Outcomes of endoscopic retrograde cholangiopancreatography: a series from a provincial New Zealand hospital.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an essential tool in the management of pancreaticobiliary pathology. It is technically demanding and has the potential to cause significant morbidity and mortality. Several trials have identified small centres and lower hospital volume as risk factors for lower success rates and higher complication rates. Taranaki Base Hospital (TBH) is a provincial hospital with a catchment of 100 000, providing its population with an on-site ERCP service. Transporting patients to the nearest tertiary centre would incur significant costs to both the patient and district health board. AIMS: To determine the outcomes of performing ERCP at TBH and compare these with published figures. To determine if it is a safe and effective option for patients in this region. METHODS: An ambi-directional study of all ERCP procedures at TBH between January 2011 and December 2015 was conducted. Patient demographics, procedure indication and procedural details were captured via ProVation® MD and endoscopist's notes. Complications were identified through patient's notes and recorded if occurring within 30 days of the procedure. All complications were graded mild, moderate or severe based on a grading system described by Cotton et al. RESULTS: A total of 445 procedures were performed. Bile duct cannulation rate was 92.3% and therapeutic success rate was 89.9%. Complications occurred in 8.99% of patients and ERCP-specific mortality was 0.22%. Haemorrhage occurred in 1.35% of patients, pancreatitis in 5.2% and perforation in 0.45%. Success and complication rates are similar to other published studies. CONCLUSION: ERCP can be safely and successfully performed in a provincial centre.

Time delays in presentation and treatment of acute scrotal pain in a provincial hospital.

BACKGROUND: Acute scrotal pain is a urological emergency due to the possibility of testicular torsion and subsequent testicular loss if correction is not carried out in a timely manner. METHODS: We conducted a retrospective review of all patients who underwent surgical exploration for acute scrotal pain in a provincial hospital in New Zealand between 1 January 2001 and 31 December 2010. RESULTS: A total of 91 cases were identified. The median delay pre-hospital was 9 h and in-hospital was 2.5 h. Patients who had a non-viable testicular torsion and patients under the age of 14 had longer pre-hospital delays of 24 and 72 h, respectively. In-hospital delays were similar between all pathologies except for non-viable testicular torsions with 7 h and 45 min. Viable testicular torsions had a median in-hospital delay of 2 h and 13 min. CONCLUSION: Delay from the time of testicular pain until surgical exploration is important for the chances of testicular salvage and is made up mostly of pre-hospital delays. Patients under the age of 14 had longer delays pre-hospital.

The incidence and risk factors for lower limb skin graft failure.

Lower limb skin grafts are thought to have higher failure rates than skin grafts in other sites of the body. Currently, there is a paucity of literature on specific factors associated with lower limb skin graft failure. We present a series of 70 lower limb skin grafts in 50 patients with outcomes at 6 weeks. One-third of lower limb skin grafts went on to fail with increased BMI, peripheral vascular disease, and immunosuppressant medication use identified as significant risk factors.

Interhospital transfer of acute general surgical patients in the Taranaki region of New Zealand.

AIM: This study investigated the transfer of acute general surgical patients from HPH to TBH in order to evaluate Interhospital transfer time in a rural New Zealand setting. It specifically investigates the prioritisation and time to transfer of unwell patients who required ICU/HDU admission following transfer. METHOD: 9 months case-control retrospective study based on review of ambulance' "patient transfer sheets" and patients' medical records. Ambulance transfers of General Surgical emergencies were divided into two groups and analysed with group 1 admitted to ICU (ICU group) versus those admitted to the wards (non-ICU group). RESULTS: The majority of patients in the non-ICU group (34 patients, 77%) were managed conservatively while 8 patients (18%) underwent operative intervention. Four patients (24%) in the ICU group had surgery while 7 patients (41%) needed specialist investigations such as gastroscopy (n=5), ERCP (n=1) or angiography (n=1). One patient in each group died during their admission at TBH. CONCLUSIONS: There was no statistically significant difference in ambulance transfer times between the ICU and non-ICU groups (138 versus 124 minutes respectively), with the main determinant being the "ambulance response time" which could have been shortened by better identification of acute general surgical patients who ultimately required ICU/HDU care following transfer. The development of local protocols and checklists ensuring necessary communication between hospital and ambulance staff may allow better triage and prioritisation of transfer and lead to shorter transfer times for more unwell patients.

Ureteric Injury due to the Use of LigaSure.

Background. LigaSure is a bipolar clamping device used in open and laparoscopic surgeries for producing haemostasis in vascular pedicles up to 7 mm in diameter ("Covidien LigaSure technology: consistent, reliable, trusted vessel sealing," 2012). The use of LigaSure has made securing haemostasis and tissue dissection relatively easy especially in laparoscopic surgery; however, if not used with care it can cause damage to the surrounding structures through lateral spread of energy. Case Report. This case report discusses the induction of a thermal ureteral injury associated with the use of LigaSure. An 80-year-old gentleman was operated for bowel cancer. LigaSure was used for securing haemostasis and tissue dissection. Postoperatively, he was found to have damage to the right ureter secondary to lateral spread of energy from the jaws of LigaSure with high abdominal drain output. Conclusion. Judicious and careful use of electrosurgical devices should be done to prevent inadvertent damage to the surrounding structures. Early recognition and involvement of a urologist can prevent long-term complications.

