Oral versus intravenous antibiotics in the treatment of uncomplicated colonic diverticulitis: results of a randomized non-inferiority control trial.

BACKGROUND: Colonic diverticular disease is common and its incidence increases with age, with uncomplicated diverticulitis being the most common acute presentation (1). This typically results in inpatient admission, placing a significant burden on healthcare services (2). We aimed to determine the safety and effectiveness of using intravenous or oral antibiotics in the treatment of uncomplicated diverticulitis on 30-day unplanned admissions, c-reactive protein (CRP), White Cell Count (WCC), pain resolution, cessation of pain medication, return to normal nutrition, and return to normal bowel function. METHODS: This single centre, 2-arm, parallel, 1:1, unblinded non-inferiority randomized controlled trial compared the safety and efficacy of oral antibiotics versus intravenous antibiotics in the outpatient treatment of uncomplicated colonic diverticulitis. Inclusion criteria were patients older than 18 years of age with CT proven acute uncomplicated colonic diverticulitis (Modified Hinchey Classification Stage 0-1a). Patients were randomly allocated receive either intravenous or oral antibiotics, both groups being treated in the outpatient setting with a Hospital in the Home (HITH) service. The primary outcome was the 30-day unplanned admission rate, secondary outcomes were biochemical markers, time to pain resolution, time to cessation of pain medication, time to return to normal function and time to return to normal bowel function. RESULTS: In total 118 patients who presented with uncomplicated colonic diverticulitis were recruited into the trial. Fifty-eight participants were treated with IV antibiotics, and 60 were given oral antibiotics. We found there was no significant difference between groups with regards to 30-day unplanned admissions or inflammatory markers. There was also no significant difference with regards to time to pain resolution, cessation of pain medication use, return to normal nutrition, or return to normal bowel function. CONCLUSION: Outpatient management of uncomplicated diverticulitis with oral antibiotics proved equally as safe and efficacious as intravenous antibiotic treatment in this randomized non-inferiority control trial.

Nosocomial bacterial infections in Victoria decreased during the COVID-19 pandemic.

Background: A number of infection control interventions were implemented during the COVID-19 pandemic in order to reduce the spread of this virus. Objective: The purpose of this study was to determine if these interventions were associated with reduced nosocomial bacterial infections in Victoria, Australia. Methods: Observational data were obtained from the Victorian Healthcare Associated Infection Surveillance System (VICNISS) based on admitted hospital patients in two 6-month timeframes representing pandemic and pre-pandemic hospital practices. Data were collected for surgical site infections, Staphylococcus aureus bacteraemia, Clostridioides difficile infection, and central line-associated bloodstream infections. Results: There was a significant reduction in the rates of S. aureus bacteraemia (0.74 infections/10, 000 bed days pre-pandemic vs. 0.53/10,000 bed days in the pandemic period [rate ratio 0.72, 95% CI 0.57-0.90]; p = .003) and in C. difficile infections (2.2 infections/10,000 bed days pre-pandemic vs. 0.86/10 000 bed days in the pandemic era [rate ratio 0.76, 95% C.I. 0.67-0.86]; p <.001). There was no change in the overall rate of surgical site infections or central line-associated infections however. Discussion: The increased emphasis on infection control and prevention strategies during the pandemic period was associated with reduced transmission of S. aureus and C. difficile infections within hospitals.

Failure to Rescue in Major Abdominal Surgery: A Regional Australian Experience.

BACKGROUND: Failure to rescue (FTR) is increasingly recognised as a measure of the quality care provided by a health service in recognising and responding to patient deterioration. We report the association between a patient's pre-operative status and FTR following major abdominal surgery. METHODS: A retrospective chart review was conducted on patients who underwent major abdominal surgery and who suffered Clavien-Dindo (CDC) III-V complications at the University Hospital Geelong between 2012 and 2019. For each patient suffering a major complication, pre-operative risk factors including demographics, comorbidities (Charlson Comorbidity Index (CCI)), American Society of Anaesthesiology (ASA) Score and biochemistry were compared for patients who survived and patients who died. Statistical analysis utilised logistic regression with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: There were 2579 patients who underwent major abdominal surgery, of whom 374 (14.5%) suffered CDC III-V complications. Eighty-eight patients subsequently died from their complication representing a 23.5% FTR and an overall operative mortality of 3.4%. Pre-operative risk factors for FTR included ASA score ≥ 3, CCI ≥ 3 and pre-operative serum albumin of < 35 g/L. Operative risk factors included emergency surgery, cancer surgery, greater than 500 ml intraoperative blood loss and need for ICU admission. Patients who suffered end-organ failure were more likely to die from their complication. CONCLUSION: Identification of patients at high risk of FTR should they develop a complication would inform shared decision-making, highlight the need for optimisation prior to surgery, or in some cases, result in surgery not being undertaken.

