ANZ Journal of Surgery

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Syndicate content
Wiley Online Library : ANZ Journal of Surgery
Updated: 5 hours 23 min ago

Adrenal ganglioneuroblastoma in an adult

September 19, 2017 - 09:47

Neoadjuvant systemic therapy for breast cancer: the Westmead experience

September 19, 2017 - 09:46
Background

Neoadjuvant systemic therapy (NAST) can be used to treat breast cancer. Pathologic complete response (pCR) is a surrogate marker for improved survival. This study examined response in the breast and axilla to NAST and identified features associated with pCR.

Methods

Patients undergoing NAST and surgery between January 2012 and June 2016 by surgeons at Westmead Breast Cancer Institute were identified. Patients with inflammatory or metastatic disease were excluded. Data were analysed to identify factors predictive of pCR.

Results

Ninety-one patients were identified. Mean age was 49 years. Forty-one patients had axillary metastases identified prior to NAST. Eighty-three patients received chemotherapy alone, six endocrine therapy alone and two had both. Thirty-seven patients had mastectomy and 54 had breast-conserving surgery. The overall breast pCR rate was 29% higher in patients with triple-negative (50%) or HER2-positive (39%) disease and lower in luminal disease (11.6%, P = 0.001). Forty percent of node-positive patients became node negative. The only variable associated with pCR was tumour biology. Patients with HER2-positive breast cancer were more likely to have axillary pCR than those with luminal cancer (odds ratio: 28, P = 0.00005).

Conclusion

pCR in either the breast or axilla was most likely to be achieved in patients with HER2-positive or triple-negative breast cancers. In patients with luminal cancers, the goal of NAST is best considered to facilitate surgical options rather than obtaining a pCR.

Unicortical and bicortical plating in the fixation of comminuted fractures of the clavicle: a biomechanical study

September 19, 2017 - 09:46
Background

Intraoperative neurovascular complications with clavicle fracture fixation are often due to far cortex penetration by drills and screws, but could be avoided using a unicortical construct. The objective of this study was to compare the bending and torsional strength of a unicortical locking screw plate construct and a hybrid (with central locked and outer non-locked long oblique screws) unicortical plate construct for clavicle fracture fixation with that of a conventional bicortical locking screw construct of plate fixation.

Methods

Twenty-four human clavicle specimens were harvested and fractured in a comminuted mid-shaft butterfly configuration. Clavicles were randomly allocated to three surgical fixation groups: unicortical locking screw, bicortical locking screw and hybrid unicortical screw fixation. Clavicles were tested in torsion and cantilever bending. Construct bending and torsional stiffness were measured, as well as ultimate strength in bending.

Results

There were no significant differences in bending stiffness or ultimate bending moment between all three plating techniques. The unicortical locked construct had similar torsional stiffness compared with the bicortical locked construct; however, the hybrid technique was found to have significantly lower torsional stiffness to that of the bicortical locking screw construct (mean difference: 87.5 Nmm/degree, P = 0.028).

Conclusions

Unicortical locked screw plate fixation and hybrid unicortical plating fixation with centrally locked screws and outer long, oblique screws may alleviate far cortex penetration, protecting nearby anatomical structures, and may ease implant removal and conversion to bicortical fixation for revision surgery; however, use of long oblique screws may increase the risk of early loosening under torsion.

Why do surgeons receive more complaints than their physician peers?

September 10, 2017 - 10:50
Background

Compared with other doctors, surgeons are at an increased risk of medicolegal events, including patient complaints and negligence claims. This retrospective study aimed to describe the frequency and nature of complaints involving surgeons compared with physicians.

Methods

We assembled a national data set of complaints about surgeons and physicians lodged with medical regulators in Australia from 2011 to 2016. We classified the complaints into 19 issues across four domains: treatment and procedures, other performance, professional conduct and health. We assessed differences in complaint risk using incidence rate ratios (IRRs). Finally, we used a multivariate model to identify predictors of complaints among surgeons.

