Evolution of sentinel lymph node biopsy for breast cancer patients in a rural setting: 10 years' experience.

Sentinel lymph node (SLN) biopsy is the standard axillary staging procedure of early breast cancer. Superparamagnetic iron oxide (SPIO) nanoparticles have been found to be comparable to, while overcoming many of the limitations associated with, the current standard of care for SLN biopsies (dual localisation with radioisotope and patent blue dye). Here, SPIO dual localisation (Sienna+® and blue dye) is compared to blue dye alone for SLN biopsies in a rural centre where radioisotope techniques are not readily available. Sienna+® dual localisation is shown to be more likely to detect nodes (detection rate of 99% compared to 90% when using blue dye alone), and detect more nodes, than blue dye alone. The use of Magseed, a magnetic tracer, was not found to influence node detection. The results from this work show that Sienna+® dual localisation is superior to blue dye alone for detecting SLN, suggesting that it is an excellent alternative to dual localisation of radioisotope and blue dye for small centres lacking easy access to a nuclear medicine department.

Rare case of intrahepatic splenosis masquerading as malignancy.

A 54-year-old man presented with abdominal pain and a history of post-traumatic splenectomy 33 years prior, imaging revealed an incidental hepatic mass.

Impact of public-private partnership on a regional colonoscopy service.

BACKGROUND: A public-private partnership for endoscopy was introduced in Geelong where there was no capacity for public hospital endoscopy lists to expand. This paper presents the impact of this partnership on colonoscopy services. METHODS: Data were collated from prospectively maintained databases. Wait-times to outpatient appointments, colonoscopy and follow-up were analysed between July 2015 and June 2017 allowing for a 12-month period of analysis before and after the initiation of the contract. Data are presented as medians (interquartile range). RESULTS: A total of 1300 colonoscopies were done between July 2015 and June 2016 compared to 2114 colonoscopies (P < 0.01) after the initiation of the public-private contract; 1073 (51%) colonoscopies were done on private contract. Prior to public-private contract, 41% patients waited more than 120 days from first presentation to healthcare services to diagnostic colonoscopy, this decreased to 19% after. Improvements were seen in both the waiting time for outpatient consultation (reduced from 92 days (39-136) prior to July 2016 to 73 days (32-122); P < 0.01) after) and the time taken from consultation to colonoscopy (from 125 days (70-207) to 36 days (21-159); P < 0.01) for category 1 patients. CONCLUSION: Wait-times for both specialist outpatient assessment and colonoscopy have been significantly reduced through the introduction of a unique public-private partnership in the Greater Geelong area, resulting in more timely access for public patients and improved compliance with new guidelines.

Hospital-wide implementation of an electronic-workflow solution aiming to make surgical practice improvement easy.

BACKGROUND: In measuring quality of health-care delivery, digital infrastructure is essential. The aim at this tertiary centre was to create a hospital-wide workflow system that collected data prospectively as part of daily practice. METHODS: In moving towards an electronic health record, a hospital-wide integrated workflow system was introduced in 2013, which electronically managed the perioperative patient journey while simultaneously facilitating surgical audit. Analysis of its implementation was carried out presenting early outcomes using general surgery as an example. RESULTS: Theatre-bookings (44 953) were made with compliance approaching 90% for all services. Of 7179 general surgical operations over 24 months, 5785 (80%) had an operation note created using the new system. Cumulative summation of uptake of synoptic operative reporting (SOR) for laparoscopic cholecystectomy (LC) was 81% with documentation being superior in terms of antibiotic use and steps to safe cholecystectomy (P < 0.001). A LC SOR took 4 min to complete (interquartile ranges 2-5 min, n = 425) and was immediately available on the day of surgery compared to narrative operative reports taking 2 days (interquartile ranges 1-5 days, n = 174) (P < 0.001). From July 2014 to November 2015, 557 (10%) complications were recorded for 5749 general surgical operations with 99% of complications being reviewed. CONCLUSION: The rapid and sustained uptake of both theatre-bookings and SOR likely reflect high end-user satisfaction with the system. Service metrics indicate a significant improvement in the time of delivery. The ability to seamlessly complete the audit cycle at an individual, department and hospital level has been achieved.

