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Time is of the essence: evaluation of emergency department triage and time performance in the preoperative management of acute abdomen

ANZ Journal of Surgery - 21 May 2019 - 10:54pm

Time is of the essence: Evaluation of emergency department triage and time performance in the pre‐operative management of acute abdomen.


Background

Acute abdomen is a time‐critical condition, which requires prompt diagnosis, initiation of first‐line preoperative therapy and expedient surgical intervention. The earliest opportunity to intervene occurs at presentation to the emergency department triage. The aim of this audit was to evaluate the relationship between emergency triage and time performance measures in the preoperative management of abdominal emergencies.

Methods

Retrospective audit of time performance measures of key clinical events from emergency triage. Patient characteristics, elapsed time from triage to commencement of fluid resuscitation, intravenous antibiotics and emergency surgery and post‐operative outcomes were obtained from review of operative medical records data over a 1‐year duration.

Results

There was variability in triage allocation of patients with acute abdomen requiring urgent surgery. Category 3 was the most commonly assigned triage category (65.6%). The majority of patients (94.8%) had initial clinical assessment within the National Emergency Access Target ‘4‐hour’ rule, and 41.7% seen within 1‐h from triage. Despite this, in cases of intra‐abdominal sepsis, there was nearly a fourfold elapsed time for first dose intravenous antibiotics, beyond the 1‐h recommendation in the Sepsis Kills pathway. There was non‐significant trend in faster overall time performances with successive higher triage category allocation.

Conclusion

This study highlights an opportunity to consider alternative triage methods or fast‐track of patients with acute abdomen to promote early surgical assessment, resuscitation, antibiotic therapy and definitive intervention.

Fenestrated endovascular aneurysm repair is associated with lower perioperative morbidity and mortality compared with open repair for complex abdominal aortic aneurysms

Journal of Vascular Surgery - 20 May 2019 - 12:45am
The Zenith Fenestrated Endovascular Graft (ZFEN; Cook Medical, Bloomington, Ind) has expanded the anatomic eligibility of endovascular aneurysm repair (EVAR) for complex abdominal aortic aneurysms (AAAs). Current data on ZFEN mainly consist of single-institution experiences and show conflicting results. Therefore, we compared perioperative outcomes after repair using ZFEN with open complex AAA repair and infrarenal EVAR in a nationwide multicenter registry.

Using bifurcated endoprosthesis after iliac artery recanalization for concomitant abdominal aortic aneurysm and chronic total occlusions of access routes

Journal of Vascular Surgery - 20 May 2019 - 12:45am
Concurrent abdominal aortic aneurysm (AAA) and unilateral iliac occlusion is a challenge in the implantation of bifurcated stent grafts (BFGs). The endovascular approach is less invasive than open surgery; the aortouni-iliac (AUI) graft with crossover femorofemoral bypass (CFFB) has many problems associated with extra-anatomic reconstruction. We attempted endovascular aneurysm repair (EVAR) using BFGs in such cases and evaluated the outcomes.

The role of heparin in endovascular repair of blunt thoracic aortic injury

Journal of Vascular Surgery - 18 May 2019 - 12:00am
Early diagnosis and treatment are essential to improve survival of patients with blunt thoracic aortic injury (BTAI). Often, aortic surgical intervention may be delayed because of increased risk of bleeding with heparin, particularly in polytrauma victims. We believe that surgical delay may be remedied by proceeding without heparinization. This study reviewed the outcome of patients subjected to thoracic endovascular aortic repair (TEVAR) under full, low-dose, and no intraoperative systemic heparinization.

Factors associated with elimination of type II endoleak during the first year after endovascular aneurysm repair

Journal of Vascular Surgery - 18 May 2019 - 12:00am
The natural history of endoleak type II (ET II) after endovascular aneurysm repair (EVAR) is still debatable. The aim of this study was to examine the presence of preoperative and postoperative factors associated with persistence of ET II during the initial 12-month follow-up period.

Frailty assessment in older adults undergoing interventions for peripheral arterial disease

Journal of Vascular Surgery - 18 May 2019 - 12:00am
Frailty is a multidimensional syndrome that influences postoperative morbidity and mortality after vascular procedures; however, its integration in clinical practice has been limited, given the lack of consensus on how to measure it. This study sought to compare the incremental predictive value of six different nonphysical performance frailty scales to predict poor outcomes after interventions for peripheral arterial disease (PAD).

