ANZ Journal of Surgery

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ANZ Journal of Surgery
Table of Contents for ANZ Journal of Surgery. List of articles from both the latest and EarlyView issues.
Updated: 2 days 7 hours ago

Oncoplastic breast surgery versus conventional breast‐conserving surgery: a comparative retrospective study

17 April 2019 - 2:11am

Oncoplastic breast surgery is oncologically safe, allows large resection volumes, achieving more frequently clear margins. The re‐excision rates are three times lower than with conventional surgery group. The need for additional surgery is drastically reduced.


Background

In addition to conventional breast‐conserving surgery (BCS), oncoplastic breast surgery (OBS) is an operation technique that strives simultaneously to increase oncological safety and patient's satisfaction. It is the combination of the best‐proven techniques in plastic surgery with surgery for breast cancer. In a growing number of indications, OBS overcomes the limit of conventional BCS by allowing larger resection volumes while avoiding deformities. The aim of our retrospective study (2012–2014) was to compare oncological outcomes of OBS versus BCS.

Methods

We compared two groups of patients with primary non‐metastatic breast tumours: group A (n = 291), where BCS was performed, versus group B (n = 52), where OBS was performed. Surgical interventions were performed in German and Swiss teaching hospital settings. The surgeon for group B had subspecialist training in OBS. We assessed outcome in term of re‐excision rates, resection margin and complications.

Results

Groups were homogenous (no significant differences in terms of age, tumour size, tumour type or grade). The resection margin was larger in group B (7 mm) than in group A (3 mm). Re‐excision rate of group B (8%) was significantly lower than in group A (31%). Complication rates were comparably low in groups A and B.

Conclusion

Despite the limits of retrospective design, our study confirms that OBS is safe and reduces the re‐excision rates and the need for further surgery. OBS has the potential to improve oncological care and should be more widely adopted.

Inadvertent puncture of right ventricle during chest tube insertion

16 April 2019 - 5:34am
ANZ Journal of Surgery, EarlyView.

Stereotactic body radiation therapy for early hepatocellular carcinoma: a retrospective analysis of the South Australian experience

16 April 2019 - 5:33am

This article provides the first Australian data on the emerging technique of stereotactic body radiation therapy for small hepatocellular carcinoma. It deals with a common scenario for hepatobiliary and transplant surgeons, when small and curable HCCs cannot be either resected or ablated.


Background

Stereotactic body radiation therapy (SBRT) is an emerging treatment option for liver tumours unsuitable for established curative treatment such as ablation or surgery. The aim of the study is to evaluate the efficacy and safety of SBRT in the treatment of small hepatocellular carcinoma (HCC) in South Australia.

Methods

From 2014 to 2018, 13 HCC patients were treated with SBRT. Eligibility criteria for SBRT included: unsuitable for standard curative therapies (resection or percutaneous ablation), lack of complete response to prior transarterial chemoembolization, Child–Pugh classification ≤B7, tumours ≤5 cm and minimum of up to 6 months follow‐up post‐SBRT. The prescribed radiation dose was determined by liver function with doses ranging from 40 to 45 Gy in three or five fractions. Records for all patients were reviewed, and treatment response was scored according to the modified response evaluation criteria in solid tumours. Toxicity was graded according to the Common Terminology Criteria for Adverse Events version 4.0.

Results

The median follow‐up time was 22.7 months, and the median tumour size was 40 mm. The 1 year local control was 92.3%, recurrence‐free survival was 67.7% and overall survival was 86.4% at end of study. Three patients underwent liver transplant. No grade ≥3 non‐haematological toxicities were observed. One patient experienced acute grade ≥3 haematological toxicity.

Conclusion

SBRT is a safe, effective and non‐invasive alternative treatment option for patients with small HCCs, unsuitable for standard, evidence‐based therapies and lacking complete response to transarterial chemoembolization. Randomized controlled trials are required to further investigate the role of SBRT in HCC.

