ANZ Journal of Surgery

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Wiley Online Library : ANZ Journal of Surgery
Updated: 3 hours 32 min ago

Arthroscopic, open and mini-open approach for rotator cuff repair: no difference in pain or function at 24 months

September 22, 2017 - 09:00
Background

The New Zealand Rotator Cuff Registry was established in 2009 to collect prospective functional, pain and outcome data on patients undergoing rotator cuff repair (RCR).

Methods

Information collected included an operation day technical questionnaire completed by the surgeon and Flex Shoulder Function (SF) functional and pain scores preoperatively, immediately post-operatively and at 6, 12 and 24 months. A multivariate analysis was performed analysing the three surgical approaches to determine if there was a difference in pain or functional outcome scores.

Results

A total of 2418 RCRs were included in this paper. There were 418 (17.3%) arthroscopic, 956 (39.5%) mini-open and 1044 (43.2%) open procedures. Twenty-four-month follow-up data were obtained for pain and Flex SF in 71% of patients. At 24 months, there was no difference in the average Flex SF score for the arthroscopic, mini-open and open groups. There was no difference in improvement in Flex SF score at 24 months. At 24 months, there was no difference in mean pain scores. There was no difference in improvement in pain score from preoperation to 24 months. Most patients returned to work within 3 months of surgery, with no difference between the three surgical approaches.

Conclusion

RCR has good to excellent outcomes in terms of improvement in pain and function at 2-year follow-up. We found no difference in pain or functional outcome at 24 months between arthroscopic, open and mini-open approaches for RCR.

Benchmarking against the National Emergency Laparotomy Audit recommendations

September 20, 2017 - 10:06
Background

The Royal College of Anaesthetists published the National Emergency Laparotomy Audit (NELA) to describe and compare inpatient care and outcomes of major emergency abdominal surgery in England and Wales in 2015 and 2016. The purpose of this article is to compare emergency abdominal surgical care and mortality in a regional hospital (Logan Hospital, Queensland, Australia) with NELA results.

Methods

Data were extracted from two databases. All deaths from May 2010 to April 2015 were reviewed and patients who had an emergency abdominal operation within 30 days of death were identified. The health records of all patients who underwent abdominal surgery were extracted and those who had an emergency laparotomy were identified for analysis.

Results

Three hundred and fifty patients underwent emergency laparotomy and were included in the analysis. The total 30-day mortality during this 5-year period was 9.7%. Factors affecting mortality included age, Portsmouth-Physiological and Operative Severity Score (P-POSSUM) and admission source. Timing of antibiotic administration, use of perioperative medical service and frequency of intensive care admission were the same in patients who died and survived.

Conclusion

Mortality in patients following emergency laparotomy at Logan Hospital compares favourably with 11.1% reported by NELA. This may be partly attributable to case mix distribution as for each P-POSSUM risk Logan Hospital mortality was at the upper end of that reported by NELA. Further Australia data are required. Improved compliance with NELA recommendations may improve outcomes.

Functional outcome of low rectal resection evaluated by anorectal manometry

September 19, 2017 - 09:50
Background

Low anterior resection syndrome (LARS) covers disordered bowel function after rectal resection, leading to deterioration in patients’ quality of life. The aim of this study was to evaluate anorectal function after laparoscopic low anterior resection (LAR) by means of standardized instruments.

Methods

This was a prospective clinical cohort study conducted in a single institution to assess functional outcome of patients 1 year after laparoscopic LAR by means of LARS score and high-resolution anorectal manometry.

Results

In total, 65 patients were enrolled in the study. Mean tumour height was 9.4 ± 1.8 cm; total mesorectal excision during laparoscopic LAR with low end-to-end colorectal anastomosis was performed in all patients. One year after the surgery, minor LARS was detected in 33.9% of patients, major LARS in 36.9% of patients. Anorectal manometry revealed decreased resting pressure and normal squeeze pressure of the anal sphincters in the majority of our patients. Rectal compliance and rectal volume tolerability (first sensation, urge to defaecate and discomfort volume) were significantly reduced. The statistical testing of the correlation between LARS and manometry parameters showed that with increasing seriousness of LARS, values of some parameters (resting pressure, first sensation, urge to defaecate, discomfort volume and rectal compliance) were reduced.

Conclusion

This study indicates that the majority of patients after laparoscopic LAR experience symptoms of minor or major LARS. These patients have decreased resting anal sphincter pressures, decreased rectal volume tolerability and decreased rectal compliance.