Anatomy of the vesicovaginal fascia and its relation to branches of the inferior hypogastric plexus.

The inferior hypogastric plexus (IHP) lies in the extraperitoneal pelvis, and supplies branches to pelvic and perineal viscera. In men, the rectoprostatic fascia (Denonvillier's fascia) forms a distinct double fascial layer between the seminal glands and the rectum. The hypogastric nerve projections to the prostate and seminal glands run anterior to this. An analagous fascial layer in women between the vagina and cervix posteriorly and the urinary bladder anteriorly has recently been described. The purpose of this study was to examine the anatomy of the vesicovaginal fascia (VVF) and to determine its relationship to the anterior branches of the IHP. This dissection study examined the fascial layers between the posterior urinary bladder and anterior vagina/cervix (VVF) in 15 female embalmed cadavers and three fresh specimens. Anterior branches of the IHP were identified and followed distally. The relationship between these nerve projections and the VVF was examined. In 16 dissection, the VVF was identified as a complete fascial plane extending beneath the vesicouterine pouch to the neck of the bladder inferiorly and to the endopelvic fascia laterally. Anterior projections from the hypogastric nerves and IHP maintained an extraperitoneal course passing anteriorly to the VVF towards the urinary bladder The VVF is a distinct fascial structure and projections of the hypogastric nerves pass anterior to this. This may have implications for nerve sparing hysterectomy.

Can the alcohol withdrawal scale be applied to post-operative patients?

BACKGROUNDS: Assessment scales are commonly used to diagnose and treat alcohol withdrawal syndrome (AWS) in acute hospitals, although they have only been validated for use in detoxification facilities. There is a significant overlap between the symptoms and signs of AWS and other clinical presentations, including systemic inflammatory response syndrome (SIRS) and the physiological response to surgery. This may lead to both over-diagnosis and inappropriate treatment of AWS. This study sought to determine the false-positive rate for the commonly used Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) among post-operative patients. METHODS: This was a prospective study of patients undergoing major abdominal surgery at University Hospital Geelong. Patients were recruited who were NOT at risk of alcohol dependency (using the World Health Organisation Alcohol Use Disorders Identification Test). Patients were assessed for AWS using the CIWA-Ar day one post-operatively with a false positive measured as a CIWA-Ar > 7. RESULTS: A total of 67 patients were included in the study. There were 31 (46%) men and 36 women. Their median age was 52 years (range 27-85). Thirty-six (52%) of patients underwent elective procedures, and 32 were emergencies. Twelve of the 67 patients (18%) had CIWA-Ar scores >seven. CONCLUSION: In the early post-operative period, the CIWA-Ar tool over-diagnoses AWS in 18% of patients. These false-positives could lead to delayed treatment of serious underlying conditions. We call for caution in the use of alcohol withdrawal scales in the acute hospital setting.

Self-expandable metal stent (SEMS) placement or emergency surgery as palliative treatment for obstructive colorectal cancer: A systematic review and meta-analysis.

Previous meta-analyses on palliative treatment of malignant colorectal obstruction with Self-Expandable Metal Stent (SEMS) or emergency surgery reported contradictory results for morbidity, and frequently included extracolonic obstruction. Therefore, the current meta-analysis aimed to exclusively analyze palliative treatment for primary obstructive colorectal cancer, with early complication rate as a primary outcome. A systematic literature search was performed on studies comparing palliative SEMS and emergency surgery. Corresponding authors were contacted for additional data. Eighteen studies were selected (1518 patients). Early complication rate was 13.6 % for SEMS and 25.5 % for emergency surgery (Odds Ratio (OR) 0.46, 95 % confidence interval (CI) 0.29-0.74). Mortality was 3.9 % and 9.4 % (OR 0.44, 0.28-0.69). Stomas were present in 14.3 % and 51.4 % of patients (OR 0.17, 0.09-0.31). More late complications occurred after SEMS (23.2 % versus 9.8 %, OR 2.55, 1.70-3.83), mostly due to SEMS obstruction. In conclusion, SEMS placement seems the preferred treatment of obstructing colorectal cancer in the palliative setting.

