ANZ Journal of Surgery

  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
  • warning: date() [function.date]: It is not safe to rely on the system's timezone settings. You are *required* to use the date.timezone setting or the date_default_timezone_set() function. In case you used any of those methods and you are still getting this warning, you most likely misspelled the timezone identifier. We selected 'Australia/Melbourne' for 'AEST/10.0/no DST' instead in /home/lambertn/public_html/content/modules/aggregator/aggregator.pages.inc on line 259.
Syndicate content
Wiley Online Library : ANZ Journal of Surgery
Updated: 9 hours 12 min ago

Paediatric vertebral artery aneurysms: a literature review

March 21, 2017 - 09:19

Vertebral artery (VA) aneurysms in the paediatric population are a rare but a serious condition. However, the epidemiology of paediatric VA aneurysms is poorly understood and there is little consensus on what constitutes the appropriate treatment. Although multiple treatment options are available, including surgery, endovascular approaches, coil embolization and parent artery occlusion, there is limited clinical evidence regarding which approach is most optimal. This review outlines the current literature and evidence outlining the epidemiology, presentation, pathogenesis and treatment of paediatric VA aneurysms.

Soft tissue infections from fish spike wounds: normal commensal bacteria are more common than marine pathogens

March 21, 2017 - 09:19
Background

A fish spike injury can be sustained by anyone handling fish; during fishing, meal preparation or in retail. Case reports of fish spikes inoculating victims with virulent marine-specific pathogens and causing systemic illness led us to question whether empirical treatment of these injuries with amoxicillin and clavulanic acid is adequate.

Methods

This 2-year prospective observational study was conducted at Middlemore Hospital, Auckland, New Zealand. Wound swabs and tissue samples belonging to patients presenting to the Department of Plastic and Reconstructive Surgery with an upper limb fish spike injury were sent to the laboratory (n = 60). A series of stains and cultures were performed to look specifically for marine bacteria not typically isolated in other soft tissue injuries. Patient demographic data and injury details were collected.

Results

Of the patients with adequate microbiology samples, 12% (6/50) grew clinically relevant bacteria resistant to amoxicillin and clavulanic acid. These included methicillin-resistant Staphylococcus aureus (8%, 4/50), Enterobacter cloacae (2%, 1/50) and an anaerobic sporing bacillus (2%, 1/50). Only one patient grew a true marine-specific bacteria, Photobacterium damselae, which was susceptible to amoxicillin and clavulanic acid.

Conclusion

The authors concluded that amoxicillin and clavulanic acid is an adequate first-line antibiotic for fish spike injuries but that flucloxacillin may be more appropriate given most bacteria were from patients’ own skin flora. The authors suggest that clinicians consider the presence of resistant marine-specific bacteria in cases where there is sepsis or inadequate response to initial therapy.

Perforating and deep lymphatic vessels in the knee region: an anatomical study and clinical implications

March 20, 2017 - 20:01
Background

To determine the relationship between the perforating and deep lymphatic vessels in the knee region for clinical implications.

Methods

Four lower limbs from two unembalmed human cadavers were used. Under a surgical microscope, 6% hydrogen peroxide was employed to detect lymph vessels accompanying the small saphenous vein, anterior tibial, posterior tibial and fibular blood vessels all commencing from distal ends of specimens. Each lymphatic vessel was inserted by a 30-gauge needle and injected with a barium sulphate mixture. Each specimen was dissected, radiographed and photographed to determine the perforating and deep lymphatic vessels in the region.

Results

A perforating lymph vessel was observed in the popliteal fossa of each specimen. It arose from the superficial popliteal lymph node and terminated in the deep popliteal lymph node. The anterior tibial, posterior tibial and peroneal lymph vessels were discovered in the region travelling with the corresponding vascular bundles. After penetrating the vascular aperture of the interosseous membrane between the tibia and fibula, the anterior tibial lymph vessel entered directly into the deep popliteal lymph node or converged to either the posterior tibial or fibular lymph vessel, before entering the node. The posterior tibial and peroneal lymph vessels entered the deep popliteal lymph node. The efferent lymph vessel of the deep popliteal lymph node travelled with the femoral vascular bundle.

Conclusion

The perforating and deep lymphatic vessels in the knee region has been presented and discussed. The information advances our anatomical knowledge and the results will benefit clinical management.

