Evaluation of community-based CT abdomen for acute abdominal pain during COVID-19.

AIM: The purpose of this study was to determine the utility of community-based imaging to reduce use of inpatient surgical resources and enforce social distancing at the outset of the COVID-19 pandemic. METHOD: A prospective evaluation of community-based CT for patients presenting to Christchurch general practitioners with acute abdominal pain from April to November 2020. Eligible patients were discussed with the on-call general surgical team, and then referred for CT abdomen rather than hospital assessment. The positivity rate of CT scans, the 30-day all-cause hospital admission rate, and the proportion of patients where community scanning altered management setting and the number of incidental findings, were all assessed. RESULTS: Of 131 included patients, 67 (51%) patients had a positive CT scan. Thirty-nine (30%) patients were admitted to hospital within 30 days, 34 (87%) of whom had a positive CT scan and were admitted under a surgical specialty. Ninety-two (70%) patients did not require hospital admission for their acute abdominal pain, thirty-three (35%) of whom had a positive CT scan. There were three deaths within 30 days of the community CT, and the setting of the community CT did not contribute to the death of any of the cases. Forty patients (30%) had incidental findings on CT, 10 (25%) of which were significant and were referred for further investigation. CONCLUSION: Community based abdominal CT scanning is a feasible option in the management of acute abdominal pain. While trialed in response to the initial nationwide COVID-19 lockdown in New Zealand, there may be utility for acute community-based CT scanning in regular practice.

New Zealand and Australia emergency laparotomy mortality rates compare favourably to international outcomes: a systematic review.

BACKGROUND: Almost 20 000 people undergo an emergency laparotomy each year in New Zealand and Australia. Common indications include small and large bowel obstruction, and intestinal perforation. Considered a high-risk procedure, emergency laparotomy is associated with significantly high morbidity and mortality. The aim of this review was to identify and compare 30-day, 90-day and 1-year mortality rates following emergency laparotomy in New Zealand and Australia. METHODS: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Electronic searches were performed in Medline, Embase, PubMed and Scopus in April 2020. RESULTS: Thirty-three papers met the inclusion criteria. Studies ranged in size from 58 to 75 280 patients. Weighted mean 30-day mortality was 8.40% (8.39-8.41). Mortality rates increased with longer postoperative follow up with 90-day weighted mortality rate of 14.14% (14.13-14.15) and the weighted mortality rate at 1 year of 24.60% (24.56-24.66). There was significant variability in mortality rates between countries. CONCLUSION: There is a wide variability of 30-day, 90-day and 1-year mortality rates internationally. Lowering postoperative mortality rates following emergency laparotomy through quality improvement initiatives could result in up to 120 lives in New Zealand and over 250 lives in Australia being saved each year. The continued work of the Australian and New Zealand Emergency Laparotomy Audit - Quality Improvement is crucial to improving emergency laparotomy mortality rates further in New Zealand and Australia.

Psychometric Characteristics of the Revised Illness Perception Questionnaire (IPQ-R) in People Undergoing Weight Loss Surgery.

The Illness Perception Questionnaire-Revised (IPQ-R) has been used extensively across many health conditions to measure patient illness and treatment perceptions. The constructs have an association with treatment adaptation and adherence which, in turn, are considered core factors involved in bariatric surgery outcome. This study examines the factorial validity and internal reliability of a modified (IPQ-R) in bariatric surgery candidates. After wording modifications, participants (N = 310) completed the IPQ-R as part of standard pre-surgery assessments. After removal of two items, confirmatory factor analysis (CFA) supported the original 7-factor solution of the Beliefs scale, with good to marginal subscale internal consistency. Exploratory factor analysis (EFA), with two items removed only partially supported the original 5-factor Causal Attributions scale. Internal consistency was unacceptably low for two subscales. Further research is needed to generate new items which better fit the IPQ-R to this population before research can explore the relevance of illness perceptions.

