Laparoscopic Ventral Hernia Repair in South Auckland, New Zealand-A Retrospective Review.

BACKGROUND: Ethnic disparities in surgical care and outcomes have been previously reported in studies for other surgical procedures. In addition, it has been reported that ethnic differences in postoperative analgesia exist. We aimed to determine ethnic disparities in postoperative outcomes, total opioid analgesia use, and complication rates of all patients who underwent a laparoscopic ventral hernia repair (LVHR) at our institution over a 3-y period. METHODS: A retrospective review of all patients who underwent an LVHR at Counties Manukau Health from January 1, 2013, to December 31, 2015, was performed in line with the Strengthening the Reporting of Observational Studies in Epidemiology statement. RESULTS: A total of 267 ventral hernias were repaired in 254 patients at Counties Manukau Health over the study period, of which most were primary umbilical ventral hernias. The majority of patients in our cohort were New Zealand European and male. Major complications, as per the Clavien-Dindo classification grade 3 and above, were observed in six patients with no deaths (2.4%). There were no statistically significant ethnic disparities in length of stay, receipt of opioid analgesia, and rates of complication observed after linear regression modeling after adjustment for confounding factors. CONCLUSIONS: Our study showed that the majority of patients who had a ventral hernia repaired at our institution were mostly New Zealand European and male. Although significant ethnic disparities in patient characteristics were observed, these were not associated with ethnic disparities in postoperative outcomes after an LVHR.

Measurement of patient-reported outcomes after laparoscopic cholecystectomy: a systematic review.

BACKGROUND: Patient-reported outcome (PRO) measures (PROMs) are increasingly used as endpoints in surgical trials. PROs need to be consistently measured and reported to accurately evaluate surgical care. Laparoscopic cholecystectomy (LC) is a commonly performed procedure which may be evaluated by PROs. We aimed to evaluate the frequency and consistency of PRO measurement and reporting after LC. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting PROs of LC, between 2013 and 2016. Data on the measurement and reporting of PROs were extracted. RESULTS: A total of 281 studies were evaluated. Forty-five unique multi-item questionnaires were identified, most of which were used in single studies (n = 35). One hundred and ten unique rating scales were used to assess 358 PROs. The visual analogue scale was used to assess 24 different PROs, 17 of which were only reported in single studies. Details about the type of rating scale used were not given for 72 scales. Three hundred and twenty-three PROs were reported in 162 studies without details given about the scale or questionnaire used to evaluate them. CONCLUSIONS: Considerable variation was identified in the choice of PROs reported after LC, and in how they were measured. PRO measurement for LC is focused on short-term outcomes, such as post-operative pain, rather than longer-term outcomes. Consideration should be given towards the development of a core outcome set for LC which incorporates PROs.

Reporting of complications after laparoscopic cholecystectomy: a systematic review.

BACKGROUND: Consistent measurement and reporting of outcomes, including adequately defined complications, is important for the evaluation of surgical care and the appraisal of new surgical techniques. The range of complications reported after LC has not been evaluated. This study aimed to identify the range of complications currently reported for laparoscopic cholecystectomy (LC), and the adequacy of their definitions. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting clinical outcomes of LC, between 2013 and 2016. RESULTS: In total 233 studies were included, reporting 967 complications, of which 204 (21%) were defined. One hundred and twenty-two studies (52%) did not provide definitions for any of the complications reported. Conversion to open cholecystectomy was the most commonly reported complication, reported in 135 (58%) studies, followed by bile leak in 89 (38%) and bile duct injury in 75 (32%). Mortality was reported in 89 studies (38%). CONCLUSION: Considerable variation was identified between studies in the choice of measures used to evaluate the complications of LC, and in their definitions. A standardised set of core outcomes of LC should be developed for use in clinical trials and in evaluating the performance of surgical units.

Radiological versus surgical implantation of first catheter for peritoneal dialysis: a randomized non-inferiority trial.

