ANZ Journal of Surgery最新文献

Background: Metastasis to the lateral lymph nodes (LLNs) occurs in 15%-20% of patients with cT3-4 low rectal cancer and remains a key factor in local recurrence after surgery. While laparoscopic LLN dissection (LLND) is increasingly performed, its technical demands raise concerns regarding safety and efficacy. This study aimed to evaluate the feasibility, safety, and oncological equivalence of the laparoscopic approach compared with the open approach.

Methods: This retrospective, single-centre study included 60 patients who underwent LLND between 2007 and 2022. Peri-operative and oncological outcomes were compared between the laparoscopic (n = 33) and open (n = 27) approaches. In addition, peri-operative outcomes of laparoscopic LLND were compared between the initial 16 and the subsequent 17 cases.

Results: Blood loss was significantly reduced in the laparoscopic group (median, 200 mL vs. 794 mL; p < 0.001), with a significant reduction in the latter laparoscopic cases compared with the initial cases (100 vs. 323.5 mL; p < 0.001). Post-operative hospital stay was significantly shorter in the laparoscopic group (16 vs. 23 days; p = 0.006) and was further reduced in the latter laparoscopic cases compared with the initial cases (14 vs. 19 days; p < 0.001). No significant differences were observed in terms of 5-year cancer-specific survival (96.4 vs. 95.7%; p = 0.46), relapse-free survival (85.6 vs. 82.6%; p = 0.71), or cumulative local recurrence rates (7.1 vs. 4.3%; p = 0.69).

Conclusion: Laparoscopic LLND provides clear short-term advantages over open dissection while achieving comparable oncological outcomes. Moreover, the peri-operative outcomes of laparoscopic LLND improve further with increasing surgical experience.

Background: Emergency laparotomy is associated with high postoperative morbidity and mortality. Accurate early risk stratification is essential for guiding clinical decision-making and resource allocation. This study aimed to develop and internally validate a robust predictive scoring system for 30-day mortality using routinely available preoperative variables.

Methods: A retrospective cohort study was conducted among 402 adult patients who underwent emergency laparotomy. The dataset was randomly split into training (70%) and testing (30%) subsets. An elastic net logistic regression model (α = 0.5) was developed on the training set with 10-fold cross-validation to optimize model performance and select predictors. Model discrimination was assessed using cross-validated area under the receiver operating characteristic curve (AUROC) and bootstrap-based ROC analysis. Calibration was evaluated using the calibration belt method.

Results: Twelve preoperative predictors were retained in the final model, including ASA grade, cardiovascular disease, serum creatinine, preoperative sepsis, and follow-up surgery. The cross-validated AUROC was 0.7922 (95% CI: 0.7278-0.8440), and the bootstrap AUROC was 0.7895 (95% CI: 0.7365-0.8394), indicating good discriminative ability. The model demonstrated statistically significant fit (LR χ² = 86.57, p < 0.001) with a pseudo R² of 0.1991. A nomogram was constructed to facilitate bedside risk prediction.

Conclusion: The developed scoring system demonstrated good predictive performance in estimating 30-day mortality following emergency laparotomy. Incorporating routine clinical and laboratory parameters, the tool is readily applicable in resource-limited settings. External validation is warranted to assess generalizability and potential for integration into surgical risk assessment workflows.

Introduction: High-volume surgeons and hospitals have historically been associated with superior outcomes for high-risk procedures in many surgical domains. It may therefore be reasonable to suggest that patients requiring distal femur replacement (DFR) may show improved outcomes with such providers. This study aimed to describe DFR workload trends and compare outcomes between high- and low-volume surgeons and hospitals.

Patients and methods: Data were obtained from the Australian Orthopaedic Association National Joint Replacement Registry for all DFRs performed between 1 January 2003 and 31 December 2021. Low- and high-volume surgeons and hospitals were determined as those below the 10th and above the 90th percentiles, respectively, for mean annual DFR volumes. Cumulative percent revision rates, indications for revision, length of stay, and mortality rates were compared.

Results and conclusions: In total, 1359 DFRs, including 853 primary and 506 revision cases, were analysed. In Australia, 'high-volume' surgeons and hospitals performed less than four DFRs per year. The reoperation rate was significantly lower after revision DFR in high-volume hospitals compared to medium-volume hospitals. There were no other clinically meaningful, significant differences in measured outcomes between low- and high-volume providers, nor between public and private hospitals. Overall, these results suggest minimal difference between low- and high-volume surgeons and hospitals performing DFR in Australia. Despite utilising national registry-level data, these findings may be underpowered by the small differences in volume between low and high-volume providers. Diversion of DFR to specialist providers may help to increase the level of expertise in DFR within Australia, whilst reducing revision rates of revision DFR.