Overview of arterial pathology related to repetitive trauma in athletes

Journal of Vascular Surgery - 18 May 2019 - 12:00am
Sport-related vascular trauma is an important consequence of increased physical activity. Repetitive, high-intensity movements predispose athletes to vascular disease, including arterial pathology, by exerting increased pressure on neurovascular structures. This is an important source of morbidity in an otherwise young and healthy population. Arterial pathology associated with repetitive trauma is often misdiagnosed as musculoskeletal injury. This article increases awareness of sport-related arterial disease by reviewing the symptomatology, investigation, and treatment modalities of this pathology.

Utility of skin perfusion pressure values with the Society for Vascular Surgery Wound, Ischemia, and foot Infection classification system

Journal of Vascular Surgery - 18 May 2019 - 12:00am
The addition of skin perfusion pressure (SPP) might enhance the predictive value of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system. The purpose of the present study was to evaluate the SPP for each WIfI classification stage among patients with foot wounds by cross-referencing the results of prospectively monitored limb outcomes and to derive the SPP criteria that could be combined with other measurements to grade ischemia for the WIfI classification.

Results of infrainguinal revascularization with bypass surgery using a heparin-bonded graft for disabling intermittent claudication due to femoropopliteal occlusive disease

Journal of Vascular Surgery - 18 May 2019 - 12:00am
The purpose of this study was to analyze the results of infrainguinal revascularization for disabling intermittent claudication (IC) due to femoropopliteal occlusive disease using bypass graft (BPG) surgery with a heparin-bonded expanded polytetrafluoroethylene (HB-ePTFE) graft.

Active Tobacco Use in Patients with Claudication Does Not Affect Outcomes Following Endovascular Interventions

Annals of Vascular Surgery - 16 May 2019 - 12:00am
With the advent of endovascular procedures, the indications for intervention in claudicants have become less strict. Many interventionalists, however, will not intervene on patients with life style limiting claudication unless they have discontinued tobacco use. Many patients are unable to comply with this goal and there is little published evidence to suggest that continued tobacco use results in poorer outcomes. We sought to determine if it is justified to deny this group of patients endovascular, potentially life style improving, procedures based upon their outcomes.

Selection Bias and Endoleaks: Can We See Through the Fog?

In the current issue of EJVES, Nolz et al. provide details on a study of risk prediction for type I or III endoleaks using combined baseline clinical and anatomical parameters.1 The concept is naturally appealing: if one could use available pre-operative characteristics to determine the risk of important complications such as direct endoleaks, decision making and informed consent would be improved. However, this cannot be adequately demonstrated by the present study.

Arteriotomy Closure: More About Keeping Options Open

An increasing number of therapeutic interventions are via large bore percutaneous femoral access, such as endovascular aneurysm repair (EVAR) and transcatheter aortic valve implantation (TAVI),1 as emphasised by Chen et al.2 As minimally invasive interventions, today it makes little sense to access the femoral artery via open cutdown, with the particular recognition of reduction in complications such as pain,3 seroma formation, and wound infection,4 and increase in benefits such as reduced operating time5 and early return to activity.

Role of nerve block as a diagnostic tool in pudendal nerve entrapment

ANZ Journal of Surgery - 15 May 2019 - 6:40pm
Background

Pudendal nerve entrapment is a disabling condition which is difficult to diagnose and treat. Nantes criteria include the requirement of positive anaesthetic pudendal nerve block that is widely used to allow identification of patients likely to benefit from the definitive but invasive pudendal nerve release. This study aimed to determine if pudendal nerve blockade under general anaesthesia could diagnose and temporarily treat pudendal nerve entrapment in patients suffering from chronic pelvic/perineal pain and/or organ dysfunction.

Methods

This retrospective analysis of a prospectively maintained database examined the outcomes of all recipients of diagnostic pudendal nerve block in a quaternary referral centre between 2012 and 2017. Primary outcome was relief of perineal pain (transient or permanent). Secondary outcomes were demographics, referral patterns for definitive procedure and complication rates. Statistical analysis was performed using SPSS v 24.

