Surgery (Western Health) - Research Publications
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ItemAbility of malnutrition screening and assessment tools to identify computed tomography defined low muscle mass in colorectal cancer surgery(WILEY, 2022-06)BACKGROUND: Malnutrition and low muscle mass are independently associated with poor outcomes in colorectal cancer (CRC). However, tools to identify low muscle mass are limited in the clinical setting. We investigated the ability of existing malnutrition screening and assessment tools to identify low muscle mass assessed by computed tomography (CT). Secondary aims were to determine the feasibility of CT analysis and handgrip strength (HGS). METHODS AND ANALYSIS: An exploratory study of patients who underwent curative surgery for CRC between February and September 2019. Nutrition tools used included body mass index (BMI), Malnutrition Screening Tool (MST), and Patient-Generated Subjective Global Assessment (PG-SGA). Muscle mass was determined by preoperative CT image at the third lumbar vertebral level (L3), and muscle strength was determined by HGS dynamometry. Fisher's exact and Mann-Whitney U tests were used to compare results of nutrition tools with CT muscle assessment. RESULTS: In total, 57 patients were included. MST classified 18 patients (32%) as at risk of malnutrition, and PG-SGA classified 10 patients (17%) as malnourished. Fifty-one (90%) CT scans were analysable and 21 (47%) had low muscle mass. Of those with low muscle mass, PG-SGA classified 22 patients (92%) as well nourished and MST classified 17 patients (71%) as not being at nutrition risk. No tool was able to identify CT-diagnosed low muscle mass. Inability to complete HGS was associated with malnutrition (P = .001). CONCLUSION: In this cohort, nutrition screening and assessment tools did not identify CT-diagnosed low muscle mass. Feasible tools to identify low muscle mass in the clinical setting are required.
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ItemImpact of the evolution in RAS mutation analysis in Australian patients with metastatic colorectal cancer(WILEY, 2022-10)BACKGROUND: RAS mutation testing now routinely informs the optimal management of metastatic colorectal cancer (mCRC), specifically the finding of a RAS mutation defines patients who will not benefit from treatment with an epidermal growth factor receptor inhibitor. Over time more RAS genes have been tested and more sensitive techniques used. AIMS: To review routine care RAS testing and results over time. METHODS: A retrospective analysis of the molecular data collected prospectively in the multi-site Treatment of Recurrent and Advanced Colorectal Cancer (TRACC) registry from 2009 to 2018 was undertaken. Patients with RAS data were further analyzed. In parallel, the RAS mutation status of patients enrolled in the Test Tailor Treat (TTT) program was examined for 2011-2018. RESULTS: Of 2908 patients in the TRACC registry, 1892 (65%) were tested, with 898 (47%) of tested patients found to be RAS mutant (RASmt). RAS data were available for 5935 TTT patients. Of the tested TRACC patients diagnosed in 2009 and 2010, 38% were RASmt. For each 2-year period from 2011/2012 through to 2017/2018, the prevalence of RASmt in TRACC and TTT was 42% and 40% (2011/2012), 52% and 40% (2013/2014), 47% and 49% (2015/2016), and 47% and 49% (2017/2018). CONCLUSIONS: Based on both TRACC and TTT data, the proportion of patients reported to have a RAS mutation increased from 2009 to 2015 but has remained relatively stable in recent years. The increased proportion of RASmt patients observed over time is likely largely driven by the uptake of extended RAS testing.
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ItemElective surgery system strengthening: development, measurement, and validation of the surgical preparedness index across 1632 hospitals in 119 countries(ELSEVIER SCIENCE INC, 2022-11-05)BACKGROUND: The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. METHODS: First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. FINDINGS: In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45·6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84·5 (95% CI 84·1-84·9), which varied between HIC (88·5 [89·0-88·0]), MIC (81·8 [82·5-81·1]), and LIC (66·8 [64·9-68·7]) settings. In the third phase, 1217 (74·6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51·4%) were from HIC, 538 (44·2%) from MIC, and 54 (4·4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3·6% (95% CI 3·0-4·1; p<0·0001) increase in SVR. This was consistent in HIC (4·8% [4·1-5·5]; p<0·0001), MIC (2·8 [2·0-3·7]; p<0·0001), and LIC (3·8 [1·3-6·7%]; p<0·0001) settings. INTERPRETATION: The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs. FUNDING: National Institute for Health Research (NIHR) Global Health Research Unit on Global Surgery, NIHR Academy, Association of Coloproctology of Great Britain and Ireland, Bowel Research UK, British Association of Surgical Oncology, British Gynaecological Cancer Society, and Medtronic.
