Synchronous malignant phyllodes tumour and invasive lobular carcinoma-case report and review.

Synchronous phyllodes tumour and invasive lobular carcinoma is an extremely rare event. We report these concurrent diagnoses in a patient observed in an ipsilateral breast, suspected due to breast risk factors (family history and lobular carcinoma in situ) and the presence of malignant phyllodes. Screening breast magnetic resonance imaging was able to identify the carcinoma which was occult in other imaging. An understanding of the possibility of dual diagnoses may lead to additional investigations for its identification. Treatment may then be tailored to the individual's pathology.

Survival outcomes following aggressive treatment of oligometastatic breast cancer: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this systematic review is to assess the effectiveness of aggressive treatment of oligometastatic breast cancer (OMBC) on survival outcomes by conducting a meta-analysis of current available evidence.More specifically, the objectives are to identify the effectiveness of intensified multidisciplinary treatment with aggressive locoregional therapies on survival time, five-year survival rates and disease free survival. The population is adult women (18 years and over) with OMBC defined as single or few (five or less) metastases limited to a single organ and the comparative group is conventional palliative treatment aimed at disease control. Secondary objectives to be assessed will be adverse outcomes associated with intensified treatment regimes.

Impact of an acute surgical unit on patient outcomes in South Australia.

BACKGROUND: Compared with traditional (Trad) systems of managing emergency surgical presentations, the acute surgical unit (ASU) model provides an on-site registrar, on-call surgeon and dedicated emergency theatre, 24 h/day. To date, there have been no Australasian ASU studies of >3000 patients, nor from South Australia. METHODS: A retrospective historical control study compared the outcomes of adults admitted to the Lyell McEwin Hospital in the Trad (1 February 2010 to 31 July 2012) and ASU periods (1 August 2012 to 31 January 2015), who underwent an emergency general surgical procedure. RESULTS: A total of 4074 patients met inclusion criteria; 1688 and 2386 patients during the Trad and ASU periods, respectively. The cohorts were not significantly different in median age, gender or American Society of Anesthesiologists scores. Compared with the Trad period, improved median time from emergency department referral to theatre start (19.4 h versus 17.9 h, P < 0.0001) and median length of stay (2.32 days versus 2.06 days, P < 0.0001) were observed during the ASU period. The proportion of procedures performed in-hours was similar (77.9% versus 79.6%, P = 0.18). Secondary outcomes of rates of intensive care unit admission, emergency department representation within 30 days, in-hospital mortality and 1-year all-cause mortality were unchanged. CONCLUSION: Institution of an ASU was associated with decreased time from referral to theatre and reduced length of stay. The proportion of cases performed in-hours did not change. This may be related to the high Trad period rate and increased workload. These findings represent the largest Australasian study of an ASU and support the current model of care.

Minimally invasive parathyroidectomy using surgeon-performed ultrasound and sestamibi.

BACKGROUND: Surgeon-performed ultrasound (SPU) and (99m)Tc-sestamibi (SM) scanning can be used alone or in combination in patients with primary hyperparathyroidism to select cases suitable for minimally invasive parathyroidectomy (MIP). The aim of the study was to evaluate SPU and SM and to determine the reliability they provide the surgeon in planning and carrying out MIP. METHODS: The study was a prospective analysis of 130 patients with primary hyperparathyroidism who had preoperative localization with SPU and SM at a tertiary referral centre between 2003 and 2006. All ultrasound scans were carried out by one surgeon, followed by correlative sestamibi scan and a further 'on operating table' ultrasound to reassess the lesion and mark the operative site. Selection criteria for MIP were a positive SPU and SM, although a positive SPU or SM allowed the surgeon to focus on the nominated side. SPU and SM localizations were correlated to the operative findings. RESULTS: One hundred and thirty patients underwent both SPU and SM. There were 97 women and 33 men, with a mean age of 59 years. SPU alone identified the abnormal parathyroid in 103 cases (sensitivity 82%; positive predictive value 96.3%). SM alone identified the abnormal gland in 102 cases (sensitivity 79%; positive predictive value 99%). In 88 patients, the SPU and SM were concordant, and 94% had successful MIP. SPU and SM were both negative in 13 patients, and all these patients had bilateral neck exploration. CONCLUSION: SPU in the hands of an experienced surgeon in association with sestamibi is a reliable tool for the preoperative localization of parathyroid adenomas and facilitates a minimally invasive procedure.

Diagnostic value of plain abdominal radiographs in patients with acute abdominal pain.

OBJECTIVE: A prospective study was performed over a 3-month period in a tertiary referral centre to evaluate the appropriateness and contribution of plain abdominal radiographs (PAR) in the diagnosis and management of adult patients presenting with acute abdominal pain. METHODS: Forward stepwise logistic regression was used to examine the correlation between PAR findings and the final diagnosis. The Chi-squared test was used to determine any changes in patient management including requirement for surgical intervention based on PAR findings (p < 0.05). RESULTS: Of 168 patients (246 PAR), 59 (35%) had positive findings on PAR. PAR were most sensitive in cases of intestinal obstruction (odds ratio, OR = 33.548, r = 0.561). The sensitivity was further increased if three of the following predictive signs were present: exaggerated bowel sounds (OR = 13.350, r = 0.154), abdominal distension (OR = 2.993, r = 0.234) and age over 50 years (OR = 2.301, r = 0.027). PAR were non-diagnostic in 82% of patients with acute abdominal pain (p < 0.001). CONCLUSION: PAR do not play a major role in influencing the management of patients with acute abdominal pain without coexisting bowel obstruction.

