Outcome Comparison of Totally Implantable Venous Access Device Insertions Between Surgeons and Radiologists in Australia.

Background The need for chemotherapy treatment is increasing with the growing incidence of cancer worldwide. The insertion of totally implantable venous access devices (TIVADs) is commonly performed by surgeons and radiologists, but the procedures are not without complications. The primary outcome of this review outlines TIVAD insertion success and complication rates between general surgeons and radiologists. The secondary goal of this study is to help identify areas for improvement and consideration when performing TIVAD insertion. Methodology This was a descriptive, three-year, retrospective multicentre study of oncological patients who underwent TIVAD insertion by either general surgeons or radiologists at two peripheral Brisbane hospitals. Results Surgeons performed 61 percutaneous subclavian vein cannulations, 29 ultrasound-guided internal jugular veins, and seven open cephalic veins cut-down TIVAD insertions (n=97). Overall surgical success was 81.4%, with the internal jugular (89.7%) having the highest success rate followed by the open cut-down (85.7) and subclavian approaches (77.0%). The overall surgical complication rate was 16.4%, with five pneumothorax, five port malfunctions, three haemorrhages, two infections, one thrombus, and one mediastinal injury. Each pneumothorax was associated with subclavian cannulation attempts. Two haemorrhages were associated with both open cephalic and subclavian attempts. Radiologists performed 248 ultrasound-guided internal jugular vein TIVAD insertions (n=248) with 247 successful first attempts (99.5%). Within the radiology group, there was an overall complication rate of 15.3% with 22 infections, 14 port malfunctions, one haemorrhage, and 1 mediastinal injury. Conclusion Ultrasound-guided internal jugular vein TIVAD insertion had the highest first attempt success rate in both the surgical and radiology groups.

Situs inversus: an interesting case of spontaneous splenic rupture.

Situs inversus is described as exact mirroring of the normal anatomical arrangement of the major visceral organs. Polysplenia is a congenital anomaly associated with situs inversus and causes various splenic abnormalities. This case discusses a 62-year-old female who presented to the emergency department with hypotension and abdominal pain. Commuted tomography reveals situs inversus and a lobulated mass in the right upper quadrant consistent with a splenic rupture intraoperatively. This is the first reported case of a spontaneous splenic rupture in a patient with situs inversus. This case highlights the rarity of splenic injuries in situs inversus and the unique anatomical challenges that surgeons are faced with intraoperatively in a high-pressure environment.

Will a flexi-sig' do? A retrospective review of colonoscopies indicated by diverticulitis alone.

BACKGROUND: The incidence of colonic diverticulitis is increasing. In Australia the majority of diverticulitis occurs in the left colon and patients typically undergo colonoscopy following an attack. At present debate exists regarding the utility of this costly procedure and a flexible sigmoidoscopy has been proposed as a cheaper, less invasive alternative. This paper seeks to examine whether significant pathology is being detected in the right and transverse colon to warrant colonoscopy, as opposed to a flexible sigmoidoscopy. METHODS: A retrospective review of colonoscopies performed between August 2016 and August 2018, indicated by diverticulitis alone, performed in a single Australian metropolitan hospital. RESULTS: 189 patient colonoscopies were reviewed in combination with the pathology forms. Only 1 primary colonic malignancy was detected, found in the left colon. 110 traditional adenomas and 35 sessile serrated adenomas were detected. 41.8% of patients had a polyp detected with an average of 1.9 polyps per patient. 38.6% of polyps were resected from the left colon while 61.4% were removed from the right and transverse colon. In total 30 polyps > 10 mm or with high-risk histological features were resected, 18 (60%) from the left colon and 12 (40%) from the right and transverse. 20 patients (10.6%) met the criteria for high-risk adenomas and 50% of those had > 40% of their polyps in the right and transverse colon. There was no significant difference in age between patients with polyps and those without. CONCLUSION: Despite over half the patients having no polyps and only one left sided malignancy. This study demonstrates that the right and transverse colon is responsible for over 50% of the polyps removed and similar proportion of the advanced polyps. Where endoscopic surveillance after acute colonic diverticulitis is performed, this study supports the use of colonoscopy and cautions against flexible sigmoidoscopy alone.

