ANZ Journal of Surgery最新文献

Background: Cosmetic tourism has become increasingly popular, with patients seeking lower cost cosmetic surgery overseas. However, complications often necessitate management in local public hospitals upon their return, placing a burden on healthcare systems. This study examines the demographics, complications, interventions and resource utilisation of patients presenting to an Australian hospital with complications from overseas cosmetic surgery.

Methods: This study retrospectively reviewed patients who presented to Westmead Hospital, NSW, during two time periods-01/07/2022 to 01/01/2023 and 01/05/2024 to 30/12/2024-with complications following cosmetic surgery performed overseas. Hospital records were analysed to extract data on patient demographics, comorbidities, presenting complications, interventions, diagnostic tests and resource utilisation. Descriptive statistics were used to summarise the findings, and patterns in clinical management were evaluated.

Results: Twenty-four patients met the inclusion criteria, with a mean age of 38.4 ± 12.5 years; 87.5% were female. Comorbidities included smoking (50%), mental health conditions such as anxiety, depression, or self-harm (20.8%) and hypothyroidism (12.5%). Abdominoplasty (54.2%), breast augmentation (20.8%) and liposuction (25%) were the most frequently performed procedures. The mean Charlson Comorbidity Index was 0.2 ± 0.4, and the mean LACE Index was 5.9 ± 1.5. Complications included wound dehiscence (45.8%), infection (41.7%) and seroma (20.8%). The median time from surgery to presentation was 3.8 weeks, with a mean hospital stay of 3.3 ± 2.9 days. Interventions included oral antibiotics (83.3%), IV antibiotics (58.3%), drainage or aspiration (33.3%) and surgery (54.2%).

Conclusion: Overseas cosmetic surgery is associated with high complication rates and significant utilisation of public hospital resources. These findings highlight the impact of cosmetic tourism on the Australian healthcare system.

The sphincter of Oddi (SO), as the critical bidirectional regulatory valve structure of the pancreatobiliary system, still requires extensive research regarding its functional assessment and dysfunction repair. This systematic review examines SO regulatory mechanisms, diagnostic approaches for dysfunction, and repair strategies. Studies have demonstrated that SO myoelectrical activity is regulated by neural, humoral, and neurohumoral mechanisms, although the specific pathways involved remain incompletely understood. SO motility features both tonic and phasic contractions, with abnormalities closely linked to pancreatobiliary diseases. Pancreaticobiliary maljunction (PBM) or congenital SO anomalies may induce reciprocal reflux of pancreatobiliary secretions, thereby elevating the risk of biliary tract carcinogenesis, particularly cholangiocarcinoma and gallbladder carcinoma. While invasive SO manometry (SOM) remains the diagnostic gold standard for sphincter of Oddi dysfunction (SOD), noninvasive techniques such as quantitative hepatobiliary scintigraphy (QHBS) and secretin-stimulated magnetic resonance cholangiopancreatography (ss-MRCP) show promising clinical applicability. Current therapeutic options for SOD include endoscopic sphincterotomy (EST), endoscopic endoclip papilloplasty (EEPP), endoscopic papillary balloon dilation (EPBD), and transduodenal sphincteroplasty. In the precision medicine era, developing standardized noninvasive assessment tools and quantifiable, controllable, and visualizable methodologies for SO structure and function is imperative to achieve a precise understanding of its physiological and pathological states, ultimately maximizing patient outcomes in SO-related disorders.

Bowel anastomosis is a fundamental skill for gastrointestinal surgeons, who must be proficient in both stapled and hand-sewn methods. Various inverting suture techniques have been described, each aiming to optimize security and healing. We describe a hand-sewn, two-layer side-to-side anastomosis using a continuous inverting suture with counter-traction, accompanied by illustrative images and a video demonstration.

Background: Upper gastrointestinal tract anastomotic leaks are associated with increased morbidity and mortality, especially in the 30-day post-operative period. Techniques to reduce tension at the anastomotic site have been postulated to reduce leak rates. Our study investigates if continuous nasojejunal suction (via Freka trelumina tube) compared with standard of care passive free drainage via nasogastric tube results in reduced anastomotic leaks.

Methods: A retrospective cohort study was performed on all patients undergoing upper gastrointestinal tract resections with primary high-risk anastomosis (proximal partial, total/extended total gastrectomies and oesophagectomies) over the period between 2012 and 2023 between two major tertiary centres for malignancy. Comparative analysis of outcomes was performed between patients who did or did not receive prophylactic continuous suction, with the primary outcome being the incidence of anastomotic leak. Secondary outcome was the association between patient baseline characteristics and past medical history with anastomotic leaks. Statistical analysis was performed using SPSS v25.0.

Results: Over the 10-year period there were 351 operative cases, with prophylactic suction applied to 62.3% (n = 219) of patients. Overall incidence of anastomotic leaks was 10.3%, with higher proportions from 2-stage oesophagectomies (12.2%), compared with 3-stage oesophagectomies (5.9%) and gastrectomies (6.8%). In the overall cohort, incidence of anastomotic leaks was lower in the suction group (8.7% vs. 12.9%); however, this was not statistically significant (p = 0.210). Further subgroup analyses of 2-stage oesophagectomies showed marginal significance (9.0% vs. 18.9%, p = 0.050). Statistically significant risk factors for anastomotic leaks include any smoking history, elevated BMI, history of ischaemic heart disease, and prolonged operation duration.