Achalasia: a 13-year, single-centre experience comparing endoscopic balloon dilatation and laparoscopic Heller myotomy.

BACKGROUND: Idiopathic achalasia is a non-curable, primary motility disorder of the oesophagus. Most established long-term palliative treatment options are laparoscopic Heller myotomy (LHM) and endoscopic balloon dilatation (BD). AIM: We aimed to compare the outcome of both therapies and the risk of serious complications, defined as perforation or death, in a single-centre series. METHOD: In this retrospective study, patients with BD or LHM were identified from 1997-2010. The symptom score (modified Zaninotto score) before treatment and at time of interview was evaluated via a telephone questionnaire. RESULTS: Ninety-nine patients fulfilled the inclusion criteria and treatment was provided with BD-only in 63, surgery-only in 23, BD crossover to surgery in 12, and surgery crossover to BD in one patient. Mean age was 62 years in the BD-only, and 39 years in the surgery-only group. One hundred and fifteen BD were performed on 76 patients with multiple dilatations required in 46 patients (38%). Sixty-four percent of all patients alive (n=81) were interviewed. Satisfactory outcomes were achieved in 79% in the BD group and in 88% in the surgery group, with a mean follow-up of 81 and 69 months, respectively. There was a single perforation in the BD group (0.9%) and no deaths occurred. CONCLUSION: LHM and on-demand BD were safe and within the limitations of our study design both methods appeared similarly effective treatments for achalasia, resulting in a satisfactory outcome in 88% and 79% of patients with a mean follow-up of 69 and 81 months. Serious complications occurred in less than 1% of procedures and there were no deaths.

The Pattern of Adjustments after Laparoscopic Adjustable Gastric Band.

BACKGROUND: The success of laparoscopic adjustable gastric band (LAGB) is dependent on gradual adjustments over time. The aim of this study is to describe that pattern of LAGB adjustments that are required after surgery. METHODS: A non-randomized observational study of consecutive LAGB from a single practise. Patients were sourced from a prospective database. Details of each LAGB adjustment were recorded along with weight loss and complications. RESULTS: There were 125 consecutive LAGB between March 2009 and September 2011 (mean age 46.6 ± 11.9 years; 113 female, BMI 42.1 ± 5.9 kg/m(2)). The mean %EBWL was 41.4 ± 19.1 % at 2 years. There was a total of 746 band adjustments with mean 7.1 ± 4.4 per patient. Approximately, a third of patients (34 %) reached optimal volume within 6 months but 49 patients (39 %) still required adjustments beyond a year. Weight loss was maximal prior to the first adjustment (41 % of mean total weight loss). The rate of weight loss decreased down to 1-3 %EBWL between later fills despite repeated increases in band volume. Urgent deflations were required in 63 patients with 24 of these patients having multiple overfills. There were two patients who had gastric prolapse but no other LAGB-related complications occurred in the first 2 years after surgery. CONCLUSIONS: LAGB requires a considerable postoperative commitment that may take several months. Overfills are common and may be the result of a false perception that tightening the band will hasten weight loss.

The high volume debate in a low volume country: centralisation of oesophageal resection in New Zealand.

AIM: Centralisation of oesophageal resection for cancer remains an area of debate. However, no consensus for the requirements of high volume centres yet exists and some low volume centres have been able to produce a comparable outcome. With the small population of New Zealand more than one high volume centre might not be achievable. We reviewed our series of oesophageal resections and compared them to outcomes in the literature to challenge the need for only high volume centres within New Zealand METHODS: A retrospective analysis of all consecutive oesophagogastrectomies performed in Christchurch Public Hospital (Christchurch City, New Zealand) from January 1998 until June 2009 was undertaken. RESULTS: Within this period 128 oesophagogastrectomies were performed. Median admission duration was 12 days. The overall complication rate was 53.9% of which 5.5% was an anastomotic leak. Combined in-hospital and 30-day-mortality was 1.6% (2/128). The 5-year-survival was 32.4% for adenocarcinoma and 47.7% for squamous cell carcinoma. Conclusion This series has shown that a low volume centre within New Zealand is able to deliver a satisfactory level of care for oesophagectomy. Given New Zealand's low population density it is debatable to what extent care should be centralised for treatment of oesophageal carcinoma.