How will increasing surgical volume affect mortality in the Pacific, Papua New Guinea and Timor Leste?

BACKGROUND: Nine South Pacific nations, Papua New Guinea and Timor Leste, have collaborated to report and publish their surgical metrics as recommended by the Lancet Commission on Global Surgery (LCoGS). Currently, these countries experience about 750 postoperative deaths per year, representing 1% of crude mortality in the region. Given that more than 400 000 annual procedures are needed in the nine nations to reach the LCoGS target of 5000/100 000, we aimed to calculate the potential contribution of perioperative mortality to national mortality where these procedures are performed. METHODS: We utilized reported surgical metrics with current rates for surgical volume (SV) and perioperative mortality (POMR), as well as World Bank/WHO mortality statistics, to predict the likely impact of surgical scale-up to recommended targets by 2030. We tested correlations between SV and POMR in countries from our region using Pearson's r statistic. Funnel plots were used to evaluate the dataset for outliers. RESULTS: Surgical scale up would result in perioperative mortality contributing on average to 3.3% of all national crude mortality. This prediction assumes POMR stays the same, which is challenging to predict. In our region countries that achieved the LCoGS target (n = 5) had a lower POMR than countries that did not (n = 8). CONCLUSIONS: Surgical volumes in the South Pacific region must increase to meet the LCoGS target. Postoperative mortality as a proportion of all mortality may increase with the surgical scale up, however, the overall number of premature deaths is expected to reduce with better access to timely and safe surgical care.

Who tolerates early enteral feeding after colorectal surgery?

BACKGROUND: Early enteral feeding and avoidance of routine nasogastric tube (NGT) placement have become standard care following colorectal surgery. However, some patients require NGT decompression post-operatively for vomiting or distension. METHODS: This was a retrospective cohort study of all patients undergoing elective intra-abdominal colorectal surgery at University Hospital, Geelong, from 2014 to 2018. Failure of early feeding was defined by the placement of an NGT post-operatively, beyond the day of surgery. RESULTS: A total of 754 patients were identified. Of these, 28 were excluded due to protocol violations (NGT was left in situ at the end of the operation), leaving 726 patients that were included in the analysis. Overall, 156/726 (21%) patients failed early feeding. The strongest independent predictor of failure was undergoing a total or subtotal colectomy compared with all other operations (15/28 (54%) failed versus 141/698 (20%); P < 0.001). Laparoscopic surgery was independently associated with a lower risk of failure compared with open surgery (43/278 (15%) versus 113/448 (25%); P = 0.002). Risk of failure was not associated with gender, age, American Society of Anesthesiologists score, indication for procedure, presence of anastomosis or duration of surgery. CONCLUSION: Laparoscopic surgery is associated with a lower risk of failure of early feeding compared with open surgery. Patients undergoing subtotal or total colectomy have a high rate (54%) of failure. This may assist in selecting appropriate patients for early feeding after colorectal surgery.

Medical Students Can Learn Surgery Effectively in a Rural Longitudinal Integrated Clerkship.

BACKGROUND: At Deakin University School of Medicine, compulsory formal teaching in Surgery occurs in year 3. This may occur as part of a rural longitudinal integrated clerkship (LIC), or in a traditional teaching hospital block rotation (BR). The purpose of this study was to compare these groups' exposure to surgical common conditions and their academic outcomes. METHODS: Part I: This was a survey of students' encounters with patients with common surgical conditions between 2016 and 2018. Self-reported data were collected describing the nature of the encounters and their clinical settings. Part II: All third year Surgery MCQ and OSCE results from 2011 to 2017 were analyzed. Students were deidentified and grouped according to whether they were in the LIC or BR programme. RESULTS: Part I: Thirty-eight third year students (20 LIC, 18 BR) submitted data for a total of 188 clinical encounters. Both groups encountered all nominated common surgical conditions, but the settings in which this occurred were different. BR students saw most patients as hospital inpatients whereas LIC student encounters were distributed across multiple clinical sites. Part II: A total of 942 (121 [26%] LIC and 821 [74%] BR) students' assessment results were analyzed. The groups performed similarly in the MCQ (p = 0.21) and OSCE (p = 0.16) examinations. CONCLUSIONS: Students who were taught surgery in a LIC program performed similarly to on their final exams to their peers in traditional clerkships, with self-reported student data indicating both groups encountered a similar range of conditions.