Results

A total of 77 patients were included in the study. Mean age was 57.27 ± 13.55 years. Majority were females (n = 62, 80.5%). Relief of pain was experienced by 47 of 76 (68.1%) patients after initial injection. Complication rate of injection was 3.9% (n = 3) which in all cases was unilateral lower limb paraesthesia. Of the 37 patients (52.9%) referred, 20 underwent surgical decompression with 12 (60%) being successful.

Conclusion

Pudendal nerve injection is a safe and simple procedure that can provide accurate diagnosis and transient relief from this chronic and debilitating problem. This technique helps to isolate patients suitable for pudendal nerve decompression which offers high success rates.

Resectable recurrent colorectal liver metastasis: can radiofrequency ablation replace repeated metastasectomy?

ANZ Journal of Surgery - 15 May 2019 - 1:13am

As far as we know, this article is the first to compare the clinical results of radiofrequency ablation (RFA) versus repeated surgery for resectable colorectal liver metastases recurrence. We found that recurrence occurred more frequently and in shorter interval after RFA, especially in patients with tumor size >3 cm. Liver resection and percutaneous RFA achieved similar overall survival.


Background

Percutaneous radiofrequency ablation (RFA) is used as a first‐line treatment for colorectal liver metastases that recur after first liver resection in our institution. We aim to evaluate its therapeutic efficacy compared to repeated surgical resection.

Methods

A retrospective review was performed in 104 patients treated with curative intent for resectable recurrent colorectal liver metastases.

Results

Sixty‐one patients underwent RFA and 43 patients underwent surgery. The overall recurrence rates were 82% in the RFA group and 65.1% in the resection group (P = 0.05). The local recurrence rate on a lesion‐basis was markedly higher after RFA than that after resection (16.7% versus 7.3%, P = 0.04). The difference remained significant in patients with a maximum lesion diameter >3 cm (24.5% versus 7.6%, P = 0.01). RFA treatment was independently associated with recurrence on multivariate analyses (P = 0.01). 69.7% of RFA patients and 42.6% of surgery patients with intrahepatic recurrence were amenable to repeated local treatment (P = 0.05), leading to the equivalent actuarial 3‐year progression free survival rates (RFA: 29.1% versus Resection: 33.1%, P = 0.48) and 5‐year overall survival rates in the two treatment groups (RFA: 33% versus Resection: 28.4%, P = 0.36).

Conclusions

Surgery remains the treatment of choice for resectable recurrence. RFA may offer similar benefit in selected patients.

Assessing adequacy of informed consent for elective surgery by student‐administered interview

ANZ Journal of Surgery - 14 May 2019 - 10:01pm
Background

Studies show that patients often sign consent documents without fully comprehending the risks, benefits and potential complications. There is currently no Asian study performed analysing adequacy of informed consent. This study aims to assess adequacy of informed consent by evaluating patient understanding and retention of key information and complications pertaining to surgery via medical student‐administered interview.

Methods

A prospective study was performed on 48 patients undergoing groin hernia surgery, laparoscopic cholecystectomy and total thyroidectomy from 2017 to 2018 in a teaching hospital. Standardized assessment forms including major common complications and key details of the surgery were prepared. Structured one‐to‐one interviews between students and patients were performed and recorded on the morning of surgery.

Results

Although 93.8% of the patients claimed to have understood the information regarding their surgery, only 19.4%, 44.4% and 62.5% of the patients could actually recall the serious complications of groin hernia surgery, laparoscopic cholecystectomy and thyroidectomy, respectively. Elderly patients (>65 years) had poorer understanding of surgical procedure compared to the young (80% versus 100%, respectively, P = 0.008) with 26.7% of elderly patients claiming that they did not understand the indication for surgery. High satisfaction rates with this preoperative interview were reported by both patients and students (95.8% and 97.9%, respectively). Time interval from informed consent to surgery did not make any difference.

Conclusion

Understanding of information and key complications was generally low, especially in the elderly population. The structured preoperative interview achieved the dual goal of reinforcing patient gaps in knowledge and improving student communication skills.