Conclusions: Continuous gastric conduit suction may reduce the incidence of anastomotic leaks in two-stage oesophagectomies; however, a randomized controlled trial is required to investigate this further.

Introduction: The General Surgery Fellowship Examination is the final hurdle examination before being eligible for fellowship of the Royal Australasian College of Surgeons. The purpose of this study was to assess the consistency and reliability of this examination, specifically whether there was evidence of systemic gender bias.

Methods: This is a retrospective audit of marks awarded in the examination between 2018 and 2022. Examination components were marked separately by two examiners, who assigned a consensus mark after discussion. Candidates' marks were analysed according to their demographics. Inter-observer agreement between examining pairs was analysed, as were marks awarded by individual examiners.

Results: Overall, 811 candidates (548 [67%] men and 263 [33%] women) sat the examination, of whom 520 (64%) passed. The pass rate was consistent over the study period. A total of 5672 pairs of examiners' marks were analysed to determine inter-observer agreement. Inter-observer correlation was 0.89 (95% C.I. 0.88-0.89). There were 110 examiners (92 men and 18 women). No examiner's marks were outside the 95% control limit for strictness or leniency compared with their peers. Pass rates were similar for male and female candidates (343/548 [63%] male vs. 177/263 [67%], p = 0.20). There were 102 marking pairs with one female and one male examiner. Inter-rater agreement between these examiners was 0.86 (95% CI: 0.82-0.91) when examining men and 0.76 (95% CI: 0.76-0.85) for women.

Conclusion: We found the examination to be consistent, fair and reliable, with no evidence of systemic gender bias.

Background: The ward round is the main communication channel between doctors and hospitalised patients; however, it is often poorly received by patients. Patient perceptions are rarely considered when implementing interventions in inpatient environments. This study therefore aimed to thematically assess patients' perceptions of a 'Standard care' ward round versus a 'Sterile Cockpit' ward round.

Methods: There were 71 Standard Care and 70 'Sterile Cockpit' ward rounds audio-visually recorded. The 'Sterile Cockpit' group received a modified ward structure consisting of a protected zone where aviation-safety rules (allocation of team roles, no interruptions, one person speaking at a time, repeating of plan) were applied. Following the encounter, patients completed a survey on their perceptions of the ward round. Statistical analysis using Generalised Estimating Equations was conducted for quantitative outcomes, and qualitative outcomes were analysed using the six-stage process for thematic analysis.

Results: Of the 141 recorded ward round encounters (51% male, mean age 61.6 [SD: 15.4]), there were 130/141 (92%) surveys completed. Overall, patients in the 'Sterile Cockpit' group had significantly higher satisfaction than the Standard Care group, even when adjusting for the patients' sex, age, emergency/elective admission, and clustering on the patient (IRR: 1.07, 95% CI: 1.00, 1.14, p = 0.036). Thematic analysis determined that patients' perceptions of surgical ward rounds revolved around three key themes (Structure, Understanding and Engagement) and two subthemes (Communication Quality and Time).

Conclusion: Implementing the Sterile Cockpit ward round model was associated with an improved patient experience by enhancing understanding, engagement and perception of team dynamics, without increasing ward round duration. These findings suggest the Sterile Cockpit is a pragmatic solution to improving patient care and optimising the short amount of time that is available for ward rounds.

Background: Surgical stabilisation of rib fractures in select patients is shown to significantly improve outcomes. However, there is considerable variation in surgical techniques necessitating a comprehensive analysis of current practices.

Methods: The MEDLINE, EMBASE, Cochrane Library Compendex, Proquest, Scopus, and IEEE databases were systematically searched for studies across four time periods P1(2000-2006), P2(2007-2011), P3(2012-2016), and P4(2017-2021). SSRF Techniques of fixation were assessed and classified by design principles. Variation in approach, indications, and postoperative complications of different systems were described.

Results: A total of 132 clinical studies with a pooled population of 6816 were described. A further 22 pre-clinical studies were included. Numerous emerging techniques were identified in the pre-clinical literature. Established techniques of fixation with clinical data include: plating with screw fixation (n = 87 of 132 studies), plating with clip fixation (19/132), intramedullary implants (2/132), bioresorbable devices (7/132), and others. Evidence mapping showed a growing pool of clinical data for plating with screw fixation and highlights the paucity of data available for other devices preventing formal statistical comparisons of postoperative outcomes between fixation systems.

Conclusion: There is a wide range of techniques described for surgical stabilisation of unstable rib fractures, with the number of clinical studies published increasing. There is a geographical variation in the techniques described, and a burgeoning interest in minimally invasive rib fixation. Comparative studies and pooled data are uncommon. As interest in this field grows, there is a need for multicentre collaborative studies and refinement of indications for SSRF.