Safety and effectiveness of aspirin and enoxaparin for venous thromboembolism prophylaxis after total hip and knee arthroplasty: a systematic review

15 April 2019 - 10:17pm

This review assessed the risks and benefits of aspirin compared to enoxaparin as venous thromboembolism (VTE) prophylaxis after total hip and total knee arthroplasty.This review did not find statistically significant differences between aspirin and enoxaparin. Future studies should identify more evidence, particularly for rare outcomes such as pulmonary embolism (PE), as this might help decision‐makers to get consensus on the use of aspirin as VTE prophylaxis.


Background

Patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) are at risk of venous thromboembolism (VTE). Australian orthopaedic guidelines recommend aspirin and low‐molecular‐weight heparin (e.g. enoxaparin) for VTE prophylaxis; however, there is debate in the international literature around the use of aspirin as VTE prophylaxis. This review assesses the risks and benefits of aspirin compared to enoxaparin as VTE prophylaxis for patients undergoing THA or TKA.

Methods

A systematic review was conducted to identify relevant randomized controlled trials. Studies comparing enoxaparin, aspirin and/or placebo for VTE prophylaxis in THA or TKA patients were included. Network meta‐analysis (NMA) was performed to calculate risk ratios (RRs) and confidence intervals (CIs). Quality appraisal was conducted by assessing risk of bias and the strength of the evidence.

Results

Nine randomized controlled trials were eligible for inclusion. The NMA found no statistically significant differences for the investigated outcomes: total DVT rates (RR = 1.21, 95% CI 0.86, 1.72), symptomatic pulmonary embolism (PE) rates (RR = 1.02, 95% CI 0.02, 50.86), major haemorrhage (RR = 0.97, 95% CI 0.02, 50.99) and wound complication (RR = 0.73, 95% CI 0.17, 3.20). The occurrence of PE was rare. Due to limited data, sub‐group analysis was not possible. The overall quality of evidence in the NMA is considered to be very low.

Conclusion

This review did not find statistically significant differences between aspirin and enoxaparin. Future studies should identify more evidence, particularly for rare outcomes such as PE, as this might help decision‐makers to get consensus on the use of aspirin as VTE prophylaxis.

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

15 April 2019 - 10:17pm

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.

Neck lump clinic: a new initiative at North Shore Hospital

15 April 2019 - 10:17pm

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.

Oncological safety of laparoscopic versus open colorectal cancer surgery in obesity: a systematic review and meta‐analysis

15 April 2019 - 10:17pm

Laparoscopic colorectal cancer resection is challenging in the obese patients. This meta‐analysis demonstrated, in non‐randomized studies, that laparoscopic approach in the obese patients is oncologically safe.


Background

Colorectal cancer resection in the obese (OB) patients can be technically challenging. With the increasing adoption of laparoscopic surgery, the benefits remain uncertain. Hence, the aim of this study is to assess the short‐ and long‐term outcomes of laparoscopic compared to open colorectal cancer resection in the OB patients.

Methods

A systematic review and meta‐analysis was performed according to the PRISMA guidelines. The outcome measures were 5‐year disease‐free survival, overall survival, circumferential resection margin and local and distant recurrence.

Results

A total of 20 studies were included, with a total number of 6779 participants, of whom 1785 (26.3%) were OB and 4994 (73.7%) were non‐obese (NOB) participants. The OB patients had higher R1 resection (OB 6.9% versus NOB 3.1%; P = 0.011) and lower mean number of lymph nodes harvested, with standard mean difference of −0.29; P = 0.023, favouring the NOB patients. However, there was no statistical difference for local (OB 2.8% versus NOB 3.4%) or distant recurrence (OB 12.9% versus NOB 15.2%) rate between the two cohorts. There was no difference in 5‐year disease‐free survival (OB 81% versus NOB 77.4%; odds ratio 1.25, P = 0.215) and overall survival (OB 89.4% versus NOB 87.9%; odds ratio 1.16, P = 0.572). Lastly, the OB group had higher mean total blood loss, total operative time and length of hospital stay when compared to NOB patients.

Conclusion

From a pooled non‐randomized study, laparoscopic colorectal cancer resection is safe in OB patients with equivalent long‐term outcomes compared to NOB patients. However, there is a higher morbidity rate with an increased demand on hospital resources for the OB cohort.

