ORCID Profile
0000-0002-2162-2744
Current Organisation
Hunter New England Local Health District
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Publisher: Wiley
Date: 21-06-2021
DOI: 10.1111/ANS.17020
Abstract: Prior studies of telehealth report high levels of patient satisfaction, but within carefully selected clinical scenarios. The COVID‐19 pandemic led to telehealth replacing face‐to‐face care for many surgical consultations across a variety of situations. More evidence is needed regarding patient perceptions of telehealth in surgery, in particular, exploring barriers and facilitators associated with its sustained implementation beyond the pandemic. Survey invitations were emailed to a convenience s le of surgical patients by their surgeon following a telehealth consultation during the COVID‐19 pandemic. Surgeons were recruited from a s le ( n = 683) who completed a survey on telehealth (distributed via email to all Australian Fellows of the Royal Australasian College of Surgeons). Mixed methods analysis was performed of the patient survey data. A total of 1166 consultations were captured: 50% routine reviews, 17% initial appointments and 20% post‐operative reviews. Video‐link was used in 49% of consultations. The majority of patients (94%), were satisfied with the quality of their surgical telehealth consultation and 75% felt it delivered the same level of care as face‐to‐face encounters. Telehealth was convenient to use (96%) and led to cost savings for 60% of patients. When asked about future appointment preferences after the pandemic, 41% indicated they would prefer telehealth (24% video‐link and 17% telephone) over face‐to‐face appointments. There was a perception by patients that telehealth consultation fees should be less than face‐to‐face consultation fees. Patient satisfaction with surgical telehealth consultations is high. Barriers to more widespread implementation include financial, clinical appropriateness, technical and confidentiality concerns.
Publisher: Wiley
Date: 02-07-2019
DOI: 10.1111/CODI.14720
Abstract: Postoperative pain remains a major factor in recovery from colorectal resection. There is increasing interest in opioid-sparing analgesia, and intraperitoneal local anaesthetic (IPLA) has recently been shown to be useful in minor laparoscopic and open colorectal procedures. The aim of this study was to evaluate the impact of IPLA on functional recovery following major laparoscopic surgery. In this controlled trial, mobility, as measured by the De Morton Mobility Index (DEMMI), was used as a surrogate for postoperative functional recovery. Patients undergoing laparoscopic colorectal resection were randomized either to continuous ropivacaine (0.2% at 4-6 ml/h) or to saline (0.9%) which were administered via intraperitoneal catheter for 3 days postoperatively. Results were analysed in a double-blind manner. DEMMIs were assessed on postoperative days 1, 2, 3, 7 and 30, and data on pain, opioid consumption, gut and respiratory function, length of stay (LOS) and complications were recorded. Ninety-six patients were recruited. There was no difference in primary outcome (i.e., functional recovery) between IPLA and placebo groups. Opioid consumption and LOS were similar between groups, and no differences were found for any secondary outcome measure. There were no adverse events related to ropivacaine. Infusional intraperitoneal local anaesthetic appears to be safe but does not improve functional recovery or analgesic consumption following elective laparoscopic colorectal surgery, in the setting of an established enhanced recovery programme.
Publisher: Wiley
Date: 26-02-2021
DOI: 10.1111/ANS.16693
Publisher: Wiley
Date: 06-04-2023
DOI: 10.1111/ANS.18455
Abstract: Surgical Site Infection (SSI) of the abdominal incision is a dreaded complication following colorectal surgery. Identifying the intraoperative surgical site microbes may provide clarity in the pathogenesis of SSIs. Genomic sequencing has revolutionized the ability to identify microbes from clinical s les. Utilization of 16S rRNA licon sequencing to characterize the intraoperative surgical site may provide the critical information required to predict and prevent infection in colorectal surgery. This is a pilot, prospective observational study of 50 patients undergoing elective colorectal resection. At completion of surgery, prior to skin closure, swabs were taken from the subcutaneous tissue of the abdominal incision to investigate the microbial profile. Dual swabs were taken to compare standard culture technique and 16S rRNA sequencing to establish if a microbial profile was associated with postoperative SSI. 8/50 patients developed an SSI, which was more likely in those undergoing open surgery (5/15 33.3% versus 3/35, 8.6% P = 0.029). 16S rRNA licon sequencing was more sensitive in microbial detection compared to traditional culture. Both culture and 16S rRNA demonstrated contamination of the surgical site, predominantly with anaerobes. Culture was not statistically predictive of infection. 16S rRNA licon sequencing was not statistically predictive of infection, however, it demonstrated patients with an SSI had an increased bio ersity (not significant) and a greater relative abundance (not significant) of pathogens such as Bacteroidacaea and Enterobacteriaceae within the intraoperative site. 16S rRNA licon sequencing has demonstrated a potential difference in the intraoperative microbial profile of those that develop an infection. These findings require validation through powered experiments to determine the overall clinical significance.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 20-12-2022
DOI: 10.1097/DCR.0000000000002171
