identified through an operative Medicare Benefits Schedule item number search. Clinical documentation was reviewed with length of stay, mesh infection, chronic pain, recurrence and re‐operation as primary data points.

Results

A total of 514 patients underwent 780 laparoscopic inguinal hernia repairs with self‐gripping polyester mesh during this period. There were 53 female (10.3%) and 461 male patients (89.7%). Unilateral hernia repair was performed in 248 patients (48.2%) and bilateral repair in 266 patients (51.8%). Almost all repairs (779, 99.8%) were primary hernias. There were no mesh infections. Four recurrences were noted (0.51%) and three of these subsequently underwent open redo‐hernia repairs (0.38%). Post‐operative follow‐up was up to 4.4 years.

Conclusions

Our series of laparoscopic groin hernia repair with self‐gripping mesh demonstrate this is a safe and reliable mesh and effective technique with low recurrence rates.

Sarcopenia is an independent predictor of delayed gastric emptying following pancreaticoduodenectomy: a retrospective study

August 27, 2019 - 02:18

High body mass index, clinically relevant post‐operative pancreatic fistula and sarcopenia were predictor of delayed gastric emptying (DGE) after pancreaticoduodenectomy. Sarcopenia is likely to be involved in the pathogenesis of DGE after pancreaticoduodenectomy. Improved pre‐operative sarcopenia might prevent DGE.


Background

The pathogenesis of delayed gastric emptying (DGE), a common complication of pancreaticoduodenectomy, is unclear. Loss of skeletal muscle mass (sarcopenia) is associated with post‐pancreaticoduodenectomy complications; however, few studies have investigated the relationship between sarcopenia and DGE. The aim of this study was to investigate whether post‐pancreaticoduodenectomy DGE is affected by pre‐operative skeletal muscle mass.

Methods

We retrospectively analysed the data of 112 consecutive patients who had undergone pancreaticoduodenectomy and divided them into the following two groups: no DGE (n = 100) and with DGE (n = 12). Patients were stratified by quartiles according to each element of body composition. The lowest quartile for skeletal muscle mass was defined as having sarcopenia.

Results

Ten and two patients had grades B and C DGE, respectively. According to univariate analysis, body mass index (P = 0.031), clinically relevant post‐operative pancreatic fistula (P < 0.001) and skeletal muscle mass (P = 0.002) were significantly associated with DGE. According to multivariate analysis, high body mass index (≥25 kg/cm2) (P = 0.005), post‐operative pancreatic fistula (P = 0.027) and low skeletal muscle mass (P = 0.004) were independently associated with DGE.

Conclusion

Sarcopenia is an independent predictor of DGE after pancreaticoduodenectomy.

Long‐term significance of an anastomotic leak in patients undergoing an ultra‐low anterior resection for rectal cancer

August 26, 2019 - 21:40

A study that looks at the long‐term consequences of anastomotic leaks in patients who have undergone an ultra‐low anterior resection for rectal cancer. An evaluation of morbidity and mortality in both anastomotic leaks and diverting ileostomy were undertaken. Risk factors identified include male gender and response to radiotherapy.


Background

Australia has one of the highest rates of colorectal cancer worldwide. Despite technological advances in colorectal surgery, anastomotic leaks (ALs) continue to cause significant morbidity and mortality. Ultra‐low anterior resections (ULARs) carry the highest prevalence of AL. The aim of the study is to evaluate the incidence, treatment and consequences of AL following ULAR for colorectal cancer from a single colorectal unit.

Methods

This is a retrospective evaluation of prospectively collected data on patients undergoing ULAR following rectal cancer. The main end points include the prevalence and management of AL following initial operation and the morbidity, re‐operation and mortality rates associated with AL. A stepwise logistic regression analysis and a multivariate analysis were performed to identify independent risk factors.