Why Taranaki women choose to have a mastectomy when suitable for breast conservation treatment.

BACKGROUND: Breast conservation treatment (BCT) rate is recognized as a marker of surgical practice. An historically low BCT rate may reflect the requirement for Taranaki women to travel for adjuvant radiotherapy. The aim of this study was to determine the reasons Taranaki women with breast cancer choose mastectomy or BCT. METHODS: Prospective information, on all women presenting with breast cancer between May 2004 and December 2006, was collected on a standardized questionnaire. RESULTS: BCT was offered to 68% (140 of 206), but chosen by only 46% (n = 64) of suitable patients. If radiotherapy had been available locally, 23% (17 of 73) of patients who chose mastectomy would have instead opted for BCT. A quarter of each group of women thought they knew their surgeon's treatment preference and most chose this option. Fear of local recurrence and need for further surgery were significantly more important to those choosing mastectomy over BCT whereas what the surgeon was perceived to prefer was more important to those choosing BCT. CONCLUSION: The rate of BCT in Taranaki is low, despite it being offered by surgeons to the majority of patients. Local availability of radiotherapy may increase the BCT rate to a level more consistent with larger centres in New Zealand. Care must be taken to provide neutral patient guidance.

Skin grafts: a rural general surgical perspective.

BACKGROUND: Skin grafts are a common method of closing skin defects. The literature comparing methods of graft application and subsequent outcomes is poor, but reports indicate a graft failure rate between 2 and 30%. The aim of this study was to audit our current skin graft practice. METHODS: Data were collected prospectively on all skin grafts performed by the general surgical department between 1st December 2005 and 1st December 2006. A standardized proforma on each patient included data on age, gender, graft indication, application method, comorbidities, length of stay, and graft outcomes including graft take at 1, 2 and 6 weeks post-operatively. RESULTS: There were 85 grafts performed on 74 patients, median age 72 years (9-102 years), with 10 (12%) acute admissions. Prophylactic antibiotics were given to 50% (38 of 74) of patients. Successful grafts (>80% take) were performed in 68 (80%) patients. The overall graft complication rate was 24.7% (22 of 85 grafts). Infection occurred in 13 of 17 graft failures. No patients underwent re-operation for graft failure. Patients who received prophylactic antibiotics had a reduced risk of graft failure (Fisher's exact test, P = 0.016). CONCLUSION: Skin grafts were performed successfully in the majority of patients. Graft complication and failure rates compare well with the world literature. The use of prophylactic antibiotics was the only predictor of successful graft take.

Sentinel lymph node biopsy experience in Taranaki: a prospective audit in a provincial New Zealand hospital.

AIM: Sentinel lymph node biopsy has been rapidly incorporated into the management of early stage invasive breast cancer. The aim of this study was to review the adoption of sentinel lymph node biopsy at a provincial centre in New Zealand and compare markers of performance against established standards. METHODS: The Taranaki Breast Database was created in 2002 and prospectively records data from all breast cancer patients in the Taranaki area. Data on all patients undergoing sentinel lymph node biopsy were retrieved and the results reviewed. RESULTS: Between October 2002 and August 2007, 152 sentinel lymph node biopsies were undertaken in 151 patients. The initial 49 patients (training set) also underwent routine axillary clearance as part of an initial audit on the accuracy of sentinel lymph node biopsy. A sentinel node was identified in 97% of patients (93% including the training set) and a mean of two nodes per biopsy were removed. Metastatic nodal disease was identified in 40 of 152 (26%) of biopsies of which nine were micrometastases. In the training set there was a false negative rate for nodal spread of 5% (two of 40) and a 92% negative predictive value. CONCLUSIONS: The performance of sentinel lymph node biopsy in Taranaki is comparable to international centres. Adoption of this technique as routine may spare many Taranaki women the morbidity of axillary clearance, without jeopardising safety.

Risk-adjusted general surgical audit in octogenarians.

