A double-blinded randomised controlled study of fluid restriction versus liberal fluid during induction of labour: A pilot study.

BACKGROUND: Excess intravenous fluid for women requiring an induction of labour may adversely affect the duration of labour and maternal/neonatal outcomes. AIMS: This study aimed to determine the difference in duration of labour and outcomes with a low background infusion rate, compared to liberal background intravenous fluid management. MATERIALS AND METHODS: A double blind randomised controlled pilot study was performed on 200 women who underwent induction of labour at a single institution. Women were randomised to an intravenous rate of 40 mL/h versus 250 mL/h of Hartmann's solution. Fluid boluses were strictly controlled to limit bias. This trial was registered with the Australian clinical trial registry: ACTRN12621001298808. RESULTS: Analysis of the total amount of fluid received showed good separation with Group 1 (40 mL/h) receiving 1,736 mL less than Group 2 (250 mL/h), median (interquartile range) 841 mL (458, 1691) versus 2,577 mL (1620, 4326) (P < 0.001). Median duration of labour was shorter in Group 1 by 24 min (P = ns). Subset analysis of nulliparous women showed that duration of labour was shorter in Group 1 by 83.5 min (P = ns). CONCLUSION: As this was a pilot study, a significant difference in duration of labour or secondary outcomes was not seen. Given the increasing numbers of nulliparous women having an induction of labour, potential for adverse maternal and neonatal outcomes and the associated higher rate of operative birth, this study guides power calculations and supports proof of concept for future research into optimum fluid management during induction of labour for these women.

Radioembolization for Treatment of Hepatocellular Carcinoma: Current Evidence and Patterns of Utilization.

Primary liver malignancy, of which hepatocellular carcinoma (HCC) is the most common type, is the second most common cause of death due to cancer worldwide. Given the historically poor prognosis of liver cancer, there has been major research on its treatment options, with significant advancements over the last decade. Transarterial radioembolization (TARE) is a locoregional treatment option for HCC that involves transarterial delivery of the ß-emitter yttrium-90 via resin or glass microspheres to arterialized tumor vasculature, delivering a tumoricidal dose to the tumor. The recent 2022 update of the Barcelona Clinic Liver Cancer (BCLC) treatment algorithm features a more prominent role for locoregional treatment, including the incorporation of radioembolization for very-early-stage (BCLC-0) and early-stage (BCLC-A) diseases. This review provides a contemporary summary of the evolving role of TARE in treatment of HCC in light of recent and upcoming trials.

Inefficient Admissions for Abdominal Pain Under an Acute General Surgical Unit.

BACKGROUND: The acute general surgical unit (AGSU) model has become a standard of efficient acute surgical care. Whilst the AGSU has been compared to the traditional surgical model, there is a lack of research auditing referrals and admissions. This study evaluates abdominal pain referrals to AGSU and the necessity of admission. METHODS: A retrospective cohort study of adult abdominal pain admissions was conducted over a two-year period at a single centre in metropolitan Victoria, Australia. The data were extracted from electronic medical records and key endpoints of data included the diagnosis, length of stay, investigations and subjective pain outcomes. RESULTS: A total of 1587 patients met the study criteria of which 1116 (70.3%) had a non-surgical diagnosis with the majority having non-specific abdominal pain. The non-surgical patients had a lower median length of stay (25.3 h) compared to surgical patients (44.2 h, p < 0.001). They were less likely to have an abnormal haemoglobin (p = 0.004), elevated white cell count (p = 0.02) or elevated C-reactive protein > 50 mg/L (p < 0.001). On multivariable analysis, surgical patients had higher odds of having a CRP > 50 mg/L (p = 0.024) and a positive imaging result (p < 0.001). The patient's pain control also correlated with length of stay. CONCLUSION: A large population of patients with non-specific abdominal pain are admitted to AGSU. These patients do not require surgery and have a short length of stay. Incorporating a negative CRP result and negative imaging result may be utilised in conjunction with optimised analgesia to help avoid these unnecessary admissions, thereby improving AGSU efficiency and workload.

