Surgery (Austin & Northern Health) - Research Publications
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Circulating concentrations of B group vitamins and urothelial cell carcinoma
B-group vitamins, as components of the one carbon metabolism pathway, are involved in DNA synthesis, repair and methylation. Our aim was to investigate associations between circulating plasma levels of B vitamins and urothelial cell carcinoma (UCC). We conducted a nested case-control study of UCC within the Melbourne Collaborative Cohort Study. B vitamins were measured in pre-diagnostic plasma samples. Conditional logistic regression was used to estimate odds ratios (OR) for UCC risk associated with circulating B vitamins in 363 matched cases and controls. In a case-only analysis (N = 390), hazard ratios (HR) for overall survival associated with plasma B vitamins were estimated using Cox regression. There were no strong associations between UCC risk and pre-diagnostic levels of plasma B vitamins. No heterogeneity in UCC risk was observed by subtype (invasive or superficial), sex, smoking status or alcohol intake. There was no heterogeneity by country of birth for most B vitamins, except for folate (p-homogeneity = 0.03). In UCC cases, there were no strong associations between plasma B vitamins and overall survival. We found no associations between pre-diagnostic plasma concentrations of B-group vitamins and UCC risk or survival.
Exploring pathways towards improving patient experience of robot-assisted radical prostatectomy (RARP): assessing patient satisfaction and attitudes
OBJECTIVE: To determine patient satisfaction and experience after robot-assisted radical prostatectomy (RARP) for prostate cancer, using a convergent mixed-method qualitative analysis approach. PATIENTS AND METHODS: 412 patients who underwent RARP between January 2014 and June 2016 were mailed questionnaires and invited to participate in focus groups. Qualitative data was thematically analysed using NVivo. Descriptive statistics were obtained from the questionnaire using SPSS. RESULTS: 214 patients responded (52% of sample size) of whom 97.6% were satisfied and 91.1% would likely recommend RARP. Key themes from the qualitative data highlighted the psychosocial impacts of the diagnosis and RARP process. The importance of early recovery, the benefits of pelvic floor exercises and educational resources were emphasised. CONCLUSION: Patients were overwhelmingly satisfied with RARP, largely due to relevance and timeliness of the information and support provided both before and after surgery. With an increased understanding of the factors and outcomes that are most important to patients regarding all aspects of hospital care, we can create more targeted care pathways. Key themes will help inform the implementation of an enhanced recovery after surgery (ERAS) protocol to further improve recovery and early return to function.
Early repeat computed tomographic imaging in transferred trauma and neurosurgical patients: Incidence, indications and impact
INTRODUCTION: Computed tomographic (CT) imaging is widely available in Australian rural and remote hospitals and is often performed prior to patient transfer to definitive tertiary hospital care. We hypothesised that critically ill trauma and neurosurgical patients might have CT scans repeated after interhospital transfer and that the utility of this practice might be low in relation to the additional financial cost and radiation exposure. METHODS: We conducted a retrospective review of clinical records to determine the proportion of trauma and neurosurgical patients transferred to our tertiary ICU from other hospitals between 1 June 2013 and 30 June 2014 who underwent a repeat CT scan. The additional effective radiation dose was estimated using the dose length product method and the Australian Medicare Benefits Schedule was used to estimate the associated cost. RESULTS: Of the 247 patients transferred for trauma and neurosurgical indications, many (144; 58%) had undergone CT imaging at the referring hospital. Repeat scans were performed in 60 (42%) already imaged patients (24% of all transferred patients), most frequently for changed clinical indications. While in 11 (18%) of those 60 already imaged patients the repeat scan led to an identifiable change in management, for another 13 (22%) patients the repeat scans appeared to be potentially avoidable. The median cost of a repeat scan was AU$250 and the median additional effective radiation dose was 2.74 mSv per patient. CONCLUSION: Repeat CT scans for patients already imaged prior to transfer were relatively common, occurring mostly for apparently valid clinical reasons. However, the additional radiation risk and financial cost of these repeat scans appeared on retrospective audit to be potentially avoidable in approximately one in five cases.
