A clinical observation algorithm for anterior abdominal stab wound is safe in an Australian setting.

INTRODUCTION: We previously published the outcomes associated with the use of diagnostic laparoscopy to determine peritoneal breach for AASW patients without an immediate indication for laparotomy. Although this pathway was 100% sensitive there was a 54% non-therapeutic laparotomy rate. Another option that has been extensively reported is the clinical observation algorithm (COA) however, majority of the data originate from high-volume centres. We hypothesized that a COA would also be a safe option in an Australian setting, and reduce the rate of non-therapeutic operative intervention in managing AASW. METHODS: This was a prospective cohort study examining patients with AASW admitted to a level 1 trauma centre in Sydney, Australia, between June 2021 and August 2023. Patient, injury, management and outcome data were collected from electronic medical records and the hospital trauma registry. Data were then analysed to determine the diagnostic accuracy of the COA, complication rates and median hospital length-of-stay (LOS). RESULTS: A total of 48 patients presented with AASW. Of these patients, 11 (22.9%) proceeded to immediate laparotomy. Seven patients had a contraindication to COA and underwent diagnostic laparoscopy. Thirty patients were managed with the COA, with three (10%) patients subsequently requiring a laparotomy. Only one patient (3.3%) underwent a non-therapeutic laparotomy. There were no missed injuries. The COA sensitivity was 100%, specificity 92.7%, PPV 50% and NPV 100%. Patients managed with COA had no complications. Overall median hospital LOS was 1 day (1.0-2.3). CONCLUSION: A COA is a safe approach for evaluating patients with AASW in an Australian setting with adequate resources. It reduces the rate of non-therapeutic operative intervention and has acceptable outcomes compared with a diagnostic laparoscopy pathway.

Codesign of health technology interventions to support best-practice perioperative care and surgical waitlist management.

OBJECTIVES: This project aimed to determine where health technology can support best-practice perioperative care for patients waiting for surgery. METHODS: An exploratory codesign process used personas and journey mapping in three interprofessional workshops to identify key challenges in perioperative care across four health districts in Sydney, Australia. Through participatory methodology, the research inquiry directly involved perioperative clinicians. In three facilitated workshops, clinician and patient participants codesigned potential digital interventions to support perioperative pathways. Workshop output was coded and thematically analysed, using design principles. RESULTS: Codesign workshops, involving 51 participants, were conducted October to November 2022. Participants designed seven patient personas, with consumer representatives confirming acceptability and diversity. Interprofessional team members and consumers mapped key clinical moments, feelings and barriers for each persona during a hypothetical perioperative journey. Six key themes were identified: 'preventative care', 'personalised care', 'integrated communication', 'shared decision-making', 'care transitions' and 'partnership'. Twenty potential solutions were proposed, with top priorities a digital dashboard and virtual care coordination. DISCUSSION: Our findings emphasise the importance of interprofessional collaboration, patient and family engagement and supporting health technology infrastructure. Through user-based codesign, participants identified potential opportunities where health technology could improve system efficiencies and enhance care quality for patients waiting for surgical procedures. The codesign approach embedded users in the development of locally-driven, contextually oriented policies to address current perioperative service challenges, such as prolonged waiting times and care fragmentation. CONCLUSION: Health technology innovation provides opportunities to improve perioperative care and integrate clinical information. Future research will prototype priority solutions for further implementation and evaluation.

Meta-analysis - perineural invasion as prognostic factor in rectal cancer / Metanálise -invasão perineural como fator prognóstico no câncer retal

ABSTRACT Objectives: The aim of this analysis was to determine prognostic value of perineural invasion in rectal cancer. Methods: Medline (PubMed, Ovid), Embase and Cochrane Library were searched for relevant reports published from January 1980 up to December 2017. All clinical trials which studied perineural invasion in rectal cancer, prospective observational studies, clinical registry data and retrospective case series which reported perineural invasion as an outcome were included. Case reports, abstracts, letters and comments were excluded. hazard ratio (HR) with 95% confidence interval (CI) was used to determine the prognostic value. Results: Nineteen studies comprising 6438 patients with rectal cancer were analysed. The results indicate that perineural invasion is a negative prognostic factor as evident from the overall survival (HR = 1.30, 95% CI 1.13-1.50, p < 0.01) and disease-free survival (HR = 2.14, 95% CI 2.06-2.22, p < 0.01). Conclusion: This study shows that presence of perineural invasion is associated with poor prognosis in rectal cancer.