It's not you, it's me: a descriptive study of patient complaints and surgeon understanding.

BACKGROUND: Patient complaints are an underutilized and under-addressed issue in general surgery. They represent a unique sphere of interaction for surgeons and patients to understand motivations and failures in the delivery of healthcare. The aims of this study were to identify motivators of patient complaints and understand surgeon's awareness of this issue. METHODS: A retrospective review of patient complaint data in a single regional general surgical department was undertaken between the periods October 2017 to June 2020 and June 2018 to October 2020 relating to patient demographics and subject of complaint. Secondly, an anonymous survey was conducted across the same department and results tabulated by seniority. RESULTS: Two hundred and nineteen complaints were received during the study period. One hundred and thirteen were made by patients, while 56 were made by family members. One hundred and fifty-nine complaints were related to an inpatient episode of care, and 152 were made in writing. The majority of complainants were female, with a mean age of 52. The most common reason for complaint was "treatment" (n = 102), followed by communication (n = 48), and humaneness/caring (n = 44). Consultant surgeons and surgical trainees placed communication, humaneness/caring, and professionalism as most likely to incite complaints, while interns were more likely to prioritize other measures such as patient healthcare rights and medications. CONCLUSION: Patient complaints remain a relatively under-utilized resource in addressing the downfalls of general surgical departments. This study reports patient demographics that are congruent with the literature and highlights that surgeons prioritize many non-technical skills in the maintenance of the doctor-patient relationship, in contrast to preconceptions.

Keratinocyte Skin Cancers in General Surgery: The Impact of Anaesthesia, Trainee Supervision, and Choice of Reconstruction.

BACKGROUND: Keratinocyte skin cancers are common in Australia, incurring disproportionately high health expenditure in comparison with mortality. General surgeons often excise these lesions as day-surgery. Balancing individual complexities of these cancers with trainee supervision and health expenditure is key to deliver efficacious care and maintain day-surgery volume for patients during a pandemic. METHODS: A retrospective, cross-sectional study was performed, examining 414 procedures from January 2019 to December 2020. Pathology was reviewed, and benign lesions excluded. Complete excision was based on 5 mm margins for squamous cell carcinoma (SCC), 0.5 mm microscopic margins for low-risk basal cell carcinoma (BCC) subtypes, and 3 mm for high-risk. Results of trainee-performed local anesthetic (LA) excision and general anesthetic (GA) excision (consultant scrubbed) were compared. RESULTS: 288 excisions were reviewed for completeness, location, and reconstruction modality. 69% were BCC (199), and 31% were SCC (89). These were excised under GA (72.5%) and LA (27.5%). 25.6% of BCC excisions were "close," and 22.6% were "positive" under GA, whilst 31% were "close" and 15.5% were "positive" under LA. 52.8% of SCC excisions were "close," and 7.8% were "positive" under GA, compared with 42.8% "close" and 9.5% "positive" under LA. Complex reconstruction (skin graft, flap) was more common under GA (38% SCC and 36.1% BCC), but occurred at a modest rate under LA (22% BCC and 28.5% SCC). CONCLUSIONS: The results confirm that comparable margins and reconstruction options are achievable when excising keratinocyte cancers under LA by surgical trainees. This is fundamental in cost and timesaving, as well as reducing risk of aerosolisation of virus during GA, in a pandemic.

Low thrombin tissue sealant ARTISS (Baxter), in complex primary closure after Fournier's gangrene.

The following case report describes the reconstruction of Fournier's gangrene (FG) which failed initial conventional primary closure due to issues with wound edge friability, large dead spaces, and significant tension and shearing forces created by excess adipose tissue in the patient's groin. In the first reported case that could be found in the literature ARTISS (Baxter), a low thrombin concentration fibrin sealant was used as a tissue adhesive to close the large post FG debridement wound flaps and ensure enough working time to allow for precise wound edge approximation. Employing Artiss in the closure of the large wound allowed for successful healing where simple primary closure had failed, aided an expedient recovery and reduced post reconstructive morbidity.