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: 10 hours 2 min ago

Re: Lack of online video educational resources for open colorectal surgery training

April 30, 2019 - 01:16
ANZ Journal of Surgery, Volume 89, Issue 5, Page 618-618, May 2019.

Bedside ultrasonography by surgeons: a new diagnostic adjunct for cholecystitis and gallstone disease

April 30, 2019 - 01:16
ANZ Journal of Surgery, Volume 89, Issue 5, Page 460-461, May 2019.

Being a better surgeon: a multi‐competency challenge

April 30, 2019 - 01:16
ANZ Journal of Surgery, Volume 89, Issue 5, Page 461-463, May 2019.

American College of Surgeons National Surgical Quality Improvement Program: first Australian experience

April 30, 2019 - 01:16
ANZ Journal of Surgery, Volume 89, Issue 5, Page 459-460, May 2019.

25, 50 & 75 years ago

April 30, 2019 - 01:16
ANZ Journal of Surgery, Volume 89, Issue 5, Page 469-470, May 2019.

Multidisciplinary care of cancer patients: a passing fad or here to stay?

April 30, 2019 - 01:16
ANZ Journal of Surgery, Volume 89, Issue 5, Page 464-465, May 2019.

Gender bias in sexual health education: why boys do not know where the prostate is?

April 30, 2019 - 01:16
ANZ Journal of Surgery, Volume 89, Issue 5, Page 467-468, May 2019.

Chest drain management post‐oesophagectomy: a survey of Australian and New Zealand surgeons

April 30, 2019 - 01:16
ANZ Journal of Surgery, Volume 89, Issue 5, Page 465-467, May 2019.

Issue information ‐ TOC

April 30, 2019 - 01:16
ANZ Journal of Surgery, Volume 89, Issue 5, Page 454-457, May 2019.

Issue information ‐ PI

April 30, 2019 - 01:16
ANZ Journal of Surgery, Volume 89, Issue 5, May 2019.

Surgical Diseases of the Pancreas and Biliary Tree

April 30, 2019 - 01:16
ANZ Journal of Surgery, Volume 89, Issue 5, Page 596-596, May 2019.

Selective Cholecystectomy: using an evidence‐based prediction model to plan for cholecystectomy

April 30, 2019 - 01:16
Background

Symptomatic gall stones are treated safely and efficiently with laparoscopic cholecystectomy. Conversion to open cholecystectomy may be associated with adverse outcomes. Accurate prediction of conversion should decrease the incidence of conversion and improve patient care.

Methods

The recent literature on conversion at laparoscopic cholecystectomy is reviewed to identify robust prediction models that are both internally and externally validated.

Results

Two prediction models are identified which meet these criteria.

Conclusions

The Cairns Prediction Model using nomograms, is an easily applied tool predicting conversion, which is presently in use. Routine use of this tool should decrease conversion, and improve the process of patient consent.

Minimally invasive surgery for hilar cholangiocarcinoma: state of art and future perspectives

April 30, 2019 - 01:16
Background

Hilar cholangiocarcinoma (HCCA) occurs in the core section of the biliary system and has a strong tendency to broadly invade the surrounding vascular system, perineural tissue and major liver parenchyma. Thus, minimally invasive resection can only be achieved in limited cases. This article reviews the current laparoscopic and robotic surgery techniques for HCCA and analyses the difficulties and limitations of the current minimally invasive surgical techniques for HCCA.

Methods

A systematic literature search was conducted using multiple electronic databases. All studies involving minimally invasive resections of HCCA were included (up to November 2017).

Results

Twelve studies were included, of which eight concerned laparoscopic surgery of HCCA and four involved robotic surgery for HCCA. For laparoscopic surgery, most of the surgical procedures were limited to partial hepatectomy or even bile duct resection; the post‐operative morbidity rate was approximately 38.9% (range 0–100%); those with fewer complications were mostly restricted to Bismuth type I or type II carcinomas. For robotic surgery, only one study concerned caudate lobectomy of HCCA, with a reported median operative time of 703 min and post‐operative morbidity of 90%.