Dietary intake of nutrients involved in one-carbon metabolism and risk of urothelial cell carcinoma: A prospective cohort study
Nutrients involved in one-carbon metabolism may play a role in carcinogenesis through DNA replication, repair and methylation mechanisms. Most studies on urothelial cell carcinoma (UCC) have focused on folate. We sought to examine the association between B-group vitamins and methionine intake and UCC risk, overall and by subtype, and to test whether these associations are different for population subgroups whose nutritional status may be compromised. We followed participants in the Melbourne Collaborative Cohort Study (N = 41,513) for over 20 years and observed 500 UCC cases (89% originating in the bladder; superficial: 279, invasive: 221). Energy-adjusted dietary intakes of B vitamins (B1, B2, B3, B5, B6, B8, B9 and B12) and methionine were estimated from a 121-item food frequency questionnaire administered at baseline (1990-1994), using the residuals method. We used Cox regression models to compute hazard ratios (HRs) of UCC risk per standard deviation (SD) of log-transformed nutrient intakes and 95% confidence intervals, adjusted for potential confounders. We investigated associations by tumor subtype, and tested interactions with sex, country of birth, smoking and alcohol drinking. The risk of UCC appeared not to be associated with intake of B-group vitamins or methionine, and findings were consistent across tumor subtypes and across demographic and lifestyle characteristics of the participants. A potential interaction between vitamin B1 and alcohol drinking was observed (all participants: HR per 1 SD = 0.99 (0.91-1.09), never drinkers: HR = 0.81 (0.69-0.97), p-interaction = 0.02), which needs to be confirmed by other studies. Our findings do not indicate that dietary intake of nutrients involved in one-carbon metabolism are associated with UCC risk.
Limited utility of routine chest X-ray in initial evaluation of neutropenic fever in patients with haematological diseases undergoing chemotherapy
BACKGROUND: Routine chest X-ray (CXR) is recommended for neutropenic fever (NF) management however its role is relatively understudied in haematology patients. AIM: To investigate the utility of CXR in the diagnosis and management of patients with haematological conditions complicated by NF. METHODS: Retrospective, single-centre analysis of haematology patients admitted with NF between January 2011 and December 2015. Baseline demographics, treatment details and outcomes were collected from electronic patient records. CXR underwent independent radiology review. Primary endpoints were a proportion of NF episodes in which CXR detected a probable chest infection in the absence of respiratory symptoms/signs and/or resulted in a change in antibiotic management. RESULTS: Four hundred and thirty-five episodes were identified; CXR was performed in 75% of patients (65% within 2 days of NF). In 4 of 164 (2.4%) asymptomatic patients, CXR was consistent with infection, in contrast to 19 of 119 (16%) patients with clinical signs of respiratory infection. Only 3 of 283 (1.1%) CXR resulted in a change to antibiotics. CXR consistent with infection was not associated with increased mortality or increased admission length, although there was an association with intensive care unit admission (odds ratios: 7.61, 95% confidence interval: 2.04-28.31). CONCLUSION: In haematology patients with NF, CXR rarely detected chest infection or changed management in patients with no respiratory symptoms or signs. CXR in our institution is no longer part of routine assessment of NF in the absence of these features.
Radiotherapy-related complications presenting to a urology department: a more common problem than previously thought?
OBJECTIVE: To quantify the burden of the side effects of radiotherapy on a tertiary referral urology department. PATIENTS AND METHODS: A prospective study of all urology admissions to a public urology department at a tertiary hospital in a 6-month period was performed. Patients admitted with complications attributable to radiotherapy were included in the study. Data obtained included patient demographics, radiotherapy details, complication type and management required. RESULTS: A total of 1198 patients were admitted; 921 (77%) were elective and 277 (23%) were emergency admissions. Thirteen out of the 921 (1.4%) elective admissions and 20 out of the 277 (7.2%) emergency admissions were attributable to radiotherapy complications. Radiotherapy complications was the fourth most common reason for emergency admission, ahead of acute urinary retention. These 33 admissions were accounted for by 21 patients. A total of 39 separate complications attributable to radiotherapy were diagnosed, with some patients having multiple complications. The median (interquartile range) time to onset of complications was 4 (1-9) years. The surgical intervention rate was 67%. The commonest procedures were washout with/without clot evacuation or diathermy in theatre (15.8%) and urethral dilatation/bladder neck incision (15.8%). Two urinary diversions and two cystoprostatectomies plus urinary diversion were performed. CONCLUSION: Radiotherapy complications are consequential and account for a substantial proportion of a tertiary urology department's emergency workload. These complications generally occur years after radiotherapy and frequently require surgical intervention.
