ANZ Journal of Surgery最新文献

Backgrounds: Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic procedure for biliary and pancreatic diseases. Post-ERCP pancreatitis (PEP) is a common complication. The efficacy of somatostatin and octreotide for PEP prevention is controversial. This study aimed to compare somatostatin and octreotide formulations for PEP prevention.

Methods: A retrospective trial analyzed patients undergoing ERCP, stratified by medication type and dosage. The primary outcome was PEP incidence. Secondary outcomes included hyperamylasemia incidence, the duration of hospitalization due to pancreatitis, and postoperative pancreatic function. Post-ERCP complications and adverse events were recorded to evaluate safety.

Results: A total of 191 patients undergoing 202 ERCP procedures were analyzed. The overall incidences of PEP and hyperamylasemia were 12.4% and 10.9%, respectively. There was no significant difference in PEP incidence between the somatostatin and octreotide groups (13.1% vs. 9.7%, p > 0.05). PEP incidence was significantly lower in the high-dose somatostatin group compared to the low-dose group (1.8% vs. 20%, p < 0.05), and in the high-dose octreotide group compared to the low-dose group (0.0% vs. 18.8%, p < 0.05). No significant differences in hyperamylasemia rates, post-ERCP amylase and lipase levels, duration of hospitalization due to pancreatitis, complications, and adverse events were observed across groups.

Conclusion: High-dose somatostatin (at least 6 mg) or octreotide (at least 0.5 mg) within 24 h after ERCP are suggested for preventing PEP in patients at average risk.

Background: The supraclavicular flap (SCF) is a well-established reconstructive option for defects of the head and neck. It combines the pliability of a fasciocutaneous flap with the benefits of locoregional reconstruction. These characteristics enable the flap to be widely applicable in the head and neck region.

Method: The anatomy and surgical execution for the supraclavicular flap is reviewed with emphasis on the decision-making process pre- and intra-operatively to improve success along with illustration of a case series of patients.

Results: In a retrospective case series of 18 patients in a single institution, the SCF was utilised both as primary and salvage options in head and neck reconstruction. The indications for SCF included skin and soft tissue resurfacing (n = 9), comorbid patients not eligible for free flaps (n = 7) and in salvage surgery (n = 2). We had three flap related complications requiring return to theatre to facilitate healing prior to commencement of post-operative radiotherapy. These included two cases of minor dehiscence which were re-debrided and inset; and one case of flap tip necrosis which was treated with debridement and skin grafting.

Conclusion: The supraclavicular flap is a reliable option for locoregional head and neck reconstruction. It also has several advantages over more traditional options such as the pectoralis major flap, providing a more functional and aesthetic result with close to ideal skin colour, pliability, and contour.

Background: Free tissue transfer is standard of care in the reconstruction of large defects in the head and neck. Many patients who undergo free flap reconstruction have had prior head and neck radiotherapy (HNRT). The aim of this study is to compare the surgical outcomes of HNRT versus HNRT naïve patients undergoing free flap reconstruction in a large Australian cohort.

Methods: Data from patients who underwent free flap reconstruction of head and neck defects between January 2017 and December 2020 were extracted from a prospectively collated database at Chris O'Brien Lifehouse (Sydney, Australia). Participants were divided into two groups based on whether or not they had HNRT prior to their free flap procedures. Subgroup analysis was performed comparing patients with mucosal vs. those with cutaneous disease reconstruction.

Results: From a total of 525 patients who had undergone free flap reconstruction, 117 (22.3%) had prior HNRT. Prior HNRT was associated with higher rates of flap complications (14.5% vs. 7.8%, p = 0.045), recipient site complications (31.6% vs. 21.1%, p = 0.025), and higher Clavien Dindo Classification (p = 0.040). In the mucosal disease subgroup, prior HNRT was associated with higher rates of flap complications (17.2% vs. 7.8%, p < 0.001). In the cutaneous disease subgroup, there was no difference in complication rates between HNRT naïve and those who had prior HNRT.

Conclusion: Prior HNRT increases the risk of both flap and recipient-site complications. However, this mainly occurs in patients undergoing reconstruction of mucosal disease.