Abstract: There is much debate surrounding the ideal antiseptic skin preparation agent to reduce postoperative surgical site infection. International guidelines suggest that chlorhexidine- and alcohol-containing compounds have superior efficacy. However, there are minimal clinical trials specifically looking at skin preparation agents for colorectal surgery. The aim of this study was to compare the efficacy of chlorhexidine in alcohol versus povidone-iodine in alcohol versus povidone-iodine in aqueous solution for the prevention of surgical site infection in colorectal surgery. This is a prospective, 3-armed, randomized controlled trial. This study was conducted at the 800-bed John Hunter Hospital and Newcastle Private Hospital, with all subspecialty services in New South Wales, Australia. All eligible, consenting adults undergoing colorectal surgery between July 2015 and December 2018 were included. Patients were andomized to receive preincision skin preparation with one of the following: chlorhexidine in 70% alcohol, povidone-iodine in 70% alcohol, or povidone-iodine in aqueous solution. The primary measure was surgical site infection within 30 days. A total of 482 patients were randomized to chlorhexidine in alcohol, povidone-iodine in alcohol, or aqueous povidone-iodine. The overall surgical site infection rate was 22% (107/482). There was no difference in rates of surgical site infection: 20.6% (29/141), 22.8% (44/193), and 23.0% (34/148), respectively ( p = 0.5267). There was no difference in complication rates: 54.6% (77/141), 46.1% (89/193), and 49.3% (73/148), respectively ( p = 0.1762). The median length of stay was 6 days in all 3 groups. This is a subset analysis of a larger clinical trial for all forms of incisional surgery (the NewSKIN Prep trial), and noninferiority cannot be assessed. Changes in government regulations resulted in a change from 0.5% chlorhexidine in 70% ethanol to 2% chlorhexidine in 70% ethanol during the trial. This large, prospective, randomized clinical trial appears to indicate that there is no difference in surgical site infection, complications, or length of stay among the 3 commonest forms of skin preparation in colorectal surgery. See Video Abstract at links.lww.com/DCR/B875. New Zealand Clinical Trials registry: ACTRN12615000021572 Agentes antisépticos para la preparación de la piel para prevenir la infección del sitio quirúrgico en la cirugía colorrectal: un ensayo clínico aleatorizado de tres grupos Existe un gran debate en torno al agente de preparación de la piel antiséptico ideal para reducir la infección posoperatoria del sitio quirúrgico. Las pautas internacionales sugieren que los compuestos que contienen clorhexidina y alcohol tienen una eficacia. Sin embargo, existen ensayos clínicos mínimos que analizan específicamente los agentes de preparación de la piel para la cirugía colorrectal. Comparar la eficacia de la clorhexidina en alcohol versus povidona yodada en alcohol versus povidona yodada en solución acuosa para la prevención de la infección del sitio quirúrgico en cirugía colorrectal. Este es un ensayo controlado aleatorio prospectivo de tres brazos. Este estudio se realizó en el Hospital John Hunter de 800 camas y el Hospital Privado de Newcastle con todos los servicios de subespecialidad en Nueva Gales del Sur, Australia. Se incluyeron todos los adultos elegibles que dieron su consentimiento para someterse a una cirugía colorrectal entre julio de 2015 y diciembre de 2018. Aleatorizados para recibir una preparación para la piel previa a la incisión con uno de: clorhexidina en alcohol al 70%, povidona yodada en alcohol al 70% o povidona yodada en solución acuosa. La medida principal fue la infección del sitio quirúrgico dentro de los 30 días. Un total de 482 pacientes fueron aleatorizados para recibir clorhexidina en alcohol, povidona yodada en alcohol o povidona yodada acuosa. La tasa global de infección del sitio quirúrgico fue del 22% (107/482). No hubo diferencias en las tasas de infección del sitio quirúrgico 20,6% (29/141), 22,8% (44/193) y 23,0% (34/148) respectivamente p = 0,5267. No hubo diferencia en las tasas de complicaciones 54,6% (77/141), 46,1% (89/193) y 49,3% (73/148) respectivamente p = 0,1762. La duración media de la estancia hospitalaria fue de 6,0 días en los tres grupos. Este es un análisis de subconjunto de un ensayo clínico más grande para todas las formas de cirugía incisional (el ensayo NewSKIN Prep) y no se puede evaluar la no inferioridad. Los cambios en las regulaciones gubernamentales dieron como resultado un cambio de clorhexidina al 0,5% en etanol al 70% a clorhexidina al 2% en etanol al 70% durante la prueba. Este gran ensayo clínico prospectivo y aleatorizado parece indicar que no hay diferencia en la infección del sitio quirúrgico, las complicaciones o la duración de la estancia entre las 3 formas más comunes de preparación de la piel en la cirugía colorrectal. Consulte Video Resumen en links.lww.com/DCR/B875. (Traducción—Dr. Gonzalo Hagerman ) Este ensayo se registró de forma prospectiva en el registro de ensayos clínicos de Australia Nueva Zelanda el 15/01/2015: ACTRN12615000021572
Publisher: Springer Science and Business Media LLC
Date: 06-10-2010
DOI: 10.1007/S00134-010-2039-6
Abstract: To determine the effect of random assignment to fluid resuscitation with albumin or saline on organ function and mortality in patients with severe sepsis. Pre-defined subgroup analysis of a randomized controlled trial conducted in the intensive care units of 16 hospitals in Australia and New Zealand. Of 1,218 patients with severe sepsis at baseline, 603 and 615 were assigned to receive albumin and saline, respectively. The two groups had similar baseline characteristics. During the first 7 days mean arterial pressure was similar in the two groups, but patients assigned albumin had a lower heart rate on days 1 and 3 (p = 0.002 and p = 0.03, respectively) and a higher central venous pressure on days 1-3 (p < 0.005 each day). There was no difference in the renal or total Sequential Organ Failure Assessment score of the two groups 113/603 (18.7%) of patients assigned albumin were treated with renal replacement therapy compared to 112/615 (18.2%) assigned saline (p = 0.98). The unadjusted relative risk of death for albumin versus saline was 0.87 [95% confidence interval (CI) 0.74-1.02] for patients with severe sepsis and 1.05 (0.94-1.17) for patients without severe sepsis (p = 0.06 for heterogeneity). From multivariate logistic regression analysis adjusting for baseline factors in patients with complete baseline data (919/1,218, 75.5%), the adjusted odds ratio for death for albumin versus saline was 0.71 (95% CI: 0.52-0.97 p = 0.03). Administration of albumin compared to saline did not impair renal or other organ function and may have decreased the risk of death.
