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.
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Large pulmonary arteriovenous malformation with paradoxical cerebral infarction

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E337-E338, July/August 2019.

Gastrointestinal stromal tumour with an unusual presentation as a huge prostatic mass: a case report

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E341-E342, July/August 2019.

Weight loss and retroperitoneal mass

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E339-E340, July/August 2019.

Type 4 Luschka duct: a rare anatomical variant to be wary of

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E315-E316, July/August 2019.

Nothing lasts forever: Donald D. Trunkey, MD, FACS 1937–2019

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page 807-808, July/August 2019.

Acute chylous peritonitis as a result of jejunal volvulus and small bowel obstruction from a congenital band adhesion

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E345-E346, July/August 2019.

Pancreatic adenosquamous carcinoma masquerading as a locally invading splenic abscess

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E343-E344, July/August 2019.

Fatal cervicomediastinal necrotising fasciitis due to cholesteatoma

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E350-E351, July/August 2019.

Pre‐treatment wait time for head and neck cancer patients in Western Australia: description of a new metric and examination of predictive factors

August 5, 2019 - 00:12
Background

Prolonged pre‐treatment wait times in head and neck cancer are associated with increased morbidity and reduced survival. Traditional metrics exclude delays prior to biopsy, which represents an important and measurable period of time. This study aims to describe total wait time for head and neck cancer patients in our institution, to define a more accurate representation of the clinically relevant pre‐treatment wait time, and to evaluate predictive factors for prolonged wait times.

Methods

A retrospective review of head and neck cancer patients treated over 2 years in a tertiary referral centre was conducted. Patient demographics, referral symptoms, tumour details, treatment plan and key dates were analysed to identify total wait time and factors predictive of increased wait time.

Results

Two hundred and ninety‐four patients were included. Mean total wait time from initial referral to treatment initiation was 71.6 (median 61) days. The period from referral to biopsy represented 29% of mean total wait time. Factors predictive of increased wait time included presenting symptom of hoarseness, laryngeal cancer and treatment with definitive radiotherapy.

Conclusions

This study demonstrates that time from referral to biopsy represents a significant portion of total wait time, and we suggest that this be incorporated into future wait time metrics for improved clinical relevance. Furthermore, we have identified factors predicting increased wait time which can be targeted for future service improvement.

National trends in urinary diversion over the past 20 years: an Australian study

August 5, 2019 - 00:12

Over the last two decades, the annual number of cystectomies and urinary diversion procedures performed in Australia has been steadily rising. In contrast to major international academic institutions and despite increased experience, the incidence of continent urinary diversion has not increased.


Background

To investigate the trends in urinary diversion (UD) in Australia over the past 20 years, to correlate with patient demographics and to compare with international data.

Methods

A retrospective analysis of Medicare Australia data was performed using the relevant Medicare Benefit Schedule procedure codes over the past 20 years. Included diversion procedures were ureterocutaneous, ureterocolonic, intestinal conduit and continent reservoir. All patients aged older than 15 years were included in the analyses.

Results

Over the past two decades, 6124 cystectomies and 7166 UDs were subsidized by Medicare Australia. The median age group for UD was 65–74 years old and 71.8% were male. Intestinal conduit accounted for the majority of UDs (84.9%), followed by continent reservoirs (11.8%). Ureterocolonic and ureterocutaneous accounted for small proportions (2.9% and 0.4%, respectively). The absolute numbers of UD procedures increased over the past 20 years but the proportion of different methods remained constant. The rates of continent reservoir UD were significantly higher in men and people aged less than 55 years old (P < 0.001 for both). Over the course of the study, the proportion of people aged greater than 75 years undergoing UD increased significantly (P < 0.001).

Conclusion

In contrast to major international academic institutions, the proportion of continent reservoir UDs performed in Australia has not changed over the past two decades. Intestinal conduit remains the most common UD procedure.

Number of nodal metastases and prognosis in metastatic cutaneous squamous cell carcinoma of the head and neck

August 5, 2019 - 00:12

This study aimed to determine if the number of metastatic lymph nodes is an independent prognostic factor in metastatic cutaneous squamous cell carcinoma of the head and neck and whether it provides additional prognostic information to the American Joint Committee on Cancer staging. On multivariate analysis, increasing number of nodal metastases significantly predicted reduced disease‐free survival, with a 17% increased risk of recurrence or death for each additional node. This remained significant in multivariate models adjusted for American Joint Committee on Cancer 8th edition N and TNM stages. Number of nodal metastases was also associated with risk of distant metastatic failure.