What young Australians think about a tax on sugar-sweetened beverages.

OBJECTIVE: To determine support for a tax on sugar-sweetened beverages (SSBs) among young Australian adults and the potential impact on SSB consumption if a tax is introduced. METHODS: Cross-sectional convenience survey of Australians aged 18-30 years sampled in the City of Greater Geelong, Australia, in November-December 2017. RESULTS: A total of 1,793 responses were recorded. Overall, 48% supported a tax on SSBs, which increased to 74% and 72% if tax revenue was allocated to subsidising fruit and vegetables or funding community exercise facilities, respectively. If a tax of $0.40/100g of sugar were introduced, 53% of participants would reduce their SSB consumption and most of this group (63%) reported that they would consume more water instead. Participants who consumed SSBs more frequently were less likely to support a tax or reduce their consumption. Gender, obesity and SES were not associated with support for a tax. CONCLUSIONS: Most young adults supported the idea of a tax on SSBs if tax revenue would be used to support healthy eating or physical activity. If a tax was introduced, most indicated that they would reduce their SSB consumption and substitute water for SSBs. Implications for public health: Policymakers can expect support from young people should an SSB tax be introduced in Australia.

Loop ileostomy reversal after laparoscopic versus open rectal resection.

BACKGROUND: One of the potential advantages of laparoscopic abdominal surgery is in reducing the development of adhesions, making later surgery easier. The purpose of this study is to determine whether using the laparoscopic versus open approach for a rectal resection with a diverting ileostomy affects the speed and safety of subsequent ileostomy reversal. METHODS: This is a retrospective study using patients who underwent ileostomy reversal following a rectal cancer resection with curative intent with a diverting ileostomy at the University Hospital Geelong between January 2006 and June 2017. Demographic information, operative technique and histological staging for the initial resection were recorded. Theatre time and complication rates for the ileostomy reversal were also recorded. RESULTS: A total of 82 patients were included in this study (22 had laparoscopic resections as the primary operation, 50 had open resections and 10 had laparoscopic converted to open resections). The three groups were similar in age, body mass index, American Society of Anesthesiologists score and proportion undergoing chemoradiotherapy. Median (range) theatre time for ileostomy reversal was 118 (50-200) min after a laparoscopic resection, 80 (30-360) min after a laparoscopic converted to open resection and 65 (50-160) min after an open resection (P = 0.009). Complication rates after ileostomy reversal were similar between the three groups (P = 0.97). CONCLUSION: Ileostomy reversal took longer to perform if the primary rectal resection was performed laparoscopically.

Complete state-wide outcomes in elective colon cancer surgery.

BACKGROUND: Maintaining high standards in colon cancer surgery requires the measurement of quality indicators and the re-allocation of resources to address deficiencies. We used state-wide administrative data to determine the inpatient mortality for patients undergoing elective colon cancer surgery and to compare individual hospital rates. METHODS: The Dr Foster Quality Investigator Tool was used to explore the Victorian Admitted Episodes Dataset for elective admissions for colon cancer surgery between 2012 and 2016. The inpatient mortality rate, 30-day readmission rate and the proportion of patients with increased length of stay were measured. Risk-adjusted rates were used to compare public and private hospitals. A peer group of 14 hospitals were studied using funnel plots to determine inter-hospital variation in mortality. RESULTS: There were 6120 colectomies performed for colon cancer in Victoria over 3 years. The crude inpatient mortality rate was 1.3%. It was significantly higher in public than private hospitals, even after risk adjustment. Variation in crude mortality was demonstrated among 14 selected hospitals. The lowest volume hospitals had significantly higher inpatient mortality rates. Right hemicolectomy was the commonest procedure performed. CONCLUSION: Using an efficient method of complete state-wide data capture, we have demonstrated that the inpatient mortality rate after elective colon cancer surgery in Victoria is low. However, complexity remains around the interpretation of inter-hospital variation, defining outliers, and comparing outcomes between public and private hospitals. Resolving these complexities and defining additional quality indicators remain a priority in the use of administrative data to audit the quality of colon cancer care.