BACKGROUND: The success of peritoneal dialysis (PD) is dependent on timely and adequate PD catheter access. In many centres, including our own, PD catheter insertion technique has evolved by laparoscopic surgery. An alternative method of catheter insertion is performed by radiologists using a percutaneous modified Seldinger technique under fluoroscopic guidance. However, there are no clinical trials comparing these two methods of catheter insertion. METHODS: From 1 April 1999 to 30 August 2004, we randomly assigned 113 pre-dialysis patients to receive PD catheter insertion using fluoroscopic guidance under local anaesthesia by radiologists or insertion using laparoscopy under general anaesthesia by a surgeon. The primary endpoint was the occurrence of dialysis catheter complications (complication-free catheter survival) by Day 365, a composite endpoint that included complications secondary to mechanical and infectious causes. Secondary endpoints were the occurrence of catheter removal (overall catheter survival) and death from any cause (patient survival) by Day 365, procedure pain, procedure time, procedure room utilization time, length of inpatient admission and direct hospital costs. Results were analysed by univariate and multivariate methods and by Kaplan-Meier survival curves. RESULTS: Complication-free catheter survival was significantly higher at 42.5% [95% confidence interval (CI) 29.3-55] in the radiological group compared with 18.1% (95% CI 8.9-29.8) in the laparoscopic group (P-value = 0.03). Excess complications in the laparoscopic group included peritonitis, peritoneal dialysate leaks and umbilical herniae. One-year overall catheter survival and 1-year subject survival were not different between the groups. Hospital costs were significantly higher in the laparoscopic group by almost a factor of two. CONCLUSIONS: Radiological insertion of first PD catheters using fluoroscopy is a clinically non-inferior and cost-effective alternative to surgical laparoscopic insertion.

Quality of life following laparoscopic inguinal hernia surgery with self-adhesive mesh in 552 patients: a two surgeon experience.

BACKGROUND: Given negative publicity surrounding surgical mesh in the media, the aim of this study was to assess post-operative morbidity and quality of life (QoL) following laparoscopic inguinal hernia surgery with self-adhesive ProgripTM mesh. METHODS: This study is a retrospective analysis of ProgripTM mesh for laparoscopic inguinal hernia repairs by two experienced surgeons in the public and private sectors. Data were collected by screening electronic clinical records. A sample of participants were contacted directly for QoL assessment using the Carolinas Comfort Scale (CCS). Descriptive statistical analysis was performed in Microsoft Excel. RESULTS: Five hundred and fifty-two patients had 648 hernia repairs using ProgripTM mesh from 2013 to 2019. The rate of hernia recurrence was 0.2% (n = 1). The rate of reoperation was 0.5% (n = 3). There were no mesh explant procedures, no adhesion-related readmissions and no perioperative deaths. Haematoma was the most common post-operative complication, occurring in 3.1% of participants (n = 17). The CCS assessment had a response rate of 55.8%. A total of 93% of CCS questions were answered with no sensation of mesh, 92% with no pain and 98% with no movement limitation. No participants reported severe or disabling symptoms. CONCLUSION: In this cohort, laparoscopic inguinal hernia repair with ProgripTM has shown a low recurrence rate and excellent post-operative QoL. The QoL data shows that the public perception of mesh based on media reports of complications may not be relevant for this operation. The knowledge gained from this study reinforces the potential value of a national mesh registry such as those seen overseas.

Days alive and out of hospital after laparoscopic cholecystectomy.

BACKGROUND: Days alive and out of hospital (DAOH) is a metric that incorporates several outcomes into a single, standardized measure. This study aimed to explore the utility of DAOH in assessing the outcomes of a retrospective cohort of patients undergoing laparoscopic cholecystectomy (LC). METHODS: Patients undergoing LC at Auckland City Hospital between 1 January 2010 and 31 August 2015 were included. DAOH values were calculated for the 90 days from the date of surgery (DAOH90 ) and described using median and interquartile ranges (IQR). DAOH90 distributions were compared using a two-tailed (non-parametric) Wilcoxon-Mann-Whitney test. RESULTS: 1652 patients undergoing LC were studied. Patients experiencing complications (n = 70, 4.2%) had fewer DAOH90 (median 83, IQR 79, 86) than patients who underwent uncomplicated LC (median 88, IQR 86, 88), P < 0.001. Patients who were converted to open cholecystectomy (n = 70, 4.2%) also had fewer DAOH90 (median 82.5, IQR 79, 84) than patients who underwent uncomplicated LC, P < 0.001. Post-operative complications and conversion had a statistically significant effect on DAOH90 at each of the tested quantiles, except for conversion at the 0.1 quantile. CONCLUSION: DAOH90 is readily calculable from existing New Zealand administrative data sources and is sensitive to the occurrence of complications after LC.