RESUMO Objetivo: Este estudo buscou determinar o valor prognóstico da invasão perineural no câncer retal. Métodos: Relatos relevantes publicados entre janeiro de 1980 e dezembro de 2017 foram buscados nas bases de dados Medline (PubMed, Ovid), Embase e Cochrane Library. Todos os ensaios clínicos que avaliaram a IPN no câncer de reto, estudos observacionais prospectivos, dados de registro clínico e séries de casos retrospectivos que relataram IPN como um desfecho foram incluídos. Relatos de casos, resumos, cartas e comentários foram excluídos. A razão de risco (hazard ratio [HR]) com intervalo de confiança (IC) de 95% foi usada para determinar o valor prognóstico. Resultados: Foram analisados 19 estudos compreendendo 6.438 pacientes com câncer retal. Os resultados indicam que a invasão perineural é um fator prognóstico negativo, conforme demonstrado pela sobrevida global (HR = 1,30; IC 95%: 1,13-1,50; p < 0,01) e sobrevida livre de doença (HR = 2,14; IC 95%: 2,06-2,22, p < 0,01). Conclusão: O estudo demonstrou que a presença de invasão perineural está associada a um prognóstico ruim no câncer retal.

Systematic review of efficacy of LIFT procedure in crpytoglandular fistula-in-ano / Revisão sistemática da eficácia do procedimento LIFT em fístula anal criptoglandular

BACKGROUND: fistula-in-ano is a common problem. Ligation of intersphincteric fistula tract (LIFT) is a new addition to the list of operations available to deal with complex fistula-in-ano. OBJECTIVE: we sought to qualitatively analyze studies describing LIFT for crpytoglandular fistula-in-ano and determine its efficacy. DATA SOURCES: MEDLINE (Pubmed, Ovid), Embase, Scopus and Cochrane Library were searched. STUDY SELECTION: all clinical trials which studied LIFT or compared LIFT with other methods of treatment for anal fistulae, prospective observational studies, clinical registry data and retrospective case series which reported clinical healing of the fistula as the outcome were included. Case reports, studies reporting a combination with other technique, modified technique, abstracts, letters and comments were excluded. INTERVENTION: the intervention was ligation of intersphincteric fistula tract in crpytoglandular fistula-in-ano. MAIN OUTCOME MEASURE: primary outcome measured was success rate (fistula healing rate) and length of follow-up. (AU)

BACKGROUND: fístula anal é um problema comum. A ligadura interesfincteriana do trajeto fistuloso (LIFT) é uma nova adição à lista de cirurgias disponíveis para tratar a fístula anal complexa. OBJETIVO: buscou-se analisar qualitativamente estudos descrevendo o uso de LIFT para fístula anal criptoglandular e determinar a sua eficácia. FONTES DE DADOS: as bases de dados MEDLINE (Pubmed, Ovid), Embase, Scopus e Biblioteca Cochrane foram pesquisadas. SELEÇÃO DOS ESTUDOS: todos os ensaios clínicos que estudaram LIFT ou compararam LIFT com outros métodos de tratamento da fístula anal, estudos observacionais prospectivos, dados de registros clínicos e série de casos retrospectivos que relataram a cura clínica da fístula anal como desfecho foram incluídos. Relatos de casos, estudos que relatam uma combinação com outra técnica, técnica modificada, resumos, cartas e comentários foram excluídos. INTERVENÇÃO: a intervenção foi ligadura interesfincteriana do trajeto fistuloso em fístula anal criptoglandular. MEDIDA DO DESFECHO PRINCIPAL: a medida do desfecho principal foi a taxa de sucesso (taxa de cura da fístula) e período de seguimento. (AU)