Is there an alternative to centralization for pancreatic resection in New Zealand?

BACKGROUND: Internationally pancreatic surgery has become increasingly centralized; however, geographical and population distribution within New Zealand (NZ) limits the practicalities of such an approach. The aim of this study was to review the short-term outcomes of patients undergoing pancreatic surgery by a single hepato-pancreato-biliary trained surgeon in a centre that would meet the minimum criteria set by the NZ National Standards but not necessarily the definition of a high-volume surgeon/centre. METHODS: A retrospective review of consecutive patients undergoing pancreatic resection within an enhanced recovery programme by a single surgeon between March 2005 and April 2013. Primary outcomes were 30-day morbidity and 90-day mortality. RESULTS: A total of 156 patients who underwent a pancreatic resection were included. Eighty-two (53%) patients underwent a pancreaticoduodenectomy. Forty-seven (30%) underwent a left pancreatectomy. Overall, 30-day morbidity was 64% and overall 90-day mortality was 2.6%. Overall median length of stay was 11 (3-140) days. CONCLUSIONS: Acceptable outcomes have been achieved for patients undergoing pancreatic resection within a centre that meets the criteria proposed by the NZ National Standards for treatment of pancreatic cancer.

Twelve years' experience of sentinel lymph node biopsy for melanoma at a rural New Zealand hospital.

AIM: To document the false-negative sentinel lymph node biopsy (SLNB) rate for melanoma patients at a rural NZ hospital and the likelihood of further nodal involvement on completion lymph node dissection (CLND). METHODS: All patients undergoing SLNB for melanoma at this centre were identified from the study period. Basic demographics along with histological data of both the primary lesion and SLNB were collated. Local and regional recurrences were recorded as was mortality. RESULTS: Between January 2000 and July 2012, 95 patients underwent SLNB for melanoma. Ten patients (11%) underwent CLND after positive SLNB. A further two patients had a median of two additional nodes involved (range 1-3). After a median follow-up period of 65 months (range 47-112), 6 patients suffered nodal recurrence where previously a negative SLNB had been harvested, giving a false-negative rate of 38%. Recurrence occurred a median of 16 months after WLE and SLNB. CONCLUSION: A high false negative-negative rate was observed in this study. For those with a positive SLNB, a further 20% have further nodal involvement on CLND.

Effects of introducing an enhanced recovery after surgery programme for patients undergoing open hepatic resection.

OBJECTIVES: Enhanced recovery after surgery (ERAS) protocols are coming to represent the standard of care in many surgical procedures, yet data on their use following hepatic surgery are scarce. The aim of this study was to review outcomes after the introduction of an ERAS programme for patients undergoing open hepatic resection. METHODS: A retrospective review of patients undergoing open hepatic resection from March 2005 to June 2011 was carried out. The primary outcome measure was total hospital length of stay (LoS) (including readmissions). Principles associated with enhanced recovery after surgery were documented and analysed as independent predictors of hospital LoS. RESULTS: A total of 120 patients underwent 128 consecutive hepatic resections, 84 (65.6%) of which were performed in patients with underlying colorectal metastases and 64 (50.0%) of which comprised major hepatic resections. The median hospital LoS was reduced from 6 days to 3 days from the first to the fourth quartiles of the study population (P = 0.021). The proportion of patients suffering complications (26.6%) remained constant across the series. Readmissions increased from the first quartile (none of 32 patients) to the fourth quartile (seven of 32 patients) (P = 0.044). Following multivariate analysis, only the development of a complication (P < 0.001), total postoperative i.v. fluid (P = 0.003) and formation of an anastomosis (P = 0.006) were independent predictors of hospital LoS. CONCLUSIONS: An ERAS programme can be successfully applied to patients undergoing open hepatic resection with a reduction in hospital LoS, but an increase in the rate of readmissions.

Index cholecystectomy: a continuing challenge for a provincial hospital.