Histopathological tumour viability after neoadjuvant chemotherapy influences survival in resected pancreatic cancer: analysis of early outcome data

March 20, 2017 - 20:01
Background

Neoadjuvant therapy is increasingly recognized as an effective strategy prior to pancreatoduodenectomy. We investigate the role of neoadjuvant chemotherapy (NAC) followed by surgery and the predictive role of viable residual tumour cells histopathologically on outcomes.

Methods

The study population comprised of 195 consecutive patients with pancreatic adenocarcinoma who were treated with either NAC or a surgery-first (SF) strategy. Histopathological viable tumour cells were examined in the NAC patients and clinicopathological factors were correlated with overall survival.

Results

Forty-two patients (22%) were treated with NAC and 153 patients (78%) underwent SF. NAC was associated with higher estimated blood loss during surgery (928 mL versus 615 mL; P = 0.004), fewer (<15) excised lymph nodes (37% versus 17%; P = 0.015) and lower rates of lymphovascular invasion (65% versus 45%; P = 0.044) when compared with SF. Two-year survival of patients undergoing NAC was 63% and 51% in patients undergoing SF (P = 0.048). The 2-year survival of patients who had >65% residual tumour cells was 45% and 90% in patients who had <65% residual tumour cells (P = 0.022). Favourable responders (<65% viable tumour cells) were observed to have shorter operation time (<420 min) (55% versus 13%; P = 0.038), trend towards negative lymph node status (38% versus 10%; P = 0.067) and greater lymph node harvest in node positive patients (≥4 positive lymph nodes) (77% versus 37%; P = 0.045).

Conclusion

The improved survival of patients undergoing NAC indicates effective management of micrometastatic disease and is an effective option requiring further investigation. Histopathological viable tumour cells after NAC was a surrogate marker for survival.

Caecal bascule: a case series and literature review

March 20, 2017 - 20:00
Background

Caecal bascule is a rare condition characterized by the inferior pole of the caecum folding on a horizontal axis antero-superiorly towards the ascending colon, potentially causing obstruction. An unusual variant of volvulus, diagnosis is challenging due to its obscurity. We present the experience of an Australian tertiary-referral hospital with the diagnosis/management of caecal bascule, and review cases reported in the literature to raise awareness of this uncommon diagnosis.

Methods

Medical records of patients diagnosed with caecal bascule during 2001–2016 were reviewed. Data relating to their presentation, investigations, management and outcomes were obtained. A literature search was conducted through PubMed and Medline databases.

Results

Caecal bascule was diagnosed in four patients (median age: 60.5 (range: 48–75) years, two females). Patients presented with abdominal pain (4/4), distension (3/4), vomiting (3/4) and confusion (1/4) over a 1- to 4-day period. Computed tomography identified caecal displacement in three cases, and bascule was diagnosed at laparotomy in all cases. All patients underwent right hemicolectomy, with primary ileo-colic anastomosis in three cases and formation of Abcarian stoma in one case. Median length of stay was 15.5 days (range: 10–24), with no mortality. Fifteen cases of caecal bascule have been reported in the literature to date, with authors suggesting resection as definitive treatment.

Conclusion

Correct diagnosis of caecal bascule requires a high index of suspicion and avoids delay of appropriate management. Recent operation, particularly laparoscopic cholecystectomy, may be contributing factors. Resection is recommended, a sentiment echoed by reported cases in the literature.

Blue nevus-like and blue nevus-associated melanoma: a comprehensive review of the literature

March 20, 2017 - 20:00
Background

Malignant blue nevus, blue nevus-associated melanoma and blue nevus-like melanoma are all terms used to describe malignant melanomas arising from, in association with, or resembling blue nevi. This review is aimed at summarizing the available literature to reduce the confusion surrounding this rare malignancy, and aid the surgeon in choosing further diagnostic or therapeutic measures.

Methods

We conducted a search of Medline, Embase, Science Direct, Scopus and the Cochrane Library for all full text articles published in English that reported on a malignant melanoma arising from, in association with, or resembling a blue nevus.

Results

We identified 91 cases that fit the criteria above. The mean age at diagnosis was 45 years, with a slight male predominance (males: 48; females: 43). Metastatic cases were reported in 55% (n = 50), of which 16 were metastatic at the time of diagnosis, 16 developed metastases within the first year and 18 within 5 years of initial diagnosis. The mean Breslow thickness was 6.8 mm at the time of diagnosis (n = 39).

