Search

Background: Total (procto)colectomy is indicated in 15%–20% of ulcerative colitis(UC) patients during their disease course. Reconstruction options to avoid a permanent ileostomy include an ileoanal pouch anastomosis (IPAA) or ileorectal anastomosis (IRA). This study aimed to investigate reconstruction rates using Australian‐based population‐level data, and factors influencing reconstruction. Methods: A retrospective data linkage study of the NSW population over a 19‐year period was performed. Patients with UC who underwent total (procto)colectomy with a minimum of 1‐year follow up were included. The main outcome was reconstruction with either IPAA or IRA. The influence of hospital and patient factors on reconstruction rates was assessed by Cox regression. Results: Overall, 1047 patients underwent a (procto)colectomy for UC (mean age 45.9 years [SD ± 18.3], 640 [61.1%] male). The 5‐year reconstruction rate was 55% (IPAA 89%). Advanced age, emergent colectomy, higher comorbidity burden, and geographical remoteness were significantly associated with lower reconstruction rates. A lower reconstruction rate was also observed in the most recent time‐period (2014–2019) (aHR 0.68[95% CI 0.54–0.86]), and where index (procto)colectomy was performed in low‐volume (<1 pouch/year) pouch hospitals (aHR 0.60 [95% CI 0.43–0.82]). Conclusions: NSW Australia has the highest reported rate of reconstruction following UC (procto)colectomy globally. However, rates reduced in the most recent time‐period. There was variation in reconstruction rates across centres, with primary and overall reconstruction rates proportionate to hospital pouch volume. Reconstruction rates were also lower for patients living outside major cities. To ensure equitable opportunities for reconstruction, patients being considered for IBD pouch surgery should be centralized to a limited number of specialist pouch centres. [ABSTRACT FROM AUTHOR]

Aim: Total (procto)colectomy for ulcerative colitis (UC) is associated with significant morbidity, which is increased in the emergency setting. This study aimed to evaluate the outcomes following total (procto)colectomies at a population level within New South Wales (NSW), Australia, and identify case mix and hospital factors associated with these outcomes. Methods: A retrospective data linkage study of patients undergoing total (procto)colectomy for UC in NSW over a 19‐year period (2001–2020) was performed. The primary outcome was 90‐day mortality. The influence of hospital level factors (including annual volume) and patient demographic variables on outcomes was assessed using logistic regression. Temporal trends in annual volume and evidence for centralization were assessed. Results: In all, 1418 patients (mean 47.0 years [SD 18.7], 58.7% male) underwent total (procto)colectomy during the study period. The overall 90‐day mortality rate was 3.2% (emergency 8.6% and elective 0.8%). After adjusting for confounding, increasing age at total (procto)colectomy, higher comorbidity burden, public health insurance (Medicare) status, emergency operation and living outside a major city were significantly associated with increased mortality. Hospital volume was significantly associated with mortality at a univariate level, but this did not persist on multivariate modelling. Conclusions: Outcomes of UC patients undergoing total (procto)colectomy in NSW Australia are comparable to international experience. Whilst higher mortality rates are observed in low volume and public hospitals, this appears attributable to case mix and acuity rather than surgical volume alone. However, as inflammatory bowel disease surgery is not centralized in Australia, only one NSW hospital performed >10 UC total (procto)colectomies annually. Variation in mortality according to insurance status and across regional/remote areas may indicate inequality in the availability of specialist inflammatory bowel disease treatment, which warrants further research. [ABSTRACT FROM AUTHOR]

Background: This study aims to investigate the trends in UC surgery in New South Wales (NSW) at a population level. Methods: A retrospective data linkage study of the NSW population was performed. Patients of any age with a diagnosis of UC who underwent a total abdominal colectomy (TAC) ± proctectomy between Jul‐2001 and Jun‐2019 were included. The age adjusted population rate was calculated using Australian Bureau of Statistics data. Multivariable linear regression modelled the trend of TAC rates, and assessed the effect of infliximab (listed on the Pharmaceutical Benefits Scheme for UC in Apr‐2014). Results: A total of 1365 patients underwent a TAC ± proctectomy (mean age 47.0 years (±18.6), 59% Male). Controlling for differences between age groups, the annual rate of UC TACs decreased by 2.4% each year (95% CI 1.4%–3.4%) over the 18‐year period from 1.30/100000 (2002) to 0.84/100000 (2019). An additional incremental decrease in the rate of TACs was observed after 2014 (OR 0.83, 95% CI 0.69–1.00). There was no change in the proportion of TACs performed emergently over the study period (OR 1.02, 95% CI 0.998–1.04). The odds of experiencing any perioperative surgical complication (aOR 1.54, 95% CI 1.01–2.33, P = 0.043), and requiring ICU admission (aOR 1.85, 95% CI 1.24–2.76, P = 0.003) significantly increased in 2014–2019 compared to 2002–2007. Conclusions: The rate of TACs for UC has declined over the past two decades. This rate decrease may have been further influenced by the introduction of biologics. Higher rates of complications and ICU admissions in the biologic era may indicate poorer patient physiological status at the time of surgery. [ABSTRACT FROM AUTHOR]

