ANZ Journal of Surgery最新文献

Indocyanine green fluorescence guided video-assisted thoracoscopic ligation of the thoracic duct.

Background: Hartmann's procedure is widely performed for colorectal emergencies, with reversal typically considered within 6-12 months to restore intestinal continuity. However, the decision to undergo reversal remains complex, requiring a balance between surgical risks and benefits. Despite its prevalence, limited research directly compares quality of life (QoL) outcomes between patients who only undergo Hartmann's procedure and those who proceed with reversal.

Methods: This single-centre study included 91 patients (50 post-Hartmann's, 41 post-reversal). Participants were asked to complete the Colorectal Surgery Quality of Life Questionnaire 1 year after surgery. This 35-item questionnaire includes the Low Anterior Resection Syndrome score alongside questions assessing patients' physical wellbeing, sexual function, daily life impact, and attitude towards a stoma.

Results: Patients who underwent Hartmann's reversal reported significantly better postoperative work productivity (p = 0.046) and physical wellbeing (p < 0.001) compared to those who only had the Hartmann's procedure. Reversal was also associated with better postoperative sexual function (p = 0.005) after adjusting for age and sex. Within the reversal cohort, however, a small subset (n = 7, 17%) developed Low Anterior Resection Syndrome (LARS) and appeared to report poorer physical wellbeing (p < 0.001) and sexual function (p < 0.001). Although most patients preferred not to have a stoma, those with LARS in our study were more likely to favour retaining one (p < 0.001).

Conclusion: This study offers valuable insights into the QoL outcomes of Hartmann's procedure and its reversal, highlighting the importance of preoperative counselling, particularly regarding the potential for LARS in patients considering reversal surgery.

Backgrounds: Sarcopenia is associated with higher mortality and morbidity in emergency laparotomies. Sarcopenia is traditionally measured with single 2D axial computed tomography (CT) slice at the L3 level, which is time-consuming and provide limited data. This study aims to determine if sarcopenia, measured using Artificial intelligence (AI) 3D-derived body composition (BC), can predict adverse outcomes after emergency abdominal surgery.

Methods: Retrospective analysis of Australian and New Zealand Emergency Laparotomy Audit-Quality Improvement (ANZELA-QI) patients treated at a tertiary Australian hospital from 2018 to 2023 was conducted. Multiple CT slices from lumbosacral regions were used for 3D BC analysis using a validated AI segmentation model. Sarcopenia was defined based on the lowest quartile for skeletal muscle radiodensity.

Results: 408 patients were included. Sarcopenic patients had lower skeletal muscle mass (< 0.001) with higher volumes of visceral adipose tissue (p < 0.001) and subcutaneous adipose tissue (p < 0.02). Sarcopenia was associated with age (73 vs. 57 years; p < 0.001), increased length of stay (26 vs. 15 days; p = 0.041) and intensive care unit admission (p < 0.001). Sarcopenia was not associated with significant post-operative complications (Clavien-Dindo ≥ 3) (p = 0.903) or worse discharge status (p = 0.138).

Conclusion: Sarcopenia is a significant predictor of adverse postoperative outcomes in patients undergoing emergency abdominal surgery. CT-derived 3D lumbosacral BC may help identify high-risk patients to guide risk stratification. AI has the potential to aid future implementation of 3D BC into routine clinical application.

Purpose: Surgical site infection is common after emergency abdominal surgery. In this study, we aimed to determine the surgical site infection rate in emergency abdominal surgery with primary wound closure and ordinary wound dressings in an advanced bundle care setting. Secondly, we aimed to identify risk factors for surgical site infection.

Method: A retrospective analysis of patients undergoing emergency abdominal surgery for visceral perforation, ischemia, hemorrhage, bowel obstruction, or other urgent pathology with primary wound closure and use of standard surgical dressings was conducted in Copenhagen University Hospital North-Zealand, Denmark.

