Isolated non-hepatic metastasis from upper gastrointestinal adenocarcinoma: a case for surgical resection

Case ReportINTRODUCTION: Upper Gastrointestinal Tract (UGIT) malignancy is an increasing problem in western society and its prognosis is generally poor. The prognosis dims even further with the presence of loco regional recurrences or distant metastasis. This article looks at the feasibility and potential benefit from resection of non-hepatic, non-nodal metastases and recurrences. PRESENTATION OF CASE: Case 1. A 72-year-old male who underwent total gastrectomy for a gastric adenocarcinoma presented with a splenic mass 40 months later and underwent a splenectomy. He is disease free at 30 months post-metastectomy. Case 2. A 54-year-old male with oesophagogastric junctional adenocarcinoma, underwent an Ivor-Lewis oesophagectomy. He developed a distal pancreatic mass at 24 months follow-up and underwent distal pancreatectomy and splenectomy. He is disease free at 12 months post-metastectomy. Case 3. A 75-year-old male underwent subtotal gastrectomy for lesser curvature adenocarcinoma. At 42 months follow-up, he developed solitary abdominal wall recurrence. This was locally resected with clear margins. After 12 months, he developed another full thickness abdominal wall recurrence with involvement of the hepatic flexure. Enbloc resection including right hemicolectomy was performed and he is disease free at 3 months. DISCUSSION: There is very scarce literature on resection of non-hepatic, non-nodal recurrences/distant metastasis in oesophagogastric cancers. Based on these cases, a surgical resection in selected cases may provide prolonged survival with good quality of life. CONCLUSION: Resection for isolated recurrences and metachronous metastasis from UGIT cancers may be worthwhile, especially if patients have minimal co-morbidities.A.K.J. Kiu, A.N. Lord, M.I. Trochsler, G.J. Maddern, H.A. Kanher

Trends in utilisation of ultrasound by older Australians (2010-2019)

Background: Older people have increasingly complex healthcare needs, often requiring appropriate access to diagnostic imaging, an essential component of their health and disease management planning. Ultrasound is a safe imaging tool used to diagnose several conditions commonly experienced by older people such as deep vein thrombosis. Purpose To evaluate the utilisation of major ultrasound services by Australians≥65 years old between 2009- and 2019. Methods: This population-based and yearly cross-sectional study of ultrasound utilisation per 1,000 Australians≥65 years old was conducted using publicly available data sources. Overall, examination site and age- and sexspecifc incidence rate (IR) of ultrasound per 1,000 people, adjusted incidence rate ratios (IRRs) and 95% confdence intervals (CIs) were calculated using negative binomial regression models. Results: Over the study period, the crude utilisation of ultrasound increased by 83% in older Australians. Most ultrasound examinations were conducted on extremities (39%) and the chest (21%), with 25% of all ultrasounds investigating the vascular system. More men than women use ultrasounds of the chest (184/1,000 vs 268/1,000 people), particularly echocardiograms (177/1,000 vs 261/1,000 people), and abdomen (88/1,000 vs 92/1,000 people), especially in those≥85 years old. Hip and pelvic ultrasound were used more by women than men (212/1,000 vs 182/1,000 people). There were increases in vascular abdominal (IRR:1.07, 95%CI:1.06–1.08) and extremeties (IRR:1.06, 95%CI:1.05– 1.07) ultrasounds over the study period, particularly in≥75 years old men. Conclusions: Ultrasound is a common and increasingly used diagnostic tool for conditions commonly experienced by older Australians.Virginie Gaget, Maria C. Inacio, David R. Tivey, Robert N. Jorissen, Wendy J. Babidge, Renuka Visvanathan, and Guy J. Madder

Public reporting of surgeons' performance

Guy J Madder

New surgical technology: do we know what we are doing?

Guy J Madder

Trainee satisfaction in surgery residency programs

Guy J. Madder

Surgical implications of global warming

Joseph W Smith, Guy J Madder

Assuring quality in HPB surgery – efficacy and safety1

Surgical innovations have made enormous contributions towards the welfare of patients when they have been appropriate, effective and applied with expertise and overall care. However, the potential for advancement and for harm of new surgical techniques, and the level of expertise necessary for their safe introduction, are not always immediately apparent. Furthermore, it is difficult and time-consuming to assess the efficacy and safety of new procedures in the clinical setting. In 1998 the Royal Australasian College of Surgeons established ASERNIP-S, the Australian Safety and Efficacy Register of New and Interventional Procedures – Surgical, to help ensure that new technologies that are being introduced are well proven in concept, are as safe and effective as possible, and are utilized with high levels of skill underpinned by the level of training

Appendicectomy mortality: an Australian national audit

BACKGROUND:Appendicectomy is a safe surgical procedure with minimal risks. Low mortality rates (0.04-0.24%) have been reported from a number of countries. Appendicectomy mortality rates have not been reported in Australia in recent years. The aim of the study was to conduct an appendicectomy mortality audit, to identify clinical management issues and to calculate the mortality rate of appendicectomy in Australia. METHODS:This study analysed data from a peer review of appendicectomy deaths in Australian hospitals of all states and territories, from 2006 to 2017. Additional procedural data were obtained from the Australian Institute of Health and Welfare for the calculation of mortality rates. RESULTS:The final analysis included 82 patients of whom 62 were elderly (age >65 years) with 47 males and 35 females. Two or more comorbidities were present in 68 patients. Open operation was performed in 62 patients, with complicated appendicitis found in 50 cases. The majority of management issues were non-surgical. Of the 16 surgical management issues identified, 11 issues occurred post-operatively in the elderly, which were potentially preventable. The overall mortality was 0.02% with 0.01% in the young (age <65 years) and 0.20% in the elderly. CONCLUSION:Australia's appendicectomy mortality rate was very low and comparable to international figures. Surgical management of appendicectomy was satisfactory in general. However, post-operative care in the elderly was found to be poor at times, with room for improvement. Further research is needed whether improvements in post-operative care could alter the clinical course to death in the elderly.E. Young, S. Stewart, G. A. J. McCulloch, G. J. Madder

Fatal flaws in clinical decision making

Background: Clinical decision making is a core competency of surgical practice, involving a continuous and evolving process of data interpretation and evaluation. The aim of this article is twofold. First, to recognize patient deaths where a clinical incident arose following unsatisfactory clinical decision making, determining where in the clinical decision-making process each failure occurred. Second, to discuss and explore individual incidents to provide lessons from which the surgical community can learn. Methods: Using the Australian and New Zealand Audit of Surgical Mortality database, all deaths from 1 January 2015 to 31 December 2015 were analysed. All deaths in which the surgeon or assessor identified an aspect of patient management that was inadequate were recognized. Clinical incidents deemed by the assessor to be an area of concern or an adverse event were individually reviewed to determine if a clinical decision-making incident (CDMI) occurred. CDMIs were categorized into various themes depending on the nature of the incident. Results: A total of 3422 fully audited deaths occurred throughout the study period; from these cases, 226 individual CDMIs were identified. Decision to operate was the most commonly identified CDMI (n = 99, 43.8%), followed by diagnostic error (n = 49, 21.7%). The least common CDMI identified was inadequate post-operative assessment (n = 14, 6.2%). Conclusion: This paper demonstrates thought-provoking examples of clinical decision-making failure implicated in patient death. Clinical decision-making failures most commonly occur around the decision to operate with increased discussion of complex cases possibly required. Further CDMI evaluation should be considered to complement more traditional methods of surgical mortality evaluation.Sean S. Davis, Wendy J. Babidge, Glenn A.J. McCulloch, and Guy J. Madder