Conclusions

The histological criteria for diagnosing this malignancy are very poorly defined, and may contribute to the substantial confusion surrounding the terminology. There is no consensus on which prognostic indicators predictive of outcome in ‘conventional’ malignant melanoma are applicable to blue nevus-like melanoma/blue nevus-associated melanoma. However, two larger case series have demonstrated a significant association between Breslow thickness (or largest tumour dimension when non-epidermal) and recurrence-free survival, as well as rate of local recurrence, but larger studies are needed to confirm this.

Trends in the surgical treatment of benign prostatic hyperplasia in a tertiary hospital

March 20, 2017 - 11:25
Background

To assess current treatment trends and perioperative outcomes of transurethral resection of the prostate (TURP) and photoselective vaporization of the prostate (PVP) in a tertiary institution.

Methods

We prospectively collected a database of all patients undergoing TURP and PVP for benign prostatic hyperplasia (BPH) at a tertiary hospital between January 2011 and December 2013. Patient characteristics such as length of stay, readmission, anticoagulation status, American Society of Anesthesiologists (ASA) score and need for blood transfusion were recorded and analysed.

Results

In total, 560 cases were included: 204 (36.4%) underwent TURP and 356 (63.6%) PVP. Patients undergoing PVP had higher ASA scores (P < 0.001) and were more frequently on continuing anticoagulant therapy (P < 0.001). With regards to non-aspirin/asasantin coagulation therapy, 61 (17.1%) patients underwent PVP with their anticoagulants continued while no patients who received TURP continued anticoagulation. Blood transfusion percentages were similar at 1.0% for TURP and 1.7% for PVP but readmission proportions were higher after PVP (32 patients, 9.0%) compared to TURP (10 patients, 4.9%). These differences were attenuated when excluding patients continuing anticoagulation during the procedure.

Conclusion

At our institution, the use of PVP has been increasing on a year-by-year basis. The results of the current study demonstrated that PVP is safe in patients with increased anaesthetic risk or on active anticoagulation when compared to traditional TURP. While this makes PVP an attractive alternative to TURP in high-risk anticoagulated patients, these patients may have complex post-discharge issues that should be addressed during the informed consent process.

Diagnostic accuracy of computed tomography-guided biopsy in pathological fractures

March 17, 2017 - 21:40
Background

Obtaining a histological diagnosis is essential for appropriate management of pathological fractures. Computed tomography (CT) is an accurate method of obtaining diagnosis for musculoskeletal tumours. We analysed whether diagnostic accuracy was maintained in the evaluation of pathological fractures.

Methods

A retrospective review of 101 consecutive patients presenting to our tertiary musculoskeletal tumour centre with pathological fracture was performed. Patients underwent core needle biopsy under CT guidance of pathological fractures diagnosed by plain radiography and either CT or magnetic resonance imaging. The histopathology of the CT-guided biopsy was compared with the sample obtained from open biopsy or definitive surgery to determine diagnostic accuracy.

Results

The mean age at diagnosis was 52 ± 20 years (range: 18–85) in a cohort of 46 men and 55 women. Diagnostic accuracy of CT-guided biopsy was 82.18%. There were 65 malignant and 36 benign tumours with diagnostic accuracy of 86.15% and 80.56%, respectively. The positive predictive value for a malignant tumour was 98.21% whilst it was 93.1% for benign tumours. The femur (53 cases) and humerus (25 cases) were the commonest bones fractured. The most frequent diagnoses were metastasis (20.79%), giant cell tumour (17.82%), osteosarcoma (9.90%) and myeloma (9.90%). There were no complications of CT-guided biopsy.

Conclusion

Pathological fracture does not confound the diagnosis of musculoskeletal tumours. CT-guided biopsy is an accurate diagnostic tool in the evaluation of pathological fractures. Final diagnosis and management should be made in the context of appropriate anatomical and functional imaging using a multidisciplinary approach.

Causes of pain and loss of function in rotator cuff disease: analysis of 1383 cases

March 17, 2017 - 21:21
Background

The New Zealand Rotator Cuff Registry is a multicentre, nationwide prospective study of rotator cuff repairs established in March 2009.