Publisher: Wiley
Date: 12-05-2020
DOI: 10.1111/ANS.15882
Publisher: Wiley
Date: 10-12-2018
DOI: 10.1111/CEN.13897
Abstract: Post-thyroidectomy hypocalcaemia is a significant cause of morbidity and prolonged hospitalization, usually due to transient parathyroid gland damage, treated with calcium and vitamin D supplementation. We present a randomized, double-blinded placebo-controlled trial of preoperative loading with high-dose cholecalciferol (300 000 IU) to reduce post-thyroidectomy hypocalcaemia. Patients (n = 160) presenting for thyroidectomy at tertiary hospitals were randomized 1:1 to cholecalciferol (300 000 IU) or placebo 7 days prior to thyroidectomy. Ten patients withdrew prior to surgery. The primary outcome was post-operative hypocalcaemia (corrected calcium <2.1 mmol/L in first 180 days). The study included 150 patients undergoing thyroidectomy for Graves' disease (31%), malignancy (20%) and goitre (49%). Mean pre-enrolment vitamin D was 72 ± 26 nmol/L. Postoperative hypocalcaemia occurred in 21/72 (29%) assigned to cholecalciferol and 30/78 (38%) participants assigned to placebo (P = 0.23). There were no differences in secondary end-points between groups. In pre-specified stratification, baseline vitamin D status did not predict hypocalcaemia, although most in iduals were vitamin D replete at baseline. Post-hoc stratification by day 1 parathyroid hormone (PTH) (<10 pg/mL, low vs ≥10 pg/mL, normal) was explored due to highly ergent rates of hypocalcaemia in these groups. Using a Cox regression model, the hazard ratio for hypocalcaemia in the cholecalciferol group was 0.56 (95%CI 0.32-0.98, P = 0.04) after stratification for Day 1 PTH. Further clinical benefits were observed in these subgroups. Pre-thyroidectomy treatment with high-dose cholecalciferol did not reduce the overall rate of hypocalcaemia following thyroidectomy. In subgroups stratified by day 1 PTH status, improved clinical outcomes were noted.
Publisher: BMJ
Date: 12-2022
DOI: 10.1136/BMJOPEN-2022-068452
Abstract: Despite advances in achieving low mortality rates with pancreaticoduodenectomy (PD), morbidity remains high. A key contributor to this morbidity is delayed gastric emptying (DGE) occurring with an incidence of up to 30%. The utility of a Braun enteroenterostomy (BE) appears promising to reducing the incidence of DGE, but current research is not definitive. This project will be designed as a prospective multicentre randomised controlled blinded study to assess how BE effects the rate of DGE after PD in the setting of malignancy, within Australia—with blinding of patients, outcome assessors and data analysts. Patients will be randomly assigned to PD with Billroth II reconstruction with BE versus PD with Billroth II reconstruction without BE. The primary outcome is the incidence of DGE as defined by the International Study Group of Pancreatic Surgery. Secondary outcomes will include length of hospital stay, postoperative pancreatic fistula incidence, development of major complications (Clavien-Dindo≥3 a), quality of life and 90-day mortality. The study will be powered at 80% to detect a reduction in DGE rate from 30% to 15%, requiring a total of 264 study participants. An interim analysis will be performed once a total of 104 study participants have been recruited at which point the study will be able to detect reduction in DGE from 30% to 10% with 80% power. Statistical analysis will be done with intention-to-treat principles. The proportion of patients suffering DGE will be compared between treatment arms using a χ 2 test, with p values used to represent statistical significance. The study has been ethically approved by the Hunter New England Human Research Ethics Committee (2021/ETH11939), with results disseminated through presentation and publication. CTRN12622000048785.