Results: 772 patients were analyzed. The overall surgical site infection rate was 12.6%. Patients undergoing an emergency laparoscopy had significantly less surgical site infection compared to open surgery (3.0% vs. 15.9%, p < 0.001). We identified body mass index ≥ 30 (OR: 2.2; 95% CI: 1.3-3.7 [p = 0.004]), peritonitis (OR: 1.9; 95% CI: 1.2-3.2 [p = 0.011]), stoma formation (OR: 1.9; 95% CI: 1.1-3.4 [p = 0.023]), and laparotomy (OR: 5.8; 95% CI: 2.4-14.5 [p < 0.001]) to be significant risk factors for the development of surgical site infection.

Conclusion: We conclude that primary wound closure and ordinary dressings after emergency abdominal surgery in an advanced bundle care setting showed low rates of surgical site infection.

Purposes: The use of the textbook outcome (TO) as a multidimensional measurement method allows for an accurate assessment of the ideal hospitalization process for surgical patients. This study aims to construct a nomogram for predicting non-TO in patients undergoing hepatectomy for hepatocellular carcinoma (HCC) based on Lasso-Logistic regression.

Methods: A retrospective study was conducted to analyze preoperative clinical data from HCC patients who underwent hepatectomy at The University of Hong Kong-Shenzhen Hospital between 2013 and 2021. Lasso regression was employed to identify risk factors and develop a novel nomogram. The performance of the nomogram in terms of discrimination, calibration, and clinical utility was evaluated through internal validation.

Results: Compared to the TO group, the non-TO group exhibited a higher proportion of male patients, fewer patients in the 0/A stage, a greater tumor burden score (TBS), fewer patients with an AFP level of ≤ 400 μg/L, a higher incidence of tumors located in segments 7/8, and a greater number of patients undergoing major hepatectomy. The variables selected through Lasso regression included sex, Charlson comorbidity index, history of abdominal surgery, BCLC staging, TBS, AFP level, tumor location in segments 7/8, and extent of resection. These factors were incorporated into a logistic model to establish the nomogram. The ROC curve demonstrated an area under the curve of 0.755, which was significantly superior to using TBS or BCLC staging alone. The Hosmer-Lemeshow test indicated that the model exhibited good fit (p = 0.582).

Conclusion: This study presents a clinically applicable nomogram that reliably predicts non-TO prior to hepatectomy for HCC. With its favorable performance, the model facilitates informed patient consent and supports strategic resource allocation, ultimately contributing to enhanced healthcare quality and efficiency.

Background: Extravasation is the leakage of intravenous drugs, chemicals, or fluids into the extravascular compartment and is common in paediatric patients. These injuries can cause ulceration with tissue loss. This study investigates whether a washout procedure can reduce the incidence of partial- or full-thickness skin loss following extravasation.

Methods: All extravasation injuries referred to the Plastic and Maxillofacial Department at the Royal Children's Hospital, Melbourne, from June 2018 to June 2023 were prospectively identified and reviewed. Data collected included patient demographics, extravasated fluid potency, injury grade, anatomical site, washout timing, and outcomes at 24 and 48 h. Logistic regression was used to identify predictors of skin loss.

Results: A total of 216 extravasation injuries were analysed; 61.1% were male, and 41.7% were under 1 year old. Washout was performed in 50.5% of cases, and 16.7% developed skin loss. Multivariate analysis identified lower limb site (OR = 7.46; p = 0.008), grade 3 injury (OR = 193.10; p < 0.001), and grade 4 injury (OR = 441.30; p < 0.001) as strong predictors of skin loss. Absence of washout significantly increased the risk (OR = 7.51; p = 0.018), particularly in grade 3 and 4 injuries (OR = 15.48; p = 0.003). Fluid potency and age were not independent predictors after adjusting for confounders.

Conclusion: Washout is effective for reducing skin loss in paediatric extravasation injuries, particularly in grades 3 and 4. Lower limb cannulation carries a significantly higher risk of skin loss. Injury grade should guide urgent washout intervention.