Introduction: Peripheral arterial disease in the superficial femoral and popliteal arteries is common and increasingly treated with drug coated technologies. While drug coated balloons (DCB) are typically used following pre-dilatation with an uncoated balloon; the procedure and patient follow-up are otherwise essentially identical. Published literature demonstrates improved primary patency and reduced target lesion revascularisation with DCB use, however there is little published data on potential cost implications of using this additional device. We hypothesise there is cost equivalence with DCB use when adjusted for reduced re-intervention rate.

Methods: An updated systematic search was performed to identify reintervention rates, restricted to RCT level evidence. Weighted averages of reintervention rates at 1-5 year time points were applied to a local patient cohort, and cost projections calculated to 5 years based on assumed DCB device costs of $900 and $1500 (exaggerated).

Results and conclusion: In a claudicant biased population, cost projections favour DCB at 1, 2, 3, and 5 year time points. For the exaggerated cost group, DCB is also favourable at 1-3 years, with near equivalence at 5 years. Further benefits such as reduced hospital admissions, QALY and angiography suite opportunity costs are not assessed in our projections; but remain important considerations.

Background: Multi-modal analgesia is recommended for enhanced recovery after colorectal and abdominal surgery. Previous reviews have reported highly discordant observations around the benefits and risks of non-steroidal anti-inflammatory drugs (NSAIDs). This umbrella review aimed to provide a recommendation based on the best available evidence.

Methods: A systematic search was performed for reviews exploring benefits and risks of NSAIDs after abdominal surgery. The quality of reviews was assessed using the AMSTAR-2 tool. Outcomes of interest comprised clinical efficacy (pain, opioid consumption, return of gut function) and safety (intestinal bleeding, anastomotic leak, acute kidney injury). The presence of discordant conclusions across reviews was investigated using the Jadad decision algorithm to determine the best available evidence.

Results: Twenty-seven reviews were included, reporting evidence for pain (n = 10/27), opioid-consumption (n = 11/27), gut function (n = 4/27), bleeding (n = 1/27), anastomotic leak (n = 13/27), and acute kidney injury (n = 2/27). The quality of all reviews was 'critically low'. The reviews were concordant in showing that NSAIDs reduce pain, opioid consumption, and time to gut recovery. Studies reporting anastomotic leak after colorectal surgery were highly discordant. The best available evidence showed an increased risk of anastomotic leak with non-selective NSAIDs, but not convincingly for COX-2 inhibitors.

Conclusion: NSAIDs after abdominal surgery reduce pain, opioid consumption, and the time to gut recovery. In the context of colorectal surgery, non-selective NSAIDs may increase the risk of anastomotic leak, but this is based on low quality data. Their use should be limited to selective NSAIDs until robust evidence is available to guide decision-making.

Background: Faecal incontinence can be functionally debilitating, with significant impact on patients' quality of life. Injectable perianal bulking agents such as PTQ implants are shown to improve faecal incontinence in the short- to mid-term; however, long-term outcomes remain poorly understood.

Objective: To assess long-term outcomes of PTQ implants for management of faecal incontinence.

Methods: A retrospective cohort study of 101 patients receiving PTQ implants at St Vincent's Public and Private Hospitals, Fitzroy, between 2007 and 2023. Mean follow up time was 8 years (range 2-17). Primary outcomes were patient satisfaction, duration of improvement and post-treatment quality of life, assessed using Wexner and Faecal Incontinence Quality of Life scores. Secondary outcomes included repeat treatment and complications.

Results: Following treatment with PTQ implants, 56% (n = 55/101) of patients were satisfied with improvement in symptoms. Fifty seven percent (n = 56/101) of patients reported a duration of improvement of at least 1 year and 39% (n = 39/101) for two or more years. Post-treatment quality of life outcomes were poorer in female compared to male patients, whilst no statistically significant difference was otherwise noted between other patient groups. Further intervention to manage symptoms was required in 50% (n = 50/101), of which the majority (n = 31/101) were treated with a second PTQ treatment. Complications were observed in 3% (n = 3/101) of patients.

Conclusion: Over half of patients treated with PTQ implants reported satisfaction with its effect on faecal incontinence, with low complication rates. PTQ implants are a minimally invasive treatment option for faecal incontinence that may provide longer-term benefit in appropriately selected patient cohorts.