A systematic review of venous thromboembolism mechanical prophylaxis devices during surgery.

PURPOSE: Hospitalisation and surgery are major risk factors for venous thromboembolism (VTE). Intermittent pneumatic compression (IPC) and graduated compression stockings (GCS) are common mechanical prophylaxis devices used to prevent VTE. This review compares the safety and efficacy of IPC and GCS used singularly and in combination for surgical patients. METHODS: Ovid Medline and Pubmed were searched in a systematic review of the literature, and relevant articles were assessed against eligibility criteria for inclusion along PRISMA guidelines. RESULTS: This review is a narrative description and critical analysis of available evidence. Fourteen articles were included in this review after meeting the criteria. Results of seven studies comparing the efficacy of IPC versus GCS had high heterogeneity but overall suggested IPC was superior to GCS. A further seven studies compared the combination of IPC and GCS versus GCS alone, the results of which suggest that combination mechanical prophylaxis may be superior to GCS alone in high-risk patients. No studies compared combination therapy to IPC alone. IPC appeared to have a superior safety profile, although it had a worse compliance rate and the quality of evidence was poor. The addition of pharmacological prophylaxis may make mechanical prophylaxis superfluous in the post-operative setting. CONCLUSION: IPC may be superior to GCS when used as a single prophylactic device. A combination of IPC and GCS may be more efficacious than GCS alone for high-risk patients. Further high-quality research is needed focusing on clinical relevance, safety and comparing combination mechanical prophylaxis to IPC alone, particularly in high-risk surgical settings when pharmacological prophylaxis is contraindicated.

Outcomes following common bile duct exploration versus endoscopic stone extraction before, during and after laparoscopic cholecystectomy for patients with common bile duct stones.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. The best method for CBD stone removal is debatable. The aim of this study was to compare outcomes following LCBDE and/or ERCP, including laparoscopic cholecystectomy. METHODS: Data were collected retrospectively for patients undergoing LCBDE and/or ERCP at a single centre from 2008 to 2018. Patients were grouped by intention-to-treat (single-stage LCBDE, pre-operative-, intra-operative-, or post-operative ERCP) and eventual plan (surgical or endoscopic). Outcomes included complication rates (minor Clavien-Dindo 1/2, major Clavien-Dindo 3/4, non-biliary complications) and mortality. RESULTS: Of 671 patients, 578 patients received LCBDE and 93 patients received ERCP as primary care. Endoscopic clearance had significantly higher complications and mortality compared to surgical clearance. On an intention-to-treat basis LCBDE had the lowest minor-, major- and non-biliary complications, and mortality (5.2%, 6.1%, 2.9% and 0.5%, respectively), whilst pre-operative ERCP the worst (39.6%, 27.1%, 29.2% and 8.3%, respectively) (p=<0.001). LCBDE and postERCP had similar major complications and mortality. CONCLUSION: Surgical clearance of CBD stones was potentially safer than endoscopic clearance. Pre-operative ERCP had the worst outcomes. LCBDE and postERCP are likely to have similar short-term patient outcomes.

Everyone has Their Role to Play During the World Health Organisation Surgical Safety Checklist in Australia: A Prospective Observational Study.

BACKGROUND: The World Health Organisation Surgical Safety Checklist (SSC) is a mandated part of surgical practice. Adherence to the SSC has been shown to result in improved patient outcomes. The aim of this study was to determine the current adherence to the timeout section of the SSC and, in particular, the function of individual team members. METHODS: A prospective pre- and post-intervention observational audit was conducted on the timeout section. The intervention involved an in-hospital display of interim results and distribution to theatre staff. Data were collected on participants, duration and compliance with checklist items for 400 theatre cases. There were 200 cases before and after the intervention. RESULTS: There were no cases in which the timeout section was completed correctly in its entirety. Post-intervention, there was a significant improvement in participation of theatre staff (excluding surgeons) as well as a significant improvement in items discussed and documented. Discussion of items such as anticipated critical events, pressure areas and the team introduction remained low. Some items on the checklist were discussed significantly more when a particular staff member participated. CONCLUSION: Observed completion rates of the timeout section of the SSC were poor. Individual team members positively influenced checklist items more aligned to their role, highlighting the importance of timeout being performed by the entire theatre team. Improved performance was seen following audit and feedback.