Conclusions

Minimally invasive surgery for HCCA is restricted to highly selected cases and is deemed technically achievable in experienced hands. However, technical and instrumental improvement is needed to reduce the relevant morbidity and popularize the use of minimally invasive surgery to treat HCCA.

Detecting tumour response and predicting resectability after neoadjuvant therapy for borderline resectable and locally advanced pancreatic cancer

April 30, 2019 - 01:16
Background

This systematic review aimed to determine the accuracy of imaging modalities to predict resectability and R0 resection for borderline resectable (BRPC) or locally advanced pancreatic cancer (LAPC) after neoadjuvant therapy (NAT).

Methods

A systematic search of major databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines.

Results

Fifteen studies identified 995 patients of which 683 had BRPC and 312 LAPC. Computed tomography (CT) scan was the most common modality for re‐staging (n = 14), followed by positron emission tomography (PET)‐CT (n = 3) and endosonography (EUS) (n = 2). Stable disease on RECIST criteria was found in 67% of patients (range 53–80%) with 20% demonstrating reduction in tumour size. A total of 60% of patients underwent surgery post‐NAT (range 31–85%) with a R0 rate of 88% (range 57–100%). Accuracy for predicting R0 resectability and T‐stage on CT scan was 71 and 49%. A reduction in SUVmax on PET‐CT and reduction of tumour stiffness on EUS elastography positively correlated with resectability.

Conclusions

More than half the patients undergo resection post‐NAT for LAPC and BRPC. Stable, or reduction of, tumour disease may predict resectability. Reduction in tumour SUVmax on PET‐CT and decreased tumour stiffness on EUS elastography may be potential markers of NAT response and resectability.

Are breast conservation treatment rates optimized for Asian women with symptomatic malignancies?

April 30, 2019 - 01:16

Breast conservation treatment (BCT) rates among Asian women have been reported to be between 20% and 40%, which is significantly below the benchmark of 50%. This study was performed to determine if BCT rates can be further increased in the light of contemporary data which suggest that women receiving BCT have superior overall, breast cancer‐specific and local recurrence‐free survival rates.


Background

Published data indicate that 20–40% of patients undergo breast conservation treatment (BCT) in Asia, which is below an indicative benchmark of 50%. With an increasing body of evidence suggesting that BCT might be associated with improved survival outcomes, it is exigent to increase BCT utilization. This study was therefore undertaken to evaluate BCT rates for women presenting with symptomatic breast cancer and potential for de‐escalation of surgical treatment.

Methods

All patients who presented with symptomatic tumours and underwent surgical treatment at the authors’ healthcare facility between January 2009 and December 2011 were included in this retrospective study. Standard wide excision was performed to achieve clear margins and reasonable cosmetic outcomes for BCT‐eligible patients. Oncoplastic techniques such as therapeutic mammoplasty or volume replacement with flaps were not employed.

Results

A total of 116 women presented with symptomatic breast cancer. The majority (92.2%) were Asian. Mean age at diagnosis was 48.3 years and mean tumour size was 23.4 mm. Ninety‐five patients (81.9%) underwent BCT. Of the 22 patients, 13 (59%) who underwent neoadjuvant chemotherapy had sufficient tumour size downstaging to successfully undergo BCT instead of mastectomy.

Conclusion

It is possible for more than 80% of Asian women with symptomatic breast malignancies to undergo BCT, with the appropriate use of neoadjuvant medical therapy and surgical techniques. As increasing data indicate improved survival with BCT, this should be offered as the treatment of choice.

Epithelial tissue cut‐out following needle insertion into a joint: a potential complication during arthroscopy

April 30, 2019 - 01:16
Background

Knee arthroscopy is a common orthopaedic procedure and often involves insertion of a needle through skin into a joint. This needle insertion can create epithelial tissue cut‐outs possibly containing commensal bacteria that can be flushed into the joint, and potentially lead to post‐arthroscopy septic arthritis. This study aims to assess the frequency of epithelial tissue cut‐out creation on insertion of different needle sizes at different angles to the skin.