BACKGROUND: Surgical admissions in patients more than the age of 80 years are increasing. Age-related comorbidities place this group at particular risk of complications and death. The aim of this study was to specifically document our current outcomes in patients more than 80 years old admitted to a surgical unit, in particular, to assess the risk-adjusted scoring tool used to predict outcomes in this patient population for operative and non-operative patients. METHODS: A prospective audit of all patients older than 80 years admitted to the general surgical unit between the 1 January and 30 November 2006 was carried out. Morbidity and mortality data were collected on standardized pro forma. RESULTS: There were 243 consecutive admissions in 223 surgical patients (readmission 8.2%, n = 20) comprising 70 emergency admissions (28.8%), 82 elective admissions (33.8%) and 91 non-operative admissions (37.5%). Complications occurred in 47.1% of emergency admissions, 18.3% of elective admissions and 23.3% of non-operative admissions. Thirty-day mortality was 15.7% (n = 11) for emergency admissions, 0% for elective admissions and 17.4% (n = 16) for non-operative admissions. Emergency laparotomy 30-day mortality was 31.6% (n = 6). There was no evidence of lack of fit when using the risk-adjusted scoring tool to compare observed with predicted deaths in all patient groups. CONCLUSION: In all patients more than the age of 80 years admitted to General Surgery, Taranaki Base Hospital, morbidity and mortality results were acceptable when compared with published work. Risk-adjusted prediction of mortality compared favourably with observed outcomes, but more data are required to validate this tool in elective patients.

Paediatric surgery carried out by general surgeons: a rural New Zealand experience.

BACKGROUND: There are increasing moves towards centralization in paediatric surgery. With only four paediatric tertiary centres in New Zealand, many general surgeons still routinely carry out paediatric surgery. We present an audit of paediatric surgical patients admitted to our general surgical unit. METHODS: Data were prospectively recorded using a standardized pro forma on all children aged 15 years and below, who presented to general surgery between 11 December 2005 and 11 December 2006. RESULTS: There were 209 admissions (194 children); the median age was 8 years (range 6 weeks to 15 years) with 153 (73%) acutes. Male : female ratio was 3:2 and 37 children (18%) were less than 2 years of age. Procedures (n = 119) comprised appendicectomy (35), inguinal herniotomy (30), skin procedures (29), endoscopy (10), testicular (10) and others (5). The commonest acute and elective operations were appendicectomy and inguinal herniotomy, respectively, with 51% of all operations carried out acutely. There were 10 tertiary hospital transfers (5%) for burns (4), pyloric stenosis (3), intussusception (1), neonatal inguinal hernia (1) and pyoderma gangrenosum (1). Median age of transfers was 11 months (range 6 weeks to 14 years). Complications were wound infection (1), postoperative ileus (2) and infarcted ovary (1). CONCLUSION: A large number of children presented to our surgical department. Approximately half required surgery and half of the operations were acute. There is still a significant need for general paediatric surgery in the provinces and hence close collaboration with specialist paediatric surgeons.

Prospective audit of colorectal resections in a peripheral public hospital.

BACKGROUND: Colorectal disease requiring surgery is common in New Zealand where there is no established national colorectal screening programme. We established an audit to review our current practice in colorectal surgery. METHODS: Prospective audit data were collected on consecutive patients undergoing colorectal resection between April 2003 and December 2004, using a standardized pro forma. RESULTS: In all, 170 colorectal resections were carried out of which 117 (69%) were for malignancy and 120 (71%) were elective. Median patient age was 72 years (interquartile range 62-78 years) and median length of stay was 10 days (interquartile range 8-14 days). Colonoscopy was the most common method of investigation. In elective patients with malignancy, the average delay between onset of symptoms and surgery was 25 weeks. Duke's stage C was the most common stage at presentation (44%). Complications developed in 83 (49%) of patients including 20 (12%) patients returned to theatre, 5 (3%) anastomotic leaks and 8 deaths (5%). In patients undergoing surgery aged over 80 (n = 40) the median length of stay was 10 days (7-14) with a complication rate of 21 (55%) including 5 (13%) who were returned to theatre and 6 (16%) deaths. CONCLUSION: This audit has confirmed that there is an acceptable level of care at Taranaki Base Hospital when compared with those in published work. Elective patients with malignancy have a delay of nearly 6 months between the onset of symptoms and surgery. Patients in Taranaki are more likely to present with an advanced stage of tumour compared with other unscreened populations.

Quality of life assessment in patients with inguinal hernia.

BACKGROUND: The natural history of untreated inguinal hernia (IH) is poorly understood. Whether a delay in operative repair of IH leads to excessive physical suffering or significant psychosocial impairment is not known. This study attempts to quantify the morbidity of patients with IH by assessing their quality of life (QOL) while on a waiting list for IH surgery. METHODS: QOL was measured in adult patients with IH who were on the waiting list using a standardized SF-36 questionnaire. Scores were compared with a sample of age-, sex- and comorbidity-matched controls. RESULTS: A total of 143 patients were identified, of which 106 were included in the study. Patients with IH had significantly impaired QOL compared with comorbidity- and demographic-matched controls across all of the domains measured. Subgroup analysis showed an inverse relationship between the size of the IH and the QOL and patients employed in manual work tended to have lower QOL compared with those with sedentary vocations. CONCLUSIONS: In conclusion, we showed that the SF-36 score is a good measure of QOL in this patient group. Those patients on the elective waiting list for repair of IH have a significantly impaired QOL compared with age-, sex- and comorbidity-matched controls.