Laparoscopic adjustable gastric bands and the effect of living in distant towns.

AIM: To investigate whether the results of laparoscopic adjustable gastric bands (LAGB) are adversely affected when patients live in towns distant from their surgeons. METHODS: A retrospective observational cohort study was conducted of patients having LAGB at Christchurch, New Zealand between March 2009 and March 2011. Patient demographics, postoperative band adjustments, and weight loss were recorded. The results were compared between those patients living in Christchurch and those that reside outside this region. RESULTS: There were 142 patients (123 female) with 97 (68%) living in Christchurch. These local patients were younger on average (mean age 45.6 plus or minus 11.3 years compared to 49.9 plus or minus 8.9 years; p=0.026) and of lesser size (mean BMI 43.1 plus or minus 7.1 kg/m2 compared 55.0 plus or minus 12.3 kg/m2; p<0.001) than those living beyond this region. There was no significant difference in the number of postoperative band adjustments between the two groups (Christchurch mean of 7.8 plus or minus 4.5 adjustments compared to 6.5 plus or minus 4.2 adjustments; (p=0.156) nor in the final volume that the band was adjusted to (Christchurch mean 4.6 plus or minus 1.3 mL compared to 4.1 plus or minus 1.7 mL; p=0.069). There was no significant difference in the weight loss between the groups at 2 years (Christchurch mean 41.4 plus or minus 17.3% excess body weight lost (EBWL) compared to 42.5 plus or minus 15.2% EBWL; p=0.829). DISCUSSION: This current study demonstrates that patients undergoing LAGB in Christchurch are not disadvantaged if they live in towns beyond this region.

Primary oesophageal malignant melanoma.

INTRODUCTION: Primary oesophageal malignant melanoma is an extremely rare disease. While this aggressive tumour is generally considered to have a dismal prognosis, long-term survival can be achieved by radical resection in selected cases. CONCLUSIONS: We report two cases of primary oesophageal malignant melanoma treated with Ivor-Lewis oesophagogastrectomy and review the literature.

Diaphragmatic hernias complicating pregnancy.

BACKGROUND: Diaphragmatic hernias complicating pregnancy are not a common problem but they can have catastrophic consequences. They can present to the surgeon as a life-threatening emergency or pose a management dilemma when detected incidentally. In this paper, recommendations for the management of non-hiatal maternal diaphragmatic hernias are made based on our experience and the available published reports. METHODS: The presentation, management and outcomes of a series of three recent cases are described. A review of all other reported cases of diaphragmatic hernias complicating pregnancy was also carried out. RESULTS: All three cases were emergency presentations in the third trimester of pregnancy, resulting from compression of thoracic contents. All cases required emergency laparotomy and one also required thoracotomy. Delivery was by Caesarean section at the time of emergency surgery in two cases and was delayed in the third case. There was one fetal and no maternal deaths. One mother suffered persistent pleural infection. One baby also had a diaphragmatic hernia requiring postnatal repair. Published reports showed only 36 previously reported cases of diaphragmatic hernias identified in pregnancy. There is a consensus that hernias presenting with evidence of strangulation represent a surgical emergency and mandate operative management, irrespective of fetal maturity. Elective management of asymptomatic hernias is more controversial and both conservative and operative approaches have been suggested. CONCLUSION: Diaphragmatic hernias can cause life-threatening complications in pregnancy. Consideration should be given to operative repair in the second trimester if asymptomatic hernias are identified during pregnancy. If vaginal delivery is attempted in the presence of a hernia, this should only be carried out under closely monitored conditions.