Publisher: Wiley
Date: 17-03-2017
DOI: 10.1111/ANS.13937
Abstract: Anastomotic leakage is a feared complication following colorectal surgery. Early prediction results in improved clinical outcome, but accurate predictive factors remain elusive. Many biomarkers have been studied with respect to diagnosis of anastomotic leakage but the concept of trajectory testing, using biomarkers, has not been assessed with regards to early diagnosis of anastomotic leak. C-reactive protein (CRP), procalcitonin (PCT), white cell count (WCC) and gamma-glutamyl transferase were assessed for predictive utility in diagnosing anastomotic leakage with emphasis on identifying an association with change in their levels or trajectory. Levels were collected preoperatively and daily for the first 5 post-operative days on patients undergoing elective colorectal surgery, involving an anastomosis. Anastomotic leakage was defined clinically by operative or radiological intervention. Comparison was made between biomarkers and clinical anastomotic leakage, using receiver operator characteristic curves for logistic models, based on trajectory of the four biomarkers. A total of 197 consecutive patients were analysed. Eleven patients developed clinical anastomotic leakage. An association of biomarker trajectory with anastomotic leakage was observed for WCC, PCT and CRP, but not for gamma-glutamyl transferase. CRP was the superior biomarker based on trajectory, with area under the receiver operator curve of 0.961. This study identifies change in CRP, WCC and PCT as potential markers of anastomotic leakage following colorectal surgery and in particular highlights CRP trajectory as extremely accurate in diagnosing anastomotic leakage requiring intervention. External validation should be sought before incorporating this into routine clinical practice, given the numbers in this study.
Publisher: Wiley
Date: 12-12-2021
DOI: 10.1002/BCO2.133
Abstract: To assess if the introduction of routine pre‐operative cardiopulmonary exercise testing (CPET) in radical cystectomy has delayed surgical intervention. A prospective database of patients undergoing radical cystectomy in our local health network was maintained. A retrospective analysis of two years (2018–2020) included 38 patients. Of these, 15 patients had CPET pre‐operatively, and a direct comparison was performed. The mean time from diagnosis to cystectomy was 95 days in patients who did not have CPET compared to 110 days for those who did ( p = 0.32), with comparable rates of neoadjuvant chemotherapy (NAC) (62.5% and 64.29%). Average length of stay was 18.6 days compared with 13.87 ( p = 0.16), favouring the CPET group. The CPET group also had a lower readmission rate within 30 days (13.33% compared with 21.05%, p = 0.35). Cause‐specific mortality within 90 days was 10.2% and within the study timeframe was 36.84% (estimated 5‐year mortality rate 43–65%). Within the CPET group, eight had an anaerobic threshold (AT) of ml/kg/min (range 6.3–10.5): Of these, 50% had Clavien‐Dindo complications of grade 2 or higher and the 90‐day mortality rate was 37.5% (cf. 0% in those with AT 11 ml/kg/min in this series). CPET is a valuable risk evaluation tool. This study suggested that CPET contributed to a minor non‐significant delay to surgery, however was associated with reduced length of stay and readmission rates, and was a valuable risk evaluation tool. We found that CPET AT ml/kg/min is associated with higher rates of patient morbidity and perioperative mortality.
Publisher: Wiley
Date: 07-2018
DOI: 10.1111/ANS.14766
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2018
DOI: 10.1097/DCR.0000000000000943
Abstract: Lower GI hemorrhage is a common source of morbidity and mortality. Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss in a variety of clinical conditions. Information regarding the use of tranexamic acid in treating lower GI hemorrhage is lacking. The aim of this trial was to determine the clinical efficacy of tranexamic acid when used for lower GI hemorrhage. This was a prospective, double-blind, placebo-controlled, randomized clinical trial. The study was conducted at a tertiary referral university hospital in Australia. Consecutive patients aged years with lower GI hemorrhage requiring hospital admission from November 2011 to January 2014 were screened for trial eligibility (N = 265). A total of 100 patients were recruited after exclusions and were randomly assigned 1:1 to either tranexamic acid or placebo. The primary outcome was blood loss as determined by reduction in hemoglobin levels. The secondary outcomes were transfusion rates, transfusion volume, intervention rates for bleeding, length of hospital stay, readmission, and complication rates. There was no difference between groups with respect to hemoglobin drop (11 g/L of tranexamic acid vs 13 g/L of placebo p = 0.9445). There was no difference with respect to transfusion rates (14/49 tranexamic acid vs 16/47 placebo p = 0.661), mean transfusion volume (1.27 vs 1.93 units p = 0.355), intervention rates (7/49 vs 13/47 p = 0.134), length of hospital stay (4.67 vs 4.74 d p = 0.934), readmission, or complication rates. No complications occurred as a direct result of tranexamic acid use. A larger multicenter trial may be required to determine whether there are more subtle advantages with tranexamic acid use in some of the secondary outcomes. Tranexamic acid does not appear to decrease blood loss or improve clinical outcomes in patients presenting with lower GI hemorrhage in the context of this trial. see Video Abstract at links.lww.com/DCR/A453.
