Showing papers by "Guy J. Maddern published in 2007"

Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review.

Abstract: Colorectal cancer can result in malignant obstruction of the colon or rectum, through the presence of either intrinsic or extrinsic tumors. Acute or subacute bowel obstruction can lead to abdominal pain, nausea, vomiting, bowel rupture, and eventual death if left untreated. Conventional therapies for relieving malignant colorectal obstruction include surgical resection (potentially curative) or palliative colostomy. Resection is more frequently an option in patients with less advanced cancer, and is ideally carried out as a single-stage procedure, with anastomosis to restore bowel continuity. Multistage procedures may also be undertaken, with resection and stoma formation in one procedure, followed by restoration of continuity in another procedure.1 However, a significant proportion of patients receiving a staged procedure never undergo reversal of the colostomy.2 Permanent stoma creation is the standard treatment of bowel obstruction caused by nonresectable tumors, relieving the symptoms of bowel obstruction. Although it is the standard treatment modality, stoma creation is associated with high morbidity and mortality rates, particularly when undertaken under emergency conditions.1 Furthermore, stoma creation is recognized as having a highly negative impact on patients' psychosocial well-being3 and can be a burden to caregivers as well as the patient during the final months of their life. Endoscopic treatments to palliate rectal obstruction have also been developed in recent years but are not yet a standard treatment option. Medical management, including the use of opioids, anticholinergics, and antiemetics, is most commonly used in hospices and palliative care settings to assist in maintaining an acceptable quality of life in patients with terminal illness. Self-expanding metallic stents (SEMS) are expandable metallic tubes that are advanced to the site of the obstruction along a guidewire in a collapsed state, under fluoroscopic and/or endoscopic guidance. Once deployed, the stents slowly expand radially to their maximum diameter under their own force, thereby achieving patency of the obstructed anatomy. Almost all stenting procedures are carried out transanally, and are generally well tolerated by patients with only conscious sedation, or no anesthesia. The value of stent placement is as a minimally invasive alternative to open surgical techniques, such as resection or stoma creation. SEMS may be used as a definitive palliative measure or can be used as a “bridge to surgery” to allow stabilization of the patient's condition before surgery is carried out as an elective procedure at a later date. A number of stents have been designed specifically for use in the lower gastrointestinal tract and are available in a variety of lengths and diameters, so that the appropriate stent can be selected based on factors such as the length of the obstructed section of bowel and anatomic location of the obstruction. While stenting procedures are becoming a more frequent treatment modality, it is currently unclear whether stenting represents a safe and effective alternative to surgical procedures for the treatment of malignant colorectal obstructions. The aim of this review is to assess the safety and efficacy of SEMS placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature.

Unicompartmental knee arthroplasty for the treatment of unicompartmental osteoarthritis: a systematic study

Abstract: Unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA) and high tibial osteotomy (HTO) may all be used to treat unicompartmental osteoarthritis, but they are often used for different patient groups. However, there is considerable overlap in indications for all three options. The aim of this review was to assess the safety and efficacy of UKA compared with TKA and HTO in unicompartmental osteoarthritis. Studies that compared UKA with either TKA or HTO were identified and included for review. For knee function and postoperative pain, UKA appeared similar to TKA and HTO at 5 years follow up. Range of motion was better in UKA compared with TKA. Complication rates after UKA and TKA appeared similar, although deep vein thrombosis was reported more often after TKA. There were more complications after HTO than UKA. Survival of UKA prostheses was approximately 85-95%, compared with at least 90% for TKA at 10 years follow up. Survivorship for HTO appeared to be less than 85%. It was not clear whether there were more revisions after UKA than TKA, but there appeared to be fewer revisions in UKA compared with HTO. UKA is considered at least as safe as TKA and HTO. For function, UKA appears to be at least as efficacious as TKA and HTO. The survival of UKA compared with TKA and HTO cannot be determined based on the available evidence.

Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals

Abstract: Objectives: To assess the effectiveness of an intervention package comprising intense education, a range of reporting options, changes in report management and enhanced feedback, in order to improve incident-reporting rates and change the types of incidents reported. Design, setting and participants: Non-equivalent group controlled clinical trial involving medical and nursing staff working in 10 intervention and 10 control units in four major cities and two regional hospitals in South Australia. Main outcome measures: Comparison of reporting rates by type of unit, profession, location of hospital, type of incident reported and reporting mechanism between baseline and study periods in control and intervention units. Results: The intervention resulted in significant improvement in reporting in inpatient areas (additional 60.3 reports/10 000 occupied bed days (OBDs); 95% CI 23.8 to 96.8, p<0.001) and in emergency departments (EDs) (additional 39.5 reports/10 000 ED attendances; 95% CI 17.0 to 62.0, p<0.001). More reports were generated (a) by doctors in EDs (additional 9.5 reports/10 000 ED attendances; 95% CI 2.2 to 16.8, p = 0.001); (b) by nurses in inpatient areas (additional 59.0 reports/10 000 OBDs; 95% CI 23.9 to 94.1, p<0.001) and (c) anonymously (additional 20.2 reports/10 000 OBDs and ED attendances combined; 95% CI 12.6 to 27.8, p<0.001). Compared with control units, the study resulted in more documentation, clinical management and aggression-related incidents in intervention units. In intervention units, more reports were submitted on one-page forms than via the call centre (1005 vs 264 reports, respectively). Conclusions: A greater variety and number of incidents were reported by the intervention units during the study, with improved reporting by doctors from a low baseline. However, there was considerable heterogeneity between reporting rates in different types of units.