Response of the Australian Medical Services to restoration of mobile warfare on the Western Front in 1918 (part I)

ANZ Journal of Surgery - 14 May 2019 - 10:00pm

On 21 March 1918, after nearly 4 years of static warfare on the Western Front, German forces launched a massive offensive from the Hindenburg Line against a depleted British Fifth Army. Elite storm troops smashed through British forward and battle zone positions and advanced more than 17 miles in 2 days. By 5 April, the Germans were outside the town of Villers‐Bretonneux, 40 miles from their starting position and 15 miles from the railway junction of Amiens. This paper examines the response of Australian Medical Services to the restoration of mobile warfare and explains the measures that were put in place to deal with the evacuation of casualties.


On 21 March 1918, after nearly 4 years of static warfare on the Western Front, German forces launched a massive offensive from the Hindenburg Line against a depleted British Fifth Army. Elite storm troops smashed through British forward and battle zone positions and advanced more than 17 miles in 2 days. By 5 April, the Germans were outside the town of Villers‐Bretonneux, 40 miles from their starting position and 15 miles from the railway junction of Amiens. This paper examines the response of the Australian Medical Services to the restoration of mobile warfare and explains the measures that were put in place to deal with the evacuation of casualties.

Response of the Australian Medical Services to restoration of mobile warfare on the Western Front in 1918 (part II)

ANZ Journal of Surgery - 14 May 2019 - 10:00pm

On 4 July 1918, at the Battle of Hamel, Australian Medical Services used a Field Ambulance Resuscitation Team for the first time, delivering life‐saving blood transfusion and early definitive surgery to badly wounded soldiers very soon after their wounds had been inflicted. During the closing months of the war, many lives and limbs were saved by early resuscitation and effective surgery, an achievement which stands out in marked contrast to the situation in 1914, when inadequate resuscitation, outdated surgical methods and appalling delays in delivering treatment resulted in great numbers of unnecessary deaths.


On 4 July 1918, at the Battle of Hamel, the Australian Medical Services used a Field Ambulance Resuscitation Team for the first time, delivering life‐saving blood transfusion and early definitive surgery to badly wounded soldiers very soon after their wounds had been inflicted. During the closing months of the war, many lives and limbs were saved by early resuscitation and effective surgery, an achievement that stands out in marked contrast to the situation in 1914, when inadequate resuscitation, outdated surgical methods and appalling delays in delivering treatment resulted in great numbers of unnecessary deaths.

Outcomes following radical cystectomy: a population‐based study from Queensland, Australia

ANZ Journal of Surgery - 14 May 2019 - 9:59pm

This population‐based study of outcomes following radical cystectomy found 30‐ and 90‐day mortality was low. Some population sub‐groups, such as older patients are at heightened risk of post‐operative mortality. Regular monitoring of outcomes following oncologic surgery using quality indicators allows clinicians to reflect on practice and helps to identify areas for improvement.


Background

Radical cystectomy (RC) is a complex uro‐oncology surgical procedure with high surgical morbidity. We report on outcomes following RC for bladder cancer using a population‐based cohort of patients.

Methods

Patients receiving an RC from 2002 to 2016 were included and linked to their cancer‐related surgical procedures. Hospitals were categorized as high (>7 RCs/year) and low (≤7 RCs/year). Outcomes included 30‐ and 90‐day mortalities and 2‐year overall survival (OS). Multivariable logistic regression models were used to examine factors associated with the outcomes of interest. OS was estimated using the Kaplan–Meier survival function.

Results

During the 15‐year study period, 1230 patients underwent an RC for invasive bladder cancer. In‐hospital mortality was 1.1%, and 30‐ and 90‐day mortality was 1.4% and 2.9%, respectively. Both 30‐ and 90‐day mortalities were significantly higher for older versus younger patients (P = 0.01 and P < 0.001, respectively), and lymph node involvement was significantly associated with 90‐day mortality (P = 0.002). Patients treated more recently were about 80% less likely to die within 90 days. The 2‐year OS was 71.5%, with significant improvements observed over time (P < 0.001). While we found no evidence of a hospital‐volume relationship for post‐operative mortality or survival, patients treated in low‐volume compared to high‐volume hospitals were more likely to have surgical margin involvement (10.9% versus 7.1%, respectively, P = 0.03).

Conclusion

We observed low post‐operative mortality rates overall, with rates decreasing significantly over time. Some subgroups of patients experience poorer post‐operative outcomes. Reporting on post‐operative outcomes, and survival over time helps monitor clinical progress and identify areas for improvement.

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