Methods

Using an ex‐vivo porcine limb tissue model, needles of various gauge (14–23G) were inserted at angles of 90, 60, 45 and 30° to the skin surface. Ten passes were undertaken at each angle. Needle lumen contents were then examined for solid tissue cut‐out.

Results

Two hundred and eighty needle passes were performed resulting in 70 tissue cut‐outs (25%) containing solid material. This was more common amongst lower gauge needles. 8 of the 70 (11.4%) tissue cut‐outs contained macroscopic evidence of epithelium. The overall rate of epithelial tissue cut‐out was 2.9%. The 23G needle had the lowest rate of tissue cut‐out creation, occurring twice out of 40 passes (P = 0.002). Neither of these contained macroscopic epithelial tissue.

Conclusion

Hypodermic needle insertion through skin into a joint can create epithelial tissue cut‐out. Epithelial tissue cut‐out occurs more frequently with use of lower gauge needles. This study suggests use of a 23G needle during arthroscopy, inserted either at 60 or 90° to the skin, to reduce epithelial tissue cut‐out and any potential contribution to post‐arthroscopy septic arthritis.

Safety of single‐anaesthetic versus staged bilateral primary total knee replacement: experience from the New Zealand National Joint Registry

April 30, 2019 - 01:16
Background

Surgical management options for bilateral knee osteoarthritis comprise staged or single‐anaesthetic bilateral total knee replacements (SABTKRs). We examined the New Zealand Joint Registry hypothesizing there would be no difference between these practices compared to unilateral total knee replacement (TKR) examining 30‐day mortality, all‐cause revision rate and function.

Methods

For this study, 84 946 primary TKRs were identified. We compared three groups: unilateral TKRs, all SABTKRs and all staged bilateral TKRs with intervals of 1 to 90 days, 91 days to 1 year and >1 year. Cumulative revision rates were calculated (Kaplan–Meier method). Mortality risks were compared to unilateral TKR and hazard ratios (HRs) calculated. Six‐month Oxford scores were compared using analysis of variance.

Results

Thirty‐day mortality for SABTKR was 0.219%: unilateral TKR 0.236% (HR 0.43; 95% confidence interval (CI) 0.38–0.48; P < 001). Staged TKR had lower mortality than unilateral TKR at three time interval groups unless performed within 90 days (adjusting for age and American Society of Anesthesiologists grade) TKR (<90 days HR 0.92; 95% CI 0.703–1.371; P = 0.915; 91–365 days HR 0.783; 95% CI 0.687–0.891; P < 0.001; >365 days HR 0.394; 95% CI 0.344–0.451; P < 0.001). Revision risk with SABTKR was lower at 0.43/100 component years (95% CI 0.37–0.49/100 component years) compared to unilateral 0.56/100 component years (95% CI 0.53–0.59; P < 0.05). Six‐month Oxford scores were superior in SABTKR versus unilateral TKR (38.6 (95% CI 38.2–39) versus 36.9 (95% CI 36.8–37.1); P < 0.001).

Conclusions

SABTKR is at least as safe as unilateral TKR or staged bilateral TKR in appropriately selected cases. Surgeons should wait at least 90 days before the second procedure.

Predictive energy equations are inaccurate for determining energy expenditure in adult burn injury: a retrospective observational study

April 30, 2019 - 01:16

Using indirect calorimetry (IC) to measure energy expenditure (EE) in adults with severe burn injury, this study found that prediction equations yielded clinically important overestimation of energy requirements compared with EE measured using IC. Measured EE correlated with day post‐burn (r = 0.42, P = 0.004), but not with % total body surface area (r = 0.02, P = 0.9). These results indicate the value of IC in determining EE in burn injury.


Background

Severe burn injuries are associated with hypermetabolism. This study aimed to compare the measured energy expenditure (mEE) with predicted energy requirements (pERs), and to correlate energy expenditure (EE) with clinical parameters in adults with severe burn injury.

Methods

Data were retrospectively analysed on 29 burn patients (median (interquartile range) age: 46 (28–61) years, % total body surface area burn: 37% (18–46%)) admitted to an intensive care unit. Indirect calorimetry was performed on 1–4 occasions per patient to measure EE. mEE was compared with pER calculated using four prediction equations. Bland–Altman and correlation analyses were performed.

