Robert C. Gandy

Should the non‐operative management of appendicitis be the new standard of care?

Appendicitis is one of the most commonly encountered emergency presentations to the general surgical services. The operative management of this condition is associated with significant financial costs and represents a significant workload on the emergency surgical services. Negative appendicectomy rates remain high (20–25%) despite advancements in laboratory testing and imaging techniques. Recent data from randomized controlled trials suggests that non‐operative management in patients presenting with uncomplicated or non‐perforated acute appendicitis is a viable alternative, with only 23% of patients requiring an appendicectomy at 1 year and an overall reduction in complications. In view of this, the traditional teaching of mandatory appendicectomy for all patients with acute appendicitis should be challenged. This article briefly reviews the evidence that supports the use of diagnostic tests to reduce the negative appendicectomy rate and examines the potential selection criteria for non‐operative management. The data raises the questions: can a 20–25% negative appendicectomy rate be defended as best practice and can the traditional dogma of early appendicectomy to prevent perforation be supported?

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.

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.