Body composition assessment by artificial intelligence can be a predictive tool for short-term postoperative complications in Hartmann's reversals.

BACKGROUND: Hartmann's reversal, a complex elective surgery, reverses and closes the colostomy in individuals who previously underwent a Hartmann's procedure due to colonic pathology like cancer or diverticulitis. It demands careful planning and patient optimisation to help reduce postoperative complications. Preoperative evaluation of body composition has been useful in identifying patients at high risk of short-term postoperative outcomes following colorectal cancer surgery. We sought to explore the use of our in-house derived Artificial Intelligence (AI) algorithm to measure body composition within patients undergoing Hartmann's reversal procedure in the prediction of short-term postoperative complications. METHODS: A retrospective study of all patients who underwent Hartmann's reversal within a single tertiary referral centre (Western) in Melbourne, Australia and who had a preoperative Computerised Tomography (CT) scan performed. Body composition was measured using our previously validated AI algorithm for body segmentation developed by the Department of Surgery, Western Precinct, University of Melbourne. Sarcopenia in our study was defined as a skeletal muscle index (SMI), calculated as Skeletal Muscle Area (SMA) /height2 < 38.5 cm2/m2 in women and < 52.4 cm2/m2 in men. RESULTS: Between 2010 and 2020, 47 patients (mean age 63.1 ± 12.3 years; male, n = 28 (59.6%) underwent body composition analysis. Twenty-one patients (44.7%) were sarcopenic, and 12 (25.5%) had evidence of sarcopenic obesity. The most common postoperative complication was surgical site infection (SSI) (n = 8, 17%). Sarcopenia (n = 7, 87.5%, p = 0.02) and sarcopenic obesity (n = 5, 62.5%, p = 0.02) were significantly associated with SSIs. The risks of developing an SSI were 8.7 times greater when sarcopenia was present. CONCLUSION: Sarcopenia and sarcopenic obesity were related to postoperative complications following Hartmann's reversal. Body composition measured by a validated AI algorithm may be a beneficial tool for predicting short-term surgical outcomes for these patients.

"A button in my Benjamin" - Self-inflicted insertion of button batteries into the male urethra: Management and complications.

We present a case of self-insertion of multiple button batteries into the urethra. Button batteries are corrosive and tissue liquefaction and necrosis can occur within 2 hours. Emergent removal, intravenous antibiotics, suprapubic and indwelling catheter insertion and close monitoring are required to prevent further tissue injury. In our case, the batteries were removed with stent grasper forceps. There was extensive caustic circumferential injury to the urethral mucosa on cystoscopic examination. This was complicated by periurethral necrosis and abscess, requiring urgent incision and debridement. No reconstruction was performed due to the very high risk of graft failure.

Reversal of Hartmann's procedure: timelines, preoperative investigations and early outcomes. A single Australian institution's ten-year experience.

BACKGROUND: Real-world data on outcomes following Hartmann's reversal is necessary to help optimize the patient experience. We have explored the timing between the index operation and its reversal; what investigations were carried out prior to this, and the associated short-term outcomes. METHODS: A retrospective study of all patients who underwent Hartmann's reversal from 2010 to 2020 within a tertiary referral centre in Melbourne, Australia. One hundred from a total of 406 (25%) who underwent an emergency Hartmann's procedure had a subsequent reversal. Complete patient data was available for 83 of these patients. RESULTS: The average patient age was 60 years, and the median time for reversal was 14.0 (IQR 10-23) months. Seventy-nine of 83 (95%) reversals had a preoperative endoscopic evaluation of both their rectal stump and a complete colonoscopy. Stoma stenosis (n = 2), patient refusal (n = 1) and emergency reversal (n = 1) were cited reasons for not undergoing preoperative endoscopic evaluation. A third (n = 28, 34%) had a computed tomography prior to reversal; the majority was due to their underlying cancer surveillance (n = 21, 75%). Reversal was associated with a morbidity rate of 47% (n = 39). Surgical site infections (SSIs) (n = 21, 25%) were the most common type of complications encountered, with the majority being superficial (n = 15, 71%). SSIs were associated with steroid use (5/21 versus 4/62, p = 0.03) and greater hospital length of stay (6 versus 10 days, p = 0.03). CONCLUSION: Only a quarter of emergency Hartmann's procedures within our institution were reversed. A significant proportion developed postoperative complications. Surgical site infection was the most common morbidity.

Evaluating the effect of online surgical education on intraoperative cholangiogram interpretation: a pilot study.

BACKGROUND: Web-based educational tools can support practitioners in their early years of surgical training. Such tools may be an alternative platform to meet the changing needs in surgical training and professional development and may help explain complex surgical principles providing a structured learning platform that is relevant in the day-to-day surgical operating room setting. We investigated the impact of an online surgical education initiative on inter-observer variability and accuracy of IOC interpretation. METHODS: A convenience sample of seven surgical observers evaluated 100 IOCs before and after an online surgical series to evaluate their interpretation. The online video series characterized IOCs using nine key elements. The seven observers were surgical trainees of varying experience, from first-year surgical trainees to surgical fellows, within a metropolitan hospital in Melbourne, Australia. RESULTS: Inter-observer variability improved within six of nine key elements following the online tutorial. The accuracy of three out of these interpretations also significantly improved following the tutorial. Inter-observer agreement of proximal biliary opacification improved from moderate (kappa (κ) = 0.491) to good (κ = 0.725), with an improvement in accuracy from 95% to 99% (P = 0.009). Similarly, inter-observer agreements of cystic duct leaks dramatically improved from no agreement (κ = -0.089) to moderate agreement (κ = 0.548), with detection rates improving from 67% to 82% (P < 0.05). CONCLUSION: Through an innovative pilot online surgical education, inter-observer agreement and overall accuracy in the key elements of IOC interpretation improved. A larger multicenter study evaluating the effect of online surgical education on intraoperative cholangiogram interpretation is justified.

Preventing calcium and vitamin D deficiencies following weight loss and metabolic surgery.

INTRODUCTION: Uncertain nutritional outcomes following common metabolic surgical techniques are concerning given the long-term potential for postoperative metabolic bone disease. This study aims to investigate the variations in serum calcium, vitamin D, and parathyroid hormone (PTH) levels following Roux-en-Y Gastric bypass (RYBP) and Sleeve Gastrectomy (SG). METHODS: A retrospective analysis of 370 patients who underwent metabolic surgery at a single-centre group practice in Melbourne, Australia, over 2 years. RESULTS: Patients underwent SG (n = 281) or RYGP (n = 89), with 75% and 87% of the cohort being female, respectively. Postoperative mean serum calcium levels and median serum vitamin D levels improved significantly by 24 months within both cohorts. Serum PTH levels within the RYBP group were significantly higher than the SG group across all time points. PTH levels significantly fell from 5.7 (IQR 4.2-7.4) to 5.00 (4.1-6.5) pmol/L by 24 months following SG. However, PTH levels following RYBP remained stable at 24 months, from 6.1 (IQR 4.7-8.7) to 6.4 (4.9-8.1) pmol/L. Furthermore, we failed to notice a significant improvement in PTH levels following RYBP among those with higher PTH levels preoperatively. CONCLUSION: Higher PTH levels following RYBP, compared to SG, may imply we are undertreating patients who are inherently subjected to a greater degree of malabsorption and underlying nutritional deficiencies. This finding calls for a tailored supplementation protocol, particularly for those with high preoperative PTH levels undergoing RYBP, to prevent deficiencies.