Achieving a textbook outcome in patients undergoing gastric resections in a low incidence, high-volume Australian Upper GI unit.

BACKGROUND: Textbook outcome (TBO) has been proposed as a composite measure of quality in esophagogastric surgery, and achieving a TBO has been associated with improved overall survival (OS). The Dutch Upper Gastrointestinal Cancer Audit group determined their TBO rate for gastrectomy to be 32.1%, using 10 parameters. Our study aimed to assess the TBO rate in patients who had a gastrectomy for cancer in an Australian Upper GI unit, allowing for comparisons with international specialist centers. METHODS: Retrospective analysis of a prospectively maintained database of patients who had a gastrectomy for cancer performed by the surgeons in a single Australian center between 2013 and 2018. Postoperative complications were analyzed using Clavien-Dindo (CD) ≥2 and CD ≥3 definitions. Baseline factors and their association with TBO were analyzed using multivariable logistical regression. The association between TBO and survival rates was determined by Cox proportional hazards regression analysis. RESULTS: In 136 patients, 84 (62%) achieved a TBO when complications were graded as CD ≥2. Greatest negative impact on TBO was the complication rate, lymph node yield, and length of stay. Patients more likely to achieve a TBO were younger, with an increased body mass index and absence of underlying respiratory disease. A nonsignificant trend toward improved OS was seen when TBO was achieved. CONCLUSION: Our TBO rate compares favorably with published data from high-volume centers. Assessment of a unit's TBO may provide a stronger evaluation of quality when assessing where complex surgery should be performed within Australia.

Diagnostic laparoscopy in penetrating abdominal trauma.

BACKGROUND: Penetrating abdominal trauma is uncommon in Australia. There are multiple potential approaches to the patient without an indication for immediate laparotomy. This study examined the management of patients with a penetrating anterior abdominal injury in a Level 1 trauma centre, and in particular investigated the outcomes of those patients who underwent diagnostic laparoscopy. METHODS: A retrospective review was undertaken of all patients presenting to a Level 1 trauma centre with an anterior abdominal stab wound over a 15-year period. Patient demographic, injury, examination, treatment and outcome data were extracted. These data were analysed using SPSS PASW version 20. RESULTS: A total of 318 patients were identified. Immediate laparotomy was performed in 121 of those patients. Of the remaining 197 patients, 146 underwent diagnostic laparoscopy. Peritoneal breach was identified in 87 patients, 79 of whom then had exploratory laparotomy. The laparotomy was therapeutic in 36 of 79 patients (45.6%). Multiple stab wounds were an independent predictor of therapeutic laparotomy (hazard ratio 2.39, 95% CI 1.16-4.93). Diagnostic laparoscopy was 100% sensitive, 60.9% specific and had a negative predictive value of 100% and a positive predictive value of 40%. Non-therapeutic laparotomy was associated with a median length of stay of 5.5 days and a complication rate of 9.3%. CONCLUSION: Diagnostic laparoscopy to detect peritoneal breach is a safe approach in the management of anterior abdominal stab wounds. However, utilizing peritoneal breach as an indication for laparotomy is associated with a moderate incidence of non-therapeutic laparotomy. Measures to decrease the negative laparotomy rate should be considered.

Rectal perforation following paclitaxel and carboplatin chemotherapy for advanced ovarian cancer: a case report and review of the literature.

BACKGROUND: Paclitaxel is a chemotherapy drug commonly used in the management of ovarian cancer. Colonic perforation is an extremely rare complication of paclitaxel administration with few case reports in the medical literature. We report a case of a patient with advanced ovarian cancer who had a rectal perforation following administration of paclitaxel. There has only been one other case report of rectal perforation in the medical literature following paclitaxel therapy. CASE PRESENTATION: A 55-year-old Caucasian woman with advanced ovarian cancer awaiting elective debulking surgery for her tumor presented to our emergency department with abdominal pain, vomiting, and diarrhea. She was admitted to hospital for neoadjuvant chemotherapy and management of her systemic symptoms. She became acutely unwell following one cycle of chemotherapy with paclitaxel. A computed tomography scan of her abdomen showed typhlitis of her descending colon and a corresponding rectal perforation. Surgical intervention was deemed inappropriate as she had a heavy burden of disease and neutropenia. She died following a period of conservative management with strong intravenously administered antibiotics. CONCLUSIONS: This case highlights the importance of recognizing gastrointestinal complications following chemotherapy and the need to be aware of the possibility of bowel perforation. Prompt surgical review and intervention must be requested in patients with acute abdominal pain and persistent gastrointestinal symptoms such as diarrhea and vomiting.