Search

The majority of analysed patients with cholangitis have hepatic fibrosis8 and the development of severe hepatic fibrosis in the presence of multiple intrahepatic stones may lead to LT, even in the setting of preserved liver function. Biliary atresia is a rare progressive inflammatory destruction of the bile ducts in the perinatal period, with complete obstruction of all or part of the extrahepatic bile ducts leading to liver fibrosis and ultimately liver failure. [Extracted from the article]

Background: Interhospital transfers in Australia facilitate access to acute surgical services, however transfer delays can occur. The aims of this study were to examine Australian mortality audit data on acute surgical patients who were transferred after presenting with a surgical emergency, and to identify modifiable predictors of transfer delay. Methods: Surgical admissions between 1 January 2001 and 18 August 2020 were retrospectively extracted from the Australian and New Zealand Audit of Surgical Mortality database. Relevant factors and themes of interest were collated. Results were presented as odds ratios (OR) and 95% confidence intervals (CI), with statistical significance defined as P <0.05. Results: After exclusion, a final 8270 cases were analysed. Non‐modifiable predictors identified were female gender (OR 1.34, 95% CI 1.05–1.70, P = 0.0184), comorbidities (OR 1.50, 95% CI 1.40–161, P <0.0001) and major non‐trauma non‐vascular specialty (OR 1.54 to 7.77, depending on specialty, P < 0.05). Modifiable predictors were inadequate clinical assessment (OR 49.48, 95% CI 32.91–74.38, P <0.0001), poor communication (OR 6.62, 95% CI 3.70–11.85, P <0.0001) and multiple transfers (OR 6.30, OR 95% 4.31–9.21, P <0.0001). Age, lack of bed and after‐hours transfer did not predict transfer delays. Metropolitan transfers was protective against transfer delays (OR 0.64, 95% CI 0.47–0.86, P = 0.0035). Conclusion: In the view of the receiving surgeon or assessor, all transfer delays potentially contributed to patient deaths, and may have been preventable. Strategies directed at modifiable factors could minimize delays. Increased surgical services in non‐metropolitan regions could reduce need for transfer. Prospective data is required to examine if the same predictors are observed in surgical patients who survive. [ABSTRACT FROM AUTHOR]

Background: Although modern Australian healthcare systems provide patient‐centred care, the ability to predict and prevent suboptimal post‐procedural outcomes based on patient demographics at admission may improve health equity. This study aimed to identify patient demographic characteristics that might predict disparities in mortality, readmission, and discharge outcomes after either an operative or non‐operative procedural hospital admission. Methods: This retrospective cohort study included all surgical and non‐surgical procedural admissions at three of the four major metropolitan public hospitals in South Australia in 2022. Multivariable logistic regression, with backwards selection, evaluated association between patient demographic characteristics and outcomes up to 90 days post‐procedurally. Results: 40 882 admissions were included. Increased likelihood of all‐cause, post‐procedure mortality in‐hospital, at 30 days, and 90 days, were significantly associated with increased age (P < 0.001), increased comorbidity burden (P < 0.001), an emergency admission (P < 0.001), and male sex (P = 0.046, P = 0.03, P < 0.001, respectively). Identification as ATSI (P < 0.001) and being born in Australia (P = 0.03, P = 0.001, respectively) were associated with an increased likelihood of 30‐day hospital readmission and decreased likelihood of discharge directly home, as was increased comorbidity burden (P < 0.001) and emergency admission (P < 0.001). Being married (P < 0.001) and male sex (P = 0.003) were predictive of an increased likelihood of discharging directly home; in contrast to increased age (P < 0.001) which was predictive of decreased likelihood of this occurring. Conclusions: This study characterized several associations between patient demographic factors present on admission and outcomes after surgical and non‐surgical procedures, that can be integrated within patient flow pathways through the Australian healthcare system to improve healthcare equity. [ABSTRACT FROM AUTHOR]

