Koroush S. Haghighi

Acute-care surgical service: a change in culture

The provision of acute surgical care in the public sector is becoming increasingly difficult because of limitation of resources and the unpredictability of access to theatres during the working day. An acute‐care surgical service was developed at the Prince of Wales Hospital to provide acute surgery in a more timely and efficient manner. A roster of eight general surgeons provided on‐site service from 08.00 to 18.00 hours Monday to Friday and on‐call service in after‐hours for a 79‐week period. An acute‐care ward of four beds and an operating theatre were placed under the control of the rostered acute‐care surgeon (ACS). At the end of each ACS roster period all patients whose treatment was undefined or incomplete were handed over to the next rostered ACS. Patient data and theatre utilization data were prospectively collected and compared to the preceding 52‐week period. Emergency theatre utilization during the day increased from 57 to 69%. There was a 11% reduction in acute‐care operating after hours and 26% fewer emergency cases were handled between midnight and 08.00 hours. There was more efficient use of the entire theatre block, suggesting a significant cultural change. Staff satisfaction was high. On‐site consultant‐driven surgical leadership has provided significant positive change to the provision of acute surgical care in our institution. The paradigm shift in acute surgical care has improved patient and theatre management and stimulated a cultural change of efficiency.

Chicken bone perforation of a sigmoid diverticulum.

Diverticular disease of the colon is common. It is estimated to be present in up to 20% of the adult population in Western countries and is associated with elderly people and those who have a lowfibre diet. 1 The clinical manifestations of this disease are many and range from asymptomatic diverticulae to life-threatening complications. An interesting case of complications arising in the setting of sigmoid diverticulosis is described in the present case report.

Controlled study of in-line ovine spleen transection assisted by radiofrequency ablation.

BACKGROUND Trauma to the spleen or tumors of the spleen often require total splenectomy for control of hemorrhage. Partial splenectomy is the preferred technique because of the short- and long-term sepsis problems in asplenic patients. Multiple techniques for partial splenectomy have been tried in the past with limited success. The authors designed the in-line radiofrequency ablation (ILRFA) probe for liver surgery. It uses radiofrequency energy to make a linear coagulative plane that allows the parenchyma of solid vascular organs to be divided. In this study, for the first time, the efficiency of ILRFA was tested with the ovine spleen. METHODS Seven sheep were used for this study. With the sheep under general anesthesia, a laparotomy was performed. The first sheep was used for a pilot study. Eight partial splenectomies were made in the remaining six sheep using ILRFA. For a control, a matching partial splenectomy was made in each sheep using diathermy and sutures. Blood loss was measured by determining the difference in the weights of dry sponges and blood-stained sponges after resection. A paired t test was used to compare the bleeding between the control and the ILRFA techniques. RESULTS The mean blood loss was 33.14 +/- 17 g using ILRFA and 123.43 +/- 72 g in the control group. The bleeding was significantly reduced in the ILRFA group (p = 0.0056). The time required to apply ILRFA was 12 minutes. CONCLUSION Partial splenectomy was achieved in the ovine spleen using radiofrequency energy with minimal blood loss.

Refining the care of patients with pancreatic cancer: the AGITG pancreatic cancer workshop consensus

A meeting of the Australasian Gastro‐Intestinal Trials Group (AGITG) was held to develop a consensus statement defining when a patient with pancreatic cancer has disease that is clearly operable, is borderline, or is locally advanced/inoperable. Key issues included the need for multidisciplinary team consensus for all patients considered for surgical resection. Staging investigations, to be completed within 4 weeks of presentation, should include pancreatic protocol computed tomography, endoscopic ultrasound, and, when possible, biopsy. Given marked differences in outcomes, the operability of tumours should be clearly identified by categories: those clearly resectable by standard means (group 1a), those requiring vascular resection but which are clearly operable (group 1b), and those of borderline operability requiring vascular resection (groups 2a and 2b). Patients who may require vascular reconstruction should be referred, before exploration, to a specialist unit. All patients should have a structured pathology report with standardised reporting of all seven surgical margins, which identifies an R0 (no tumour cells within a defined distance of the margin) if all surgical margins are clear from 1 mm. Neo‐adjuvant therapy is increasingly recommended for borderline operable disease, while chemotherapy is recommended as initial therapy for patients with unresectable loco‐regional pancreatic cancer. The value of adding radiation after initial chemotherapy remains uncertain. A small number of patients may be downstaged by chemoradiation, and trimodality therapy should only be considered as part of a clinical trial. Instituting these recommendations nationally will be an integral part of the process of improving quality of care and reducing geographic variation between centres in outcomes for patients.

Short‐ and long‐term outcomes of elderly patients undergoing liver resection for colorectal liver metastasis

Metastatic colorectal cancer is a disease of advancing age. Increased life expectancy has dramatically increased the number of older patients being assessed for hepatectomy. The objective of the study is to assess the safety and survival of hepatic resection in older patients, with colorectal liver metastases (CLM) and compare that with younger patients.

Hepatic resection of non‐colorectal non‐endocrine liver metastases

Hepatic resection is standard treatment for liver metastases from colorectal and neuroendocrine cancers as well as primary biliary and hepatic carcinomas. The role of hepatic resection in patients with non‐colorectal non‐endocrine liver metastases (NCNELM) is less defined. Overall survival in this group of patients is poor with few patients surviving beyond two years, even with modern chemotherapy.