Results

The rate of complaints was 2.3 times higher for surgeons than physicians (112 compared with 48 complaints per 1000 practice years, P < 0.001). Two-fifths (41%) of the higher rate of complaints among surgeons was attributable to issues other than treatments and procedures, including fees (IRR = 2.68), substance use (IRR = 2.10), communication (IRR = 1.98) and interpersonal behaviour (IRR = 1.92). Male surgeons were at a higher risk of complaints, as were specialists in orthopaedics, plastic surgery and neurosurgery.

Discussion

Surgeons are more than twice as likely to attract complaints as their physician peers. This elevated risk arises partly from involvement in surgical procedures and treatments, but also reflects wider concerns about interpersonal skills, professional ethics and substance use. Improved understanding of these patterns may assist efforts to reduce harm and support safe practise.

Medicine in small doses

September 6, 2017 - 10:07

25, 50 & 75 years ago

September 6, 2017 - 10:07

Surgeons and big data

September 6, 2017 - 10:07

Issue information - JEB

September 6, 2017 - 10:07

Issue information - TOC

September 6, 2017 - 10:07

Rare finding of a giant ischioanal lipoma

September 5, 2017 - 11:07

Transperineal rectocele repair: a systematic review

September 5, 2017 - 11:06
Background

Transperineal rectocele repairs, either as isolated fascial repair or in combination with mesh augmentation, are hypothesized to reduce the risk of complications compared with alternative techniques.

Aim

The aim of this study was to ascertain long-term success and complication rates following transperineal rectocele repairs.

Method

A literature search of PubMed and Embase was performed using the terms ‘transperineal rectocele’, ‘rectocele’, ‘transperineal’ and ‘repair’. Prospective studies, case series and retrospective case note analyses from 1 January 1994 to 1 December 2016 were included. Those that detailed outcomes of the transperineal approach or compared it to transanal/transvaginal approaches were included. The main outcome measures were reported complications and functional outcome scores.

Results

A total of 14 studies were included. Of 566 patients, 333 (58.8%) underwent a transperineal rectocele repair and 220 (41.2%) a transanal repair. Complications were identified in 27 (12.3%) of the 220 transanal repairs and in 41 (12.3%) of the 333 transperineal repairs. A significant complication following transperineal repair was noted in eight studies. There are not enough data to make a reliable comparison between mesh and non-mesh transperineal repairs or to compare biological and synthetic mesh use.

Limitations

Outcome reporting differed between studies, precluding a full meta-analysis.

Conclusion

Transperineal rectocele repair offers an effective method of symptom improvement and appears to have a similar complication rate as transanal rectocele repair. Concomitant use of synthetic and biological mesh augmentation is becoming more common; however, high-quality comparative data are lacking, so a direct comparison between surgical approaches is not yet possible.

Resection accuracy of patient-specific cutting guides in total knee replacement

August 30, 2017 - 13:40
Background

Patient-specific guides (PSGs) have been thoroughly investigated with regards to reconstitution of mechanical alignment in total knee arthroplasty (TKA). The ability to replicate the preoperative surgical plan is essential for optimal outcomes but intraoperative measurements to confirm accurate progression through the operation are limited. This leads to our clinical question: can PSGs replicate the planned bone resection depth during TKA?

Methods

This is a prospective case series of 118 patients who underwent TKA using magnetic resonance imaging-based patient-specific cutting guides. Intraoperative bone resection thickness was measured and compared with the preoperative planned bone resections as a primary outcome. Secondary outcomes included the need for additional bone resections, the number of cases for which the PSG technique was abandoned, final component sizes and mechanical alignment.

Results

PSGs could not accurately recreate preoperative plan. PSGs resulted in over-resection in all bone cuts compared with the preoperative surgical resection plan. Secondary osteotomies were required in 37% of patients. PSGs had to be abandoned in 10.5% of cases, mostly due to suboptimal fit of the femoral block. The tibial component size was altered more frequently than the femoral.

Conclusion

Intraoperatively, PSGs could not accurately recreate the preoperative plan. PSGs are marketed as user-friendly tools to simplify TKA but our research demonstrates the need for surgeons to monitor surgical progression and compensate for errors occurring during the use of PSGs.