Distribution and characterisation of CCK containing enteroendocrine cells of the mouse small and large intestine
There is general consensus that enteroendocrine cells, EEC, containing the enteric hormone cholecystokinin (CCK) are confined to the small intestine and predominate in the duodenum and jejunum. Contrary to this, EEC that express the gene for CCK have been isolated from the large intestine of the mouse and there is evidence for EEC that contain CCK-like immunoreactivity in the mouse colon. However, the human and rat colons do not contain CCK cells. In the current study, we use immunohistochemistry to investigate CCK peptide presence in endocrine cells, PCR to identify cck transcripts and chromatography to identify CCK peptide forms in the mouse small and large intestine. The colocalisation of CCK and 5-HT, hormones that have been hypothesised to derive from cells of different lineages, was also investigated. CCK immunoreactivity was found in EEC throughout the mouse small and large intestine but positive cells were rare in the rectum. Immunoreactive EEC were as common in the caecum and proximal colon as they were in the duodenum and jejunum. CCK gene transcripts were found in the mucosa throughout the intestine but mRNA for gastrin, a hormone that can bind some anti-CCK antibodies, was only found in the stomach and duodenum. Characterisation of CCK peptides of the colon by extraction, chromatographic separation and radioimmunoassay revealed bioactive amidated and sulphated forms, including CCK-8 and CCK-33. Moreover, CCK-containing EEC in the large intestine bound antibodies that target the biologically active sulfated form. Colocalisation of CCK and 5-HT occurred in a proportion of EEC throughout the small intestine and in the caecum but these hormones were not colocalised in the colon, where there was CCK and PYY colocalisation. It is concluded that authentic, biologically active, CCK occurs in EEC of the mouse large intestine.
Laparoscopic bisegmentectomy 6 and 7 using a Glissonian approach and a half-Pringle maneuver
BACKGROUND: Despite accumulated experience and advancing techniques for laparoscopic hepatectomy, surgeons still face challenging resections that require specific and innovative intraoperative maneuvers. The right posterior sectionectomy presents special concerns about its location, the extensive transection area, and the difficult access to the pedicle. The intrahepatic Glissonian approach allows safe en masse control of the portal structures without prolonged dissection. Its association with the half-Pringle maneuver results in less bleeding during parenchymal transection. METHODS: A 34-year-old woman was referred for treatment of an 8-cm hepatocellular adenoma located at segments 6 and 7. She was placed in a semi-supine position, and six ports were located in a distribution that resembled a Makuuchi incision. The right liver was mobilized, and preparation for an anatomic Glissonian approach was performed. A vascular clamp was placed to ensure that full control of the right posterior pedicle was possible. Then a vascular stapler replaced it, with division of the right posterior Glissonian pedicle. A vascular clamp was inserted from the inferior right-flank 5-mm trocar for performance of a half-Pringle maneuver of the right pedicle to minimize blood loss during parenchymal transection. The liver parenchyma was transected with a harmonic scalpel and a vascular stapler. The right hepatic vein was divided intraparenchymally with a vascular stapler. The specimen was extracted through a Pfannenstiel incision. RESULTS: The total surgical time was 210 min, and the estimated blood loss was 200 ml. No blood transfusion was required. The recovery was uneventful, and hospital discharge occurred on postoperative day 5. Pathology confirmed the diagnosis of an hepatocellular adenoma. CONCLUSIONS: Technical issues initially hindered the development of laparoscopic liver resections [7-10]. Surgeons were concerned about hemostasis, bleeding control, safe and effective parenchymal transection, adequate visualization, and the feasibility of working on deeper regions of the liver. During the past decade, many limitations were overcome, but lesions located on the posterosuperior liver are still considered tough to beat. Large series and extensive reviews show that resections located on the posterior segments still are infrequent. Limited access to the portal triad, difficult pedicle control, and a large transection area and its anatomic location, attached to the diaphragm