Antigen-specific CD4+ CD25+ T cells induced by locally expressed ICOS-Ig: the role of Foxp3, Perforin, Granzyme B and IL-10 - an experimental study.

We have previously reported that ICOS-Ig expressed locally by a PIEC xenograft induces a perigraft cellular accumulation of CD4+ CD25+ Foxp3+ T cells and specific xenograft prolongation. In the present study we isolated and purified CD4+ CD25+ T cells from ICOS-Ig secreting PIEC grafts to examine their phenotype and mechanism of xenograft survival using knockout and mutant mice. CD4+ CD25+ T cells isolated from xenografts secreting ICOS-Ig were analysed by flow cytometry and gene expression by real-time PCR. Regulatory function was examined by suppression of xenogeneic or allogeneic primed CD4 T cells in vivo. Graft prolongation was shown to be dependent on a pre-existing Foxp3+ Treg, IL-10, perforin and granzyme B. CD4+ CD25+ Foxp3+ T cells isolated from xenografts secreting ICOS-Ig demonstrated a phenotype consistent with nTreg but with a higher expression of CD275 (ICOSL), expression of CD278 (ICOS) and MHC II and loss of CD73. Moreover, these cells were functional and specifically suppressed xenogeinic but not allogeneic primed T cells in vivo.

Correction to: An Acute General Surgical Unit (AGSU) Negates the Impact of the Tokyo Guidelines 2018 (TG18) Diagnostic Criteria for the Treatment of Acute Cholecystitis.

The original article can be found online.

An Acute General Surgical Unit (AGSU) Negates the Impact of the Tokyo Guidelines 2018 (TG18) Diagnostic Criteria for the Treatment of Acute Cholecystitis.

PURPOSE: The Tokyo Guidelines 2018 (TG18) were developed to aid diagnosis and treatment for acute cholecystitis. The benefits of being treated in an acute general surgical unit (AGSU) include earlier diagnosis and treatment. This study aims to define the usefulness of TG18 before and after the introduction of AGSU. METHODOLOGY: Patients who underwent cholecystectomy at Northern Health were audited retrospectively and assessed for TG18 diagnostic criteria and outcomes between 1 February 2012 and 1 February 2014 (one-year pre- and post-AGSU). RESULTS: Five hundred and eighty-seven patients underwent emergency cholecystectomy with 203 (34.6%) patients having a suspected diagnosis, and 234 (39.9%) patients with a definitive diagnosis of acute cholecystitis using TG18 diagnostic criteria. After the introduction of AGSU, time from imaging to operation improved from 2.5 to 1.7 days (p = 0.012). There were more operations occurring during in-hours following AGSU implementation (75.8% vs. 62.7%, p < 0.001). Maximum pre-operative CRP of >26.6 mg/L had a higher likelihood of Clavien-Dindo complication grade 3 or 4 (OR 3.86, 95%CI 1.18-12.63, p = 0.027) compared with TG18 definitive diagnosis criteria (OR 1.50, 95%CI 0.46-4.91, p = 0.501). Surprisingly, there was a trend towards higher complications and readmissions for patients operated within 24 h, although this trend was not significant. CONCLUSION: Patients with suspected acute cholecystitis should be stratified clinically and with CRP in an AGSU with TG18 adding little value in a busy metropolitan unit.

Combined hepatectomy and hepatic pedicle lymphadenectomy in colorectal liver metastases is justified.