Background: The frequency of oxycodone adverse reactions, subsequent opioid prescription, effect on pain and patient care in general surgery patients are not well known. This study aimed to determine prevalence of documented oxycodone allergy and intolerances (independent variables) in a general surgical cohort, and association with prescribing other analgesics (particularly opioids), subjective pain scores, and length of hospital stay (dependent variables). Methods: This retrospective cohort study included general surgery patients from two South Australian hospitals between April 2020 and March 2022. Multivariable logistic regression evaluated associations between previous oxycodone allergies and intolerances, prescription records, subjective pain scores, and length of hospital stay. Results: Of 12 846 patients, 216 (1.7%) had oxycodone allergies, and 84 (0.7%) oxycodone intolerances. The 216 oxycodone allergy patients had lower odds of receiving oxycodone (OR 0.17, P < 0.001), higher odds of tramadol (OR 3.01, P < 0.001) and tapentadol (OR 2.87, P = 0.001), but 91 (42.3%) still received oxycodone and 19 (8.8%) morphine. The 84 with oxycodone intolerance patients had lower odds of receiving oxycodone (OR 0.23, P < 0.001), higher odds of fentanyl (OR 3.6, P < 0.001) and tramadol (OR 3.35, P < 0.001), but 42 (50%) still received oxycodone. Patients with oxycodone allergies and intolerances had higher odds of elevated subjective pain (OR 1.60, P = 0.013; OR 2.36, P = 0.002, respectively) and longer length of stay (OR 1.36, P = 0.038; OR 2.24, P = 0.002, respectively) than patients without these. Conclusions: General surgery patients with oxycodone allergies and intolerances are at greater risk of worse postoperative pain and longer length of stay, compared to patients without. Many still receive oxycodone, and other opioids that could cause cross‐reactivity. [ABSTRACT FROM AUTHOR]

Background: The applicability of the vital signs prompting medical emergency response (MER) activation has not previously been examined specifically in a large general surgical cohort. This study aimed to characterize the distribution, and predictive performance, of four vital signs selected based on Australian guidelines (oxygen saturation, respiratory rate, systolic blood pressure and heart rate); with those of the MER activation criteria. Methods: A retrospective cohort study was conducted including patients admitted under general surgical services of two hospitals in South Australia over 2 years. Likelihood ratios for patients meeting MER activation criteria, or a vital sign in the most extreme 1% for general surgery inpatients (<0.5th percentile or > 99.5th percentile), were calculated to predict in‐hospital mortality. Results: 15 969 inpatient admissions were included comprising 2 254 617 total vital sign observations. The 0.5th and 99.5th centile for heart rate was 48 and 133, systolic blood pressure 85 and 184, respiratory rate 10 and 31, and oxygen saturations 89% and 100%, respectively. MER activation criteria with the highest positive likelihood ratio for in‐hospital mortality were heart rate ≤ 39 (37.65, 95% CI 27.71–49.51), respiratory rate ≥ 31 (15.79, 95% CI 12.82–19.07), and respiratory rate ≤ 7 (10.53, 95% CI 6.79–14.84). These MER activation criteria likelihood ratios were similar to those derived when applying a threshold of the most extreme 1% of vital signs. Conclusions: This study demonstrated that vital signs within Australian guidelines, and escalation to MER activation, appropriately predict in‐hospital mortality in a large cohort of patients admitted to general surgical services in South Australia. [ABSTRACT FROM AUTHOR]

Background: This study aimed to examine the performance of machine learning algorithms for the prediction of discharge within 12 and 24 h to produce a measure of readiness for discharge after general surgery. Methods: Consecutive general surgery patients at two tertiary hospitals, over a 2‐year period, were included. Observation and laboratory parameter data were stratified into training, testing and validation datasets. Random forest, XGBoost and logistic regression models were evaluated. Each ward round note time was taken as a different event. Primary outcome was classification accuracy of the algorithmic model able to predict discharge within the next 12 h on the validation data set. Results: 42 572 ward round note timings were included from 8826 general surgery patients. Discharge occurred within 12 h for 8800 times (20.7%), and within 24 h for 9885 (23.2%). For predicting discharge within 12 h, model classification accuracies for derivation and validation data sets were: 0.84 and 0.85 random forest, 0.84 and 0.83 XGBoost, 0.80 and 0.81 logistic regression. For predicting discharge within 24 h, model classification accuracies for derivation and validation data sets were: 0.83 and 0.84 random forest, 0.82 and 0.81 XGBoost, 0.78 and 0.79 logistic regression. Algorithms generated a continuous number between 0 and 1 (or 0 and 100), representing readiness for discharge after general surgery. Conclusions: A derived artificial intelligence measure (the Adelaide Score) successfully predicts discharge within the next 12 and 24 h in general surgery patients. This may be useful for both treating teams and allied health staff within surgical systems. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure worldwide. The aim of this study was to examine cases of mortality after ERCP to identify clinical incidents that are potentially preventable, to improve patient safety. Methods: The Australian and New Zealand Audit of Surgical Mortality provides an independent and externally peer‐reviewed audit of surgical mortality pertaining to potentially avoidable issues. A retrospective review of prospectively collected data within this database was performed for the 8‐year audit period from 1 January 2009 to 31 December 2016. Clinical incidents were identified by assessors through first‐ or second‐line review, and thematically coded into periprocedural stages. These themes were then qualitatively analysed. Results: There were 58 potentially avoidable deaths following ERCP, with 85 clinical incidents. Preprocedural incidents were most common (n = 37), followed by postprocedural (n = 32) and then intraprocedural (n = 8). Communication issues occurred across the periprocedural period (n = 8). Preprocedural incidents included delay to procedure, inadequate resuscitative management, decision to perform procedure and inadequate assessment. Intraprocedural incidents comprised technical factors and inadequate support. Postprocedural incidents involved inappropriate treatment, delay in definitive surgical treatment or in recognizing complications, inappropriate second‐line intervention and inadequate assessment. Communication incidents comprised inadequate documentation, failure to escalate care and poor inter‐clinician communication. Conclusion: Causes of mortality following ERCP are wide‐ranging, and reviewing clinical incidents associated with potentially avoidable mortality can serve to inform and educate practitioners. In collating a subset of cases in which procedure‐related mortality was deemed avoidable, a series of cautionary tales about ERCP is presented that may provide cues to practitioners on improving patient safety and inform future surgical practice. [ABSTRACT FROM AUTHOR]