Aggressive multimodality treatment for primary malignant peritoneal mesothelioma

There is a well-recognized link between asbestos and mesothelioma. 3 The peritoneal variant appears to be related more to heavy asbestos exposure, whereas the pleural tumour predominates in the much larger number of transiently exposed patients. It must be noted that only half the patients with pleural and peritoneal mesothelioma have documented asbestos exposure. Primary malignant peritoneal mesothelioma is a rare disease of the abdominal cavity that was first described in 1908 and accounts for approximately 15% of all mesotheliomas. 4 It can be classified into diffuse, well-differentiated papillary, and multicystic mesothelioma. 5 The diffuse malignant form occurs between the ages of 45 and 65 years, predominantly in men and tends to be aggressive and rapidly fatal. 6 Local invasion and metastases are common. 7 Most patients with diffuse peritoneal mesothelioma die within 1 year of diagnosis of the disease and approximately 14 months after the onset of symptoms. The disease follows a more lethal course compared to the pleural variant. 4,6–9

Monitoring quality of care for patients with pancreatic cancer: a modified Delphi consensus

BACKGROUND Best practise care optimises survival and quality of life in patients with pancreatic cancer (PC), but there is evidence of variability in management and suboptimal care for some patients. Monitoring practise is necessary to underpin improvement initiatives. We aimed to develop a core set of quality indicators that measure quality of care across the disease trajectory. METHODS A modified, three-round Delphi survey was performed among experts with wide experience in PC care across three states in Australia. A total of 107 potential quality indicators were identified from the literature and divided into five areas: diagnosis and staging, surgery, other treatment, patient management and outcomes. A further six indicators were added by the panel, increasing potential quality indicators to 113. Rated on a scale of 1-9, indicators with high median importance and feasibility (score 7-9) and low disagreement (<1) were considered in the candidate set. RESULTS From 113 potential quality indicators, 34 indicators met the inclusion criteria and 27 (7 diagnosis and staging, 5 surgical, 4 other treatment, 5 patient management, 6 outcome) were included in the final set. CONCLUSIONS The developed indicator set can be applied as a tool for internal quality improvement, comparative quality reporting, public reporting and research in PC care.

Centralising care for patients with pancreatic cancer: a hybrid model approach

The vastmajority of patientswith pancreatic cancerwho present to medical services have locally advanced or disseminated disease. This is largely because of the absence of symptoms during early stage disease. Apart from the classic symptoms of jaundice, weight loss and epigastric pain, important red flags include unexplained pancreatitis and recent onset of type 1 diabetes, especially in older patients. There is currently no strategy for detecting early stage disease; although a number of promising biomarkers that could be useful in screening tests have been identified, trials are still in the early stages. In the consensus findings published earlier this year in the MJA, the Pancreatic Cancer Workshop of the Australasian GastroIntestinal Trials Group recommends standardised protocols for the staging and work-up of patients with suspected pancreatic adenocarcinoma. A multidisciplinary team (MDT) approach is strongly recommended, together with compulsory registration with a hepato-pancreato-biliary MDT to facilitate standardised, appropriate care and prospective data collection, and to improve access to clinical trials. In the study published in this issue of the MJA, Creighton and colleagues analysed data collated from several retrospective sources and compiled by the Centre for Health Care Linkage. In New South Wales, considerable variation between local health districts in the rates of curative intent treatment for pancreatic cancer was identified. It is impossible to ascertain whether this variation was at the primary or tertiary care levels, but the general suggestion is that patients from regionalNSWare not receiving the same care as those in metropolitan areas. The argument that in some centres toomanypatients undergopancreatectomy is refuted by the finding that areas with higher rates of resection were associated with improvements in long term survival. Advances in pancreatectomy techniques have increased the numbers of patients who can undergo curative surgery; despite this rise in numbers, morbidity and mortality rates have fallen. The volumeeoutcome relationship was also investigated by Creighton and her co-authors, with medium and higher volume centres (six or more resections per year) having higher survival rates, a finding that makes the case for centralising pancreatectomy procedures.

Emergency pancreatic resection for glucagonoma associated with severe necrolytic migratory erythema

cial detachable embolization coils are available and there is no evidence of superiority among the coils. The main principle applicable regardless of the embolization coil device is that it is imperative for the aneurysm to be packed as tightly as possible in order to facilitate thrombosis and occlusion of the aneurysm. In our case, there was successful exclusion of the aneurysmal sac with no significant flow noted at the efferent branches. Placement of a stent-graft was considered for complete occlusion of the feeding vessel. This was however not performed given the satisfactory angiographic result, and placement of a stent at this point would have been excessive. Additional stent graft placement at the thoracic aorta would also increase the risk of spinal ischaemia. It is also of the authors’ opinion that a stent-graft would have negated future possibilities of endovascular therapy in this patient. It may be more prudent to follow-up the patient and to place a stent-graft in the future if the need arises. In summary, we report a case of a large mediastinal BAA with short vascular neck that was successfully treated with coil embolization. Endovascular therapy is being increasingly used as it is effective, less invasive and is associated with lesser morbidity and shorter hospital stays as compared to surgical treatment.