Search

BACKGROUND Many hospitals across Australia and New Zealand have implemented acute care surgery (ACS) models over the past decade, often with improved outcomes such as reductions in wait time to surgery, complications and length of stay. The aim of this study was to evaluate the outcomes of patients who underwent non-elective appendicectomy and cholecystectomy and compare these with the results observed shortly after the implementation of an ACS model at our institution 10 years earlier. METHODS A retrospective review of contemporary patients who underwent non-elective appendicectomy and cholecystectomy compared with historical data was performed. Primary outcomes were wait time to surgery, surgical complications and length of stay. RESULTS In the contemporary cohort, 263 patients underwent non-elective appendicectomy over a 1-year period compared with 226 patients in the historical cohort. The median wait time to surgery had increased (17.7 versus 9.6 h, P

BACKGROUND: The Royal Australasian College of Surgeons awards scholarships to surgeons, surgical trainees and recipients focused on developing their clinical knowledge and improving outcomes for patients. A bibliometric analysis of research scholarship recipients publications and h-index scores was conducted to understand the benefits of receiving these scholarships. METHODS: A bibliometric analysis of Royal Australasian College of Surgeons scholarship recipients in 2015 was performed using Open Researcher and Contributor ID (ORCID), Scopus, Google Scholar, ResearchGate, LinkedIn and PubMed to identify the number of publications, h-index scores, field-weighted citation impact and the relative citation ratio. RESULTS: Nineteen research scholarship recipients authored 842 publications, with 491 (58%) published after completion of their scholarship. Seven recipients published 50% or more of their articles in the 5 years since completion. Five recipients have each published more than 45 articles since 2015. H-index scores varied between Scopus and Google Scholar (overall range: 4-34). Scopus identified the most publications, followed by ResearchGate. Determining publication numbers for recipients was problematic due to self-reporting in some databases (i.e. Google Scholar, ResearchGate), variations in author names (i.e. maiden to married name), duplication of publications and the inclusion of supplementary material (i.e. extra tables) in self-reporting databases. Field-weighted citation impact and relative citation ratio values exceeded 1 on 12 occasions demonstrating recipients are more cited than the global average. CONCLUSION: Continuous tracking of publication rates and h-index scores of scholarship recipients demonstrates recipients' continuing interest in advancing and disseminating medical knowledge to improve patient outcomes. The 2015 scholarship recipients publication numbers continued to increase after their scholarship tenure.

Background and objectives There is limited evidence to guide the management of patients with oligometastatic anal squamous cell carcinoma (SCC). We aimed to address this question by reporting the outcome of SCC patients who were treated with organ-directed therapies at two large cancer centers. Methods Patients with advanced anal SCC who were treated with surgery, stereotactic radiotherapy, or radiofrequency ablation (RFA) with a curative intent from 2008 to 2017 were retrospectively identified from the institutional electronic patient records. Results Eight patients with liver or lung metastases met the study inclusion criteria. Seven were treated with surgery while one received RFA and radiotherapy. Median progression-free survival was 5 months (range, 4-39). Three patients underwent repeat organ-directed treatment upon failure of the initial surgery with no evidence of further recurrent disease at the last follow-up. Median overall survival from the time of the first organ-directed therapy was 31 months (range, 11-96) with two out of eight patients being alive and disease-free at 5 years. Conclusions Our study confirms that consideration should be given to the adoption of a multidisciplinary treatment approach in carefully selected, oligometastatic anal SCC patients as organ-directed therapies may offer the chance of achieving a relatively long disease control.

Small bowel obstruction is a common and significant surgical presentation. Approximately 30% of presentations will require surgery during admission. The great challenge of adhesive small bowel obstruction (ASBO) management is the early detection of silent intestinal ischaemia in patients initially deemed suitable for conservative therapy. Recent literature emphasizes the effectiveness of computed tomography enterography and water-soluble contrast studies in the management of ASBO. Low-volume undiluted water-soluble contrast has been shown to have both triage and therapeutic value in the management of ASBO. Their use has been demonstrated to reduce the need for surgery to below 20%. There has also been growing interest in clinicoradiological algorithms which aim to predict ischaemia early in the course of presentation. The aim of this review is to summarize the latest evidence and clarify previous uncertainties, specifically regarding the duration of conservative treatment, timing of contrast studies and the reliability of predictive algorithms. Based on this latest evidence, we have formulated a management protocol which aims to integrate these latest developments and formalize a strategy for best management in ASBO.

Small bowel obstruction is a common and significant surgical presentation. Approximately 30% of presentations will require surgery during admission. The great challenge of adhesive small bowel obstruction (ASBO) management is the early detection of silent intestinal ischaemia in patients initially deemed suitable for conservative therapy. Recent literature emphasizes the effectiveness of computed tomography enterography and water-soluble contrast studies in the management of ASBO. Low-volume undiluted water-soluble contrast has been shown to have both triage and therapeutic value in the management of ASBO. Their use has been demonstrated to reduce the need for surgery to below 20%. There has also been growing interest in clinicoradiological algorithms which aim to predict ischaemia early in the course of presentation. The aim of this review is to summarize the latest evidence and clarify previous uncertainties, specifically regarding the duration of conservative treatment, timing of contrast studies and the reliability of predictive algorithms. Based on this latest evidence, we have formulated a management protocol which aims to integrate these latest developments and formalize a strategy for best management in ASBO.