Background: Skin-reducing mastectomy (SRM) allows implant-based immediate breast reconstruction in women with large, ptotic breasts. This study aimed to evaluate the surgical and patient-reported outcomes (PRO) following SRM.

Methods: A retrospective analysis was conducted on patients who underwent SRM between January 2011 and December 2014. Surgical complications, oncological outcomes, and PRO (using BREAST-Q) were collected, with a median follow-up of 10 years.

Results: Fifty-five women (95 breasts) underwent SRM and completed the first round of the BREAST-Q questionnaire. 82.3% (n = 45) had SRM for cancer treatment, and the remaining had risk-reducing surgery. 83.6% (n = 46) had direct-to-implant reconstruction, and the remainder had a tissue expander inserted. The mean breast weight was 714 g, and the mean implant volume was 398 mL. The overall complication rate was 58.9%. The most common complication was skin loss due to flap/skin necrosis (24.2%), followed by capsular contracture (18.9%), seroma (7.4%), wound dehiscence (5.3%), implant infection (2.1%), and bleeding (1%). The early implant loss rate was 10.5%. At 10 years (n = 17), the local recurrence rate was 4.4%, the overall survival rate was 97.7%, and the disease-free survival rate was 88.9%. Breast-Q scores were comparable to previous studies (mean score of 65.33). 30.9% of patients (n = 17) completed the modified BREAST-Q questionnaire at 10 years of follow-up. Reconstructed breast satisfaction was high, and 76.5% of patients would choose to undergo SRM again if given the option.

Conclusion: In certain patients with larger breasts, SRM can facilitate implant-based immediate breast reconstruction without the need for mesh. Despite relatively high complication rates, patient satisfaction remains high.

Background: Enhanced recovery after surgery (ERAS) pathways are increasingly utilised in autologous breast reconstruction (ABR) to improve patient outcomes. This Australian study evaluates the impact of our centre's newly standardised electronic ERAS pathway from 2023 to 2024 compared to a transitional ERAS cohort from 2017 to 2018.

Methods: A perioperative ERAS protocol was implemented for patients undergoing DIEP flap reconstruction for therapeutic or prophylactic mastectomies. Key components included comprehensive patient education, standardised perioperative surgical proformas, goal-directed fluid resuscitation, mitigation of opioid use, early mobilisation, and diet reintroduction. Outcomes from the 2023-2024 cohort were compared with the 2017-2018 cohort. The primary endpoint was length of stay (LoS), from admission to discharge. Secondary endpoints included daily and total oral morphine-equivalent daily dosage (oMEDD, mg), incidence and duration of patient-controlled analgesia (PCA, hours), Days 1-4 pain scores and rates of major and minor complications alongside standardised Clavien-Dindo classifications.

Results: A total of 102 patients were analysed (transitional ERAS, n = 48; standardised ERAS, n = 54). LoS for the whole cohort of unilateral and bilateral patients decreased from 5.8 days (5.0-6.6) to 4.5 days (4.1-5.0), p = 0.007. Total oMEDD reduced from 155.0 mg (134.3-175.5) to 111.6 mg (85.0-138.2), p = 0.011. PCA incidence remained unchanged at 16.7%, but duration decreased from 31.8 h (19.9-43.8) to 14.2 h (11.7-16.7), p = 0.010. These trends were consistent across subgroup analysis. No significant difference in major complication rate was observed. Minor complications showed a marginal decline.

Conclusion: Our standardised ERAS pathway for DIEP flap reconstruction significantly reduced LoS and PCA duration without increasing major or minor complication rates. These findings underscore the value of multidisciplinary perioperative collaboration and establish a framework for best practices in ABR within the Australian healthcare context.

Objectives: To understand the adoption of reusable surgical and anaesthetic devices across public hospital operating suites and recovery areas in Victoria.

Methods: Snapshot audit of procurement data of common medical devices utilised in operating theatres that are available as either reusable or single-use devices. A list of 49 common medical devices was created, and the usage data were obtained through surveys conducted by remote interviews of procurement or theatre staff between August 2024 and January 2025. Descriptive statistics were used to summarise data. Nine public health networks (i.e., 14 hospitals) were surveyed, comprising 121 operating theatres and 21 endoscopy/procedure rooms.

Results: Eight out of nine (89%) metropolitan public health services in Victoria use mostly single-use surgical and anaesthetic devices in the operating theatre. Of the 49 surgical and anaesthetic devices surveyed, 46/49 (94%) had a reusable alternative available at a minimum of one of the nine health services surveyed. Five of 16 (31%) anaesthetic devices, 15/27 (56%) surgical devices, and 2/7 (29%) recovery room devices had a reusable alternative available. The average hospital adoption of surveyed reusable devices across all sites was 22/49 (45%).

Conclusions: Most (8/9) public health services in Melbourne surveyed utilise mostly single-use devices in perioperative settings. This audit provides a snapshot where reusable alternatives are available to influence future procurement. As the Victorian healthcare system rapidly transitions to renewable energy sources of electricity, there are considerable procurement opportunities to reduce scope three greenhouse gas emissions from healthcare.