The safety and efficacy of radiofrequency and electrolytic ablation created adjacent to large hepatic veins in a porcine model.

Abstract: Introduction Immediately adjacent to large hepatic veins, tumour ablation by radiofrequency or electrolysis may be impaired by heat or current sink effects Ablation may also cause vessel injury and thrombosis The aim of this study was to evaluate the safety and efficacy of radiofrequency and electrolytic ablative techniques adjacent to large hepatic veins Methods Electrolytic and radiofrequency zones of ablation were created adjacent to hepatic veins in large white pigs After 72 h the zones of ablation created were examined histologically for (a) the extent of tissue necrosis up to the vessel and (b) the presence of intimal damage and mural thrombus in the veins Results An unexpected complication of electrolysis near large veins was cardiac tamponade This current related phenomenon could easily be avoided In seven of nine electrolysis zones of ablation necrosis was completely adjacent to the vessel wall, but in only four of seven radiofrequency zones of ablation All zones of ablation were associated with intimal necrosis, and most with mural thrombosis Conclusions Ablation of hepatic tumours by radiofrequency and electrolysis is unreliable adjacent to hepatic veins Both techniques are associated with mural thrombus formation, and so risk thrombo-embolic complication These ablative modalities are not recommended for zones of ablation adjacent to hepatic veins

The outcome of endovascular repair of small abdominal aortic aneurysms.

Abstract: Abdominal aortic aneurysm (AAA) affects approximately 5% of men and 1% of women over 60 years, and the incidence is increasing.1 The principal complication of AAA is aortic rupture, which usually results in death.2 Rupture risk is presently best predicted by aortic diameter, with AAAs >6 cm having a rupture risk of approximately 10% per year.3 Since AAA is usually asymptomatic, the condition is often diagnosed as an incidental finding during abdominal imaging. Recently, a number of randomized controlled trials have demonstrated that ultrasound screening of selected population can reduce deaths associated with AAA.4,5 The more widespread use of ultrasound screening and abdominal imaging has led to an increase in the number of small AAAs referred for management. Two randomized trials have supported a conservative policy for small AAAs, whereby following identification aneurysms are followed by ultrasound surveillance unless the aneurysm expands to >5.5 cm in maximal diameter when surgery is advised.6,7 The introduction of endovascular aneurysm repair (EVAR) has made available a less invasive surgical option, which had been demonstrated to be associated with lower perioperative mortality than open surgery for the repair of large aneurysms.8,9 However, EVAR has a number of complications that only become apparent during longer-term follow-up, such as late aortic rupture, endoleak, graft migration, and graft limb occlusion.10,11 Intermediate follow-up of patients randomized to EVAR for the treatment of large AAAs demonstrated no reduction in all-cause mortality in comparison to open surgery and increased requirement for reintervention.10,11 The favorable perioperative results, the greater anatomic suitability and the belief that the outcome of EVAR is better have all encouraged the extension of this technique to patients normally treated conservatively with small AAAs. The aim of this study was to examine the perioperative and intermediate results of EVAR for AAAs of ≤5.5 cm.

Clinical audits: why and for whom.

Abstract: Every surgical activity poses some element of risk to the public and should include a quality control initiative. Surgical audit is one strategy used to maintain and/or improve standards in surgical care. The Royal Australasian College of Surgeons is committed to ensuring best practice in surgical care and strongly endorses the use of audits to achieve this. This review provides an overview of clinical audit and its role in surgical practice.

Silver dressings versus other dressings for chronic wounds in a community care setting.

Abstract: Objective: To assess differences in effectiveness between silver dressings and other types of dressings in chronic wound management in the community setting. Method: The study used client data retrospectively collected as part of routine care management. The cohort comprised 2687 clients who received 3716 episodes of care between September 2005 and January 2006. Outcome measures were the length of time for which clients received care from community nurses for each wound and the number of visits required. Results: The median number of visits was statistically significantly higher for the silver-dressing users than for users of other dressings (31 versus 11, p<0.0001), while the median treatment duration was also greater (97 days versus 39 days, p<0.0001). In addition, the interval between visits was significantly shorter in the silver dressing group (p<0.001). Conclusion: These results question the effectiveness of silver dressing materials in the management of chronic wounds in a community care setting. H...