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ItemApplication of Machine Learning to Ranking Predictors of Anti-VEGF Response(MDPI, 2022-11)Age-related macular degeneration (AMD) is a heterogeneous disease affecting the macula of individuals and is a cause of irreversible vision loss. Patients with neovascular AMD (nAMD) are candidates for the anti-vascular endothelial growth factor (anti-VEGF) treatment, designed to regress the growth of abnormal blood vessels in the eye. Some patients fail to maintain vision despite treatment. This study aimed to develop a prediction model based on features weighted in order of importance with respect to their impact on visual acuity (VA). Evaluations included an assessment of clinical, lifestyle, and demographic factors from patients that were treated over a period of two years. The methods included mixed-effects and relative importance modelling, and models were tested against model selection criteria, diagnostic and assumption checks, and forecasting errors. The most important predictors of an anti-VEGF response were the baseline VA of the treated eye, the time (in weeks), treatment quantity, and the treated eye. The model also ranked the impact of other variables, such as intra-retinal fluid, haemorrhage, pigment epithelium detachment, treatment drug, baseline VA of the untreated eye, and various lifestyle and demographic factors. The results identified variables that could be targeted for further investigation in support of personalised treatments based on patient data.
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ItemEvaluation of palliative treatments in unresectable pancreatic cancer(WILEY, 2021-05)BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) presents as unresectable disease in 80% of patients. Limited Australian data exists regarding management and outcome of palliative management for PDAC. This study aims to: (i) identify patients with PDAC being managed with palliative intent; (ii) assess the type of palliative management being used. METHODS: A prospectively maintained pancreatic database at Western Health (2015-2017) was used to identify patient demographics; stage and multidisciplinary decision regarding resectability and operative interventions; palliative care; use of chemotherapy, radiotherapy and; management of exocrine and endocrine insufficiency. Data on chemotherapy use, number of hospital admissions, emergency department attendances and intensive care unit admissions 30 days prior to death were recorded. RESULTS: One-hundred and eleven patients had diagnosis of PDAC, 15% with locally advanced and 45% with metastatic PDAC. Among the locally advanced and metastatic PDAC, 48% received biliary stent insertions, 93% had palliative care referral, 45% received palliative chemotherapy and 10% received radiotherapy. Dietitian referral occurred in 79% and 36% were prescribed with a pancreatic enzyme replacement therapy. Diabetes mellitus was present in 52% of which 31% was new onset. Within 30 days prior to death, 11% patients received palliative chemotherapy, 32% were hospitalized and 11% visited an emergency department more than once. Sixty-five percent died in hospital. CONCLUSION: A high proportion of patients diagnosed with locally advanced and metastatic PDAC received palliative care referrals and appropriate level of end-of-life care. Further prospective studies are necessary, examining the management and impacts of pancreatic insufficiency in this group.
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ItemSubinguinal orchiectomy-A minimally invasive approach to open surgery(WILEY, 2020-11)OBJECTIVES: To determine the rate of morbidity and assess the oncological outcomes for the subinguinal orchidectomy technique. BACKGROUND: Radical inguinal orchiectomy is the definitive management for a testicular mass suspicious for malignancy. The standard approach involves the division of the spermatic cord at the internal inguinal ring. In addition to the morbidity of a significant incision through skin and fascia, a known complication is damage to the nerves within the canal leading to local hypoesthesia or persistent inguinal and scrotal neuralgia. The subinguinal orchiectomy technique avoids opening the inguinal canal by excising the spermatic cord at the external inguinal ring. METHODS: Patient data from three urologists who routinely perform subinguinal orchiectomies for suspected testicular malignancy was collected. A retrospective analysis between March 2011 and March 2019 was undertaken evaluating demographic, clinical, and histological data points. Descriptive analysis of oncological and surgical outcomes of subinguinal orchiectomy for testicular mass was performed. Descriptive analysis of oncological and surgical outcomes of subinguinal orchiectomy for testicular mass was performed. RESULTS: About 42 orchiectomies performed via the subinguinal approach were identified. The median age was 38 years (range 22-72) and mean follow-up time was 18.4 months (range 0.59-61). Of the 38 patients with testicular cancer, histopathology showed 26 with pT1, 9 with pT2, and 3 with pT3 disease. Three patients had involvement of the cord, with one patient having a positive surgical margin secondary to venous invasion. No patients experienced neuropathic complications, hernia, or wound break down. CONCLUSION: These data suggest that subinguinal orchiectomy provides acceptable oncological outcomes, comparable to a traditional technique, and may decrease the risk of neuropathic injury and incisional/inguinal hernia. Further investigation with a larger, prospective series is required.