BACKGROUND: The aim of this study was to describe the outcome of patients with colorectal liver metastases (CRLM) and radiological or clinical evidence of metastatic hepatic lymph node involvement who underwent combined hepatectomy and hepatic pedicle lymphadenectomy. METHODS: Retrospective analysis of a prospectively maintained audit of 2082 patients undergoing liver resection for CRLM between 1994 and 2014. Age, type of resection, CT/MRI/PET detection, location, disease recurrence and survival were analysed. RESULTS: Combined hepatectomy and hepatic pedicle lymphadenopathy was performed on 76 patients who met the inclusion criteria. 46% of enlarged lymph nodes were located in the hepatic ligament, with 38% retroportal, 38% common hepatic and 33% coeliac nodes. 50% of lymph node resections were positive for metastatic tumour. Pre-operative CT, MRI and CT/PET failed to detect histologically proven lymph node disease in 25/38 patients. Patients with negative nodal histology had a significant overall (44 vs 20 months, p = 0.008) and disease free (20 vs 11 months, p < 0.001) survival advantage. CONCLUSION: Combined hepatectomy and lymph node resection for CRLM in the setting of enlarged or suspicious lymphadenopathy is justified as imaging and operative findings are poor guides in determining positive lymph node disease.

What determines ageing of the transplanted liver?

BACKGROUND: Liver transplantation is used to treat patients with irreversible liver failure from a variety of causes. Long-term survival has been reported, particularly in the paediatric population, with graft survival longer than 20 years now possible. The goal for paediatric liver transplantation is to increase the longevity of grafts to match the normal life expectancy of the child. This paper reviews the literature on the current understanding of ageing of the liver and biomarkers that may predict long-term survival or aid in utilization of organs. METHODS: Scientific papers published from 1950 to 2013 were sought and extracted from the MEDLINE, PubMed and University of Melbourne databases. RESULTS: Hepatocytes appear resistant to the ageing process, but are affected by both replicative senescence and stress-related senescence. These processes may be exacerbated by the act of transplantation. The most studied biomarkers are telomeres and SMP-30. CONCLUSION: There are many factors that play a role in the ageing of the liver. Further studies into biomarkers of ageing and their relationship to the chronological age of the liver are required to aid in predicting long-term graft survival and utilization of organs.

Addressing disparities in health outcomes for patients with advanced pancreatic cancer and limited English proficiency.

INTRODUCTION: There are significant challenges and a lack of data related to culturally and linguistically diverse (CALD) cancer patients. We compared patient characteristics, treatment patterns, and outcomes of patients with advanced pancreatic cancer that required an interpreter. METHODS: Registry data was extracted for advanced pancreatic cancer patients from a single health institution with a comprehensive Transcultural and Language Service (TALS). Demographic and clinicopathologic characteristics were compared. Kaplan-Meier survival estimates with log-rank testing, and univariate and multivariable regression analysis were performed to compare the group with limited English proficiency (LEP) to the English proficient (EP) group. RESULTS: Of 155 patients, 32.9% (n = 51) required the TALS. The LEP group had a higher mean age (71.2 vs. 76.8 years; p = 0.005) and received less chemotherapy (42.3% vs. 31.4%, p = 0.220). Univariate analysis revealed a shorter median overall survival (OS) in the LEP group (3.6 vs. 5.0 months), with a hazard ratio [HR] of 1.51 (95% confidence interval [CI]: 1.03-2.21, p = 0.033). Upon multivariable analysis, adjusting for Eastern Cooperative Oncology Group (ECOG) performance scale, the number of sites of metastatic disease and chemotherapy use, the strength of association between LEP and OS reduced marginally (HR 1.42, 95% CI: 0.93-2.16), and was no longer statistically significant (p = 0.103). CONCLUSIONS: In patients with advanced pancreatic cancer utilizing a comprehensive TALS, there was a trend to poorer survival with limited English proficiency, although this association was not statistically significant. An ongoing research commitment to the CALD experience is necessary to build a granular understanding of this population and ensure equitable outcomes.

