The Australian and New Zealand journal of surgery最新文献

Background: A rational algorithm for the management of symptomatic pancreatic pseudocysts is necessary with the increasing availability of radiological, surgical and endoscopic methods of treatment.

Methods: A retrospective audit of the management and outcome of all patients who presented with symptomatic pancreatic pseudocysts to the Auckland Hospital over a 9-year period (1988-96) was made.

Results: There were 44 patients (28 men, 16 women; median age 50; range 18-81) in this series. Initial management was not based on pseudocyst size, duration, location, wall thickness, the patients' symptoms and comorbidity, or the aetiology of pancreatitis. Of the 27 patients who had initial conservative management, 15 pseudocysts (56%) completely resolved. Of the 17 patients who were initially or subsequently treated with percutaneous catheter drainage (PCD), 10 pseudocysts (59%) completely resolved without additional treatment. Of the 13 patients initially or subsequently treated by surgery, all but one completely resolved after the first procedure. Two patients were successfully treated with endoscopic pancreatic stent placement. Complications arose in eight patients treated with PCD (47%) and four patients treated with surgery (31%). There was no mortality. The decision for active treatment was not preceded by delineation of the pancreatic duct by ERCP (endoscopic retrograde cholangiopancreatography) in 60% of patients.

Conclusions: More than one-third of all patients with symptomatic pancreatic pseudocysts can be managed conservatively. Surgery yields excellent results but PCD has a high failure rate in patients with an underlying pancreatic duct stricture. A rational management algorithm is presented, based on pre-intervention ERCP, which should improve patient selection and outcome.

Background: A retrospective analysis of data from the Victorian Inpatient Minimum Database (VIMD) was conducted to analyse trends in prostatectomy rates in Victorian public acute-care hospitals from 1989/90 to 1994/95. The study also sought to identify predictors of adverse events (AE) after prostatectomy, and to compare in-hospital complications between open prostatectomy and transurethral resection of prostate (TURP).

Methods: All patients who had undergone any prostatectomy were identified according to the relevant ICD-9-CM procedure codes (60.2-60.4) documented in the VIMD. The main outcome measures, AE, were identified using the ICD-9-CM supplementary classification of external cause of injury (E850-858, E870-876, E878-879, E930-949). The variables used as predictors were year of prostatectomy, type of admission (planned, emergency), location of the hospital (rural, metropolitan), type of procedure (TURP, open), and teaching status of the hospital. Crude and adjusted odds ratios (OR) were based on univariate and multivariate logistic regression.

Results: The rates of prostatectomies have significantly increased over the 6-year study period (P for trend < 0.0001). The percentage of AE after prostatectomy increased simultaneously from 6.1 to 12.9% (P < 0.0001). During the same period, the in-hospital mortality rate after prostatectomy decreased from 1.2 to 0.5%, and length of stay decreased from 10.3 to 6.1 days (Kruskal-Wallis P < 0.0001). The significant predictors of outcome were year of prostatectomy (P for trend < 0.0001), emergency admissions (OR = 1.57; P < 0.0001), metropolitan hospitals (OR = 0.81; P = 0.0003), non-teaching hospitals (OR = 0.78; P < 0.0001), and open prostatectomy (OR = 1.52; P = 0.04). More in-hospital complications were associated with open prostatectomy than with TURP.

Conclusions: The rise in AE rate after prostatectomy is unlikely to reflect poor quality of care, because in the same period there was a significant decrease in in-hospital mortality after prostatectomy. A more likely explanation is heightened awareness of AE with a lower threshold for reporting such events. Important factors other than variations in quality of care can result in an increase in AE. Hence the reported increase should be interpreted with caution before attempting to conclude that changes in clinical practice could have a direct impact on these rates.

Background: Transurethral resection of prostate (TURP) is among the top 10 surgical conditions that account for hospital admission in Victoria. Bed utilization for TURP is an increasing concern in current times. This paper describes trends in length of stay (LOS) and identifies predictors of LOS for TURP in Victoria.

Methods: Trends in TURP were studied using ICD-9-CM coded Victorian hospital morbidity data from public hospitals from 1987/88 to 1994/95. Detailed morbidity data from the same source for the financial year 1995/96 were used to study predictors of LOS by logistic regression.

Results: Length of stay decreased significantly between 1987 and 1995 from 10.6 to 6.1 days. The strongest predictor of increased LOS was admission through the emergency room (odds ratio (OR) 14.7; 95% confidence interval (CI) 11.8-18.3). Other significant predictors were older age, lower socio-economic status, presence of comorbid conditions, occurrence of procedural morbidity, and hospital type and location.

Conclusions: The trend in decreasing LOS may be explained by increasingly efficient bed management in hospitals who are faced with an increasing need for cost control. Advances in surgical techniques and peri-operative care have also contributed to the decrease in LOS. Other factors that influence LOS can be divided into three categories: intrinsic patient factors, such as co-morbid conditions; procedure-specific factors such as peri-operative morbidity; and intrinsic hospital factors relating to capacity and resources. Such determinants of LOS may be of value to policy makers when considering the effective application of newer methods for treatment of benign prostatic hyperplasia.

Background: Few patients with anorectal foreign bodies will freely admit to transanal introduction. The results of long-term follow-up in these patients have been sparse.

Methods: Data from April 1989 to April 1997 were extracted from a prospective computerized database. The clinical features and the results of a departmental management protocol for anorectal foreign bodies were analysed. In addition, long-term outcomes were obtained by telephone interview.