From ancient to avant-garde: a review of traditional and modern multimodal approaches to surgical anatomy education

September 19, 2017 - 09:50

The landscape of surgical anatomy education is progressively changing. Traditional methods, such as cadaveric dissection and didacticism are being increasingly phased out in undergraduate courses for multimodal approaches incorporating problem-based learning, radiology and computer-based simulations. Although effective at clinically contextualizing and integrating anatomical information, these approaches may be a poor substitute for fostering a grasp of foundational ‘pure’ anatomy. Dissection is ideal for this purpose and hence remains the cornerstone of anatomical education. However, novel methods and technological advancements continually give way to adjuncts such as cadaveric surgery, three-dimensional printing, virtual simulation and live surgical streaming, which have demonstrated significant efficacy alone or alongside dissection. Therefore, although divergent paradigms of ‘new versus old’ approaches have engulfed and divided the community, educators should seek to integrate the ancient and avant-garde to comprehensively satisfy all of the modern anatomy learner's educational needs.

Paediatric mild head injury: is routine admission to a tertiary trauma hospital necessary?

September 19, 2017 - 09:48
Background

Previous studies have shown that children with isolated linear skull fractures have excellent clinical outcomes and low risk of surgery. We wish to identify other injury patterns within the spectrum of paediatric mild head injury, which need only conservative management. Children with low risk of evolving neurosurgical lesions could be safely managed in primary hospitals.

Methods

We retrospectively analysed all children with mild head injury (i.e. admission Glasgow coma score 13–15) and skull fracture or haematoma on a head computed tomography scan admitted to Westmead Children's Hospital, Sydney over the years 2009–2014. Data were collected regarding demographics, clinical findings, mechanism of injury, head computed tomography scan findings, neurosurgical intervention, outcome and length of admission. Wilcoxon paired test was used with P value <0.05 considered significant.

Results

Four hundred and ten children were analysed. Three hundred and eighty-one (93%) children were managed conservatively, 18 (4%) underwent evacuation of extradural haematoma (TBI surgery) and 11 (3%) needed fracture repair surgery. Two children evolved a surgical lesion 24 h post-admission. Only 17 of 214 children transferred from peripheral hospitals needed neurosurgery. Overall outcomes: zero deaths, one needed brain injury rehabilitation and 63 needed child protection unit intervention. Seventy-five percentage of children with non-surgical lesions were discharged within 2 days. Eighty-three percentage of road transfers were discharged within 3 days.

Conclusions

Children with small intracranial haematomas and/or skull fractures who need no surgery only require brief inpatient symptomatic treatment and could be safely managed in primary hospitals. Improved tertiary hospital transfer guidelines with protocols to manage clinical deterioration could have cost benefit without risking patient safety.

Non-drainage versus drainage in tourniquet-free knee arthroplasty: a prospective trial

September 19, 2017 - 09:47
Background

It is still unknown whether drainage is necessary and non-drainage is safe and acceptable after tourniquet-free total knee arthroplasty (TKA). We aim to investigate whether non-drainage use is accepted in TKA that is performed without a tourniquet.

Methods

Clinical data of 80 adult patients who did or did not receive drainage in our centres from August 2015 to December 2015 were prospective investigated.

Results

The drainage group exhibited reduced hidden blood loss (47.6 ± 43.6 mL versus 151.1 ± 97.1 mL, P < 0.001), less calf swelling (d1: 3.2% versus 5.2%, P = 0.02) and milder knee active pain (d3: 4.9 ± 1.9 versus 5.9 ± 1.2, P = 0.01; d5: 3.2 ± 1.6 versus 4.2 ± 1.5, P = 0.003) than the non-drainage group. However, the non-drainage group had higher haemoglobin level (d1: 112.1 ± 10.6 g/dL versus 106.1 ± 12.4 g/dL, P = 0.026; d3: 99.5 ± 9.6 g/dL versus 92.7 ± 13.1 g/dL, P = 0.011) and less haematopoietic medication usage (42.1% versus 66.6%, P = 0.03) in the initial postoperative period following TKA. Earlier postoperative time to ambulation (22.4 ± 12.3 h versus 30.1 ± 14.6 h, P = 0.01) and shorter length of stay (5.5 ± 1.2 days versus 6.3 ± 1.7 days, P = 0.02) were found in the non-drainage group.