Background

Existing prognostic systems for metastatic cutaneous squamous cell carcinoma of the head and neck (cSCCHN) do not discriminate between the number of involved nodes beyond single versus multiple. This study aimed to determine if the number of metastatic lymph nodes is an independent prognostic factor in metastatic cSCCHN and whether it provides additional prognostic information to the American Joint Committee on Cancer (AJCC) staging.

Methods

We retrospectively analysed 101 patients undergoing curative intent treatment for metastatic cSCCHN to parotid and/or neck nodes by surgery +/− radiotherapy at Liverpool Hospital, Sydney, Australia. The impact of number of nodal metastases on disease‐free survival (DFS) and risk of distant metastases was assessed using multivariate Cox regression.

Results

The mean number of nodal metastases was 2.5 (range 1–12). On multivariate analysis, increasing number of nodal metastases significantly predicted reduced DFS (hazard ratio 1.17; 95% confidence interval 1.05–1.30; P = 0.004), with a 17% increased risk of recurrence or death for each additional node. This remained significant in multivariate models adjusted for AJCC 8th edition nodal and TNM stages. Number of nodal metastases was also associated with risk of distant metastatic failure (hazard ratio 1.21; 95% confidence interval 1.05–1.39; P = 0.009).

Conclusion

Increasing number of nodal metastases is associated with decreased DFS and increased risk of distant metastases in metastatic cSCCHN, with a cumulative risk increase with each additional node. It provides additional prognostic information to the AJCC staging, which may be improved by incorporating information on the number of nodal metastases beyond the current single versus multiple distinction.

Major lower limb amputations in Far North Queensland

August 5, 2019 - 00:12

In this retrospective cohort analysis, patients undergoing major amputation in Far North Queensland were found to be more likely younger and diabetic than Queensland or Australian counterparts. Diabetes and renal disease were especially prevalent in our cohort, with higher rates found in Indigenous patients.


Background

Major lower limb amputation is a devastating operation most commonly performed for complications of peripheral artery disease or diabetes mellitus. Data suggest that there is a widespread variation in major amputation rates within and between countries. This study aimed to identify key characteristics of patients undergoing this procedure in our region, and to compare our population to the rest of Australia. Secondary analysis was performed to assess differences seen in the Indigenous population.

Methods

Cases were identified from a prospectively maintained database and medical records were retrospectively reviewed to record relevant clinical information. A literature review was then undertaken to compare our data to other series.

Results

A total of 51 major lower limb amputations were performed between January 2015 and January 2017, and the mean age of patients was 59.5 years. Over 70% of patients were diabetic, and one‐third required dialysis. Twenty‐three patients were identified as Indigenous, and they were significantly younger (54.6 ± 11.4 versus 63.5 ± 15.9 years, P = 0.02) and more likely to be diabetic (91.3% versus 65.2%, P ≤ 0.01) compared to non‐Indigenous patients. The most common indication was arterial ulcer or gangrene (52.9%), but Indigenous patients were more likely to have amputation due to sepsis (47.8% versus 7.1%, P < 0.01).

Conclusion

Patients undergoing major amputation in Far North Queensland are more likely to be younger and diabetic than Queensland or Australian counterparts. Diabetes and renal disease were especially prevalent in our cohort, with higher rates found in Indigenous patients.

Ureteric implantation into the bowel portion of augmented bladders during kidney transplantation: a review of urological complications and outcomes

August 5, 2019 - 00:12
Background

In patients with bladder augmentation undergoing kidney transplantation, conventional technique recommends anastomosing the transplanted ureter to the bladder. We report our technique of ureteric implantation into the bowel portion of the enterocystoplasty, and review the urological outcomes of transplantation in these patients.

Methods

Seven patients (mean age: 26 years (range 24–54 years), two females, five deceased donors) with augmented cystoplasty and subsequent kidney transplantation by a single surgeon from 2011 to 2015 were reviewed. Following standard vascular anastomosis and reperfusion of the transplanted kidney, ureteric implantation involved continuous 5/0 polydiaoxanone anastomosis between the spatulated ureter and full thickness bowel portion of the cystoplasty over a 6‐Fr double J stent. A second peri‐anastomosis layer of bowel plication was performed to prevent reflux using interrupted 3/0 vicryl sutures. Short‐term urological and kidney function outcomes were evaluated.