Pablo luis mirizzi: the man behind the syndrome

Abstract: Pablo Luis Mirizzi (1893-1964), who was born and died in the city of Cordoba in Argentina, dedicated his life to the service of surgery and the teaching of his students. Although known for the introduction of the intraoperative cholangiogram and for describing the Mirizzi syndrome - a partial obstruction of the common hepatic duct secondary to an impacted gallstone in the cystic duct, very little else is known about this man behind the brilliant surgical pioneer of the twentieth century. This biography looks beyond his important contributions to medicine, to the many facets of the man himself.

National Breast Cancer Audit: ductal carcinoma in situ management in Australia and New Zealand.

Abstract: Background: Ductal carcinoma in situ (DCIS) is a significant issue in Australia and New Zealand with rising incidence because of the implementation of mammographic screening. Current information on its natural history is unable to accurately predict progression to invasive cancer. In 2003, the National Breast Cancer Centre in Australia published recommendations for DCIS. In Australia and New Zealand, the National Breast Cancer Audit collects information on DCIS cases. This article will examine these recommendations and provide information from the audit on current DCIS management. Methods: Three thousand six hundred and twenty-nine cases of DCIS were entered by 274 breast surgeons between January 1998 and December 2004. Data items in the National Breast Cancer Audit database that were covered in the National Breast Cancer Centre recommendations were reviewed. Information was available on the following: diagnostic biopsy rates for all cases and mammographically positive cases and rates of breast conserving surgery (BCS), clear margins following BCS, postoperative radiotherapy following BCS for groups at high risk of recurrence as well as axillary procedures and tamoxifen prescription. Results: Close adherence was found in diagnostic biopsy, BCS and clear margin rates. Some high-risk groups received radiotherapy, although women with ‘close’ margins did not in 33% of cases. Axillary procedures were conducted in 23% of cases and most (81%) patients were not prescribed tamoxifen. Conclusion: There was predominantly close adherence to recommendations with three possible areas of improvement: fewer axillary procedures, an appraisal of radiotherapy practice following BCS and more investigation into tamoxifen prescription practices for DCIS.

Robotic surgery: will it be evidence-based or just "toys for boys"?

Abstract: Author details Fiona J Stanley, FAFPHM, MFCCH, FRACP, Director1 Eric M Meslin, PhD, Director, Center for Bioethics; Assistant Dean for Bioethics; and Professor of Medicine; Medical and Molecular Genetics; and Philosophy 1 Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia, Perth, WA. 2 Indiana University, Indianapolis, Ind, USA. Correspondence: fiona@ichr.uwa.edu.au

Differentiation of metastatic follicular thyroid cancer from hepatocellular carcinoma using Hep Par 1

Abstract: Hepatocellular carcinoma usually arises in a cirrhotic liver. Multiple hepatic nodules in a non-cirrhotic liver are more likely to be metastatic. The primary focus commonly arises from the gastrointestinal tract, breast or lung, but in the absence of these a primary liver pathology must be considered. The case is reported of a middle-aged woman presenting with multiple nodules on computed tomography with no clinically apparent primary for whom results of initial diagnostic investigations were potentially misleading.

Hp05 beta is better than radiofrequency ablation

Abstract: Purpose Radiofrequency ablation (RFA) is a popular method of treating unresectable liver tumours by the use of a high-frequency, alternating electrical current that heats and destroys tumour cells. The size of the ablation produced is limited by localised charring of adjacent tissue that prevents further conduction of the radiofrequency current. To overcome this problem, a Bi-modal Electric Tissue Ablation (BETA) circuit has been created that adds a direct electrical current to a radiofrequency current. Direct currents attract water to the cathode in biological tissues and this phenomenon is utilised in an effort to prevent tissue charring. The BETA circuit was tested in a pig model. Methods 2 studies have been performed with this new circuit, one to compare sizes of the ablation produced between standard RFA and the BETA circuit. This was followed by a long-term study to assess associated changes to liver function and pathological changes within the liver. Results Ablations with significantly larger diameters are created with the BETA circuit (49.6 mm +/− SE 3.46 vs 27.78 mm +/− SE 3.37, p < 0.001). Ablations produced by the BETA circuit induced coagulative necrosis within the treated hepatocytes that healed by fibrosis. Significant rises in serum liver enzymes are seen within 24 hours of treatment but these return to normal within 7 days. Treatment with the BETA circuit otherwise appears safe. Conclusions The BETA circuit produces significantly larger ablations than standard RFA. Although larger, the injuries produced behave in a similar manner to standard RFA and it is anticipated that with further refinements, the BETA circuit will become a useful treatment modality for unresectable liver tumours.