Background: Ileal pouch‐anal anastomosis (IPAA) is considered the gold standard reconstructive option in ulcerative colitis (UC). Recent efforts to improve pouch outcomes have seen a push towards centralisation of surgery. This study aimed to document outcomes following pouch surgery at a population level within New South Wales (NSW), and identify factors associated with, and temporal trends of these outcomes. Methods: A retrospective data linkage study of the NSW population over a 19‐year period was performed. The primary outcome was pouch failure in patients with UC who underwent IPAA. The influence of hospital level factors (including annual volume) and patient demographic variables on this outcome were assessed using Cox proportional hazards modelling. Temporal trends in annual volume and evidence for centralisation over the studied period were assessed using Poisson regression analysis. Results: The annual volume of UC pouches reduced over the study period. The pouch failure rates were 8.6% (95% CI 6.3–10.8%) and 10.6% (95% CI 8.0–13.1%) at 5‐ and 10‐years, respectively. Increasing age and non‐elective admission were associated with higher failure rates. One‐third of UC pouches (31.6%) were performed in a single institution, which averaged 6.5 pouches/year throughout the study period. Three‐quarters (19/25) of NSW public hospitals who performed pouches performed less than one UC pouch annually. Conclusions: The outcomes following UC pouch surgery in NSW are comparable with global standards. Concentrating IBD pouch surgery with the aim of producing specialist surgical teams may be a reasonable way forward in NSW and would ensure equity of access and facilitate research and training collaboration. [ABSTRACT FROM AUTHOR]

Background: There are no publications addressing the level of experience Australian surgical trainees achieve in inguinal hernia surgery. Internationally, some training boards have set minimum competency requirements, but this is not true in Australia. The longer learning curve for laparoscopic inguinal hernia repairs (LIHRs) compared to open inguinal hernia repairs (OIHRs) has placed greater demands on trainees. Methods: Logbook data on OIHR and LIHR for Australian surgical trainees who graduated as fellows between 2013 and 2018 were obtained. A literature review was performed to analyse international published logbook numbers for surgical trainees from the past decade. International training board requirements, estimations of the learning curve and hernia society guidelines for each procedure were reviewed. Results: In total, 7946 operations were recorded from 58 trainees. On average 49.2 OIHRs (range 13–101), 21.5 LIHRs (range 1–94) and 71.1 inguinal hernia repairs overall (range 25–129) were performed during training. The European Hernia Society recommends that at least 30–50 of each procedure be performed during training. The learning curves for LIHRs (50–100 procedures) have been shown to be longer than for OIHRs (40–64 procedures). Conclusion: Australian general surgical trainees are achieving adequate primary operator logbook numbers for OIHRs but are not completing the required number of LIHRs. The tailored approach to inguinal hernia repair requires skill in both open and laparoscopic repairs. This may not be possible with the current training structure in Australia. [ABSTRACT FROM AUTHOR]

Background: At present in Australia women are not routinely, systematically informed of the risks of childbirth. Aims: It is hoped this presentation of the perspective of some women who suffer unexpected obstetric complications will encourage change. Materials and Methods: The experience of women involved in obstetric medicolegal reports prepared by a colorectal surgeon over ten years is analysed. Results: Twenty women were identified. Sixteen had vaginal deliveries. All 16 suffered third or fourth‐degree tears, six developed rectovaginal fistulae, six required stomas and 11 developed faecal incontinence. Of the four women who delivered by caesarean section, there were two post‐operative caecal perforations, one unrecognised small bowel enterotomy, and one patient developed sepsis due to an infected haematoma. Seventeen of the 20 women were noted to suffer psychological sequalae. None of the women recollected being warned of the complication they suffered, and there was no record of such warnings in their medical records. Conclusion: Informed written 'consent' for natural vaginal delivery is, understandably, a contentious topic. Although learning from medicolegal cases may go against the grain, as medical professionals it is very difficult to ethically justify the status quo, where women are not routinely simply informed of the risks of childbirth. This is not fair. Even if informing women does not decrease the incidence of complications, the women who subsequently suffer these complications may well handle them much better, recognising they could occur. [ABSTRACT FROM AUTHOR]

Abstract: There has been increasing recognition of pre-motor manifestations of Parkinson''s disease (PD) resulting from early brainstem involvement. We sought to determine whether ventilatory control is abnormal. Patients with PD without respiratory disease were recruited. Spirometry, lung volumes, diffusing capacity and respiratory muscle strength were assessed. Occlusion pressure and ventilation were measured with increasing CO2. Arterial blood gases were taken at rest and following 20min exposure to 15% O2. A linear correlation assessed associations between respiratory function and indices of PD severity. 19 subjects (17 males) with mild-moderate PD were studied (mean (SD) age 66 (8) years). Respiratory flows and volumes were normal in 16/19. Maximum inspiratory and expiratory pressures were below LLN in 13/19 and 15/19 respectively. 7/15 had a reduced ventilatory response to hypercapnia and 11/15 had an abnormal occlusion pressure. There was no correlation between impairment of ventilatory response and reduction in respiratory muscle strength. Response to mild hypoxia was normal and there were no associations between disease severity and respiratory function. Our findings suggest that patients with mild-moderate PD have abnormal ventilatory control despite normal lung volumes and flows. [Copyright &y& Elsevier]