Methods

A total of 1383 rotator cuff repairs were included in this study, all with completed baseline Flex-SF scores, pain scores and standardized operative forms.

Results

Increasing tear size and tear retraction, over 4 cm, were associated with decreasing Flex-SF scores but not pain. Tear area (a composite of tear size and retraction) is increased with advancing age, male gender and a traumatic history but not with smoking. Increased pain scores were associated with supraspinatus (SS) single tears, compared to subscapularis tears, and with labral tears. SS/infraspinatus tears had lower Flex-SF scores compared to subscapularis/SS.

Conclusion

This study presents the relationship between baseline function, pain and tear characteristics in symptomatic rotator cuff tears. Increasing tear size and retraction are related to a loss of function but have minimal effect upon pain. Pain generators included labral pathology, and the involvement of SS. The intraoperative appearance of the long head of biceps pathology did not predict baseline pain and function.

Incidental parathyroidectomy during total thyroidectomy is not a direct cause of post-operative hypocalcaemia

March 17, 2017 - 21:20
Background

Post-operative hypocalcaemia is the most common complication after total thyroidectomy, with a reported incidence of transient hypocalcaemia up to 50% and permanent hypocalcaemia 1.5–4%. The impact of incidental parathyroidectomy (IPE) on post-operative hypocalcaemia remains controversial. This study evaluated the risk factors for IPE following total thyroidectomy and compared post-operative calcium levels serially between patients with and without IPE.

Methods

A retrospective analysis of patients undergoing total thyroidectomy from January 2009 to October 2016 at Western Health was conducted. Histopathology reports were reviewed to identify specimens that included parathyroid tissue. Risk factors and dichotomous data were analysed by exact test of difference in binomial proportions. Group comparison of serial calcium levels (preoperative to 48 h post-operative) between the no IPE and IPE patients were analysed by calculating the area under the curve producing a time series summary.

Results

Four hundred and sixty-eight patients were included: 395 were females (81%), with a median age of 51 years. IPE was confirmed histologically in 84 patients (17.7%) and was more likely to occur in patients undergoing total thyroidectomy with central neck dissection (P = 0.0003), and in patients with malignant disease (P = 0.0005). The difference in area under the curve for serial post-operative calcium levels between the no IPE and the IPE groups was 0.61 (P = 0.21, 95% confidence interval: −0.37 to 1.58).

Conclusion

Total thyroidectomy for malignancy and with central node dissection had a higher risk of IPE but did not result in significant changes in post-operative serum calcium levels.

Biomarkers and anastomotic leakage in colorectal surgery: C-reactive protein trajectory is the gold standard

March 17, 2017 - 19:52
Background

Anastomotic leakage is a feared complication following colorectal surgery. Early prediction results in improved clinical outcome, but accurate predictive factors remain elusive. Many biomarkers have been studied with respect to diagnosis of anastomotic leakage but the concept of trajectory testing, using biomarkers, has not been assessed with regards to early diagnosis of anastomotic leak.

Methods

C-reactive protein (CRP), procalcitonin (PCT), white cell count (WCC) and gamma-glutamyl transferase were assessed for predictive utility in diagnosing anastomotic leakage with emphasis on identifying an association with change in their levels or trajectory. Levels were collected preoperatively and daily for the first 5 post-operative days on patients undergoing elective colorectal surgery, involving an anastomosis. Anastomotic leakage was defined clinically by operative or radiological intervention. Comparison was made between biomarkers and clinical anastomotic leakage, using receiver operator characteristic curves for logistic models, based on trajectory of the four biomarkers.

Results

A total of 197 consecutive patients were analysed. Eleven patients developed clinical anastomotic leakage. An association of biomarker trajectory with anastomotic leakage was observed for WCC, PCT and CRP, but not for gamma-glutamyl transferase. CRP was the superior biomarker based on trajectory, with area under the receiver operator curve of 0.961.

Conclusion

This study identifies change in CRP, WCC and PCT as potential markers of anastomotic leakage following colorectal surgery and in particular highlights CRP trajectory as extremely accurate in diagnosing anastomotic leakage requiring intervention. External validation should be sought before incorporating this into routine clinical practice, given the numbers in this study.

