Enhanced recovery after surgery for oncological breast surgery reduces length of stay in a resource limited setting.

BACKGROUND: Early recovery after surgery (ERAS) protocols in breast surgery optimizes resources and reduces healthcare costs by facilitating early discharges. These protocols are well established in tertiary centres, but not commonly adopted in regional centres. ERAS implementation potentially impacts smaller hospitals significantly, where resources are limited and persistent bed shortages with mounting waitlist pressures exist. Our study evaluates the feasibility of early discharge with the application of our ERAS protocol to mastectomies in a resource-constrained and rural setting. METHODS: Breast cancer patients who underwent mastectomies with or without reconstruction between January 2017 and July 2023 were retrospectively reviewed. From January 2022, we implemented a standardized ERAS protocol for patients undergoing mastectomy. This incorporated a combination of pre-, intra- and post-operative elements to enhance patient readiness for discharge. Our study compared these patients (post-ERAS group) with the outcomes of mastectomies performed prior to January 2022 (pre-ERAS group). RESULTS: 104 patients were identified. In the post-ERAS group, 74.4% were discharged within 24 h compared to 23.1% in the pre-ERAS group. Length of stay was reduced from 2.26 to 1.42 days. There were no differences in unplanned clinician reviews or early representation to the emergency department between the two groups. CONCLUSION: Reducing the length of stay without increased complications can be achieved in a resource-limited environment with our protocolized ERAS principals. Our protocol has been instrumental in allowing safe discharges within 24 h. Other regional centres may benefit in adopting strategies implemented by us for their own ERAS protocols in breast cancer surgery.

Malignant Peritoneal Mesothelioma: An In-Depth and Up-to-Date Review of Pathogenesis, Diagnosis, Management and Future Directions.

Malignant peritoneal mesothelioma (MPM) is an extremely rare malignancy usually confined to the abdominal cavity. With an aggressive natural history, morbidity and mortality are consequences of progressive locoregional effects within the peritoneal cavity. The first reported case was in the early 20th century, however, due to the rare nature of the disease and a large gap in understanding of the clinicopathological effects, the next reported MPM cases were only published half a decade later. Since then, there has been exponential growth in our understanding of the disease, however, there are no prospective data and a paucity of literature regarding management. Traditionally, patients were treated with systemic therapy and the outcomes were very poor, with a median survival of less than one year. However, with the advent of cytoreductive surgery and locoregional chemotherapy, there have been significant improvements in survival. Even more recently, with an improved understanding of the molecular pathogenesis of MPM, there have been reports of improved outcomes with novel therapies. Given the disastrous natural history of MPM, the limited data, and the lack of universal treatment guidelines, an in-depth review of the past, present, and future of MPM is critical to improve treatment regimens and, subsequently, patient outcomes.

Overall survival and morbidity are not associated with advanced age for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a single centre experience.

Objectives: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has enabled better prognosis for patients with peritoneal surface malignancies. However, in older age groups, short -and long-term outcomes are still perceived as poor. We evaluated patients aged 70 and over and determine if age is a predictor of morbidity, mortality and overall survival (OS). Methods: A retrospective cohort analysis was performed on CRS/HIPEC patients and categorised by age. The primary outcome was overall survival. Secondary outcomes included morbidity, mortality, hospital and incentive care unit (ICU) stay and early postoperative intraperitoneal chemotherapy (EPIC). Results: A total of 1,129 patients were identified with 134 aged 70+ and 935 under 70. There was no difference in OS (p=0.175) or major morbidity (p=0.051). Advanced age was associated with higher mortality (4.48 vs. 1.11 %, p=0.010), longer ICU stay (p<0.001) and longer hospitalisation (p<0.001). The older group was less likely to achieve complete cytoreduction (61.2 vs. 73 %, p=0.004) and receive EPIC (23.9 vs. 32.7 %, p=0.040). Conclusions: In patients undergoing CRS/HIPEC, age of 70 and above does not impact OS or major morbidity but is associated with increased mortality. Age alone should not be a limiting factor in selecting CRS/HIPEC patients. Careful multi-disciplinary approach is needed when considering those of advanced age.

Outcomes of single anastomosis duodeno ileal bypass and single anastomosis stomach ileal bypass for type II diabetes: a systematic review.