Assuring quality in HPB surgery – efficacy and safety

Abstract: Surgical innovations have made enormous contributions towards the welfare of patients when they have been appropriate, effective and applied with expertise and overall care. However, the potential for advancement and for harm of new surgical techniques, and the level of expertise necessary for their safe introduction, are not always immediately apparent. Furthermore, it is difficult and time-consuming to assess the efficacy and safety of new procedures in the clinical setting. In 1998 the Royal Australasian College of Surgeons established ASERNIP-S, the Australian Safety and Efficacy Register of New and Interventional Procedures – Surgical, to help ensure that new technologies that are being introduced are well proven in concept, are as safe and effective as possible, and are utilized with high levels of skill underpinned by the level of training.

Surgery to die for

Abstract: Surgery has always been a somewhat dangerous occupation, not only for the patients but also the surgeon. In earlier times, infections secondary to contaminated surgery carried out by the exposed surgeon are well described, heralding the introduction of gloves to protect the surgeon. In more recent years, issues, such as protection from radiation injury because of intraoperative imaging, have been well appreciated, and appropriate preventive and surveillance mechanisms put in place. The article in this issue of the Journal by Moot et al. talks about yet another hazard associated with surgical activity.1 It is quite clear that volatile organic compounds are produced and contained within the diathermy plume. Whether these are of truly clinical significance remains unresolved and controversial. It is, however, unlikely that a clinical study will ever be carried out, which will show that a randomized control group receiving smoke plume on a regular basis can be compared with a group that failed to receive smoke plume. I, for one, would not wish to be randomized into the treatment group and the numbers that would need to be enrolled into such a study to gain significant results would be in the tens of thousands. The cost of follow up would be enormous, ethical approval impossible and a positive result indicating that the diathermy plume was hazardous would, in retrospect, seem to be an expected finding. Where appropriate techniques of extraction exist, as there are now, the utilization of these techniques would be common sense. There are, however, other areas of safety associated with surgical practice, which also need urgent attention and a more proactive approach to their management. Scalpel safety is a significant problem, not only for the surgeon but also for nursing staff.2 The Australian Safety and Efficacy Register of New Interventional Procedures – Surgical is currently looking at techniques of scalpel safely and surgeons will need to take note of the findings, despite the poor evidence base, and perhaps approach scalpel safety in the same way that they have embraced the scrub routine and radiation protection as part of their surgical ritual. Perhaps of even greater concern are the issues of safe working hours associated with surgical practice.3 There is a growing community concern associated with accidents associated with exhausted surgeons. The finding that a surgeon working after 24 h of duty is the equivalent of a drunk driver and recent suicides in the State of Victoria among surgical trainees have, in part, been linked to demanding surgical rosters. These are serious problems of safety, which are difficult to reliably measure. In this age, where evidence-based practice is the catch-cry of administrators, academics and surgeons, it is worth remembering that some interventions do not require irrefutable evidence to warrant their introduction. Diathermy smoke plume can be extracted by available techniques and it makes no sense to wait for the evidence to prove the validity of this approach. Scalpel safety techniques exist now, are relatively inexpensive and should be practised among surgical practitioners without waiting for increased incidences of HIV or hepatitis. Further suicides or patient accidents within the overworked surgical community should not be awaited, but rather the appropriate rosters and work practices should be altered to mitigate their recurrence. Surgery needs to be made as safe as possible, not only for our patients but also for ourselves.

Se03 anatomy in the virtual world

Abstract: Background Recently, the use of 3-dimensional virtual reality anatomy teaching tools has generated interest. Although they would appear to have the potential to revolutionise the way in which anatomy is taught, further evaluation is required. The aim of this study was to evaluate the use of 3-dimensional virtual reality as a tool for teaching anatomy to basic surgical trainees. Methods Basic surgical trainees from The Queen Elizabeth Hospital and Flinders Medical Centre in South Australia were invited to participate in an anatomy teaching session. Liver and pancreas anatomy were the topics covered during the session and these were taught using either standard or virtual reality teaching techniques. Participants were asked to evaluate the two modalities by way of multiple choice examination, pre and post session evaluation forms and commenting on their preferred teaching modality. Results 16 participants were involved in the study. 1 of 16 participants preferred teaching with standard techniques. 14 out of 16 participants found teaching with virtual reality to be either good or very good. The number who thought their knowledge of anatomy had improved with either technique was similar (7 out of 16 with virtual reality, 6 out of 16 with standard techniques). Post teaching session test results showed similar improvements with both teaching modalities. Conclusions The 3-dimensional virtual reality teaching method was very well received by participants and is at least as good as standard teaching techniques. The use of 3-dimensional virtual reality may offer a more interesting and useful option for anatomy instruction.