and retroperitoneum and hidden from the surgeon's view, makes such resections defying. The authors' team has performed 97 laparoscopic hepatectomies, including resection of 6 lesions in the right posterior sector. In their series, half-pedicle clamping was used for 12 patients, and they adopt such a maneuver as an inflow control when operating on peripheric lesions with difficult vascular control (e.g., enucleations or posterosuperiorly located segmentectomies). This technique is safe and useful because it reduces liver ischemic aggression, a very important issue with diseased livers (e.g., steatosis, steatohepatitis, prolonged chemotherapy, cirrhosis). In their series, the authors applied the Glissonian intrahepatic approach in 7 cases (2 left hepatectomies and 5 right hepatectomies). They understand that laparoscopy applies perfectly to oddly (posterosuperior) located tumors and that right posterior sectionectomy can be accomplished safely. In fact, they share the opinion of other specialized hepatobiliary centers, believing that this may be the preferred approach.
Orbital tuberculosis: perspectives from Victoria, Australia
PURPOSE: Orbital tuberculosis (TB) is a rare extra-pulmonary manifestation of tuberculosis and its clinical diagnosis poses unique challenges, with potential for destructive complications as well as social and public health implications. The aim of this study is to report our experience of patients presenting with orbital TB and to identify common aspects. METHODS: A systematic search for mandatory notifications of orbital tuberculosis between January 01, 1994 and December 12, 2016 was undertaken in the Victorian Tuberculosis database. In addition, members of the Australian and New Zealand Society of Ophthalmic Plastic Surgeons (ANZSOPS) were surveyed to identify cases of orbital tuberculosis diagnosed on biopsy in the past 20 years. Medical case notes of identified cases were reviewed retrospectively. RESULTS: Three cases were identified as having occurred in Victoria, aged 44-59 years old. All cases had emigrated from endemic countries with higher tuberculosis burden. Diagnosis of tuberculosis was often difficult due to few or non-viable acid fast bacilli and low yield of positive culture in paucicellular orbital specimens. CONCLUSIONS: Orbital TB is rare but remains an important differential diagnosis of orbital mass lesions. The diagnosis of orbital TB requires a high index of clinical suspicion and targeted investigations in patients originating from endemic areas. Diagnosis and treatment rely on effective collaboration between ophthalmologists, infectious disease physicians, and pathologists.
Surgical education and training in an outer metropolitan hospital: a qualitative study of surgical trainers and trainees
The landscape of surgical training is changing. The anticipated increase in the numbers of surgical trainees and the shift to competency-based surgical training places pressures on an already stretched health service. With these pressures in mind, we explored trainers' and trainees' experiences of surgical training in a less traditional rotation, an outer metropolitan hospital. We considered practice-based learning theories to make meaning of surgical training in this setting, in particular Actor-network theory. We adopted a qualitative approach and purposively sampled surgical trainers and trainees to participate in individual interviews and focus groups respectively. Transcripts were made and thematically analysed. Institutional human research ethics approval was obtained. Four surgical trainers and fourteen trainees participated. Almost without exception, participants' report training needs to be well met. Emergent inter-related themes were: learning as social activity; learning and programmatic factors; learning and physical infrastructure; and, learning and organizational structure. This outer metropolitan hospital is suited to the provision of surgical training with the current rotational system for trainees. The setting offers experiences that enable consolidation of learning providing a rich and varied overall surgical training program. Although relational elements of learning were paramount they occurred within a complex environment. Actor-network theory was used to give meaning to emergent themes acknowledging that actors (both people and objects) and their interactions combine to influence training quality, shifting the focus of responsibility for learning away from individuals to the complex interactions in which they work and learn.