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ItemImplementing a standardised perioperative nutrition care pathway in upper gastrointestinal cancer surgery: a mixed-methods analysis of implementation using the Consolidated Framework for Implementation Research(BMC, 2022-02-25)BACKGROUND: Implementation studies of complex interventions such as nutrition care pathways are important to health services research, as they support translation of research into practice. There is limited research regarding implementation of a nutrition care pathway in an upper gastrointestinal (UGI) cancer population. The aim of this study was to comprehensively evaluate the implementation process of a perioperative nutrition care pathway in UGI cancer surgery using The Consolidated Framework for Implementation Research (CFIR). METHODS: This was a mixed methods implementation study conducted during a pilot study of a standardised nutrition care pathway across four major hospitals between September 2018 to August 2019. Outcome measures included five focus groups among study dietitians (n = 4-8 per group), and quantitative satisfaction surveys from multi-disciplinary team (MDT) members (n = 14) and patients (n = 18). Focus group responses were analysed thematically using the CFIR constructs, which were used as a priori codes. Survey responses were summarised using means and standard deviations. A convergent parallel mixed methods approach according to CFIR domains and constructs was used to integrate qualitative and quantitative data. RESULTS: Qualitative data demonstrated that dietitian perceptions primarily aligned with five CFIR constructs (networks and communications, structural characteristics, adaptability, compatibility and patient needs/resources), indicating a complex clinical and implementation environment. Challenges to implementation mostly related to adapting the pathway, and the compatibility of nutrition coordination to existing aspects of care within each setting. Identified benefits from dietitian qualitative data and MDT survey responses included increased engagement between the dietitian and MDT, and a more proactive approach to nutrition care. Patients were highly satisfied with the service, with the majority of survey items being rated highly (≥4 of a possible 5 points). CONCLUSIONS: The nutrition care pathway was perceived to be beneficial by key stakeholders. Based on the findings, sustainability and compliance to this model of care may be achieved with improved systems level coordination and communication.
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ItemAssessment of Nutritional Status and Nutrition Impact Symptoms in Patients Undergoing Resection for Upper Gastrointestinal Cancer: Results from the Multi-Centre NOURISH Point Prevalence Study(MDPI, 2021-10)BACKGROUND: Identification and treatment of malnutrition are essential in upper gastrointestinal (UGI) cancer. However, there is limited understanding of the nutritional status of UGI cancer patients at the time of curative surgery. This prospective point prevalence study involving 27 Australian tertiary hospitals investigated nutritional status at the time of curative UGI cancer resection, as well as presence of preoperative nutrition impact symptoms, and associations with length of stay (LOS) and surgical complications. METHODS: Subjective global assessment, hand grip strength (HGS) and weight were performed within 7 days of admission. Data on preoperative weight changes, nutrition impact symptoms, and dietary intake were collected using a purpose-built data collection tool. Surgical LOS and complications were also recorded. Multivariate regression models were developed for nutritional status, unintentional weight loss, LOS and complications. RESULTS: This study included 200 patients undergoing oesophageal, gastric and pancreatic surgery. Malnutrition prevalence was 42% (95% confidence interval (CI) 35%, 49%), 49% lost ≥5% weight in 6 months, and 47% of those who completed HGS assessment had low muscle strength with no differences between surgical procedures (p = 0.864, p = 0.943, p = 0.075, respectively). The overall prevalence of reporting at least one preoperative nutrition impact symptom was 55%, with poor appetite (37%) and early satiety (23%) the most frequently reported. Age (odds ratio (OR) 4.1, 95% CI 1.5, 11.5, p = 0.008), unintentional weight loss of ≥5% in 6 months (OR 28.7, 95% CI 10.5, 78.6, p < 0.001), vomiting (OR 17.1, 95% CI 1.4, 207.8, 0.025), reduced food intake lasting 2-4 weeks (OR 7.4, 95% CI 1.3, 43.5, p = 0.026) and ≥1 month (OR 7.7, 95% CI 2.7, 22.0, p < 0.001) were independently associated with preoperative malnutrition. Factors independently associated with unintentional weight loss were poor appetite (OR 3.7, 95% CI 1.6, 8.4, p = 0.002) and degree of solid food reduction of <75% (OR 3.3, 95% CI 1.2, 9.2, p = 0.02) and <50% (OR 4.9, 95% CI 1.5, 15.6, p = 0.008) of usual intake. Malnutrition (regression coefficient 3.6, 95% CI 0.1, 7.2, p = 0.048) and unintentional weight loss (regression coefficient 4.1, 95% CI 0.5, 7.6, p = 0.026) were independently associated with LOS, but no associations were found for complications. CONCLUSIONS: Despite increasing recognition of the importance of preoperative nutritional intervention, a high proportion of patients present with malnutrition or clinically significant weight loss, which are associated with increased LOS. Factors associated with malnutrition and weight loss should be incorporated into routine preoperative screening. Further investigation is required of current practice for dietetics interventions received prior to UGI surgery and if this mitigates the impact on clinical outcomes.