ANZ Journal of Surgery最新文献

Background: Replacing single-use operating theatre equipment with reusables might be one strategy for reducing the carbon footprint of operating theatres. However, in Australia, where the energy mix is predominantly fossil-fuel-based, the re-sterilization of reusables may increase the carbon footprint. We analyzed the financial and environmental impacts of introducing reusable operating theatre light handles in two NSW hospitals.

Methods: The effects on cost, waste, and carbon footprint of replacing disposable light handle covers with reusable handles in each hospital were analyzed over 12 months using procurement, waste and sterilization data, and life cycle assessment.

Results: Energy requirement for sterilization of reusable handles, increasing alongside weight of the handle, resulted in higher carbon footprint than using disposable covers. At one hospital, using a heavy handle increased carbon emissions sixfold, while the cost of handle sterilization exceeded the cost of disposable covers, resulting in 11% higher cost per use. At the other hospital, using a lighter handle increased carbon emissions by 40% per use, while sterilization cost was less than the cost of disposable covers, resulting in 14.8% lower cost per use. Scenario modelling indicated that sterilizing handles as part of a hollowware set rather than as individual items would significantly reduce cost and carbon footprint. At both hospitals, associated clinical waste was essentially eliminated.

Conclusion: Judicious replacement of disposable covers with lightweight yet durable reusable handles can reduce costs, but increases carbon footprint in the current Australian energy context. Adopting predominantly renewable energy and more efficient sterilization practice would mitigate this.

Background: A predominantly endoscopic approach for acute admissions with choledocholithiasis with a gallbladder in situ (CGIS) resulted in prolonged hospital length of stay due to delays at investigation and treatment junctures. We initiated a quality improvement program of trans-cystic biliary stenting to facilitate efficient patient progress to acute cholecystectomy and outpatient ERCP if required.

Methods: We utilized implementation frameworks with regular re-assessment for this quality improvement project. Patients who required both ERCP and cholecystectomy for management of CGIS were identified for comparison of total length of stay before and after implementation. The outcomes for stent insertion and ERCP were also collected for analysis.

Results: Twenty-three trans-cystic stents were attempted with 22 inserted successfully. The median total length of stay for all patients requiring both ERCP and cholecystectomy for management of CGIS was shorter compared to 6 months prior to implementation (5 days (range 3-18) vs. 6 days (range 5-17); P = 0.009). The median stenting time was 14 min (range 9-48). After stent insertion, more ERCPs were performed as day-only outpatient cases (20/23 (87.0%) vs. 6/44 (13.6%) P < 0.001). The rate of pancreatic duct wire cannulation at ERCP was also lower (1/23 (4.3%) vs. 18/44 (40.9%); P = 0.002). No complications of stent insertion or ERCP were recorded in the study cohort.

Conclusion: Implementation of trans-cystic stents can lead to reductions in total hospital length of stay and improve ERCP processes. Our experience suggests that surgical initiatives can be successfully added to routine practice by establishing a project team and applying quality improvement principles.

Background: Infected pancreatic necrosis (IPN) is a major determinant of mortality in acute pancreatitis (AP). Non-invasive diagnosis of IPN could guide the intervention in AP. We aimed to investigate the role of non-invasive methods like diffusion weighted magnetic resonance imaging (DW-MRI) and clinico-laboratory parameters as predictors of IPN.

Methods: Prospective evaluation for predictors of IPN by diffusion restriction (DR) on DW-MRI and clinico-laboratory parameters was performed.

Results: Out of 39 patients included, 31 were analysed after exclusion. Twenty-six (83.8%) patients had moderately severe AP, and the rest had severe disease. They were categorized into Group A: patients with documented infection after intervention (n = 17) and Group B: successfully managed without intervention or negative culture after intervention (n = 14). On univariate analysis, Group A had significantly more incidence of fever (P = 0.020), persistent unwellness (P = 0.003), elevated neutrophil count (P = 0.007), lymphocyte count (P = 0.007), neutrophil lymphocyte ratio (NLR) (P = 0.028), DR on DW-MRI (P = 0.001) and low apparent diffusion coefficient (ADC) (P = 0.086). Multivariate analysis revealed DR on DW-MRI (P = 0.004) and NLR (P = 0.035) as significant predictors of IPN, among other factors. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DW-MRI were 94.1%, 78.6%, 91.66%, and 84.21%, respectively. The area under curve of NLR on the ROC plot was 0.85 and the best cutoff was >3.5, with sensitivity, specificity, PPV, and NPV of 70.6%, 78.6%, 80%, and 68.7% respectively.

Conclusion: DW-MRI and NLR are promising non-invasive tools for accurate prediction of IPN and hence can guide the need for intervention in acute pancreatitis.

Introduction: There is undocumented and unjustified variability in orthopaedic surgery training between countries. This study compares and contrasts the main features of orthopaedic training in Australia, New Zealand, the United Kingdom, United States, and Canada.

Methods: Comparisons included: competition for, and selection into, training; training pathway structures; training requirements, and; training length.

Results: Selection into orthopaedic surgery training is competitive in all countries assessed with acceptance rates ranging from 22%-26% in Australia and New Zealand to 85% in Canada. Minimum length of post-medical school training varies from 5 years in the USA and Canada, to 8 years in Australia, 9 years in New Zealand, and 10 years in the United Kingdom. All countries encourage participation in research during training, although there are varying requirements. Significant bottlenecks characterize selection into training in Australia, New Zealand, and the United Kingdom, meaning the majority of doctors take more than a decade from medical school graduation to obtaining their specialty surgery qualification.

Conclusions: There is high variability between the orthopaedic training programs of the studied countries. An awareness of these differences and similarities may help improve training, or provide solutions for identified gaps in each country.