AIMS: To review the management of acute gallstone disease at a provincial New Zealand centre and compare to current national/international practice. METHODS: All patients presenting to Nelson Hospital with acute gallstone-related pathology were identified from the study period. The first presentation within the audit period was defined as the index admission. Length of stay and interventions were recorded. Waiting lists were compared. RESULTS: Between January 2004 to December 2010, 390 patients were admitted with acute gallstone-related pathology to Nelson Hospital. The index cholecystectomy rate was 17% (57/329) after exclusion of 61 ineligible patients; 158/329 patients subsequently underwent elective cholecystectomy, with patients waiting a median time of 97 days (range 7-1922). There were 132 Emergency Department visits (median one (range 0-8)), and 59 readmissions with acute gallstone-related pathology for those waiting for cholecystectomy. Of the 37 admitted with gallstone pancreatitis, 11 underwent cholecystectomy within 2 weeks of index admission. Waiting lists remained unchanged over time. CONCLUSIONS: Nelson Hospital has a low rate of index cholecystectomy. High numbers of patients represent to the emergency department or are readmitted whilst waiting for definitive surgery. Patients presenting with gallstone pancreatitis fail to receive treatment in accordance with international management guidelines.

Index cholecystectomy for management of acute gallstone disease: a change of practice at a major New Zealand metropolitan centre.

OBJECTIVES: This study aimed to examine the effects of a change in practice in index cholecystectomy on waiting lists at a New Zealand metropolitan hospital. METHODS: Patients presenting with gallstone disease from January 2004 to October 2010 were identified. Data on acute and elective cholecystectomies were collated and analysed for length of stay. Waiting lists for cholecystectomy were compared. RESULTS: During the study period, 3999 patients were admitted with acute gallbladder disease. The median number of admissions decreased from 49 to 40 per month (P < 0.01). The median number of index cholecystectomies increased from three to 22 per month (P < 0.01). Total monthly bed days for all cholecystectomies decreased from 175 days to 124 days (P < 0.01), but only median postoperative bed days for acute cholecystectomy showed a similar trend, decreasing from 4 days to 3 days (P < 0.01). The number of patients on the waiting list decreased from 334 in January 2004 to 132 in January 2006 as a result of government-imposed cuts. The number of patients wait-listed for elective cholecystectomy remained unchanged. CONCLUSIONS: An increasing number of index cholecystectomies have been performed at this centre. An effect on waiting list numbers is yet to be shown, but the wait list has not ballooned to previous numbers, although the number of patients joining the wait list remains unchanged. Monthly bed days have decreased for all patients with acute gallstone disease, probably in response to a combination of the changes implemented.

A change in practice from epidural to intrathecal morphine analgesia for hepato-pancreato-biliary surgery.

BACKGROUND: This study was designed to audit the change of anesthetic practice from thoracic epidural analgesia (TEA) to intrathecal morphine (ITM) combined with patient-controlled analgesia (PCA) for hepato-pancreato-biliary (HPB) surgery. METHODS: All patients who underwent major HPB surgery and received TEA or ITM from March 2005 to March 2008 were identified. Patients who received PCA alone were used for comparison. Data were retrospectively collected and analyzed for success of TEA, perioperative intravenous fluid (IVF) volume administered, hypotension, complications, and hospital stay. RESULTS: During the study period, 51 (32%) patients received TEA, 79 (49%) received ITM plus PCA opiate, and 31 (19%) received PCA alone. The incidence of postoperative hypotension was significantly higher in those who received TEA compared with those who received ITM (21/51 (41%) vs. 7/79 (9%), P < 0.001). The median (range) perioperative IVF administration was higher in the TEA group compared with the ITM group for both the first 24 h (6 (3-11) liters vs. 5 (3-11) liters, P < 0.05) and in total (15.5 (5-48.5) liters vs. 9 (3-70) liters, P < 0.001). Respiratory complications occurred in five (10%) of the TEA group compared with one (1%) in the ITM group (P < 0.05). The median (range) hospital stay was longer in the TEA group compared with the ITM group (9 (3-36) days vs. 7 (3-55) days, P < 0.01). CONCLUSIONS: In a resource-limited setting, ITM, compared with TEA, is associated with a reduced incidence of postoperative hypotension, reduced IVF requirements, shorter hospital stay, and lowers the incidence of respiratory complication.

