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.

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.

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.

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.