Appropriate antibiotic administration in elective surgical procedures: still missing the message.

OBJECTIVE: The aim of this study was to determine the appropriateness of antibiotic prophylaxis in selected elective surgical procedures in a tertiary referral centre. METHODS: A cross-sectional study using retrospective data from January 2000 to May 2002 was performed pertaining to elective colorectal surgery, cholecystectomy and inguinal hernia repairs. Appropriateness of antibiotic administration was determined based on compliance with national and internationally accepted guidelines on prophylactic antibiotic prescribing policy. A single dose or omission of antibiotic administration was judged appropriate for cholecystectomy and inguinal hernia repair, while up to 24 hours' dosing was considered appropriate practice for colorectal surgery. RESULTS: Of 419 cases, there were 55 (13.1%) colorectal procedures, 97 (23.2%) cholecystectomies and 267 (63.7%) inguinal hernia repairs. Antibiotics were administered in a total of 306 (73%) cases, with single-dose prophylaxis in only 125 (41%) of these. Prophylaxis was inappropriately prolonged in 80%, 52% and 31% of colorectal, cholecystectomy and inguinal hernia cases, respectively. The corresponding mean duration of anti-biotic administration was 2.4+/-2.2, 1.6+/-1.8 and 1.1+/-1.3 days, respectively. CONCLUSION: Antibiotic prophylaxis in elective surgery continues to be administered haphazardly. This study supports close surveillance of antibiotic utilization by a dedicated team, perhaps consisting of microbiologists or pharmacists, to minimize inappropriate administration.

Venous thromboembolic disease prophylaxis among general surgeons in Malaysia.

OBJECTIVE: The aim of this study was to analyse the current practice of venous thromboembolism (VTE) prophylaxis among general surgeons in Malaysia. METHODS: A questionnaire survey was conducted among general surgeons attending the annual Malaysian College of Surgeons meeting in 2002. A total of 110 questionnaires were distributed to specialist-grade general surgeons with varying subspecialty interests. RESULTS: Seventy-seven (70%) surgeons returned the questionnaire. Of these, 43% were of the opinion that VTE was as common in Asian patients as in the West. Selective VTE prophylaxis was used by 99% in their practice. The indications for use, in order of frequency, were: previous VTE disease, risk grading, prolonged surgery, obesity, malignancy and age. Low molecular weight heparin was the most common type of prophylaxis used. VTE-related morbidity was reported by 44 surgeons (57%) over the past year, and 39% of these cases were fatal. CONCLUSION: The high incidence of VTE-related complications indicates that the use of thromboprophylaxis is either insufficient or not matched to the level of risk. Updated guidelines on VTE prophylaxis should be used so that a standardized approach can ensure that patients receive adequate prophylaxis where indicated.

Adult intussusception secondary to inflammatory polyps.

Adult intussusception is a rare entity that may present in the acute and subacute setting principally related to the degree of bowel obstruction. Preoperative diagnosis of this condition may be difficult. The intussusception is usually due to a definable intraluminal lesion, most probably neoplasia, unlike intussusception in children. We present the cases of two adult male patients with intussusception. The first presented with acute small-bowel obstruction secondary to a retrograde ileojejunal intussusception with a pseudopolyp as the lead point. This was possibly due to a retrograde ball-valve effect. The intussuscepting segment was resected. The second patient presented with unexplained chronic diarrhoea and an intussusception occurring within the caecum, as demonstrated at colonoscopy, with a terminal ileal pedunculated fibroid polyp as the lead point. A limited right hemicolectomy was performed. Both patients recovered uneventfully and have remained well. A brief literature review of adult intussusception complements the case reports, with an emphasis on the pathogenesis of inflammatory polyps and recommended surgical management.

Pharmacotherapy for chronic hemorrhagic radiation proctitis.

Endoscopic thermal therapy and formalin are being increasingly recommended for the treatment of chronic hemorrhagic radiation proctitis. It may be too early, however, to discard pharmacologic agents from the management process, especially in medical institutions where specialized equipment is unavailable. We prospectively assessed the effectiveness of medical therapy in 14 consecutive patients with chronic hemorrhagic radiation proctitis from July 1999 to June 2001. All 14 subjects were women (mean age 56 years), 13 of whom had had radiotherapy for cancer of the cervix. The median time to onset of symptoms following irradiation was 16 months. Six patients had a hemoglobin level of < 8 g/dl, and blood transfusion was required in 11 patients. In five patients (36%) initially treated with hydrocortisone enemas prior to referral, this treatment continued; and the remaining nine patients were commenced on sucralfate enemas. Two patients given rectal hydrocortisone continued to bleed and were treated with sucralfate enemas and topical formalin, respectively. Rectal sucralfate suspension effectively procured symptomatic alleviation in all 11 patients. Rectal bleeding recurred in two patients who had been managed exclusively with hydrocortisone and sucralfate enemas, respectively, over a mean follow-up of 6 months. Both patients were managed with topical formalin, which controlled their symptoms. Even though the number of subjects in this study is small, sucralfate enema can be recommended as an effective first-line agent for managing patients with chronic hemorrhagic radiation proctitis. The use of more specialized therapy can therefore be reserved for cases where primary treatment failure occurs with sucralfate therapy.