Conclusion

It is practicable to abandon wound drainage in uncomplicated, primary, tourniquet-free TKA.

Changing face of robot-assisted radical prostatectomy in Melbourne over 12 years

September 19, 2017 - 09:47
Background

This study aims to characterize the trends in disease presentation for robot-assisted radical prostatectomy (RARP) over a 12-year period in Melbourne, Australia.

Methods

All patients undergoing an RARP between 2004 and October 2016 while under the care of six high-volume surgeons were included in this study. Data were collected prospectively regarding patient demographics and clinical details of their cancer.

Results

Over the 12-year time span of the study, 3075 men underwent an RARP with a median age of 63.01 years. Temporal analysis demonstrated that the median age of patients undergoing prostatectomy advanced with time with the median age in 2016 being 65.51 years compared with 61.0 years in 2004 (P < 0.001). There was also a significant trend to increased D'Amico risk groups over time with the percentage procedures for high-risk patients increasing from 12.6% to 28.10% from 2004 to 2016 (P < 0.001). Upgrade rates between biopsy and pathological Gleason grade scoring significantly trended down over the period of the study (P < 0.001). There was also a shift to increased pathological stage over the 12 years with 22.1% of men having T3 disease in 2004 compared with 49.8% in 2016.

Conclusion

Our analysis demonstrates increasing treatment of older men with higher risk tumours, consistent with international trends. While this largely reflects a shift in case selection, further work is needed to assess whether the stage shift may relate partially to a decline in screening and increased presentation of higher risk disease.

Comparison of perioperative, renal and oncologic outcomes in robotic-assisted versus open partial nephrectomy

September 19, 2017 - 09:47
Background

To compare perioperative, renal and oncological outcomes after robotic-assisted partial nephrectomy (RAPN) versus open partial nephrectomy (OPN) for the treatment of renal tumours.

Methods

All partial nephrectomies performed at a Metropolitan Urology Centre between 2010 and 2016 were analysed. Baseline data was collected for patient demographics, tumour characteristics (tumour size, laterality and polarity, RENAL scores), and perioperative variables (e.g. warm ischaemic time, operation time, estimated blood loss (EBL), length of stay). Tumour characteristics included malignancy, clinical stage, Fuhrman nuclear grade and surgical margin status. Day-1 post-operative serum creatinine, estimated glomerular filtration rate (eGFR) and 6-month eGFR stage were used for assessing renal function.

Results

Two hundred patients underwent partial nephrectomy between 2010 and 2016 (n = 200; 55 OPN versus 145 RAPN). Baseline data was similar between groups, except for lower age (P = 0.0001) and higher RENAL scores (P = 0.001) in the RAPN group. RAPN demonstrated significantly lower complication rates (P = 0.015), lesser EBL (P = <0.0001), shorter hospital stays (P = <0.001) and reduced positive tumour resection margins (P = 0.039). There was no significant difference in mean operation time between RAPN and OPN (137.2 (±48.0) OPN versus 146.07 (±35.91) RAPN; P = 0.16). No statistical difference was shown for post-operative eGFR stage between groups at Day-1 and 6-month post-surgery (P = 0.15 and P = 0.861, respectively).

Conclusion

We present the largest reported Australian series on partial nephrectomy, confirming that a robotic-assisted approach is equivalent to OPN, with reduced complications, EBL, length of hospital stays and fewer positive margins, even when resecting more complex tumours.

Wound tension and ‘closability’ with keystone flaps, V-Y flaps and primary closure: a study in fresh-frozen cadavers

September 19, 2017 - 09:47
Background

Previous publications have implied that the keystone flap provides mechanical benefits compared to primary closure. This has not been objectively demonstrated.

Methods

Elliptical defects were created in ‘fresh-frozen’ cadaveric specimens. Two approaches were used to investigate the potential mechanical benefits of keystone flaps. Experiment 1 (wound closure): 18 defects were incrementally enlarged until they could not be closed primarily either with a single ‘midpoint’ suture or with a continuous suture. Attempts were then made to close these wounds with island flaps: 13 keystone flaps (seven ‘type IIA’ and six ‘Sydney Melanoma Unit (SMU) modification’) and five V-Y flaps. Experiment 2 (tension reduction): 28 defects were fashioned to be ‘closable’ under high tension. The ‘pre-flap tension’ was measured with a single midpoint suture and tensiometer. Fourteen keystone flaps (seven type IIA and seven SMU modifications) and seven V-Y flaps were then developed and mobilized with no flap constructed on the remaining seven ‘primary closure’ wounds. The secondary defects resulting from flap mobilization were closed leaving the primary defect unsutured. The primary defect ‘post-flap tension’ was then measured using the same technique.