Efficacy of dermal substitute on deep dermal to full thickness burn injury: a systematic review

March 17, 2017 - 19:52
Background

The study aims to systematically examine the efficacy of dermal regeneration templates (DRTs) in comparison to split thickness skin grafting (STSG) in the management of acute burn injuries post-excision and debridement.

Methods

Systematic literature search was conducted by two independent reviewers from the following databases: MEDLINE, EMBASE and Cochrane Library with selection criteria set a priori. Only randomized controlled trials (RCTs) were included. Main outcomes extracted were percent of STSG take, infection rate and scar quality.

Results

Seven studies were included. Three of the seven studies reported no significant difference in STSG take between burn wounds treated with dermal substitute and or STSG only. Three of the seven studies reported either low rates of infection or no significant difference in infection rates between dermal substitute and control. Four of the seven studies reported no significant difference in scar quality. Statistical pooling of data was not performed due to heterogeneity of the studies.

Conclusion

Current RCTs available are generally of small sample size with poor methodological reporting. Given the results of more recent RCTs, the risk associated with DRTs is low and it can be a useful alternative for immediate wound coverage post-burn excision. However, there is still no strong evidence to support that DRTs have significant impact on scaring.

Orthopaedic research in Australia: a bibliographic analysis of the publication rates in the top 15 journals

March 15, 2017 - 19:11
Background

To investigate the publications rates and characteristics of the authors for manuscripts originating from Australia in the 15 highest ranked orthopaedic journals over a 5-year period.

Methods

The 15 highest ranked journals in orthopaedics, based on their 2015 impact factor, were used to establish the total number of publications and cumulative impact factor points between January 2010 and December 2014. The affiliations of the primary author and co-authors were used to determine the involvement of Australian trained orthopaedic surgeons. Study location, research topic and anatomic areas were recorded.

Results

A total of 478 publications were identified; 110 of these manuscripts were principally authored by Australian trained orthopaedic surgeons or medical professionals affiliated with orthopaedics. In addition, 158 articles were published with orthopaedic surgery involvement where one of the co-authors was an Australian trained surgeon. Australian orthopaedic surgeon (FRACS) involvement was most commonly observed in the knee (n = 90; 33.6%) followed by the hip (n = 69; 25.7%) and basic sciences (n = 27; 10.1%). Surgeons in Sydney had the highest number of publications (n = 95; 35.4%), followed by Adelaide (n = 55; 20.5%) and Melbourne (n = 54; 20.1%).

Conclusion

The results of this study demonstrate that the minority (23%) of the publications originating from Australia in the 15 highest-ranking orthopaedic journals were principally authored by either an Australian trained surgeon or a trainee surgeon. A total of 59% of the publications focused on the hip and knee. Sydney was the leading region, followed by Adelaide and Melbourne. These three regions published 76% of all manuscripts identified during the 5-year study period.

Laboratory Risk Indicator for Necrotizing Fasciitis score for early diagnosis of necrotizing fasciitis in Darwin

March 15, 2017 - 19:10
Background

Soft tissue infections are a major health burden in the Top End of the Northern Territory of Australia. Necrotizing fasciitis (NF) is associated with mortality rates from 8 to 40%. Early recognition and aggressive surgical debridement are the cornerstones of successful treatment. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, developed by Wong et al., uses six routine biochemical variables to aid early diagnosis. We aim to assess the diagnostic efficacy of the LRINEC score in our population.

Methods

A retrospective review of patients with NF between 2005 and 2013 was conducted. A time matched cohort of abscesses/cellulitis was selected. Admission bloods were used to calculate the LRINEC score. An intraoperative finding of NF was used as the gold standard definition for comparison. The diagnostic accuracy of the LRINEC score was assessed.

Results

Ninety-eight patients with NF and 205 control patients were identified. The area under the receiver operator curve for the LRINEC score in detecting NF was 0.925 (0.890–0.959, P < 0.001). The sensitivity of the LRINEC ≥5 for NF was 76.3%, with a specificity of 93.1%. The positive and negative predictive values were 95.5 and 88.1%, respectively. The positive and negative likelihood ratios were 11 and 0.25.

Conclusion

The LRINEC score is a useful, robust, non-invasive and easily calculated scoring system that can be used as an adjunct to early diagnosis of NF. However, a high degree of clinical suspicion remains the most important factor in early diagnosis of NF.