ANZ Journal of Surgery

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Wiley Online Library : ANZ Journal of Surgery
Updated: 5 hours 25 min ago

Risk factors for multidrug-resistant Gram-negative infection in burn patients

August 30, 2017 - 13:40
Background

Infection with multidrug-resistant (MDR) Gram-negative organisms leads to poorer outcomes in the critically ill burn patient. The aim of this study was to identify the risk factors for MDR Gram-negative pathogen infection in critically ill burn patients admitted to a major tertiary referral intensive care unit (ICU) in Australia.

Methods

A retrospective case–control study of all adult burn patients admitted over a 7-year period was conducted. Twenty-one cases that cultured an MDR Gram-negative organism were matched with 21 controls of similar age, gender, burn size and ICU stay. Multivariable conditional logistic regression was used to individually assess risk factors after adjusting for Acute Burn Severity Index. Adjusted odds ratios (ORs) were reported. P-values < 0.25 were considered as potentially important risk factors.

Results

Factors increasing the risk of MDR Gram-negative infection included superficial partial thickness burn size (OR: 1.08; 95% confidence interval (CI): 1.01–1.16; P-value: 0.034), prior meropenem exposure (OR: 10.39; 95% CI: 0.96–112.00; P-value: 0.054), Gram-negative colonization on admission (OR: 9.23; 95% CI: 0.65–130.15; P-value: 0.10) and escharotomy (OR: 2.66; 95% CI: 0.52–13.65; P-value: 0.24). For cases, mean age was 41 (SD: 13) years, mean total body surface area burned was 47% (SD: 18) and mean days in ICU until MDR specimen collection was 17 (SD: 10) days.

Conclusion

Prior meropenem exposure, Gram-negative colonization on admission, escharotomy and superficial partial thickness burn size may be potentially important factors for increasing the risk of MDR Gram-negative infection in the critically ill burn patient.

Mental training in surgical education: a systematic review

August 29, 2017 - 20:05
Background

Pressures on surgical education from restricted working hours and increasing scrutiny of outcomes have been compounded by the development of highly technical surgical procedures requiring additional specialist training. Mental training (MT), the act of performing motor tasks in the ‘mind's eye’, offers the potential for training outside the operating room. However, the technique is yet to be formally incorporated in surgical curricula. This study aims to review the available literature to determine the role of MT in surgical education.

Methods

EMBASE and Medline databases were searched. The primary outcome measure was surgical proficiency following training. Secondary analyses examined training duration, forms of MT and trainees level of experience. Study quality was assessed using Consolidated Standards of Reporting Trials scores or Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group.

Results

Fourteen trials with 618 participants met the inclusion criteria, of which 11 were randomized and three longitudinal. Ten studies found MT to be beneficial. Mental rehearsal was the most commonly used form of training. No significant correlation was found between the length of MT and outcomes. MT benefitted expert surgeons more than medical students or novice surgeons.

Conclusion

The majority studies demonstrate MT to be beneficial in surgical education especially amongst more experienced surgeons within a well-structured MT programme. However, overall studies were low quality, lacked sufficient methodology and suffered from small sample sizes. For these reasons, further research is required to determine optimal role of MT as a supplementary educational tool within the surgical curriculum.

Left renal vein ligation for large splenorenal shunt during liver transplantation

August 29, 2017 - 20:05

Adequate hepatopetal portal vein blood flow is obligatory to ensure proper liver function after liver transplantation. Large collateral veins as shunts impair portal vein flow and even cause hepatofugal blood flow and portal steal syndrome. In particular, splenorenal shunts in liver transplant recipients can lead to allograft dysfunction and possible allograft loss or hepatic encephalopathy. Restoration of portal flow through left renal vein ligation (LRVL) is a treatment option, which is much easier compared to splenectomy, renoportal anastomosis and shunt closure, but bears the risk of moderate and temporary impairment of renal function. In addition, a patent portal vein is mandatory for LRVL. However, although LRVL has been reported to be an effective, safe and easy method to control portacaval shunts and increase hepatopetal flow in some studies, indications and safety are still not clear. In this review, we summarize existing studies on LRVL during liver transplantation.

The Perth Emergency Laparotomy Audit

August 24, 2017 - 13:11
Background

Emergency laparotomies (ELs) are associated with high mortality and substantial outcome variation. There is no prospective Australian data on ELs. The aim of this study was to audit outcome after ELs in Western Australia.

Methods

A 12-week prospective audit was completed in 10 hospitals. Data collected included patient demographics, the clinical pathway, preoperative risk assessment and outcomes including 30-day mortality and length of stay.

Results

Data were recorded for 198 (76.2%) of 260 patients. The 30-day mortality was 6.5% (17/260) in participating hospitals, and 5.4% (19 of 354) across Western Australia. There was minimal variation between the three tertiary hospitals undertaking 220 of 354 (62.1%) ELs. The median and mean post-operative lengths of stay, excluding patients who died, were 8 and 10 days, respectively. In the 48 patients with a prospectively documented risk of ≥10%, both a consultant surgeon and anaesthetist were present for 68.8%, 62.8% were admitted to critical care and 45.8% commenced surgery within 2 h. The mortality in those retrospectively (62; 31%) and prospectively risk-assessed was 9.5% and 5.2%, respectively.

Conclusion

This prospective EL audit demonstrated low 30-day mortality with little inter-hospital variation. Individual hospitals have scope to improve their standards of care. The importance of prospective risk assessment is clear.