Surgical management of large bowel obstruction and significant hepatic displacement caused by Chilaiditi syndrome.

Chilaiditi's sign is the presence of pseudopneumoperitoneum caused by colonic distension and interposition with the liver on radiographic films. Most patients with Chilaiditi's sign are asymptomatic. Chilaiditi's syndrome is defined as the development of abdominal pain or symptoms of bowel obstruction along with the presence of Chilaiditi's sign. It is a rare entity and it poses significant diagnostic challenges due to its similar radiographic appearance to pneumoperitoneum. Most patients with Chilaiditi syndrome can be managed conservatively. However, surgery is indicated for those who do not respond to conservative management or for suspicion of severe complications such as bowel ischaemia or perforation. In this case report, we described the surgical management of a patient who presented with bowel obstruction and significant hepatic displacement from Chilaiditi syndrome.

PET-positive suture granuloma of abdominal wall 56 years post-appendicectomy mimicking recurrence of lymphoma.

We present a unique case of a positron emission tomography (PET)-positive suture granuloma deep to an appendicectomy abdominal wall scar from 56 years prior in a patient with treated lymphoma. The lesion was first detected 8 years ago on a PET scan for new diagnosis of follicular lymphoma, with stable appearances 6 and 7 years later at follow-up. Ultrasound-guided biopsy and flow cytometry of the specimen could not exclude an untreated or recurrent lymphoma; thus, the patient underwent resection of the right iliac fossa abdominal wall lesion. Histopathology results noted granulomatous inflammation surrounding foreign material. The patient had an uneventful postoperative recovery and was discharged from surgical services. In this paper, we review the current literature and discuss the dilemma involved in the diagnosis and management of suture granulomas.

Comparing Stone Recurrence Following Surgical Common Bile Duct Exploration or Endoscopic Stone Extraction for Patients with Common Bile Duct Stones.

Background: Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. Aspects of CBD stone management, such as sphincterotomy, have been implicated as risks for CBD stone recurrence although evidence is weak. The aim of this study was to compare stone recurrence following LCBDE and/or ERCP. Methods: Data were collected retrospectively for patients undergoing LCBDE and/or ERCP for CBD stones at a single center from 2008 to 2018. Primary outcome was stone recurrence (>6 months after duct clearance). Risk factors for recurrence were assessed using univariate and multivariate analyses. Results: A total of 445 patients underwent LCBDE-only, 79 patients underwent ERCP-only and 80 patients underwent LCBDE-ERCP. LCBDE-only patients were younger and preoperatively less morbid than ERCP-only patients. Although there was no significant difference for recurrence, there was a trend toward higher recurrence with ERCP-only compared with LCBDE-only and LCBDE-ERCP (5.1% versus 2.0% and 2.5%, P = .280). On univariate comparison, patients with a recurrence were significantly older, had a higher admission white cell count, higher number of ERCPs, increased transampullary stent use, and higher maximum CBD diameter. Total number of ERCP was the only independent predictor of stone recurrence (odds ratio 6.85 [2.55-18.42], P < .001) following multivariate regression. Conclusion: Management plan was not associated with stone recurrence. The total number of ERCP was the only independent predictor of recurrence. Within the limitations of case selection and bias toward LCBDE, this study suggests that limiting repeated ERCP may reduce CBD stone recurrence.

An integrated interpreting service normalizes access to care for culturally and linguistically diverse (CALD) patients with colorectal cancer.