Publisher: Oxford University Press (OUP)
Date: 13-03-2021
DOI: 10.1093/BJS/ZNAB064
Publisher: Springer Science and Business Media LLC
Date: 05-08-2019
Publisher: American Medical Association (AMA)
Date: 06-10-2015
Abstract: Laparoscopic procedures are generally thought to have better outcomes than open procedures. Because of anatomical constraints, laparoscopic rectal resection may not be better because of limitations in performing an adequate cancer resection. To determine whether laparoscopic resection is noninferior to open rectal cancer resection for adequacy of cancer clearance. Randomized, noninferiority, phase 3 trial (Australasian Laparoscopic Cancer of the Rectum ALaCaRT) conducted between March 2010 and November 2014. Twenty-six accredited surgeons from 24 sites in Australia and New Zealand randomized 475 patients with T1-T3 rectal adenocarcinoma less than 15 cm from the anal verge. Open laparotomy and rectal resection (n = 237) or laparoscopic rectal resection (n = 238). The primary end point was a composite of oncological factors indicating an adequate surgical resection, with a noninferiority boundary of Δ = -8%. Successful resection was defined as meeting all the following criteria: (1) complete total mesorectal excision, (2) a clear circumferential margin (≥1 mm), and (3) a clear distal resection margin (≥1 mm). Pathologists used standardized reporting and were blinded to the method of surgery. A successful resection was achieved in 194 patients (82%) in the laparoscopic surgery group and 208 patients (89%) in the open surgery group (risk difference of -7.0% [95% CI, -12.4% to ∞] P = .38 for noninferiority). The circumferential resection margin was clear in 222 patients (93%) in the laparoscopic surgery group and in 228 patients (97%) in the open surgery group (risk difference of -3.7% [95% CI, -7.6% to 0.1%] P = .06), the distal margin was clear in 236 patients (99%) in the laparoscopic surgery group and in 234 patients (99%) in the open surgery group (risk difference of -0.4% [95% CI, -1.8% to 1.0%] P = .67), and total mesorectal excision was complete in 206 patients (87%) in the laparoscopic surgery group and 216 patients (92%) in the open surgery group (risk difference of -5.4% [95% CI, -10.9% to 0.2%] P = .06). The conversion rate from laparoscopic to open surgery was 9%. Among patients with T1-T3 rectal tumors, noninferiority of laparoscopic surgery compared with open surgery for successful resection was not established. Although the overall quality of surgery was high, these findings do not provide sufficient evidence for the routine use of laparoscopic surgery. Longer follow-up of recurrence and survival is currently being acquired. anzctr.org Identifier: ACTRN12609000663257.
Publisher: Springer Science and Business Media LLC
Date: 11-05-2023
DOI: 10.1186/S13017-023-00500-Z
Abstract: Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( t2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for ex le part of “damage control” however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. Trial registration : National Institutes of Health ( t2/show/NCT03163095 ).
Publisher: Springer Science and Business Media LLC
Date: 17-10-2019
DOI: 10.1186/S13017-019-0268-8
Abstract: The original article [1] contained a typo in author, Federico Coccolini’s name. This has now been corrected.
Publisher: Wiley
Date: 14-06-2022
DOI: 10.1111/ANS.17831
Abstract: Preoperative skin antiseptics are used prior to surgery to reduce the risk of surgical site infection (SSI). There is debate as to which is the most effective. The aim of this network meta‐analysis (NMA) is to compare the effectiveness of different skin preparations at reducing SSIs in patients undergoing incisional surgery. The study protocol was published in PROSPERO (CRD4202181599) a priori with predefined search terms and inclusion/exclusion criteria. The skin preparations for comparison were: chlorhexidine/alcohol (CHA), chlorhexidine/water (CHW), poviodine/alcohol (PVIA), poviodine/water (PVIW). The records identified were screened by two authors independently by title, abstract and in full text. The revised tool for risk‐of bias (ROB2) assessment was used. Twenty‐nine RCTs involving 15 796 patients were included in the NMA. A significant but small increase in the odds of infection was seen in the PVIW group compared to the CHA group (OR 1.34, 95%CrI 1.09–1.64), but other comparisons were not statistically significantly different. Ranking the treatment arms showed there was a 64% probability that CHA is the most effective and a 62.7% probability that PVIW is the least effective treatment. Chlorhexidine/alcohol (CHA) was found to be the most effective for prevention of superficial and deep SSI while PVIW was the least. There was no differences seen between CHA and PVIA, or CHW and PVIW. The superiority of CHA is likely due to the effect of the alcohol in the base. Hence the choice between CHA and PVIA should be based on health and cost considerations.
Publisher: BMJ
Date: 13-10-2013
Publisher: Wiley
Date: 03-04-2022
DOI: 10.1111/ANS.17658
Abstract: Sarcopenia has been shown to have significant adverse health outcomes in a range of patient populations. Particularly, sarcopenic patients having cancer surgery are a unique group who demonstrate poorer post‐operative outcomes. Currently, the gold standard in diagnosing sarcopenia is through the use of computed tomography. However, the widespread use of imaging to diagnose patients with sarcopenia is neither cost‐effective nor practical. Identifying a serum biomarker or a simple mobility scoring system as an alternative diagnostic tool may aid in identifying more patients at risk of sarcopenia. C1q, a novel biomarker, has previously been shown to correlate with sarcopenia. Similarly, we sought to explore whether mobility scores may provide a useful surrogate marker for sarcopenia. This was a prospective cohort study of patients who presented for colorectal cancer surgery between the dates of 6/10/2016 and 4/10/2017 at John Hunter Hospital. Computed tomography was utilized to calculate the psoas area at the L3 spinal level. Pre‐operative blood s les were obtained for C1q analysis and de Morton Mobility Index (DEMMI) was also performed. A total of 51 patients were included in the study. The median age of the patients were 69 years old. We did not demonstrate a correlation between serum C1q and DEMMI scores with psoas area. Our findings suggest that neither C1q nor DEMMI scores are correlated with psoas area in a colorectal cancer population.