Evaluation of Online Videos of Laparoscopic Sleeve Gastrectomy Using the LAP-VEGaS Guidelines.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric surgical procedure worldwide. Educational videos of LSGs are available from online sources with YouTube® being the most popular online video repository. However, due to the unrestricted and uncontrolled nature of YouTube®, anyone can upload videos without peer review or standardization. The LAP-VEGaS guidelines were formed to guide the production of high-quality surgical videos. The aim of this study is to use the LAP-VEGaS guidelines to determine if videos of LSGs available on Youtube® are of an acceptable standard for surgical educational purposes. METHODS: A YouTube® search was performed using the term laparoscopic sleeve gastrectomy. Appropriate videos were analysed by two individuals using the sixteen LAP-VEGaS guidelines. RESULTS: A total of 575 videos were found, of which 202 videos were included and analysed using the LAP-VEGaS guidelines. The median video guideline score was 6/16 with 89% of videos meeting less than half of all guidelines. There was no correlation between the LAP-VEGaS score and view count. CONCLUSIONS: There is an abundance of laparoscopic sleeve gastrectomy educational videos available on YouTube®; however, when analysed using the LAP-VEGaS guidelines, the majority do not meet acceptable educational standards for surgical training purposes.

Accuracy of sentinel node biopsy for breast cancer using blue dye alone.

Blue dye alone (BDA), lymphoscintigraphy alone, or, a combination of the two techniques are used for sentinel node biopsy (SNB) in breast cancer. This study reviews the effectiveness of the SNB technique using BDA by measuring the node identification rate and comparing the cohort node positivity with expected rates from established nomograms. A consecutive case series was examined from the database. This included the learning experience of six surgeons. Patients with unifocal tumors estimated at less than 31 mm were eligible. The tumor and axillary nodal histology was recorded. Published data were then used to calculate and predict node positivity rates in the study according to the size and grade of the tumors. There were 332 SNB procedures from 2001 to 2008. BDA successfully identified nodes in 94.6% (314/332) of the cases. The identification rate improved with experience. In patients with invasive cancer, 28.4% (85/299) of SNB were found to be positive for metastases or micrometastases. The node identification rate and the node positivity rate were found to be within published predicted ranges for the size and grade of the study tumors. The SNB with BDA was found to be effective in identifying sentinel nodes (SLN) in breast cancer. Surgeon experience was a factor in the success of the technique. Rates of detecting metastases were consistent with internationally published data, suggesting that BDA may perform as well as other techniques in experienced hands.

The impact of a surgical assessment unit on numbers of general surgery outliers.

AIMS: Patient care and efficiency outcomes are improved if acute patients admitted to non-specialty (outlier) wards are minimised.1 Assessment units may help to reduce numbers of outlier patients.2 A surgical assessment unit (SAU) was recently established at Middlemore Hospital. We aimed to determine the impact of its introduction on numbers of general surgery outliers on post-acute ward rounds. METHODS: A 10-bed SAU was introduced in July 2015, coinciding with the closure of 20 beds on the general surgical wards. The numbers and locations of patients on post-acute ward rounds before and after the establishment of the SAU were compared. A student two-tailed t-test was used for statistical comparisons, with p<0.05 considered significant. RESULTS: A total of 1,462 patient locations were analysed from 71 post-acute ward rounds. There were similar overall numbers of post-acute patients before and after the introduction of the SAU (mean 21 vs 20, p=0.33). There were fewer post-acute patients in outlier wards after the introduction of the SAU (mean 1.7 before vs 0.8 after, p=0.04). CONCLUSION: Despite a net reduction in general surgery beds and no change in the overall number of post-acute patients, the establishment of a SAU was associated with a reduction in outliers.

Modular acute system for general surgery: hand over the operation, not the patient.