AIM: To compare access to the initial management and overall survival with colorectal cancer for limited English proficient (LEP) patients compared with patients from an English background. METHODS: All newly diagnosed patients from 2017 with colorectal cancer from a single health service with a highly multicultural catchment area and a well-developed and integrated translation and language support (TALS) department were recruited. Time from referral to: biopsy, date seen by a surgeon, oncologist, discussion at a multidisciplinary meeting (MDM), and day of commencement of the first treatment modality, and overall survival were analyzed. RESULTS: One hundred sixty-two patients were analyzed, including 57 LEP patients from 22 countries of birth. Interpreters were present at 687/782 appointments with LEP patients. There were no differences in demographics or cancer staging. There were no differences between English background and LEP patients with regard to times from referral to biopsy (1 vs. 0 days), specialist review (surgical: 4 vs. 6 days, oncological: 45 vs. 57 days), MDM discussion (23 vs. 15 days), or commencement of treatment (32 vs. 28.5 days). There were no differences in treatment for colorectal cancer, although a higher rate of stomas was noted in LEP patients. There was no difference in overall survival between groups. CONCLUSION: Time to critical initial checkpoints and overall survival were similar in LEP and English background patients with colorectal cancer. An integrated TALS department may abrogate the language and cultural barriers that are known to disadvantage LEP patients and may contribute to normalizing care for the culturally and linguistically diverse community.

A Predictive Tool for Choledocholithiasis in Patients Undergoing Emergency Cholecystectomy.

Background: Management of acute cholecystitis with emergency laparoscopic cholecystectomy has been established; however, detection and management of concurrent choledocholithiasis are debated. The aim of this study is to develop a more accurate choledocholithiasis predictive model. Materials and Methods: A 9-year audit of emergency cholecystectomies and evaluation of preoperative factors in predictive models. Receiver Operating Curve (ROC) analysis/Youdon Index was used to identify thresholds maximizing these associations for continuous variables. Results: 1601/1828 patients were analyzed. Patients who were diagnosed with choledocholithiasis were more likely to be febrile on admission, have a higher C-reactive Protein, and higher median bilirubin (25.0 µmol/L versus 11.0 µmol/L, P < .001). When excluding bilirubin, multivariate analysis detected several significant variables, including fever, biliary tree dilatation, or a common bile duct stone seen on ultrasound. When bilirubin was included into the model, bilirubin of 20-39 µmol/L (odds ratio [OR] 2.44, 95% confidence interval [CI]: 1.74-3.44) and ≥40 µmol/L (OR 4.84, 95% CI: 3.40-6.91) were shown to have increased likelihood of choledocholithiasis detection on intraoperative cholangiogram, with the ROC model having a significant C-statistic of 0.796 (P < .001). Discussion: A perfect predictive model for concurrent choledocholithiasis in acute cholecystitis does not exist; however, the results from this study are encouraging that high and low predictive groups can be established.

Haemoglobin drift in patients following Whipple's procedure.

BACKGROUNDS: This study aims to identify the objective findings of haemoglobin (Hb) drift in patients that had a Whipple's procedure in the last 10 years, their transfusion status intraoperatively and post-operatively, the potential factors affecting Hb drift, and the outcomes following Hb drift. METHODS: A retrospective study was conducted at Northern Health, Melbourne. All adult patients who were admitted for a Whipple's procedure from 2010 to 2020 were included and information collected retrospectively for demographics, pre-operative, operative and post-operative details. RESULTS: A total of 103 patients were identified. The median Hb drift calculated from a Hb level at the end of operation was 27.0 g/L (IQR 18.0-34.0), and 21.4% of patients received a packed red blood cell (PRBC) transfusion during the post-operative period. Patients received a large amount of intraoperative fluid with a median of 4500 mL (IQR 3400-5600). Hb drift was statistically associated with intraoperative and post-operative fluid infusion leading to concurrent issues with electrolyte imbalance and diuresis. CONCLUSION: Hb drift is a phenomenon that does happen in major operations such as a Whipple's procedure, likely secondary to fluid over-resuscitation. Considering the risk of fluid overload and blood transfusion, Hb drift in the setting of fluid over-resuscitation needs to be kept in mind prior to blood transfusion to avoid unnecessary complications and wasting of other precious resources.