Results

For Experiment 1, V-Y flaps enabled closure in four of five ‘unclosable’ defects. Keystone flaps did not enable closure in any of the 13 cases (P < 0.001). For Experiment 2, the V-Y flap (n = 7) was the only group that produced a significant drop in wound tension across the primary defect (mean ‘pre-flap’ to ‘post-flap’ tension change: −53%, 95% CI: −67 to −39%, P < 0.001).

Conclusion

The data raise questions about the biomechanical benefits of keystone flaps.

Medium-term outcomes of fenestrated endovascular repair of juxtarenal abdominal aortic aneurysms

September 19, 2017 - 09:47
Background

Abdominal aortic aneurysms pose a substantial clinical burden, and a significant proportion are not anatomically suitable for open repair or standard endovascular aneurysm repair (EVAR), instead requiring fenestrated EVAR (fEVAR). We sought to compare clinical outcomes and trends over time in patients undergoing fEVAR in Australia.

Methods

We conducted a retrospective analysis of all patients undergoing fEVAR at a tertiary referral centre between 2010 and 2015, including outcomes and complications, both as inpatients and after discharge.

Results

Thirty-nine patients underwent fEVAR during the study period, with mean age of 75 years and mean aneurysm size of 61 mm. One hundred and thirty-four target vessels were treated and inhospital mortality was 5% (two patients). There were nine inhospital, eight Type II and one Type III endoleaks. Ten patients suffered acute kidney injury, one of whom required dialysis. Mean follow-up was 14.5 months (range: 0–46.7). Target vessel patency was 99.2% at follow-up. There were six Type II endoleaks at follow-up, and two patients died during the follow-up period (of non-aneurysm-related causes).

Conclusion

fEVAR is an effective treatment with low morbidity and mortality, and we have demonstrated excellent survival and target vessel patency at a mean follow-up of 14 months. Endoleak rates were low, despite the high complexity of the aneurysms treated.

Survival improvements with adjuvant therapy in patients with glioblastoma

September 19, 2017 - 09:47
Background

Evaluate survival of patients diagnosed with glioblastoma multiforme (GBM) managed with adjuvant intensity modulated radiation therapy and temozolomide since the introduction of the European Organisation for Research and Treatment of Cancer and National Cancer Institute of Canada Clinical Trials Group (EORTC-NCIC) protocol.

Methods

All patients with GBM managed between May 2007 and December 2014 with EORTC-NCIC protocol were entered into a prospective database. The primary endpoint was the median survival. Univariate predictors of survival were evaluated with respect to tumour resection, age and Eastern Cooperative Oncology Group (ECOG) performance status using log-rank comparisons.

Results

Two hundred and thirty-three patients were managed under the protocol and analysed for outcome. The median age was 57 years; the rate of gross total resection, subtotal resection and biopsy were 47.2%, 35.2% and 17.6%, respectively. At progression, 49 patients had re-resection, and in addition to second-line chemotherapy, 86 patients had Bevacizumab including 26 with re-irradiation. Median survival was 17.0 months (95% CI: 15.4–18.6). On univariate evaluation, extent of resection (P = 0.001), age, ECOG performance status and recursive partitioning analysis class III were shown to significantly improve survival (P < 0.0001). The median survival for gross total resection, age <50 years, ECOG 0–1 and recursive partitioning analysis class III were 21, 27, 20 and 47 months, respectively.

Conclusion

This study confirms the significant improvement in median survival in GBM that has occurred in recent years since introduction of the EORTC-NCIC protocol. Further improvements have occurred presumably related to subspecialized care, improved resection rates, sophisticated radiotherapy targeting and early systemic salvage therapies. However, the burden of the disease within the community remains high and the median survival improvements over time have plateaued.

Survival outcomes in elderly men undergoing radical prostatectomy in Australia

September 19, 2017 - 09:47
Background

To investigate the outcomes of patients older than 75 years of age in Victoria undergoing radical prostatectomy for prostate cancer.

Methods

Data on all men undergoing radical prostatectomy in Victoria between 1 January 2004 and 31 December 2014 were obtained from the Victorian Cancer Registry. Tumour characteristics including Gleason grade, stage of disease and cause of death were obtained. Statistical analysis was performed using chi-squared test, Cox proportional hazards method and Kaplan–Meier analysis.