Results

Mean ± SD mEE was 9752 ± 2089 kJ/day (143 ± 32% of predicted basal metabolic rate). Bland–Altman analysis demonstrated clinically important overestimation for three of the four prediction equations and wide 95% limits of agreement for all equations. Overestimation of EE was more marked early post‐burn. mEE correlated with day post‐burn (r = 0.42, P = 0.004) and number of operations prior to first EE measurement (r = 0.34, P = 0.016), but not with % total body surface area (r = 0.02, P = 0.9).

Conclusions

Patients with severe burn injury exhibit hypermetabolism. The observed poor agreement between pER and mEE at an individual level indicates the value of indirect calorimetry in determining EE in burn injury.

What is the functional result of a delayed coloanal anastomosis in redo rectal surgery?

April 30, 2019 - 01:16
Background

Delayed coloanal anastomosis (DCAA) may be used in patients with complex rectal conditions, such as chronic pelvic sepsis, low recto‐vaginal and recto‐vesical fistula; however, limited data are available. The aim is to report the morbidity and functional results of DCAA in redo rectal surgery.

Methods

All patients undergoing DCAA between January 2014 and August 2017 were retrospectively included. Success was defined as a functional anastomosis without stoma, evaluated using the Low Anterior Resection Syndrome (LARS) score and the Gastrointestinal Quality of Life Index (GIQLI) functional assessment tools.

Results

Of the 72 redo pelvic surgeries, 29 (40.3%) DCAA were performed over a 4‐year period. Indications for redo resection were chronic pelvic sepsis (n = 13, 44.8%), recto‐vaginal fistula (n = 11, 37.9%) and recto‐vesical fistula (n = 5, 17.2%). Mean interval period between the two procedures was 14 ± 3 days (8–21). Global major morbidity (Clavien‐Dindo III or IV) was seen in six patients (20.7%). Stoma closure was feasible for 22 (75.9%) patients after a median period of 78 days (interquartile range 61–98). The 6‐month success rate was 79.3%. Mean LARS was 28.8 ± 10.2 (3–41) (minor LARS) for 18 patients with no stoma at the end of follow‐up. LARS score was significantly better with a follow‐up >2 years (23.3 ± 12.2 versus 32.3 ± 7.9), P = 0.074. Mean GIQLI score was 79.2 ± 14.3 (48–98).

Conclusions

Transanal colonic pull through with delayed anastomosis for redo‐surgery in complex pelvic situations had low morbidity and avoided a permanent stoma in three out of four patients with an acceptable quality of life.

Propensity score‐matched analysis of early outcomes after laparoscopic‐assisted versus open pancreaticoduodenectomy

April 30, 2019 - 01:16
Background

Minimally invasive pancreaticoduodenectomy (PD) is a feasible option for periampullary tumours. However, it remains a complex procedure with no proven advantages over open PD (OPD). The aim of the study was to compare the outcomes between laparoscopic‐assisted PD (LAPD) and OPD using a propensity score‐matched analysis.

Methods

Retrospective review of 40 patients who underwent PD for periampullary tumours between January 2014 and December 2016 was conducted. The patients were matched 1:1 for age, gender, body mass index, Charlson comorbidty index, tumour size and haematological indices. Peri‐operative outcomes were evaluated.

Results

LAPD appeared to have a longer median operative time as compared to OPD (LAPD, 425 min (285–597) versus OPD, 369 min (260–500)) (P = 0.066). Intra‐operative blood loss was comparable between both groups. Respiratory complications were five times higher in the OPD group (LAPD, 5% versus OPD, 25%) (P = 0.077), while LAPD patients required less time to start ambulating post‐operatively (LAPD, 2 days versus OPD, 2 days) (P = 0.021). Pancreas‐specific complications and morbidity/mortality rates were similar.

Conclusion

LAPD is a safe alternative to OPD in a select group of patients for an institution starting out with minimally invasive PD, and can be used to bridge the learning curve required for total laparoscopic PD.