INTRODUCTION: Various models have been proposed to effectively provide acute surgical care in Australasia. Recently, General Surgeons Australia (GSA) has published a 12-point plan with guiding principles on this matter. This study describes a model of providing acute general surgical care in a high-volume institution, evaluates clinical outcomes and critically appraises the system against the GSA 12-point plan. METHODS: The acute care system is qualitatively described with quantitative measures of workload. The outcomes of acute laparoscopic cholecystectomy were used as a proxy of system performance. The system was critically appraised against the GSA 12-point plan. RESULTS: Teams are on call once per week with each surgeon on call once per fortnight. The three key elements of acute management - collecting patients, post-acute ward round and operating - are treated as modules. The patient remains under the care of the admitting consultant but is often operated on by another team. From June 2009 to 2010, there were 7429 acute general surgical admissions (mean: 20.4 patients per day) with 2999 acute operations (mean: 8.4 operations per day). The other activities of the department were not compromised. In that time, 388 acute laparoscopic cholecystectomies were performed with a conversion rate of 1.3% and no major bile duct injury. The system is compatible with the GSA 12-point plan. CONCLUSION: This study describes an efficient and safe system for providing acute general surgical care in a high-volume setting with satisfactory clinical outcomes. It is compatible with the GSA 12-point plan.

Gastric cancer location and histological subtype in Pacific people and Maori defies international trends.

AIMS: Gastric cancer location and histopathology in Pacific people (mostly of Samoan, Tongan, Niuean, or Cook Islands origin) and Maori in New Zealand has not been specifically examined. METHODS: A retrospective review of all histologically-proven new cases of gastric adenocarcinoma and gastro-oesophageal adenocarcinoma at Middlemore Hospital (Auckland, New Zealand) from June 2003-June 2009 was conducted. Demographic data, clinical presentation, diagnostic/ staging investigations and surgical outcomes were recorded. RESULTS: There were 133 patients of whom 79 (59%) were male. Forty-nine (37%) patients were of Pacific ethnicity and 34 (26%) were Maori. Maori (59.3 years; p=0.01) and Pacific (64.5 years; p=0.01) patients were significantly younger at diagnosis compared to European patients (77.2 years). European patients had more proximal tumours (n=18; 47%) compared to Pacific (n=5; 10%) and Maori (n=4; 12%) patients (p= 0.01). Pacific (n=25; 51%) and Maori (n=21; 62%) patients had a significantly higher percentage of diffuse-type gastric cancer compared to European (n=7; 18%) patients. There was no difference in stage of presentation between ethnic groups. CONCLUSIONS: Maori and Pacific patients present with gastric cancer at higher rates and at a younger age. They have a predominance of diffuse-type antral and gastric body cancers which stand in contrast to global trends in gastric cancer.

Acute laparoscopic cholecystectomy: preferred treatment for acute biliary disease.

BACKGROUND: Early laparoscopic cholecystectomy has been shown to be the treatment of choice for acute presentations of gallstone disease. However, currently this practice is not common in many centres. The aim of the study was to evaluate surgical management of patients presenting with acute symptomatic gallstone disease to Middlemore Hospital in 2005. METHODS: A retrospective case review of acute presentations of symptomatic gallstone disease was carried out between 1 January and 31 December 2005. RESULTS: Four hundred and two patients were included in the final analysis. Forty-six of these patients were unfit for surgery, 26 were solely admitted to the emergency department without being referred to a surgical team and 25 declined surgery. Therefore, 305 patients (76%) were eligible for surgery at index admission (IA). Two hundred and four (67%) received surgery during IA with a median time to surgery of 3 days. From the 198th patient who did not have acute surgery at IA, 112 had delayed surgery. When comparing those with surgery at IA with those who did not receive surgery at IA, median length of stay for IA was significantly longer in acute surgical group (5 vs 3 P = 0.05); however, there was no significant difference in duration of total hospital stay (6 vs 6 P > 0.05). For those who had acute surgery the conversion rate was 3% (six) compared with 7% (seven) in delayed surgery group (P = 0.09). CONCLUSION: Acute surgery remains the treatment of choice for acute biliary disease. This approach requires a committed team approach but is safe and effective.