Results

Causes of renal failure included: posterior urethral valve with reflux nephropathy (two patients), bilateral vesicoureteric reflux (two patients), lumbosacral agenesis with neurogenic bladder (one patient), tuberculosis of the urinary tract with post‐infective ureteric stricture (one patient), and lupus nephritis (one patient). Bladder reconstruction was performed at median duration of 103 months (35–171 months) before transplantation. Gastrocystoplasty was performed in two patients while colon and/or ileum were used in the remaining six. After transplantation, all reconstructed bladders except one had a Mitrofanoff for clean intermittent self‐catheterization, 5–8 times per day. There were no post‐operative ureteric/surgical complications. Delayed graft function occurred in three of seven patients. 30‐day asymptomatic bacteriuria rate was three out of seven after stent removal. 1‐year post‐transplantation, patient and graft survival were 100%. Mean serum creatinine was 142.7 (standard deviation: 51.48). Median number of hospital admissions for urinary tract infections was 0.225 (range 0–0.40). Over a median follow‐up period of 4 years (2–7 years), one graft failed from acute T‐cell‐mediated rejection. This patient passed away from cardio‐respiratory collapse after a seizure, 35 months post‐transplantation. As of June 2018, the other six kidney grafts were functioning. No complications including calculi formation and/or malignancy were reported.

Conclusion

In patients with previously augmented bladders now undergoing kidney transplantation, ureteric implantation into the bowel portion of the cystoplasty appears to be safe.

Peritoneal encapsulation with an abnormal vessel in a band causing small bowel obstruction: a rare entity

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E354-E355, July/August 2019.

Mesenteric location of a perforated Meckel's diverticulum in an elderly patient with acute appendicitis: a case report

August 5, 2019 - 00:12
ANZ Journal of Surgery, Volume 89, Issue 7-8, Page E347-E349, July/August 2019.

Composite pronator quadratus: radial forearm free flap in functional lip reconstruction

August 5, 2019 - 00:12

Large lip defects are complex and are difficult to reconstruct, especially in terms of restoring sphincteric and motor function. The innervated pronator quadratus – radial forearm free flap is a promising novel option for these challenging reconstructive scenarios.


Background

Reconstruction of lip defects following neoplasia and trauma is a common procedure in plastic surgery. Reconstruction of large lip defects is a difficult undertaking and some degree of residual functional impairment and disability are likely to occur. Microsurgical reconstruction is the recommended technique for large lip defects; however, limitations exist regarding optimal aesthetic and functional outcomes with current free flap options.

Method

We propose a new composite flap design based on the innervated pronator quadratus with the radial forearm free flap for a more dynamic reconstruction of total or near total lip defects. Results of our series of four patients have been reviewed.

Results

The radial forearm flap – innervated pronator quadratus flap has been used in four patients thus far for lip reconstruction. This flap, in our limited series has shown excellent results in achieving oral competence, good motor function and acceptable cosmetic appearance.

Conclusion

The composite radial forearm–pronator quadratus flap is a promising new lip reconstruction technique that has potential to provide a higher level of oral competence, sphincteric function and symmetrical lip movement, than current microsurgical options in dynamic lip reconstruction. This method warrants further investigation in plastic surgery literature.

Rural centres do not have a higher prevalence of post‐operative complications than urban centres: a retrospective analysis of a mortality audit

August 5, 2019 - 00:12

Rural surgery has vital roles in delivering an effective health system in Australia. This retrospective cohort study aimed to determine whether there was a relationship between geographic location (rural versus urban) of surgical procedures of varying complexity and post‐operative complications. Our findings suggest that common and simple surgical procedures may be safely performed in rural centres.


Background

The trend towards centralization of surgical care from rural to high‐volume centres is based on studies showing better outcomes for patients requiring complex surgical procedures. However, evidence that this also applies to less complex procedures is lacking. This study therefore aimed to determine whether there was a relationship between geographic location (rural versus urban) of surgical procedures of varying complexity and post‐operative complications.

Methods

This was a retrospective cohort study examining all in‐hospital deaths reported to the Australian and New Zealand Audit of Surgical Mortality (ANZASM) between 2009 and 2016. Multivariable logistic regression was used to ascertain interactive effects of location and complexity of surgical procedures on post‐operative complications, adjusted for potential confounders.

Results

There was no interactive effect of hospital location and operation complexity on the occurrence of post‐operative complications. Post‐operative complications were reported in 2160 of 6963 (31%) patients who died post‐surgery. Patients operated on in rural centres had lower risk profiles: younger, with lower American Society of Anesthesiologists grades and less likely to present with injury and circulatory diseases. Nonetheless, risk of post‐operative complications did not differ between procedures performed in rural compared with urban hospitals.

Conclusion

Results of this study suggest that a wide range of procedures may be safely performed in rural centres. Further prospective studies of unfiltered cohorts are warranted to validate these findings.

