ANZ Journal of Surgery最新文献

Background: Gender equity in surgical training is essential to delivering high-quality patient care and fostering a representative medical workforce. Despite increasing female representation in medical schools and in surgical training programs, studies suggest significant gender disparities persist in case load, procedural complexity and operative autonomy experiences. This systematic review aims to assess the extent of these disparities and evaluate their potential impact on surgical training outcomes and workforce equity.

Methods: A systematic review was conducted following PRISMA guidelines, with literature sourced from PubMed, MEDLINE and EMBASE databases up to May 2024. Eligible studies reported gender-delineated surgical trainee case loads or autonomy, with ≥ 20 participants. A random-effects meta-analysis using restricted maximum likelihood estimation was performed to calculate pooled male-to-female case ratios, accounting for heterogeneity across studies in specialty and methodology.

Results: From 2020 database records, 18 studies published between 2017 and 2024 met inclusion criteria, encompassing 4139 surgical trainees (2541 males; 1592 females) across diverse specialties and regions. A random-effects meta-analysis demonstrated a significant male advantage in overall case volumes, with a pooled M:F case ratio of 1.17 (95% CI: 1.11-1.25), indicating that male trainees performed approximately 17% more cases overall (p < 0.0001), with minimal heterogeneity (I² = 1%). Eleven studies reporting basic procedures showed a pooled log M:F ratio of 0.49 (95% CI: 0.22-0.76; p = 0.0004), corresponding to ~63% higher volumes for male trainees. Nine studies reporting complex procedures revealed a pooled log M:F ratio of 0.48 (95% CI: 0.13-0.82; p = 0.0065), equating to ~61% higher volumes for male trainees, with substantial heterogeneity (I² = 83.5%). Although individual studies varied, some approaching parity, the overall trend consistently indicated underrepresentation of female trainees in both basic and complex operative experience.

Conclusion: Despite progress in certain specialties, persistent gender disparities in operative case load and autonomy remain across much of surgical training, reflecting broader issues of implicit bias and structural barriers. Addressing these inequities requires systemic interventions, including auditing training experiences, standardising competency frameworks, faculty education and enhanced support for trainees.

Background: Acute limb ischaemia (ALI) is a vascular emergency that often involves life-or-limb-threatening consequences. For patients with irreversible limb ischaemia or those who are high-risk surgical candidates, palliative care may be underutilised. This study examined the role and use of palliative care for ALI patients at our institution.

Methods: A retrospective observational study was conducted for ALI patients referred to the vascular service from January 2019 to December 2023. Data collected included demographics, comorbidities using the Charlson comorbidity index (CCI), the primary intervention offered and their Australia-modified Karnofsky Performance Status (AKPS). Outcomes included 30-day mortality, major limb amputation and referral to palliative care.

Results: A total of 114 patients, with median age of 75, and 65 male patients were included. On presentation, 2 patients (1.8%) underwent major limb amputation and 15 patients (13.2%) received palliative care. Patients who received palliative care on presentation were, on average, older by 11.4 years, had a higher CCI score by 2.7 and a lower AKPS by 19.1 (p < 0.01) compared to patients who did not receive palliative care. Within 30 days, 12 (80%) of the primary palliation group died, compared to 8 (8.1%) in the non-palliation group. None of the patients who underwent amputation received palliative care or died within 30 days.

Conclusion: ALI is associated with high mortality. In selected patients, particularly those with non-viable limbs, advanced age, high comorbidity burden and low functional status, early palliative care may be more appropriate than surgery. Avoiding 'palliative amputation' through timely palliative care involvement offers a more holistic, patient-centred approach to care at the end of life.

Background and aims: Bile leak is a recognised complication in surgery and trauma patients, often resulting in significant morbidity. While various imaging modalities play an important role in diagnosis, their accessibility and feasibility may be limited in clinical settings. Biochemical analysis of peritoneal or drain fluid bilirubin (FB) and fluid-to-serum bilirubin ratio (FSBR) have been proposed as an adjunct diagnostic tool. However, there is limited research on the use of FB or FSBR to diagnose bile leak as various FSBR cut-offs have been proposed in existing literature. We aim to assess the usefulness of FB and FSBR to diagnose bile leak in surgical and trauma patients. The study was conducted in collaboration with Pathology, Surgical and Trauma departments to comprehensively assess pre-analytical, analytical and clinical aspects.

Methods: We performed a prospective study over a 21-month period (February 2023 to October 2024) at a metropolitan tertiary surgical and trauma centre. Contingency table and receiver operating characteristic area under curve (ROCAUC) analyses were made to assess the usefulness of FB and FSBR.

Results: Our study included 84 patients (38 post-operative surgical, 15 trauma and 31 medical control patients). Five patients (four surgical and one trauma) were diagnosed with bile leak based on radiological and clinical criteria. Both FB and FSBR are shown to be reliable markers to diagnose bile leak (ROCAUCs for both FB and FSBR > 0.9), with a FB cut-off of 75 μmol/L providing specificity 93.7% and sensitivity 100%, and a FSBR cut-off of 6.0 providing specificity 98.7% and sensitivity 100%.

Conclusion: Our study demonstrates both FB and FSBR to be useful to diagnose bile leak in both surgical and trauma patients. Further validation through larger, multicentre studies may enhance the generalisability of these findings and refine the role of FB and FSBR in clinical practice.

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.