Results: Thirty patients (25 men, 5 women) with a mean age of 46 (range 16-72) years) were treated for this condition. While 10 patients (33.3%) admitted to transanal insertion, the remaining 20 (66.7%) complained of anal pain. Among the latter, the foreign body was subsequently found on routine digital rectal examination in nine patients (45%), on X-ray in nine (45%) and it was passed out unexpectedly after fleet enema in two (10%). Factors which raised suspicion for X-rays included atypical gender behaviour, lax anal sphincters and bloody or mucoid rectal discharge. Transanal recovery was successful with sedation in 12 (40%), general anaesthesia in 13 (43.3%), and laparotomy was needed in three (10%; which included one perforated bowel at presentation). There were two complications (6.7%; one minor rectal abrasion and one bronchopneumonia). There was no long-term faecal incontinence or re-impaction of foreign bodies at 63 (range 8-96) months of follow-up.

Conclusions: Foreign bodies should be suspected in patients with obscure anal pain. Judicious transanal extraction under sedation or general anaesthesia was usually successful with minimal short- and long-term complications.

Background: Oral sodium phosphate has become an attractive alternative to polyethylene glycol for colonic cleansing preparatory to elective colorectal surgery. Its use, however, has been associated with hypokalaemia. The authors of the present study tested the hypothesis that patients with cellular depletion of potassium are at significant risk for hypokalaemia with oral sodium phosphate bowel preparation.

Methods: In 23 patients, total body potassium was measured by whole-body counting and intracellular water volume was measured by bioimpedance analysis before oral sodium phosphate bowel preparation. Patients were divided into those whose serum potassium fell to 3.5 mmol/L or lower (Group 1) and those whose did not after sodium phosphate treatment (Group 2).

Results: The fall in serum potassium concentration over the period of oral sodium phosphate administration was significantly negatively correlated with intracellular potassium concentration measured prior to administration (r = -0.65, P = 0.0009). In Group 1, serum potassium concentration fell from 4.1+/-0.1 (standard error of the mean (SEM)) mmol/L to 3.2+/-0.1 mmol/L (P < 0.0001) while in Group 2 there was no significant change in this concentration (4.0+/-0.1 vs 3.9+/-0.1 mmol/L) as a result of sodium phosphate treatment. Intracellular potassium concentration prior to administration of sodium phosphate was significantly lower in Group 1 (117+/-9 mmol/L vs 143+/-7 mmol/L, P < 0.05).

Conclusions: Caution should be exercised when treating patients with oral sodium phosphate who are considered to be cellularly depleted of potassium. These patients are at risk of hypokalaemia after this treatment.

Background: This study was undertaken to determine the incidence of preventable trauma death at a non-designated trauma centre in Singapore.

Methods: A retrospective audit was carried out on all trauma deaths that occurred between January 1993 and December 1994 at the National University Hospital, Singapore. Of the 138 deaths, 38.4% (53/138) of patients were dead on arrival and were omitted from the study. Data from the remaining 85 deaths were summarized and presented before a multidisciplinary review board and injuries were scored according to the Abbreviated Injury Scale (AIS).

Results: Except for one patient, all deaths had an AIS score of 16 or greater. Sixty-one per cent (52/85) of deaths were the result of severe head injuries, and the rest had severe injuries in more than one body region. Following the guidelines of the Trauma Research and Education Foundation of San Diego, the incidence of 'not preventable', 'potentially preventable' and 'frankly preventable' deaths were 77.6, 15.3 and 7.1%, respectively. The most common errors in management were caused by delays in inter-departmental transfer (25.9%) and missed initial diagnosis (16.5%). After assessment by the Coroner's Office, autopsies were carried out in 60% of the cases and yielded information that altered the assessment of preventable deaths, particularly in the group with multiple injuries.

Conclusions: The present study concludes that the preventable death rates in the National University Hospital are comparable to those in non-trauma designated centres elsewhere. There can only be a decrease in the preventable death rate if an improved system of pre-hospital trauma care, improved interdisciplinary communication, closer supervision of the initial attending physicians and stricter protocols on clinical monitoring are established.

Background: Severe truncal multi trauma patients often develop coagulopathy, acidosis and hypothermia that makes major reparative trauma surgery dangerous. It was aimed to try to develop physiological indicators that would predict a poor outcome when conventional reparative surgery was applied. These indicators may help in the decision to switch from conventional reparative surgery to surgery limited to the control of major haemorrhage or organ disruption: so-called 'damage-control' surgery.

Method: A retrospective review was conducted of 40 patients with severe multivisceral trauma (Injury Severity Score (ISS) > 35) who were admitted to the intensive care unit at Waikato Hospital and who underwent conventional reparative surgery.

Results: Survival was strongly associated with base deficit (BD), core temperature and ISS. Using multiple logistic regression on these indices, outcome could be predicted with 92.5% accuracy (sensitivity = 93%, specificity = 92%, positive predictive value for death = 96%). Either severe hypothermia (< 33 degrees C) or severe acidosis (BD > 12 mEq/L), or a combination of moderate core temperature < 35.5 degrees C, and a BD of > 5 mEq/L were strong predictors of death if conventional reparative surgery was practised.

Conclusions: At the above mentioned levels of physiological compromise, patient survival after conventional trauma surgery can be predicted to be very unlikely. Damage-control measures would be worth attempting.