Impact of body mass index on utilization of selected hospital resources for four common surgical procedures

August 5, 2019 - 00:12
Background

Evidence about the impact of obesity on surgical resource consumption in the Australian setting is equivocal. Our objectives were to quantify the prevalence of obesity in four frequently performed surgical procedures and explore the association between body mass index (BMI) and hospital resource utilization including procedural duration, length of stay (LOS) and costs.

Methods

A retrospective cohort study of patients undergoing four surgical procedures at a tertiary referral centre in New South Wales, between 1 January 2016 and 31 December 2016, was conducted. The four surgical procedures were total hip replacement, laparoscopic appendectomy, laparoscopic cholecystectomy and hysteroscopy with dilatation and curettage. Surgical groups were stratified according to BMI category.

Results

A total of 699 patients were included in the study. The prevalence of obesity was significantly higher than local and national population estimates for all procedures except appendectomy. BMI was not associated with increased hospital resource utilization (procedural, anaesthetic or intensive care stay duration) in any of the four surgical procedures examined after controlling for age, gender and complexity. For other outcomes of hospital resource utilization (LOS and cost), the relationship was inconsistent across the four procedures examined. A high BMI was positively associated with higher LOS, medical costs and allied health costs in those who underwent an appendectomy, and critical care costs in those who underwent laparoscopic cholecystectomy.

Conclusion

Obesity was common in patients undergoing four frequently performed surgical procedures. The relationship between BMI and hospital resource utilization appears to be complex and varies across the four procedures examined.

Neck lump clinic: a new initiative at North Shore Hospital

August 5, 2019 - 00:12

A ‘one‐stop’ neck lump clinic has been established at the North Shore Hospital (Auckland) to evaluate and manage neck lumps. Our research has shown this to be effective at reducing the number of investigations, clinics, time until surgery and cost of treatment with high patient satisfaction.


Background

Neck lumps can cause significant patient anxiety and benefit from a multidisciplinary diagnostic approach, with an ultrasound scan and fine needle aspirate. Internationally, ‘one‐stop’ clinics are used for the evaluation of neck lumps, to date no such clinic has been established in the New Zealand public hospital system. The objective of this study was to demonstrate the feasibility of a one‐stop diagnostic neck lump clinic (NLC), aiming for improved patient experience and efficiency.

Methods

A consultant‐led pilot NLC was instituted with the involvement of a head and neck surgeon, radiologist and pathologist, allowing ultrasound scan and fine needle aspirate investigations to be performed simultaneously. A retrospective audit of patients in the 12 months prior to commencement of the NLC provided a comparison group.

Results

The median number of clinic visits was 2 in the control group and 1 in the NLC (P < 0.001). Time from first specialist appointment to surgery was 192 days compared to 134.5 days for NLC (P = 0.057). Median time from first specialist appointment to treatment decision was 108.5 days compared to 0 days in the NLC (P < 0.001). Eighty‐eight percent of patients in the NLC were given a diagnosis at their first appointment. The median number of investigations required was 2 in the control group and 1 in the NLC (P < 0.001). Median cost per patient in the NLC was $794 and $1470 in the control group.

Conclusion

This pilot trial demonstrates streamlined decision‐making and efficient utilization of services with a reduction in clinic visits, investigations and cost. High patient satisfaction was reported with this service.

Regional variation in the risk of lower‐limb amputation among patients with diabetes in New Zealand

August 5, 2019 - 00:12
Background

Lower‐limb amputation is one of the most substantial and debilitating consequences of diabetes mellitus; however, the risk of lower‐limb amputation is not equally shared across the diabetic population. The aims of this study were to (i) describe regional variation in the rate of lower‐limb amputation in New Zealand among a national prevalent cohort of patients with diabetes; and (ii) explore the plausible factors that could be contributing to this variation.

Methods

Our cohort were the national prevalent cohort of individuals with diabetes in New Zealand in 2011, according to the Virtual Diabetes Register (n = 215 676). Using descriptive analysis and Poisson regression, we compared the rate of lower‐limb amputation within each of New Zealand's 20 District Health Boards with the national rate of amputation, adjusting for demographic, health care access and patient‐level factors.

Results

We observed nearly four‐fold variation in the rate of major lower‐limb amputation between regions in New Zealand, as well as nearly two‐fold variation in the rate of minor lower‐limb amputation. Adjustment for differences between regions in terms of ethnicity reduced this variation substantially for many District Health Boards. Despite adjustment for sex, age, ethnicity, deprivation, rurality, comorbidity and prior amputation, the rate of lower‐limb amputation in a number of District Health Boards remained substantially higher than the national rate.

Conclusions

These observations could help to inform the funding and provision of diabetic foot care services across New Zealand; however, more work is required to further untangle the drivers of national variation in rates of lower‐limb amputation.