INTRODUCTION: Bariatric surgery has demonstrated long-term effectiveness in inducing weight loss and improving metabolic parameters for obesity. Single anastomosis duodeno-ileal (SADI) bypass and single anastomosis sleeve-ileal (SASI) bypass have both emerged as new promising bariatric procedures. In this paper, we review the existing literature and compare the outcomes of SADI and SASI bypass procedures in regard to weight loss, complication rate, and improvement of type II diabetes (T2DM). This has not yet been done in the preexisting literature. AREAS COVERED: We conducted a systematic literature search of electronic databases focusing on weight loss outcomes, rate of complications and remission, or improvement of T2DM and other obesity-related comorbidities. Seventeen studies on SADI and nine studies on SASI were included. Both are similar in terms of surgical technique and have demonstrated fewer complications when compared to other bariatric procedures. Mean preoperative BMI was similar in both study groups: 46.4 kg/m2 in SADI and 48.8 kg/m2 in SASI. Mean %EWL at 12 months in the SADI group was 74.1% compared to 77.4% in the SASI group. Preoperative severity of T2DM appeared to be higher in the SASI patient group, with a higher preoperative HbA1c and fasting blood glucose levels. T2DM resolution was achieved in a significant proportion of both SADI and SASI patient populations (78.5% in SADI and 89.0% in SASI). Complication rates were comparable for both procedures. EXPERT OPINION: Both SADI and SASI are effective in inducing weight loss at 12 months, with a low rate of major complications and mortality. From the studies included in this review, the SASI procedure had a higher impact on T2DM resolution compared to SADI.

Survival benefits with EPIC in addition to HIPEC for low grade appendiceal neoplasms with pseudomyxoma peritonei: a propensity score matched study.

Objectives: Appendiceal cancer is a rare malignancy, occurring in roughly 1.2 per 100,000 per year. Low grade appendiceal neoplasams (LAMN) in particular can lead to pseudomyxoma peritonei (PMP), and respond poorly to systemic chemotherapy. Standard treatment includes cytoreduction surgery (CRS) with addition of heated intraoperative peritoneal chemotherapy (HIPEC). Several centres include early postoperative intraperitoneal chemotherapy (EPIC) however; the literature is mixed on the benefits. We aim to examine the benefits of additional EPIC through a propensity-matched analysis. Methods: Patients with LAMN with PMP who underwent cytoreductive surgery at St George hospital between 1996 and 2020 were included in this retrospective analysis. Propensity score matching was performed with the following used to identify matched controls; sex, age, American Society of Anesthesiologists (ASA) grade, peritoneal cancer index (PCI) and morbidity grade. Outcomes measured included length of stay and survival. Results: A total of 224 patients were identified of which 52 received HIPEC alone. Propensity matching was performed to identify 52 matched patients who received HIPEC + EPIC. Those receiving HIPEC + EPIC were younger at 54.3 vs. 58.4 years (p=0.044). There was a median survival benefit of 34.3 months for HIPEC + EPIC (127.3 vs. 93.0 months, p=0.02). Median length of stay was higher in those who received EPIC (25.0 vs. 23.5 days, p=0.028). Conclusions: In LAMN with PMP, the addition of EPIC to HIPEC with CRS improves overall survival in propensity score matched cases but results in prolonged hospitalisation. The use of EPIC should still be considered in selected patients.

Comparing Survival Outcomes and Impact of EPIC in Patients Undergoing CRS/HIPEC for Mucinous Appendiceal Neoplasm.

BACKGROUND/AIM: This study sought to investigate the difference in survival outcomes in patients with complete cytoreduction (CC)-0 or CC-1 mucinous appendiceal cancer undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC). It also investigated what effect early postoperative intraperitoneal chemotherapy (EPIC) may have on survival based on CC score and histology. PATIENTS AND METHODS: This was a retrospective single centre study of patients that underwent CRS/HIPEC +/- EPIC for mucinous appendiceal neoplasms from June 2003 to February 2022. RESULTS: A total of 545 patients were identified. Although there was a survival difference between CC-0 and CC-1 on univariate analyses, this was not statistically significant on multivariate analysis. Histology, peritoneal cancer index, and EPIC status were demonstrated to be independent factors that affected overall survival (OS) on multivariate analysis. Patients with CC-1 that received EPIC had significantly improved OS (mean OS 14 years) when compared to patients that did not receive EPIC (mean OS 6 years). In CC-1, OS was significantly improved in patients that received EPIC in both low-grade (p<0.001) and high-grade (p=0.012) disease. OS for patients that received EPIC at 1, 5, and 10 years was 95%, 80%, and 59%, respectively. OS for patients that did not receive EPIC at 1, 5, and 10 years was 84%, 49%, and 30%, respectively. CONCLUSION: There was no difference in OS between CC-0 and CC-1. The implementation of EPIC in patients with CC-1 significantly improved OS in both low-grade and high-grade disease and thus we recommend its addition in CC-1 disease to achieve optimal survival outcome.