Background An acute care surgery (ACS) model was introduced to manage emergency surgical presentations efficiently. The aim of this study was to evaluate the impact of patient handover in an ACS model on the outcomes of adhesive small bowel obstruction (SBO). Methods A retrospective study was performed on patients who were admitted with adhesive SBO at Prince of Wales Hospital. The cohort consisted of all patients treated by the ACS team from its introduction in September 2005 to February 2011. Patients in the ACS cohort were divided into two groups: those whose care was handed over to another surgeon and those whose care was not. These groups of patients were compared with a random sample of 50 patients in the pre-ACS period. Results In the ACS period, there was no significant difference in complication rates or length of hospital stay in those who were not handed over and those who were. A significantly higher proportion of operations took place during the day for the group who had been handed over (72.7% versus 36.7%; P = 0.005). There were no significant differences in complication rates or length of hospital stay in the pre-ACS and ACS period. Conclusion Management under an ACS team does not increase adverse outcomes for adhesive SBO. Patients can be safely handed over within an ACS framework. Other members of the ACS team may help facilitate continuity of care.

Objective:This study used a prospective design and the technique of structural modelling to examine the complex interrelations between psychological factors, immune status and complications after major surgery.Methods:Twenty-nine women scheduled for elective cholecystectomy were studied prospectively. Information regarding medical history, health practices, life stressors, and coping strategies was obtained two weeks prior to admission. At this initial meeting, as well as three days after surgery, and at one month follow-up immunological tests were performed and the level of psychological distress was assessed. The study additionally included measures of post-operative complications, and infections and negative effect during follow-up.Results:Pre-operative immune status emerged as a key variable exerting strong effects on subsequent immune function and, thereby producing significant, indirect effects on every recovery variable. Pre-operative distress was directly linked to increased mood disturbance at follow-up. Moreover, distress significantly influenced immune function both before and after surgery, which mediated a significant impact on most recovery variables. Active coping behaviour directly increased the risk of a complicated recovery.Conclusions:The study demonstrated that distress-induced changes in immune functioning have clinical relevance. Overall, the present findings suggest that recovery from surgery is facilitated in patients with a well-functioning immune system, a low-level of pre-operative distress and a passive coping disposition.

Errors are to be expected in health care. Adverse events occur in around 10% of surgical patients and may be even more common in emergency surgery. There is little formal teaching on surgical error in surgical education and training programmes despite their frequency.This paper reviews surgical error and provides a classification system, to facilitate learning. The approach and language used to enable teaching about surgical error was developed through a review of key literature and consensus by the founding faculty of the Management of Surgical Emergencies course, currently delivered by General Surgeons Australia.Errors may be classified as being the result of commission, omission or inition. An error of inition is a failure of effort or will and is a failure of professionalism. The risk of error can be minimized by good situational awareness, matching perception to reality, and, during treatment, reassessing the patient, team and plan. It is important to recognize and acknowledge an error when it occurs and then to respond appropriately. The response will involve rectifying the error where possible but also disclosing, reporting and reviewing at a system level all the root causes. This should be done without shaming or blaming. However, the individual surgeon still needs to reflect on their own contribution and performance.A classification of surgical error has been developed that promotes understanding of how the error was generated, and utilizes a language that encourages reflection, reporting and response by surgeons and their teams.

The provision of acute surgical care in the public sector is becoming increasingly difficult because of limitation of resources and the unpredictability of access to theatres during the working day. An acute-care surgical service was developed at the Prince of Wales Hospital to provide acute surgery in a more timely and efficient manner. A roster of eight general surgeons provided on-site service from 08.00 to 18.00 hours Monday to Friday and on-call service in after-hours for a 79-week period. An acute-care ward of four beds and an operating theatre were placed under the control of the rostered acute-care surgeon (ACS). At the end of each ACS roster period all patients whose treatment was undefined or incomplete were handed over to the next rostered ACS. Patient data and theatre utilization data were prospectively collected and compared to the preceding 52-week period. Emergency theatre utilization during the day increased from 57 to 69%. There was a 11% reduction in acute-care operating after hours and 26% fewer emergency cases were handled between midnight and 08.00 hours. There was more efficient use of the entire theatre block, suggesting a significant cultural change. Staff satisfaction was high. On-site consultant-driven surgical leadership has provided significant positive change to the provision of acute surgical care in our institution. The paradigm shift in acute surgical care has improved patient and theatre management and stimulated a cultural change of efficiency.

Background The provision of acute surgical care in the public sector is becoming increasingly more difficult due to the limitation of resources. The lack of predictability of access to theatres during the working day has the effect of displacing elective cases or forcing some acute cases to be performed after hours. An Acute Care Surgical Service was constructed at the Prince of Wales Hospital so as to provide acute surgery in a more timely and efficient manner. Methods A roster of 8 general surgeons was constructed to provide onsite service during the working day and on call service after hours for a 52 week period. An acute care ward of 4 beds and an operating theatre was placed under the control of the Acute Care Surgeon (ACS). At the end of the ACS roster all patients whose treatment was incomplete were handed on to the next rostered ACS. Patient data and theatre utilisation data was prospectively collected and compared to the preceding 52 week period. Data was analysed using unpaired t-test. Results Emergency theatre utilization during the day increased from 55% to 70%. There was a 15% reduction in acute care operating after hours. Fewer cases were done between midnight and 0800. There was more efficient use of the entire theatre block suggesting a significant cultural change. Staff satisfaction was high. Conclusion On site consultant driven surgical leadership has provided significant positive change to the provision of Acute Surgical Care in our institution. The paradigm shift in acute surgical care has improved patient and theatre management and stimulated a cultural change of efficiency.

When HIV is mentioned in a surgical forum a debate will often follow about "universal testing" and "barrier precautions". Unfortunately, there is little discussion of the many ways that HIV-infected patients may present primarily to the surgeon. Although lifestyle risk factors are important clues, unusual clinical features of a relatively common surgical disease should raise the suspicion of HIV infection.