ANZ Journal of Surgery最新文献

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.

Introduction: Acute Mesenteric Ischaemia (AMI) is a life-threatening surgical emergency, with a high mortality rate. Timely revascularisation is crucial to avoid bowel necrosis; however, once tissue becomes non-viable, surgical resection is necessary. Delineating viability is a critical challenge. Indocyanine Green (ICG) fluorescence, used to visualise tissue perfusion in elective resections, could be used to assess bowel perfusion in the emergency setting. This narrative synthesis aims to evaluate the benefit of intraoperative ICG in the context of AMI.

Methods: A systematic review following PRISMA guidelines was conducted according to a predefined protocol (PROSPERO ID: 42024581088). The following electronic databases were interrogated between January 1st 1945 and 1st May 2024: EMBASE and Medline (via OVID). All studies that investigated the use of ICG in the management of AMI were considered.

Results: The search returned 2941 articles. 84 abstracts were reviewed leaving 6 articles with a total of 196 patients for full assessment and which were included in the final narrative synthesis. Macroscopic perfusion assessment was inconsistent with ICG in 35% of cases, with ICG proposing more conservative resection in 75%. No statistically significant difference in re-look rates, morbidity or mortality was found when comparing ICG to visual assessment alone.

Conclusion: ICG may reduce length of bowel resection and both planned and unplanned re-look laparotomies. Outcomes reporting is sparse and comparative studies lacking. Randomised studies comparing ICG against direct light are needed. Improved intraoperative decision-making using ICG could optimise resection boundaries, enhance patient outcomes and reduce mortality in this critical population.

Background: Colorectal cancer (CRC) is a leading malignancy in Australia, with many patients undergoing curative surgery for stage I-III disease. Despite treatment advances, recurrence remains a significant cause of mortality. This study assessed recurrence rates, survival and surveillance adherence across three public tertiary centres in Western Australia.

Methods: A retrospective cohort study was conducted on 459 stage I-III CRC patients who underwent curative resection between 2012 and 2013. Data on patient demographics, pathological features, surgical metrics, adjuvant therapy, survival and surveillance adherence were examined. Recurrence rates were analysed using univariate and multivariate logistic regression.

Results: Recurrence rates varied significantly (p = 0.007) across hospitals, highest at Hospital C (26.2%) and lowest at Hospital A (11.4%). Most recurrences (80%) occurred within 3 years, with a median time to recurrence of 1.6 years. Routine surveillance detected 78% of recurrences, but adherence was inconsistent, with non-adherence rates of 55.6% at Hospital C, 38.9% at Hospital B, and 5.6% at Hospital A. At 5 years, overall survival was 65.6%, disease-free survival 58.8%, and cancer-specific survival (CSS) 73.9%, with Hospital C showing significantly lower CSS (68.3%, p = 0.014). Multivariate analysis identified younger age (50-59 years, OR = 0.33, p = 0.01), Stage I disease (OR = 0.33, p = 0.04), and treatment at Hospital A (OR = 0.36, p = 0.004) as protective factors against recurrence.

Conclusion: Significant variation in recurrence rates, survival, and surveillance adherence across institutions underscores the need for optimised, standardised follow-up protocols. More structured, centralised tracking systems may improve adherence and long-term outcomes for CRC patients.