Results

A total of 14 686 men underwent radical prostatectomy during the defined period, with a median follow-up of 58 months. Of these, 332 were men over the age of 75. All parameters are comparisons between patients >75 years of age and men <75 years of age. Men >75 years had a higher proportion of Gleason grade ≥8 disease (16.6% versus 11.4%, P < 0.001) but had similar stage of disease. Men >75 years had lower rates of 5- and 10-year overall survival (67.3% versus 96.3% and 27.7% versus 89.1%) and lower rates of 5- and 10-year prostate cancer-specific survival (96.2% versus 99.3% and 94.3% versus 97.4%), respectively. Age was an independent risk factor for prostate cancer specific and overall mortality on multivariate analysis (hazard ratio 1.49, 95% confidence interval 1.32–1.68; P < 0.001 and hazard ratio 4.26, 95% confidence interval 2.15–8.42; P < 0.001), when adjusted for stage and grade.

Conclusion

Older men undergoing radical prostatectomy in Victoria had higher-grade disease but similar stage. Age was an independent risk factor for worse prostate cancer-specific and overall survival.

Adrenal ganglioneuroblastoma in an adult

September 19, 2017 - 09:47

Neoadjuvant systemic therapy for breast cancer: the Westmead experience

September 19, 2017 - 09:46
Background

Neoadjuvant systemic therapy (NAST) can be used to treat breast cancer. Pathologic complete response (pCR) is a surrogate marker for improved survival. This study examined response in the breast and axilla to NAST and identified features associated with pCR.

Methods

Patients undergoing NAST and surgery between January 2012 and June 2016 by surgeons at Westmead Breast Cancer Institute were identified. Patients with inflammatory or metastatic disease were excluded. Data were analysed to identify factors predictive of pCR.

Results

Ninety-one patients were identified. Mean age was 49 years. Forty-one patients had axillary metastases identified prior to NAST. Eighty-three patients received chemotherapy alone, six endocrine therapy alone and two had both. Thirty-seven patients had mastectomy and 54 had breast-conserving surgery. The overall breast pCR rate was 29% higher in patients with triple-negative (50%) or HER2-positive (39%) disease and lower in luminal disease (11.6%, P = 0.001). Forty percent of node-positive patients became node negative. The only variable associated with pCR was tumour biology. Patients with HER2-positive breast cancer were more likely to have axillary pCR than those with luminal cancer (odds ratio: 28, P = 0.00005).

Conclusion

pCR in either the breast or axilla was most likely to be achieved in patients with HER2-positive or triple-negative breast cancers. In patients with luminal cancers, the goal of NAST is best considered to facilitate surgical options rather than obtaining a pCR.

Unicortical and bicortical plating in the fixation of comminuted fractures of the clavicle: a biomechanical study

September 19, 2017 - 09:46
Background

Intraoperative neurovascular complications with clavicle fracture fixation are often due to far cortex penetration by drills and screws, but could be avoided using a unicortical construct. The objective of this study was to compare the bending and torsional strength of a unicortical locking screw plate construct and a hybrid (with central locked and outer non-locked long oblique screws) unicortical plate construct for clavicle fracture fixation with that of a conventional bicortical locking screw construct of plate fixation.

Methods

Twenty-four human clavicle specimens were harvested and fractured in a comminuted mid-shaft butterfly configuration. Clavicles were randomly allocated to three surgical fixation groups: unicortical locking screw, bicortical locking screw and hybrid unicortical screw fixation. Clavicles were tested in torsion and cantilever bending. Construct bending and torsional stiffness were measured, as well as ultimate strength in bending.

Results

There were no significant differences in bending stiffness or ultimate bending moment between all three plating techniques. The unicortical locked construct had similar torsional stiffness compared with the bicortical locked construct; however, the hybrid technique was found to have significantly lower torsional stiffness to that of the bicortical locking screw construct (mean difference: 87.5 Nmm/degree, P = 0.028).

Conclusions

Unicortical locked screw plate fixation and hybrid unicortical plating fixation with centrally locked screws and outer long, oblique screws may alleviate far cortex penetration, protecting nearby anatomical structures, and may ease implant removal and conversion to bicortical fixation for revision surgery; however, use of long oblique screws may increase the risk of early loosening under torsion.