Fast‐track surgery for acute appendicitis in children: a systematic review of protocol‐based care

15 April 2019 - 10:17pm

‘Fast‐track surgery’ protocols aim to standardize post‐operative care, with evidence of safety and efficacy in both uncomplicated and complicated childhood appendicitis. A systematic review of the literature was performed to evaluate the current evidence underpinning fast‐track protocols for childhood appendicitis. Standardized care of childhood appendicitis has been shown to be safe and effective in several local and international centres with future directions including further integration of rationalized analgesia, a consistent classification system and identification of amenable cohorts.


Background

‘Fast‐track’ surgery protocols aim to standardize and rationalize post‐operative care, with evidence of safety and efficacy in both uncomplicated and complicated childhood appendicitis. Generalization for broader adoption has been limited by variation in protocol design, including specific antibiotic choice, discharge criteria, post‐operative monitoring and patient selection.

Methods

A systematic review of the literature was performed to evaluate the current evidence underpinning fast‐track protocols for childhood appendicitis and identify areas of consensus and controversy.

Results

About 33 studies met the inclusion criteria, including four prospective observational studies, 20 case–control studies, seven cohort studies and two randomized controlled trials studying uncomplicated (n = 9), complicated (n = 18) and mixed cohorts (n = 6). Reduction in length of hospital stay was almost universally reported, with equivalent or improved complication rates. Key themes of protocols included antibiotic choice and duration, discharge criteria and post‐operative laboratory and radiographic testing. Rationalized analgesia is an underexplored aspect of protocol design, and a standardized definition of complicated appendicitis remains elusive.

Conclusion

Standardized care of childhood appendicitis has been shown to be safe and effective in several local and international centres. Next steps include investigation of a complicated appendicitis protocol that integrates rationalized analgesia in appendicectomy recovery, and development of a consistent classification scheme for complicated disease to aid in identification of amenable cohorts.

Large saccular aneurysm of the distal ascending aorta

15 April 2019 - 10:16pm
ANZ Journal of Surgery, EarlyView.

Acute surgical unit improves outcomes in appendicectomy

15 April 2019 - 10:15pm

The acute surgical unit dedicates an on‐site registrar, an on‐call consultant and an operating theatre to the task of managing emergency general surgery presentations, 24 h/day. In this single‐centre retrospective cohort study of 1214 patients undergoing appendicectomy, compared with the prior Traditional model, the acute surgical unit model was associated with more daytime operating, fewer complications and fewer open procedures.


Background

Few large Australian studies have explored the impact of acute surgical unit (ASU) model in appendicitis.

Methods

An ASU model commenced practice at our institution on 1 August 2012. In this retrospective cohort study, patients undergoing appendicectomy 2.5 years before (Traditional group) or after (ASU group) this date were compared. Primary outcomes were median length of stay, median time from emergency department referral to theatre start and proportion of cases performed in‐hours. Secondary outcomes were rates of complications, open appendicectomy, consultant scrubbed for procedure, intensive care unit admission and re‐presentation to emergency department within 30 days.

Results

After removing those with incomplete data, 1214 patients were enrolled; 465 in the Traditional group and 749 in the ASU group. There were no significant baseline differences between groups. Compared with the Traditional group, ASU patients had similar length of stay (1.81 versus 1.81 days; P = 0.54) and time to theatre (0.59 versus 0.56 days; P = 0.14), but a greater proportion of in‐hours operation (72% versus 79%; P = 0.014). The ASU group also experienced fewer complications (9% versus 6%; P = 0.031), fewer primary open (4% versus 1%; P < 0.0001) or conversion‐to‐open appendicectomies (6% versus 2%; P < 0.0005) and had superior rates of consultant scrubbed in theatre (21% versus 56%; P < 0.00001). Rates of intensive care unit admission (1% versus 1%; P = 0.72) and re‐presentation were unchanged (5% versus 5%; P = 0.46).

Conclusion

In our institution, the introduction of an ASU model was associated with more in‐hours operations and safer care for patients undergoing appendicectomy.

Quality of life after oncoplastic breast‐conserving surgery: a systematic review

12 April 2019 - 7:48pm

The impact of oncoplastic breast‐conserving surgery compared to breast‐conserving surgery alone on quality of life is yet to be adequately investigated.