Publisher: Springer Science and Business Media LLC
Date: 02-10-2021
DOI: 10.1186/S12955-021-01867-W
Abstract: This study assessed the responsiveness and convergent validity of two preference-based measures the newly developed cancer-specific EORTC Quality of Life Utility Measure-Core 10 dimensions (QLU-C10D) relative to the generic three-level version of the EuroQol 5 dimensions (EQ-5D-3L) in evaluating short-term health related quality of life (HRQoL) outcomes after esophagectomy. Participants were enrolled in a multicentre randomised controlled trial to determine the impact of preoperative and postoperative immunonutrition versus standard nutrition in patients with esophageal cancer. HRQoL was assessed seven days before and 42 days after esophagectomy. Standardized Response Mean and Effect Size were calculated to assess responsiveness. Ceiling effects for each dimension were calculated as the proportion of the best level responses for that dimension at follow-up ost-operatively. Convergent validity was assessed using Spearman’s correlation and the level of agreement was explored using Bland–Altman plots. Data from 164 respondents (mean age: 63 years, 81% male) were analysed. HRQoL significantly reduced on both measures with large effect sizes ( 0.80), and a greater mean difference (0.29 compared to 0.16) on QLU-C10D. Both measures had ceiling effects ( 15%) on all dimensions at baseline. Following esophagectomy, ceiling effects were observed with self-care (86%), mobility (67%), anxiety/depression (55%) and pain/discomfort (19%) dimensions on EQ-5D-3L. For QLU-C10D ceiling effects were observed with emotional function (53%), physical function (16%), nausea (35%), sleep (31%), bowel problems (21%) and pain (20%). A strong correlation (r = 0.71) was observed between EQ-5D-3L anxiety and QLU-C10D emotional function dimensions. Good agreement (3.7% observations outside the limits of agreement) was observed between the utility scores. The QLU-C10D is comparable to the more widely applied generic EQ-5D-3L, however, QLU-C10D was more sensitive to short-term utility changes following esophagectomy. Cognisant of requirements by policy makers to apply generic utility measures in cost effectiveness studies, the disease-specific QLU-C10D should be used alongside the generic measures like EQ-5D-3L. Trial registration : The trial was registered with the Australian New Zealand Clinical Trial Registry (ACTRN12611000178943) on the 15th of February 2011.
Publisher: Oxford University Press (OUP)
Date: 05-2021
DOI: 10.1093/BJS/ZNAB050
Publisher: Wiley
Date: 19-12-2017
DOI: 10.1111/ANS.14317
Abstract: Adequate post-operative analgesia is essential for recovery following abdominal surgery. Abdominal wall nerve blocks have been shown to be beneficial in this respect following surgery. The purpose of this trial was to examine the efficacy of infusional versus intermittent bolus delivery of abdominal wall blocks in patients undergoing abdominal resectional gastrointestinal surgery. A prospective randomized clinical trial, involving 120 patients undergoing gastrointestinal surgery, was undertaken across three hospitals. Insertion of abdominal wall catheters was performed and patients were randomized to receive ropivacaine 0.2% by either continuous infusion or regular intermittent bolus. The primary outcome was respiratory function, as measured by spirometry on post-operative days 1-3 and 30. Secondary outcomes were pain, mobility, return of gut function, length of hospital stay, complication rates and patient satisfaction with analgesia. All 120 patients were followed up to trial completion. Patients were well matched with regards to demographics. There was no difference between groups with regards to the primary outcome of post-operative respiratory function. The bolus group had improved mobility scores on post-operative day 1 (P = 0.025). There were no complications associated with blockade, and no other differences were identified between assessed outcomes. Continuous infusion and intermittent bolus are both safe ways of delivering abdominal wall nerve blockade, with equivalent analgesic outcomes. Bolus delivery appears to provide superior early mobility in comparison with continuous infusion.
Publisher: Springer Science and Business Media LLC
Date: 24-06-2015
DOI: 10.1007/S00384-015-2286-7
Abstract: Adequate postoperative analgesia is essential for recovery following colorectal surgery. Transversus abdominis plane (TAP) blocks have been found to be beneficial in improving pain following a variety of abdominal operations. The objective of this study was to determine if TAP blocks are useful in improving postoperative recovery following laparoscopic colorectal surgery. A prospective double-blind randomized clinical trial, involving 226 consecutive patients having laparoscopic colorectal surgery, was performed by a university colorectal surgical department. Patients were randomized to either TAP blockade using ultrasound guidance, or control, with the primary outcome being postoperative pain, as measured by analgesic consumption. Secondary outcomes assessed were pain visual analogue score (VAS), respiratory function, time to return of gut function, length of hospital stay, postoperative complications, and patient satisfaction. A total of 142 patients were followed up to trial completion (74 controls, 68 interventions). Patients were well matched with regard to demographics. No complications occurred as a result of the intervention of TAP blockade. There was no difference between groups with regards to analgesic consumption (161 mEq morphine control vs 175 mEq morphine TAP p = 0.596). There was no difference between the two groups with regards to the secondary outcomes of daily VAS, respiratory outcome, time to return of gut function, length of hospital stay, postoperative complications, and patient satisfaction. We conclude that TAP blockade appears to be a safe intervention but confers no specific advantage following laparoscopic colorectal surgery.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 17-03-2023