Results

A total of 467 patients underwent an ULAR. There were 32 (6.8%) ALs. Average follow‐up time was 79 months. There were five subclinical leaks and only one (20%) required intervention. The overall survival rate at 5 years was 80% (95% confidence interval 58–91). On univariate analysis male sex was a risk factor for AL (P = 0.03). On multivariate analysis patients who had a complete response to radiotherapy were more likely to have a leak than the patients who had no radiotherapy (grade 4, odds ratio 4.0, 95% confidence interval 1.4–10.9, P = 0.01).

Conclusion

This study has highlighted the relevance of subclinical leaks and their associated morbidity. It identified that radiotherapy a risk factor for AL, but the response to radiotherapy is an even better predictor of leakage.

Novel technique of insertion of decompression tube for Ogilvie's syndrome/colonic pseudo‐obstruction

August 26, 2019 - 21:38

Novel technique of management of colonic pseudo‐obstructing using colonoscopy guided insertion of decompression tube.


Declining incidence of pyloric stenosis in New Zealand

August 26, 2019 - 21:38
Background

Pyloric stenosis is a relatively common paediatric surgical condition, but a worldwide decline in its incidence has been observed in recent decades. The objective of this study was to identify if the incidence of pyloric stenosis in New Zealand has been declining.

Methods

A retrospective review of the four New Zealand paediatric surgical centres’ theatre databases from 2007 to 2017. Demographic data were recorded for all infants who had a pyloromyotomy and annual incidences of pyloric stenosis calculated.

Results

A total of 393 infants underwent a pyloromyotomy for pyloric stenosis during the study period. Most infants (81%) were of European ethnicity. There was a significant decline (P = 0.0001) in the national incidence of pyloric stenosis from 0.73/1000 live births (LB) in 2007 to 0.39/1000 LB in 2017. From 2007 to 2017, the incidence of male infants with pyloric stenosis declined from 1.27/1000 LB to 0.62/1000 LB. The current annual incidence of pyloric stenosis in New Zealand is 0.39/1000 LB.

Conclusions

The incidence of pyloric stenosis in New Zealand has significantly declined in the last decade and is currently the lowest reported incidence in the world involving a predominantly European cohort. A decline in male infants developing pyloric stenosis was also observed. Further study is required to investigate causes for this low incidence and declining trend.

Delayed diagnosis of anorectal malformations in neonates

August 26, 2019 - 21:38
Background

Anorectal malformations (ARM) are common congenital abnormalities of the terminal hindgut. Ideally, ARM should be diagnosed at, or shortly following, birth by careful physical examination of the perineum. Delayed diagnosis has been implicated as a risk factor for complications, including intestinal perforation. This study aimed to determine the rate of delayed diagnosis and associated intestinal perforation in ARM.

Methods

A retrospective review was performed for all ARM patients managed at The Royal Children's Hospital over a 16‐year period (2000–2015). Data collected included ARM type, timing of diagnosis and complications. Delayed diagnosis was defined as being at more than 24 h of age.

Results

A total of 243 ARM patients (male 146/243, 60%) were included. The most frequent ARM types were perineal fistula (83/243, 34%) and rectovestibular fistula (40/243, 16%). Diagnosis was delayed beyond 24 h of age in 92 of 243 (38%) patients. The ARM type most commonly delayed in diagnosis was perineal fistula (37/83, 45%). Two patients in whom diagnosis was delayed suffered an intestinal perforation.

Conclusion

Delayed diagnosis in ARM patients remains a common, and potentially fatal, occurrence. Improved assessment of newborns is required to ensure timely diagnosis of ARM, and avoidance of complications associated with delayed diagnosis.

Patterns of immediate breast reconstruction in New South Wales, Australia: a population‐based study

August 16, 2019 - 22:21

This study is the most comprehensive Australian analysis of immediate breast reconstruction (IBR) utilisation patterns through a population‐based study. It revealed that wide inter‐hospital variation exists in IBR rates within NSW, which raises concerns about potential inequities in access to IBR services and unmet demand in certain areas of NSW. Explaining the underlying drivers for IBR variation is the first step in identifying policy solutions to redress the issue.