Introduction: We previously published the outcomes associated with the use of diagnostic laparoscopy to determine peritoneal breach for AASW patients without an immediate indication for laparotomy. Although this pathway was 100% sensitive there was a 54% non-therapeutic laparotomy rate. Another option that has been extensively reported is the clinical observation algorithm (COA) however, majority of the data originate from high-volume centres. We hypothesized that a COA would also be a safe option in an Australian setting, and reduce the rate of non-therapeutic operative intervention in managing AASW.

Methods: This was a prospective cohort study examining patients with AASW admitted to a level 1 trauma centre in Sydney, Australia, between June 2021 and August 2023. Patient, injury, management and outcome data were collected from electronic medical records and the hospital trauma registry. Data were then analysed to determine the diagnostic accuracy of the COA, complication rates and median hospital length-of-stay (LOS).

Results: A total of 48 patients presented with AASW. Of these patients, 11 (22.9%) proceeded to immediate laparotomy. Seven patients had a contraindication to COA and underwent diagnostic laparoscopy. Thirty patients were managed with the COA, with three (10%) patients subsequently requiring a laparotomy. Only one patient (3.3%) underwent a non-therapeutic laparotomy. There were no missed injuries. The COA sensitivity was 100%, specificity 92.7%, PPV 50% and NPV 100%. Patients managed with COA had no complications. Overall median hospital LOS was 1 day (1.0-2.3).

Conclusion: A COA is a safe approach for evaluating patients with AASW in an Australian setting with adequate resources. It reduces the rate of non-therapeutic operative intervention and has acceptable outcomes compared with a diagnostic laparoscopy pathway.

Background: Simulation-based education (SBE) has been increasingly used to train healthcare workers in low-resource settings and has been endorsed by the World Health Organization (WHO). Consideration of the educational and cultural context is important to maximize the effectiveness of SBE. Despite its demonstrable benefits, there have been no studies of the general approach in the Pacific Islands. This study aimed to determine the factors that influence the uptake and success of SBE in the Pacific Islands.

Methods: In this qualitative study, participants were recruited via professional networks to contribute to focus groups. Questions focused on participants' previous experiences and perspectives on SBE. Data were manually transcribed before thematic analysis. The reporting of the research was guided by the Standards for Reporting Qualitative Research (SRQR). Human Research Ethics Committee approval was obtained.

Results: Two focus groups were conducted with 16 participants from six Pacific Island countries. Six themes and 15 subthemes were conceptualized from the data. Uptake of SBE is challenged by resource availability, clinical workloads and geographic remoteness. However, locally-driven solutions and positive attitudes towards SBE facilitate its success.

Conclusion: This study reveals the complexity of factors affecting the uptake and success of SBE in the Pacific Islands. These findings can serve to optimize the impact of existing and future SBE programmes and may be considered by educators prior to programme implementation.

Background: The Royal Australasian College of Surgeons (RACS) recently instituted cultural safety and cultural competency as its 10th competency with formalized cultural safety training yet to be instituted. Wānanga are Indigenous Māori teaching institutions that can be used contemporarily for cultural safety training.

Methods: In 2022, surgical registrars based at Taranaki Base Hospital (TBH) held in-hospital wānanga ranging from 1 to 3 h focussed on cultural safety, professionalism and wellbeing. This study explores the perspectives of these registrars who attended wānanga using a Kaupapa Māori aligned methodological stance and interpretive phenomenological analysis.

Results: Twenty-six wānanga were held from March 22nd 2022 to January 30th 2023. Six registrars provided their perspectives with four major themes emerging from their stories including: cultural safety; unity; time, place and person; and a new era. Registrars valued the wānanga which was scheduled for Friday afternoons after daily clinical duties. Wānanga facilitated unity and understanding with registrars being able to reflect on the context within which they are practicing - describing it as a new era of surgical training. 'Time' was the biggest barrier to attend wānanga however, the number of wānanga held was testament to the commitment of the registrars.

Conclusions: Regular wānanga set up by, and for, surgical registrars cultural safety development is feasible and well subscribed in a rural or provincial NZ setting. We present one coalface method of regular cultural safety training and development for surgical registrars and trainees in NZ.

Background: This study aimed to compare the demographic differences between Māori and NZ Europeans with neck of femur fracture (NOF), identify any differences in management, surgical and post-op care and outcomes.

Methods: All cases in New Zealand between 2018 and 2020 were collected from the Australia & New Zealand Hip Fracture Registry (ANZHFR). Basic demographics, management factors, and surgical factors were collected. Key outcomes at 120 days post-fracture included walking status, residential status and survival. Univariate analysis was performed to compare differences in demographics, and management factors between ethnicities. Multivariable analysis was conducted on key outcome comparisons and management differences.

Results: Data from 9432 patients were analyzed. 305 patients were Māori (3.2%). Age-standardized incidence between Māori and NZ European were similar (103 (95% CI 91-115) vs. 95 (95% CI 92-99)/100 000/year). Māori had a longer time to theatre (38.7 vs. 34.5 h, P = 0.01). The only difference between Māori and NZ European in the key outcomes was private residential status (67% vs. 62% P < 0.01). There was no difference in survival (87% vs. 87% P = 0.68) and decrease in walking status (0.43 vs. 0.41 P = 0.99). Following multivariable analysis, Māori ethnicity was an independent risk factor for time to theatre >48 hours after adjustment for other factors (OR 1.44 (95% CI 1.07, 1.93), P = 0.016).

Discussion: Although Māori were a small percentage of patients with NOFs, there was similar age-standardized incidence compared to NZ Europeans. While there were no differences in key outcomes, identifying reasons for longer time to theatre for Māori patients is required.