DOI: 10.1097/DCR.0000000000002774
Abstract: Rubber band ligation of hemorrhoids causes less pain than excisional hemorrhoidectomy, but many patients still experience significant postprocedure discomfort. This study aimed to determine whether topical lidocaine, with or without diltiazem, is more effective than placebo for analgesia after hemorrhoid banding. This is a prospective, randomized, double-blinded, placebo-controlled trial. Patients were randomly assigned to 2% lidocaine, 2% lidocaine with 2% diltiazem, or a placebo ointment. This study was performed at 2 university public teaching hospitals and 2 private hospitals in Australia. Consecutive patients aged ≥18 years undergoing hemorrhoid banding were selected. Topical ointments were applied postprocedure 3× daily for 5 days. Visual analog pain score, opiate analgesia usage, and patient satisfaction were the main outcome measures. Of 159 eligible patients, 99 were randomly assigned (33 in each group). Pain scores were reduced at 1 hour for the lidocaine (OR 4.15 [1.12–15.41] p = 0.03) and lidocaine/diltiazem groups (OR 3.85 [1.05–14.11] p = 0.04) compared with placebo. Patients in the lidocaine/diltiazem group had improved satisfaction (OR 3.82 [1.28–11.44] p = 0.02) and were more likely to recommend the procedure to others (OR 9.33 [1.07–81.72] p = 0.04). Patients in the lidocaine/diltiazem group required approximately 45% less total and in-hospital analgesia compared with the placebo. There was no difference in complications between any of the groups. A cost/benefit analysis was not performed. Analgesic efficacy appeared to be short term and the procedures were performed only in the hospital/nonambulatory setting. Topical lidocaine reduced short-term analgesia use, whereas combination lidocaine/diltiazem was associated with both improved analgesia and patient satisfaction after hemorrhoid banding. ANTECEDENTES: La ligadura de hemorroides con banda elástica causa menos dolor que la hemorroidectomía escisional, pero muchos pacientes siguen experimentando molestias significativas tras el procedimiento. OBJETIVO: Este estudio tiene como objetivo determinar si la lidocaína tópica, con o sin diltiazem, es más eficaz que el placebo para la analgesia tras la ligadura hemorroidal. DISEÑO: Este es un ensayo prospectivo, aleatorizado, doble ciego, controlado con placebo. Los pacientes fueron aleatorizados para recibir lidocaína al 2 %, lidocaína al 2 % con diltiazem al 2 % o ungüento de placebo. AJUSTES: Este estudio se realizó en dos hospitales públicos con docencia universitaria y dos hospitales privados en Australia. PACIENTES: Se seleccionaron pacientes consecutivos de ≥18 años sometidos a ligadura para hemorroides. INTERVENCIONES: Se aplicaron ungüentos tópicos tras el procedimiento tres veces al día durante 5 días. PRINCIPALES MEDIDAS DE RESULTADO: La puntuación analógica visual del dolor, el uso de analgésicos opiáceos y la satisfacción del paciente fueron las principales medidas de resultado. RESULTADOS: De 159 pacientes elegibles, 99 fueron aleatorizados (33 en cada grupo). Las puntuaciones de dolor se redujeron a la hora para los grupos de lidocaína (OR 4,15 (1,12-15,41) p = 0,03) y lidocaína/diltiazem (OR 3,85 (1,05-14,11), p = 0,04) en comparación con el placebo. Los pacientes del grupo de lidocaína/diltiazem mejoraron su satisfacción (OR 3,82 (1,28-11,44), p = 0,02) y eran más propensos de recomendar el procedimiento a otros (OR 9,33 (1,07-81,72), p = 0,04). Los pacientes del grupo de lidocaína/diltiazem requirieron aproximadamente un 45 % menos de analgesia total e intrahospitalaria en comparación con el grupo de placebo. No hubo diferencia en las complicaciones entre ninguno de los grupos. LIMITACIONES: No se realizó un análisis de costo/beneficio. La eficacia analgésica pareció ser a corto plazo y los procedimientos solo se realizaron en el hospital/entorno no ambulatorio. CONCLUSIÓN: La lidocaína tópica mejora la analgesia a corto plazo, mientras que la combinación de lidocaína/diltiazem se asocia tanto con una mejor analgesia como con la satisfacción del paciente tras la colocación de bandas para hemorroides. (Traducción—Dr Osvaldo Gauto )
Publisher: Oxford University Press (OUP)
Date: 12-07-2018
DOI: 10.1002/BJS.10923
Abstract: Preoperative immunonutrition has been proposed to reduce the duration of hospital stay and infective complications following major elective surgery in patients with gastrointestinal malignancy. A multicentre 2 × 2 factorial RCT was conducted to determine the impact of preoperative and postoperative immunonutrition versus standard nutrition in patients with oesophageal cancer. Patients were randomized before oesophagectomy to immunonutrition (IMPACT®) versus standard isocaloric/isonitrogenous nutrition, then further randomized after operation to immunonutrition versus standard nutrition. Clinical and quality-of-life outcomes were assessed at 14 and 42 days after operation on an intention-to-treat basis. The primary outcome was the occurrence of infective complications. Secondary outcomes were other complications, duration of hospital stay, mortality, nutritional and quality-of-life outcomes (EuroQol EQ-5D-3 L™, European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC QLQ-OES18). Patients and investigators were blinded until the completion of data analysis. Some 278 patients from 11 Australian sites were randomized two were excluded and data from 276 were analysed. The incidence of infective complications was similar for all groups (37 per cent in perioperative standard nutrition group, 51 per cent in perioperative immunonutrition group, 34 per cent in preoperative immunonutrition group and 40 per cent in postoperative immunonutrition group P = 0·187). There were no significant differences in any other clinical or quality-of-life outcomes. Use of immunonutrition before and/or after surgery provided no benefit over standard nutrition in patients undergoing oesophagectomy. Registration number: ACTRN12611000178943 (www.anzctr.org.au).