Anastomotic leaks in stage IV colorectal cancer.

BACKGROUND: The purpose of this study was to determine the anastomotic leak rate for colorectal cancer resections in patients with metastases (compared to those without), and to determine the impact of anastomotic leaks on survival. METHODS: This is a retrospective analysis of all patients who underwent resection and primary anastomosis for colorectal adenocarcinoma at a single institution between January 2002 and December 2014. RESULTS: A total of 843 patients underwent a resection and primary anastomosis for colorectal adenocarcinoma (661 colon and 182 rectal). Of these, 135 (16%) had metastases and 708 (84%) did not. Anastomotic leaks occurred in 17 of 135 (13%) patients with metastases, and in 37 of 798 (5.2%) patients without metastases (P = 0.003). Peri-operative mortality occurred in 13 of 135 (9.6%) patients with metastases, compared with 19 of 708 (2.7%) patients without metastases (P = 0.0003). Anastomotic leak was associated with a reduction in overall survival (median survival 121 months without anastomotic leak versus 66 months in patients who had an anastomotic leak (P = 0.02)). If the patients who died peri-operatively are excluded from this analysis, however, long-term mortality was similar (125 months versus 101 months; P = 0.70). CONCLUSION: Metastatic disease was associated with an increased risk of anastomotic leak and a higher peri-operative mortality rate after colorectal resections for cancer. Patients with anastomotic leaks had a higher peri-operative mortality rate, but long-term survival was unaffected beyond the peri-operative phase.

Publication rate of General Surgery abstracts presented at the Royal Australasian College of Surgeons Annual Scientific Congress.

BACKGROUND: A commonly used metric for evaluating the quality and impact of presentations at a scientific meeting is the frequency with which the findings presented are published as full research papers in peer-reviewed journals. The purpose of this study was to determine the full article publication rates of abstract presentations for General Surgery and related sub-specialities at the Royal Australasian College of Surgeons Annual Scientific Congress (RACS ASC) from 2010 to 2014. METHODS: All General Surgical (including its sub-speciality groups) abstracts presented at the RACS ASC from 2010 to 2014 were identified from the ANZ Journal of Surgery. We determined the rates of full paper publication, time to publication, journals of publication and specialty rates of conversion. Full article publications were identified using the PubMed, MEDLINE and Google Scholar databases. RESULTS: A total of 1386 abstracts were identified, of which 356 (26%) were converted to full paper publications. The number of abstracts presented annually increased from 206 in 2010 to 386 in 2014, but the percentage of abstracts converted to full paper publications did not follow any temporal trend. The majority (74%) of full papers were published within 2 years of the abstract presentation. CONCLUSION: In total, 26% of General Surgery abstracts presented at the RACS ASC from 2010 to 2014 were converted to full paper publications. This could provide a baseline against which to judge the quality of presentations at other national General Surgical congresses, as well as at future RACS ASC meetings.

Colorectal multidisciplinary meetings: how do they affect the timeliness of treatment?

BACKGROUND: The aim of this study is to determine whether multidisciplinary team (MDT) meetings alter the length of time to treatment (LOTT) for patients with colorectal cancer. METHODS: We conducted a retrospective audit of all patients with colorectal cancer from the Geelong Hospital (TGH) mandatory colorectal database from 1 January 2006 to 3 February 2011. To be included, patients had to have had elective surgical intervention for primary colorectal adenocarcinoma. A comparison of historical controls was conducted between patients discussed in MDT meetings and those managed prior to the introduction of MDT meetings (3 October 2006) to determine the LOTT in days from definitive diagnosis (colonoscopy) to definitive management (surgery, radiotherapy or chemotherapy). RESULTS: In total, the median LOTT for the historical control and MDT era patient populations were 19.5 and 20 days, respectively. Within the MDT era, we noticed significantly longer times to treatment for patients with rectal cancer who were seen in an MDT meeting prior to definitive management than patients who did not have an intervening MDT meeting (P < 0.001). With a difference of 7.5 days, the clinical significance of these findings remains contentious. However, it is worthwhile recognizing this trend in patients who are exhibiting symptoms due to near obstruction or significant bleeding. The LOTT for colon cancer patients remained unchanged. CONCLUSION: The introduction of MDT meetings to TGH has prolonged the LOTT for patients with rectal cancer. These findings pave the way for further revision of the efficiency of MDT meeting at TGH.