Background: Major bile duct injury (BDI) is a severe complication of biliary surgery, associated with high morbidity, mortality, and long-term sequelae. This study aimed to identify predictors of outcomes after surgical repair of major BDI in a North African hepatopancreatobiliary center.

Materials and methods: We retrospectively analyzed 147 patients who underwent repair of Strasberg type E BDI at a single HPB department in Oran, Algeria (2014-2024). Outcomes included morbidity, 90-day mortality, and long-term complications (Terblanche grade > 1). Logistic regression identified independent predictors.

Results: Mean age was 49.1 years, 67.3% were female, and 62.6% sustained injury during laparoscopic cholecystectomy; vascular injury occurred in 17.7%. Hepaticojejunostomy was performed in 95.9%, mostly after delayed referral (> 6 weeks in 91.2%). Morbidity occurred in 35.4%, bile leakage in 16.3%, and 90-day mortality in 4.1%. At a median follow-up of 69 months, 95.8% achieved Terblanche grade 1 outcomes. Independent predictors were laparoscopic index surgery for morbidity (OR = 5.41, 95% CI 1.08-27.09; p = 0.040); age (OR = 1.10, 95% CI 1.01-1.19; p = 0.028), vascular injury (OR = 16.45, 95% CI 2.13-127.20; p = 0.007), and bilirubin ≥ 15 mg/dL (OR = 19.74, 95% CI 1.74-224.53; p = 0.016) for mortality. Immediate repair predicted unfavorable long-term outcomes (OR = 10.44, 95% CI 1.60-68.34; p = 0.014).

Conclusion: Hepaticojejunostomy providing durable reconstruction. However, laparoscopic causative surgery, advanced age, vascular injury, and severe hyperbilirubinemia predicted adverse early outcomes, while immediate repair increased the risk of late stricture.

Backgrounds: Enhanced recovery after surgery (ERAS) has revolutionised perioperative care in colorectal surgery with reduced length of stay (LOS), reduced complications and superior patient outcomes. Despite this, colorectal ERAS is still not the standard of care across Australia. A growing body of evidence shows that ERAS is associated with significant cost benefits; however, currently, there is a lack of Australian data. The aim of this study is to retrospectively compare the healthcare system costs for elective colorectal resections utilising ERAS compared with conventional perioperative management.

Methods: A single-centre, retrospective cohort study compared the total cost of an elective colorectal resection to the public healthcare system when utilising the 25 principles of ERAS versus conventional care (CC). The estimated cost of each elective resection was manually calculated, including preadmission, operation, postoperative and readmission costs between the years 2010 and 2022 with the introduction of ERAS at the start of 2015. Cost data were also cross-examined with patient outcomes to assess how variations in patient care impact costs.

Results: A total of 642 patients were included: 237 (36.9%) received conventional perioperative management, and 405 (63.1%) underwent ERAS. The use of ERAS resulted in a median cost reduction of 2010 AUD per patient (20,719 vs. 22,729 AUD, p = 0.008). Overtime, ERAS was associated with a downward cost trend each year as the program matured. This reduction in median cost was also demonstrated in a subgroup analysis of uncomplicated admissions (-961 AUD, p = 0.087) and in the presence of Grades I-II complications (-2049 AUD, p = 0.504); however, neither was statistically significant. The cost benefits of ERAS were not present in the presence of Grades III-V complications or when a patient was readmitted within 30 days. ERAS was associated with a reduced median LOS (5 vs. 6 days, p < 0.001) and a reduction in the overall complication rate (26.42% vs. 37.55%, p = 0.003), which was most appreciable in the reduced rates of Grades I-II complications (22.96% vs. 29.96%).

Conclusion: Colorectal ERAS resulted in a statistically significant reduction in the cost per patient for elective resections at an Australian public hospital. The reported cost benefits stem from the associated reduction in LOS and an improved overall complication rate, particularly in the rates of Grades I and II complications. Additionally, there was a downtrend in median cost each year as the ERAS program matured at this institution, with the potential for further benefit in future years.