Improving testicular examinations on paediatric patients in the emergency department: A quality improvement study to improve early diagnosis of testicular torsion.

Objective: Male paediatric patients presenting with abdominal and/or testicular pain are common in the emergency department. As a time-sensitive diagnosis, the importance of early recognition, referral, and definitive management is critical. Missed or delayed diagnoses and management of testicular torsion can result in significant long-term sequelae including impaired fertility and psychological burden. In this quality improvement study, we utilised educational posters aiming to improve awareness of testicular torsion as a differential for abdominal pain and therefore, improve the quality of testicular examinations performed in the emergency department. Methods: Observational pre- and post-intervention study was conducted at a tertiary hospital emergency department. A pre-interventional retrospective review of the electronic medical records was conducted. All male patients under 16-years-old presenting with "abdominal pain" or "testicular problem" were included. We assessed the rate of testicular examination and the quality of the examination based on four domains: Cremasteric reflex, lie, swelling, and hardness. Educational posters targeting both patients and clinicians were placed around the emergency department. Subsequent review of the electronic medical records post-intervention was performed assessing the same domains. Results: A total of 235 presentations were analysed with 124 in the pre-intervention group and 111 in the post-intervention group. Overall rate of documented testicular examinations increased by 14% (p=0.032). The quality of testicular examinations also improved from an average of 0.85 domains documented to 2.29 post-intervention (p<0.001). Subgroup analysis found doctors in training had a greater improvement in both rate and quality of documented testicular examination. Conclusion: Our study demonstrated the value of continuing education in promoting awareness of testicular torsion in the emergency department. We found a clear improvement in the quality of clinical documentation of a time-sensitive condition which may infer a decreased risk of missed and delayed diagnosis of testicular torsion.

Cytoreductive Surgery and HIPEC for Malignant Peritoneal Mesothelioma: Outcomes and Survival From an Australian Centre.

BACKGROUND/AIM: The aim of the study was to determine outcomes and overall survival (OS) in patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) for malignant peritoneal mesothelioma (MPM). PATIENTS AND METHODS: This was a retrospective cohort study from a prospectively maintained database of patients that underwent CRS/HIPEC for MPM from April 1999 to December 2021. RESULTS: A total of 81 patients were identified with MPM. Median OS was 53 months with a 1-, 3- and 5-year OS of 76%, 55% and 49% respectively. Multivariate analysis identified lymph node status, PCI and CC score as statistically significant prognostic factors that impact survival. Median OS for PCI 0-20 was 103 months vs. 33 months for PCI 21-39 (p=0.005). Median OS for CC0, CC1 and CC2 were 104, 30 and 2.7 months respectively (p<0.001). Hazard ratio for node-positive disease over node-negative was 2.14 (95% CI=1.07-4.31, p<0.033). Grade III/IV complication rate was 43.2% and mortality 4.9%. CONCLUSION: CRS/HIPEC remains the gold standard for treating patients with MPM with excellent patient OS. Lymph node status, PCI and CC score were independent prognostic factors that affect OS.

Rapid Formation and Rupture of Multiple Abdominal Pseudoaneurysms: A Life Threatening Case of Segmental Arterial Mediolysis.

We present a 62-year-old gentleman with rapidly forming abdominal pseudoaneurysms due to segmental arterial mediolysis (SAM). With rupture of his pseudoaneurysms, he underwent angiography and successful coil embolisation. In this case, we demonstrate the potential for rapid progression of pseudoaneurysms in SAM, with the need for prompt diagnosis and urgent endovascular intervention.

On the use of musculoskeletal models to interpret motor control strategies from performance data.

The intrinsic viscoelastic properties of muscle are central to many theories of motor control. Much of the debate over these theories hinges on varying interpretations of these muscle properties. In the present study, we describe methods whereby a comprehensive musculoskeletal model can be used to make inferences about motor control strategies that would account for behavioral data. Muscle activity and kinematic data from a monkey were recorded while the animal performed a single degree-of-freedom pointing task in the presence of pseudo-random torque perturbations. The monkey's movements were simulated by a musculoskeletal model with accurate representations of musculotendon morphometry and contractile properties. The model was used to quantify the impedance of the limb while moving rapidly, the differential action of synergistic muscles, the relative contribution of reflexes to task performance and the completeness of recorded EMG signals. Current methods to address these issues in the absence of musculoskeletal models were compared with the methods used in the present study. We conclude that musculoskeletal models and kinetic analysis can improve the interpretation of kinematic and electrophysiological data, in some cases by illuminating shortcomings of the experimental methods or underlying assumptions that may otherwise escape notice.