Background

The rate of immediate breast reconstruction (IBR) following mastectomy for breast cancer in Australia is low and varies between regions. To date, no previous Australian studies have examined IBR rates between all hospitals within a particular jurisdiction, despite hospitals being an important known contributor to variation in IBR rates in other countries.

Methods

We used cross‐classified random‐effects logistic regression models to examine the inter‐hospital variation in IBR rates by using data on 7961 women who underwent therapeutic mastectomy procedures in New South Wales (NSW) between January 2012 and June 2015. We derived IBR rates by patient‐, residential neighbourhood‐ and hospital‐related factors and investigated the underlying drivers for the variation in IBR.

Results

We estimated the mean IBR rate across all hospitals performing mastectomy to be 17.1% (95% Bayesian credible interval (CrI) 12.1–23.1%) and observed wide inter‐hospital variation in IBR (variance 4.337, CrI 2.634–6.889). Older women, those born in Asian countries (odds ratio (OR) 0.5, CrI 0.4–0.6), residing in neighbourhoods with lower socioeconomic status (OR 0.7, CrI 0.5–0.8 for the most disadvantaged), and who underwent surgery in public hospitals (OR 0.4, CrI 0.1–1.0) were significantly less likely to have IBR. Women residing in non‐metropolitan areas and attending non‐metropolitan hospitals were significantly less likely to undergo IBR than their metropolitan counterparts attending metropolitan hospitals.

Conclusion

Wide inter‐hospital variation raises concerns about potential inequities in access to IBR services and unmet demand in certain areas of NSW. Explaining the underlying drivers for IBR variation is the first step in identifying policy solutions to redress the issue.

Different clinical risk scores for prediction of early mortality after liver resection for hepatocellular carcinoma: which is the best?

August 7, 2019 - 02:49
Background

Prediction of early mortality after hepatectomies for hepatocellular carcinoma is essential to identify high‐risk patients and to decrease the operative mortality rate. Several post‐operative clinical risk scores were developed recently to predict mortality post‐hepatectomy; however, which one is the best remains undefined. Therefore, the aim of this study was to evaluate the performance of the different post‐operative clinical risk scores in predicting early mortality after hepatectomies.

Methods

A total of 240 patients who underwent liver resection for hepatocellular carcinoma at our hospital between June 2011 and July 2016 were retrospectively reviewed. Post‐operative clinical risk scores including 50–50 criteria, peak bilirubin >7 mg/dL, model for end‐stage liver disease (MELD), risk assessment for early mortality and Hyder scores were evaluated for their performance in predicting early mortality after hepatic resection using the receiver operating characteristic (ROC) curve.

Results

The 90‐day mortality rate after hepatic resection was around 2.5%. The 50–50 criteria and peak bilirubin >7 mg/dL were weak predictors of early mortality with low sensitivity (area under the ROC curve: 0.65, 0.66, respectively), whereas, Hyder, risk assessment for early mortality, and post‐operative MELD were good predictors of early mortality (area under the ROC curve: 0.89, 0.91 and 0.88, respectively). Moreover, MELD score on post‐operative day 3 was an independent risk factor for 90‐day mortality with an odds ratio of 1.4 (95% confidence interval 1.06–1.81, P = 0.02).

Conclusions

Post‐operative clinical risk scores, especially MELD, were capable of predicting early mortality after liver resection and should be used to identify high‐risk patients and provide them with more intensive medical care.

Case report of nasopharyngeal rhabdomyosarcoma causing obstructive sleep apnoea

August 6, 2019 - 22:24
ANZ Journal of Surgery, EarlyView.

Caecal volvulus: a rare complication following a routine laparoscopic appendicectomy

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E356-E357, July/August 2019.

Isolated colonic hernia through the oesophageal hiatus causing gastric outlet obstruction

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E352-E353, July/August 2019.

Colo‐ureteric fistula: a rare complication in colorectal surgery

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E327-E328, July/August 2019.