The value of voluntary morbidity and mortality meetings at a New Zealand metropolitan hospital.

AIM: To assess the value and outcomes of contemporary, voluntary meetings reviewing the morbidity and mortality among surgical patients presenting at a New Zealand metropolitan hospital. METHODS: Data on morbidity and mortality were prospectively collected and analysed over a two year period (March 2005-August 2007) from weekly departmental meetings. Patients were discussed on a patient by patient basis; the details and outcomes of this were formally constituted and documented into a database. Actual mortality numbers and unplanned returns to theatre were obtained from clinical coding. Consultant attendance was documented RESULTS: Morbidity and mortality was recorded and discussed in 900 patients (6.5% of total admissions). Morbidity was discussed in 738 patients (incidence 5%); 190 (1.4%) deaths were discussed. Only 58% of unplanned returns to theatre and 62% of mortality recorded by clinical coding were discussed. However 54% of unplanned returns to theatre and 35% of mortality that were discussed were not recorded by clinical coding. It was felt that the clinical pathway had been appropriate in 88% and 91% of discussed morbidity and mortality, respectively. Over time, there was no significant change in consultant attendance (7/13 at 6 months vs 7/13 at 2 years, p=NS) and no trend in the median number of patients discussed per month. CONCLUSIONS: In the setting of a voluntary morbidity and mortality meeting only 12% and 8% of patients discussed, respectively, resulted in further action being initiated. Despite there being significant under-reporting of both morbidity and mortality, this format identified data that had previously been missed by hospital coding. If value is gained from the morbidity and mortality meetings, it is not reflected in consultant attendance or in the number of patients submitted for discussion as these did not change over time.

Peptide fragments of the dihydropyridine receptor can modulate cardiac ryanodine receptor channel activity and sarcoplasmic reticulum Ca2+ release.

We show that peptide fragments of the dihydropyridine receptor II-III loop alter cardiac RyR (ryanodine receptor) channel activity in a cytoplasmic Ca2+-dependent manner. The peptides were AC (Thr-793-Ala-812 of the cardiac dihydropyridine receptor), AS (Thr-671-Leu-690 of the skeletal dihydropyridine receptor), and a modified AS peptide [AS(D-R18)], with an extended helical structure. The peptides added to the cytoplasmic side of channels in lipid bilayers at > or = 10 nM activated channels when the cytoplasmic [Ca2+] was 100 nM, but either inhibited or did not affect channel activity when the cytoplasmic [Ca2+] was 10 or 100 microM. Both activation and inhibition were independent of bilayer potential. Activation by AS, but not by AC or AS(D-R18), was reduced at peptide concentrations >1 mM in a voltage-dependent manner (at +40 mV). In control experiments, channels were not activated by the scrambled AS sequence (ASS) or skeletal II-III loop peptide (NB). Resting Ca2+ release from cardiac sarcoplasmic reticulum was not altered by peptide AC, but Ca2+-induced Ca2+ release was depressed. Resting and Ca2+-induced Ca2+ release were enhanced by both the native and modified AS peptides. NMR revealed (i) that the structure of peptide AS(D-R18) is not influenced by [Ca2+] and (ii) that peptide AC adopts a helical structure, particularly in the region containing positively charged residues. This is the first report of specific functional interactions between dihydropyridine receptor A region peptides and cardiac RyR ion channels in lipid bilayers.

Regulation of the calcium release channel from skeletal muscle by suramin and the disulfonated stilbene derivatives DIDS, DBDS, and DNDS.