Objective: Liver resections for non‐colorectal non‐neuroendocrine liver metastases (NCNELM) are gaining popularity. This study examines the outcomes of liver resections in patients with NCNELM in an Australian hospital. Method: A database search identified 21 attempted liver resections on 20 patients (12 men, eight women, mean age: 63.1) from 1998 to 2013. A retrospective analysis considered patient demographics and primary malignancy details. Complication rates were compared to those for colorectal metastases at the same institution. Kaplan–Meier curves were used to plot overall survival. Results: Complete resection was achieved in 16 of the 21 operations with 13 cases having proven metastases (three cases were benign lesions on final histology). Primary cancers were gastric (n = 4), gall bladder/bile duct (n = 3), renal (n = 3), soft tissue sarcoma (n = 3), melanoma (n = 2), pancreatic (n = 2), anal (n = 2), breast (n = 1) and unknown (n = 1). Primary histology types were adenocarcinoma (n = 10), sarcoma (n = 3), renal cell (n = 3), squamous cell (n = 2), melanoma (n = 2) and gastrointestinal stromal tumour (n = 1). There was no peri‐operative mortality. Significant post‐operative complications (Clavien–Dindo Grade III or more) occurred in six patients (28.5%). Overall survival at 2 and 5 years was 46.2% and 30.8%, respectively, for all 21 cases of attempted resection, and 51.9% and 34.6%, respectively, for the 13 cases of complete resection of malignant metastases. Conclusions: This study produced comparable 5‐year survival rates to those reported after liver resection for colorectal metastases and in other studies on NCNELM. Complication rates were comparable to those for colorectal liver metastasis resection at the same institution. [ABSTRACT FROM AUTHOR]

Background: Australian life expectancy is high by world standards, largely because of advanced health care. It is therefore important to determine safety and oncological benefits of major surgical procedures in the elderly. This retrospective review examines outcomes of liver resection in octogenarians. Methods: Data on all liver resections performed at The Queen Elizabeth Hospital were collected in a prospective database. The primary aim was to determine overall and disease‐free survival, and secondary aim to assess perioperative quality of life (QoL) and functionality outcomes using surrogate markers. Results: Twenty‐four octogenarians underwent 26 liver resections for colorectal liver metastases (n = 20), hepatocellular carcinoma (n = 4), cholangiocarcinoma (n = 1) and benign lesion (n = 1). Median hospital stay was 11 days. There were no major post‐operative complications and only one patient experienced a decline in QoL. There was no 90‐day mortality. Five‐year overall survival and 5‐year disease‐free survival were 47% and 37%, respectively. Median duration of follow‐up was 34 months. Conclusion: Liver resection can be performed safely in octogenarians with low morbidity, excellent overall survival and good QoL outcomes. [ABSTRACT FROM AUTHOR]

In the ANZELA-QI pilot study sample of emergency laparotomies reported by Aitken I et al i ., a preoperative risk assessment was only documented prior to 45% of operations.2 In reality, this figure is likely an overestimate considering the number of Australian hospitals not participating in ANZELA-QI. We read with interest Anderson's editorial on emergency laparotomy1 and agree with the need for further audit and improvement in the area. Two-year outcomes from the Australian and New Zealand emergency laparotomy audit-quality improvement pilot study. [Extracted from the article]

Adrenaline in local anaesthetics: do students and junior doctors still believe the myth? Of the choices of local anaesthetic preparations, two contained adrenaline (1% lignocaine with 1:100 000 adrenaline and 0.25% bupivacaine with 1:100 000 adrenaline) and three did not (1% lignocaine, 0.25% bupivacaine and 0.25% ropivacaine). Medical students and junior doctors choose to use local anaesthetic preparations without adrenaline for areas of the body supplied by end arteries, despite there is evidence that the use of adrenaline is safe and advantageous. [Extracted from the article]