Background

Oncoplastic breast‐conserving surgery (OBCS) has gained increasing attention as a treatment option for early breast cancer patients, aiming to achieve the best possible breast symmetry with concomitant oncological safety. This paper aims to systematically review the current literature on patient quality of life (QoL) after OBCS compared with QoL after breast‐conserving surgery (BCS) alone.

Methods

MEDLINE via Ovid, CINAHL via EBSCO and PsycINFO via OvidSP were searched to retrieve all relevant studies. The reference lists of identified eligible studies were manually examined to search for additional eligible studies. The methodological quality of the included studies was assessed using the Critical Appraisal Skills Programme.

Results

A total of six articles met the inclusion criteria. Most of the studies used validated patient‐reported outcome measures for assessing QoL with good response rates. However, only one study was of sufficiently good quality to provide good evidence (P < 0.05) in favour of OBCS, while the remainder were of low to moderate quality with differences in outcomes that were not statistically significant.

Conclusion

The review found that the current evidence base is limited and not adequate enough to support or to reject the assumption that OBCS is associated with improved QoL when compared with QoL post‐BCS. However, the majority of studies show that OBCS is associated with a trend towards better patient QoL. The impact of OBCS on patient QoL needs to be more adequately investigated. Large prospective cohort studies to assess the impact of OBCS on QoL compared with QoL post‐BCS are strongly recommended.

Malignant transformation of a chronic scalp lesion: a case report

12 April 2019 - 3:59am
ANZ Journal of Surgery, EarlyView.

Unusual discovery in the liver: intrahepatic portal vein aneurysm

12 April 2019 - 3:59am
ANZ Journal of Surgery, EarlyView.

Faecal loading and antipsychotics: a case study on severe bowel obstruction

11 April 2019 - 9:45pm
ANZ Journal of Surgery, EarlyView.

Complex oesophageal disease in a 72‐year‐old male

11 April 2019 - 9:44pm
ANZ Journal of Surgery, EarlyView.

Association between higher ambient temperature and orthopaedic infection rates: a systematic review and meta‐analysis

11 April 2019 - 9:44pm

A growing body of evidence has identified surges in post‐operative infection rates following orthopaedic surgery during higher temperature periods. We conducted a meta‐analysis on this topic which included 6,620 cases and 9,035 controls from 12 studies. The pooled OR indicated an overall increased odds of post‐operative infection for patients undergoing orthopaedic procedures during warmer periods (pooled OR: 1.16, 95% confidence interval: 1.04–1.30).


Introduction

Many infectious diseases display seasonal variation corresponding with particular conditions. In orthopaedics a growing body of evidence has identified surges in post‐operative infection rates during higher temperature periods. The aim of this research was to collate and synthesize the current literature on this topic.

Methods

A systematic review and meta‐analysis was performed using five databases (PubMed, Embase, CINAHL, Web of Science and Central (Cochrane)). Study quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation method. Odds ratios (ORs) were calculated from monthly infection rates and a pooled OR was generated using the DerSimonian and Lairds method. A protocol for this review was registered with the National Institute for Health Research International Prospective Register of Systematic Reviews (CRD42017081871).

Results

Eighteen studies analysing over 19 000 cases of orthopaedic related infection met inclusion criteria. Data on 6620 cases and 9035 controls from 12 studies were included for meta‐analysis. The pooled OR indicated an overall increased odds of post‐operative infection for patients undergoing orthopaedic procedures during warmer periods of the year (pooled OR 1.16, 95% confidence interval 1.04–1.30).

Conclusion

A small but significantly increased odds of post‐operative infection may exist for orthopaedic patients who undergo procedures during higher temperature periods. It is hypothesized that this effect is geographically dependent and confounded by meteorological factors, local cultural variables and hospital staffing cycles.

Necrotizing abdominal process masquerading as a ruptured strangulated inguinal hernia

11 April 2019 - 9:43pm
ANZ Journal of Surgery, EarlyView.

Colonoscopic resection of giant colonic lipoma causing subacute large bowel obstruction

11 April 2019 - 9:43pm
ANZ Journal of Surgery, EarlyView.