Activation of skeletal muscle ryanodine receptors (RyRs) by suramin and disulfonic stilbene derivatives (Diisothiocyanostilbene-2',2'-disulfonic acid (DIDS), 4,4'-dibenzamidostilbene-2,2'-disulfonic acid (DBDS),and 4,4'-dinitrostilbene-2,2'-disulfonic acid (DNDS)) was investigated using planar bilayers. One reversible and two nonreversible mechanisms were identified. K(a) for reversible activation (approximately 100 micro M) depended on cytoplasmic [Ca(2+)] and the bilayer composition. Replacement of neutral lipids by negative phosphatidylserine increased K(a) fourfold, suggesting that reversible binding sites are near the bilayer surface. Suramin and the stilbene derivatives adsorbed to neutral bilayers with maximal mole fractions between 1-8% and with affinities approximately 100 micro M but did not adsorb to negative lipids. DIDS activated RyRs by two nonreversible mechanisms, distinguishable by their disparate DIDS binding rates (10(5) and 60 M(-1) s(-1)) and actions. Both mechanisms activated RyRs via several jumps in open probability, indicating several DIDS binding events. The fast and slow mechanisms are independent of each other, the reversible mechanism and ATP binding. The fast mechanism confers DIDS sensitivity approximately 1000-fold greater than previously reported, increases Ca(2+) activation and increases K(i) for Ca(2+)/Mg(2+) inhibition 10-fold. The slow mechanism activates RyRs in the absence of Ca(2+) and ATP, increases ATP activation without altering K(a), and slightly increases activity at pH < 6.5. These findings explain how different types of DIDS activation are observed under different conditions.

The three-dimensional structural surface of two beta-sheet scorpion toxins mimics that of an alpha-helical dihydropyridine receptor segment.

An alpha-helical II-III loop segment of the dihydropyridine receptor activates the ryanodine receptor calcium-release channel. We describe a novel manipulation in which this agonist's activity is increased by modifying its surface structure to resemble that of a toxin molecule. In a unique system, native beta-sheet scorpion toxins have been reported to activate skeletal muscle ryanodine receptor calcium channels with high affinity by binding to the same site as the lower-affinity alpha-helical dihydropyridine receptor segment. We increased the alignment of basic residues in the alpha-helical peptide to mimic the spatial orientation of active residues in the scorpion toxin, with a consequent 2-20-fold increase in the activity of the alpha-helical peptide. We hypothesized that, like the native peptide, the modified peptide and the scorpion toxin may bind to a common site. This was supported by (i) similar changes in ryanodine receptor channel gating induced by the native or modified alpha-helical peptide and the beta-sheet toxin, a 10-100-fold reduction in channel closed time, with a < or = 2-fold increase in open dwell time and (ii) a failure of the toxin to further activate channels activated by the peptides. These results suggest that diverse structural scaffolds can present similar conformational surface properties to target common receptor sites.

Calsequestrin is an inhibitor of skeletal muscle ryanodine receptor calcium release channels.

We provide novel evidence that the sarcoplasmic reticulum calcium binding protein, calsequestrin, inhibits native ryanodine receptor calcium release channel activity. Calsequestrin dissociation from junctional face membrane was achieved by increasing luminal (trans) ionic strength from 250 to 500 mM with CsCl or by exposing the luminal side of ryanodine receptors to high [Ca(2+)] (13 mM) and dissociation was confirmed with sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blotting. Calsequestrin dissociation caused a 10-fold increase in the duration of ryanodine receptor channel opening in lipid bilayers. Adding calsequestrin back to the luminal side of the channel after dissociation reversed this increased activity. In addition, an anticalsequestrin antibody added to the luminal solution reduced ryanodine receptor activity before, but not after, calsequestrin dissociation. A population of ryanodine receptors (approximately 35%) may have initially lacked calsequestrin, because their activity was high and was unaffected by increasing ionic strength or by anticalsequestrin antibody: their activity fell when purified calsequestrin was added and they then responded to antibody. In contrast to native ryanodine receptors, purified channels, depleted of triadin and calsequestrin, were not inhibited by calsequestrin. We suggest that calsequestrin reduces ryanodine receptor activity by binding to a coprotein, possibly to the luminal domain of triadin.