Publisher: Wiley
Date: 22-05-2018
DOI: 10.1111/ANS.14555
Abstract: Post-operative length of stay (LOS) is an increasingly important clinical indicator in general surgery. Despite this, no tool has been validated to predict LOS or readiness for discharge in general surgical patients. The de Morton Mobility Index (DEMMI) is a functional mobility assessment tool that has been validated in rehabilitation patient populations. In this prospective cohort study, we aimed to identify if trends in DEMMI scores were associated with discharge within 1 week and overall LOS in general surgical patients. A total of 161 patients who underwent elective gastrointestinal resections were included. DEMMI scores were performed preoperatively, on days 1, 2, 3 and 30 post-operative. Statistical analysis was performed to identify any association between DEMMI scores and discharge within 1 week and LOS. Functional recovery (measured by achieving 80% of baseline DEMMI score by post-operative day 1) was significantly associated with discharge within 1 week. Presence of a stoma was associated with longer LOS. The area under the receiver operating characteristic curve using functional recovery on post-operative day 1 as a predictor of discharge within 1 week is 0.772. The DEMMI score is a fast, easy and useful tool to, on post-operative day 1, predict discharge within 1 week. The utility of this is to act as an anticipatory trigger for more proactive and efficient discharge planning in the early post-operative period, and there is potential to use the DEMMI as a comparator in clinical trials to assess functional recovery.
Publisher: Massachusetts Medical Society
Date: 27-05-2004
DOI: 10.1056/NEJMOA040232
Publisher: Springer Science and Business Media LLC
Date: 07-07-2022
DOI: 10.1007/S00268-022-06643-5
Abstract: Thyroid cancer diagnoses are increasing and treatment can lead to significant morbidity. Long-term health-related quality of life (HRQoL) in thyroid cancer is understudied and lacks reference populations. This study compares long-term HRQoL between patients with thyroid cancer or benign disease, following thyroid surgery. Patients undergoing thyroidectomy between 2000 and 2017 were identified from a pathology database. 696 participants (278 malignant, 418 benign) were invited to complete a validated disease-specific HRQoL tool, City of Hope—Thyroid Version. Propensity scores were used to adjust for demographic and clinical differences between cohorts. 206 patients (102 malignant, 104 benign), 71% female, returned surveys a median of 6.5 (range 1–19) years after thyroidectomy. Of the cancer cohort, 95% had differentiated thyroid cancer and 83% remained disease-free. There were no significant differences in overall HRQoL scores between groups. In comparison to the benign cohort, cancer patients showed a significant detriment in the social subdomain score (OR 0.10–0.96, p = 0.017) but not in other subdomains (physical, psychological, spiritual). Female gender, increasing BMI and cancer recurrence were significantly associated with decreased overall HRQoL. Compared to the benign cohort, cancer patients reported more personal and family distress associated with diagnosis and treatment, increased future uncertainty, poorer concentration and greater financial burden. Although no difference in overall HRQoL was found between patients undergoing thyroidectomy for benign or malignant disease, detriments in social well-being may persist many years after surgery. Thyroid cancer patients and their families may benefit from increased supports around the time of diagnosis and treatment.
Publisher: Oxford University Press (OUP)
Date: 16-07-2020
DOI: 10.1002/BJS.11812
Abstract: Anastomotic leak is a common complication after colorectal surgery, associated with increased morbidity and mortality, and poorer long-term survival after oncological resections. Early diagnosis improves short-term outcomes, and may translate into reduced cancer recurrence. Multiple studies have attempted to identify biomarkers to enable earlier diagnosis of anastomotic leak. One study demonstrated that the trajectory of C-reactive protein (CRP) levels was highly predictive of anastomotic leak requiring intervention, with an area under the curve of 0·961. The aim of the present study was to validate this finding externally. This was a prospective international multicentre observational study of adults undergoing elective colorectal resection with an anastomosis. CRP levels were measured before operation and for 5 days afterwards, or until day of discharge if earlier than this. The primary outcome was anastomotic leak requiring operative or radiological intervention. Between March 2017 and July 2018, 933 patients were recruited from 20 hospitals across Australia, New Zealand, England and Scotland. Some 833 patients had complete CRP data and were included in the primary analysis, of whom 41 (4·9 per cent) developed an anastomotic leak. A change in CRP level exceeding 50 mg/l between any two postoperative days had a sensitivity of 0·85 for detecting a leak, and a high negative predictive value of 0·99 for ruling it out. A change in CRP concentration of more than 50 mg/l between either days 3 and 4 or days 4 and 5 after surgery had a high specificity of 0·96–0·97, with positive likelihood ratios of 4·99–6·44 for a leak requiring intervention. This study confirmed the value of CRP trajectory in accurately ruling out an anastomotic leak after colorectal resection.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-10-2021
No related grants have been discovered for Rosemary Carroll.