Background: Although forearm fractures in adults are commonly managed operatively, there is a paucity of studies on peri-implant fractures of the forearm.

Methods: We performed a single-centre retrospective cohort study. Consecutive patients presenting with peri-implant fractures of the forearm between 2010 and 2024 were included. In this study, we described the epidemiology of peri-implant forearm fractures, fracture configuration, treatment received, and outcomes following this injury.

Results: Thirty-five patients were identified from our database. Median age at the time of injury was 39.5 years. The period prevalence was 7.7% (95% Confidence Interval (CI): 4.9-11.4). Fifteen cases (42.9%, 95% CI: 26.3-60.7) were associated with confirmed cases of domestic violence. Fractures occurred through either the proximal or distal screw in 64.3% of cases. Seventeen patients were managed operatively in the first instance, none of which experienced a complication. In the remaining 18 patients managed non-operatively, delayed or non-union was observed in four patients, necessitating further operative management in three patients. When we adjusted our findings for age, sex, Charlson Comorbidity Index, smoking, diabetes and presence of open injury, the increased odds of delayed/non-union was not statistically significant (Odds Ratio = 21.14, 95% CI: 0.51-874.03, p = 0.108).

Conclusion: The epidemiology of peri-implant forearm fractures within our patient population is greater than historic literature. As a substantial proportion of these injuries were sustained secondary to domestic violence, medical personnel should remain vigilant about the potential mechanisms behind the injury, especially if practicing in regions where there is a high prevalence of domestic violence.

Flexible cystoscopy is a common procedure in urology, traditionally performed using reusable flexible cystoscopes. However, concerns over sterilization costs, cross-contamination, and logistics have led to interest in single-use disposable cystoscopes. This study compares the cost-effectiveness of reusable versus disposable cystoscopes at a high-volume academic center. A retrospective threshold cost analysis was performed at a tertiary hospital in Singapore in 2022. Costs that were considered included device purchase, reprocessing and maintenance costs. Common procedural-related costs such as medical manpower costs and costs of consumables were not included in this analysis. In a high-volume center with an annual caseload of 3574 cystoscopies, we identified a cost-equivalent price at SGD 135, above which reusable cystoscopes became more cost-effective. This suggests reusable cystoscopes are economically advantageous in high-volume settings due to the inverse relationship between per-unit cost and annual caseload. However, disposable cystoscopes may still have value in lower-volume centers where the cost-equivalent price is higher. In conclusion, reusable cystoscopes offer cost-efficiency in high-throughput settings, whereas single-use scopes provide logistical and infection-control advantages in selected scenarios. Ongoing evaluation of cost and clinical outcomes is needed to optimize cystoscopy practices.

Introduction: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary circulatory support for patients with severe cardiac failure. Traditionally, decannulation involves open surgical cut-down of the common femoral artery, which carries a high risk of wound complications. Percutaneous techniques using vascular closure devices have emerged as a less invasive alternative. This pilot study evaluates the feasibility and early outcomes of a percutaneous VA-ECMO decannulation technique using the Abbott Pro-Style closure device, compared with surgical cut-down.

Methods: A retrospective, single-centre review was conducted of patients undergoing percutaneous VA-ECMO decannulation at Royal Prince Alfred Hospital between November 2023 and July 2024. Patients were matched by age and sex to a control group treated with surgical cut-down. Data included demographics, ECMO indication and duration, procedural characteristics, vascular complications and groin wound outcomes.

Results: The percutaneous technique was performed in 15 patients (mean age 56.7 ± 13.9 years). Technical success was achieved in 87% (n = 13), with two cases converted to open surgery due to device failure and haemorrhage. Mean procedure time was 74.3 ± 26.3 min versus 101.5 ± 47.2 min for surgical cut-down (p = 0.06). Groin wound complication occurred in one percutaneous patient compared to five surgical patients (p = 0.07). ICU stay and survival to discharge were comparable between the groups.

Conclusion: This early experience supports the feasibility of percutaneous VA-ECMO decannulation using the Abbott Pro-Style closure device, with promising signals toward reduced wound complications and shorter procedure times. Larger prospective studies are needed to confirm these preliminary findings.