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Background: Emergency presentations make up a large proportion of a general surgeon's workload. Patients who have emergency surgery carry a higher rate of mortality and complications. We aim to review the impact of surgical subspecialization on patients following upper gastrointestinal (UGI) emergency surgery. Methods: A systematic search of Ovid Embase, Ovid MEDLINE, and Cochrane databases using a predefined search strategy was completed reviewing studies published from 1st of January 1990 to August 27, 2023. The study was prospectively registered with PROSPERO (CRD42022359326). Studies were reviewed for the following outcomes: 30‐day mortality, in‐hospital mortality, conversion to open, length of stay, return to theater, and readmission. Results: Of 5181 studies, 24 articles were selected for full text review. Of these, seven were eligible and included in this study. There was a statistically significant improvement in 30‐day mortality favoring UGI specialists (OR 0.71 [95% CI 0.55–0.92 and p = 0.009]) and in‐hospital mortality (OR 0.29 [95% CI 0.14–0.60 and p = 0009]). There was a high degree of study heterogeneity in 30‐day mortality; however, a low degree of heterogeneity within in‐hospital mortality. There was no statistical significance when considering conversion to open and insufficient data to allow meta‐analysis for return to theater or readmission rates. Conclusion: In emergency UGI surgery, there was improved 30‐day and in‐hospital mortality for UGI specialists. Therefore, surgeons should consider early involvement of a subspecialist team to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Secreted Frizzled‐Related Protein 5 (SFRP5) modulates Wnt signalling pathways, affecting diverse biological processes. We assessed the diagnostic and prognostic value of circulating SFRP5 (cSFRP5) in colorectal cancer (CRC) Methods: Plasma cSFRP5 concentrations were measured using enzyme‐linked immunosorbent assay (ELISA) in healthy donors (n = 133), individuals diagnosed with CRC (n = 449), colorectal polyps (n = 85), and medical conditions in other organs including cancer, inflammation, and benign states (n = 64). Results: Patients with CRC, polyps, and other conditions showed higher cSFRP5 levels than healthy individuals (p < 0.0001). Receiver operating characteristic curves comparing healthy donors with medical conditions, polyps and CRC were 0.814 (p < 0.0001), 0.763 (p < 0.0001) and 0.762 (p < 0.0001), respectively. In CRC, cSFRP5 correlated with patient age (p < 0.0001), tumour stage (p < 0.0001), and histological differentiation (p = 0.0273). Levels, adjusted for patient age, sex, plasma age and collection institution, peaked in stage II versus I (p < 0.0001), III (p = 0.0002) and IV (p < 0.0001), were lowest in stage I versus III (p = 0.0002) and IV (p = 0.0413), with no difference between stage III and IV. Elevated cSFRP5 levels predicted longer overall survival in stages II‐III CRC (univariate: HR 1.82, 95% CI: 1.02–3.26, p = 0.024; multivariable: HR 2.34, 95% CI: 1.12–4.88, p = 0.015). Conclusion: This study confirms cSFRP5 levels are elevated in CRC compared to healthy control and reveals a correlation between elevated cSFRP5 and overall survival in stages II‐III disease. [ABSTRACT FROM AUTHOR]

Background: Reoperation for post hepatectomy complications is associated with high rates of morbidity and mortality. We aim to describe the frequency, indications, and risk factors for reoperation after liver resection in a single centre. Methods: Perioperative data of 464 patients, who underwent elective hepatectomy from 2001 to 2020 at The Queen Elizabeth Hospital in South Australia, were retrospectively analysed. The frequency and indications for reoperation for post hepatectomy complications were recorded. Binary logistic regression analysis was performed to determine variables associated with reoperation. Results: A total of seven patients (1.5%) underwent reoperation post hepatectomy. The most common indications for reoperation were intra‐abdominal abscess, post‐operative haemorrhage, bile leak, and ischaemic bowel. Three out of the seven patients died. Patients were more likely to require reoperation if an additional major non‐hepatic procedure was performed. Conclusion: Reoperation post hepatectomy is associated with morbidity and mortality and is more likely to occur in patients who have undergone a non‐hepatic procedure at the same time as the primary hepatic resection. Surgeons should ensure these patients are appropriately monitored and be selective about performing complex, multiple procedures. When possible, procedures should be staged. [ABSTRACT FROM AUTHOR]

This article discusses the opportunities, challenges, and recommendations for the use of artificial intelligence (AI) in surgical services in Australia and New Zealand. The implementation of AI must be evidence-based, safe, and ethically cautious, and should serve as an adjunct to surgical staff rather than a replacement. The article highlights the need for greater engagement with non-surgical healthcare communities and the wider society, as well as the importance of developing guidelines and infrastructure for monitoring and auditing AI tools. Ethical considerations, such as bias in training data and the lack of transparency in AI decision-making processes, must also be addressed. The article concludes with recommendations for the future use of AI in surgical services, emphasizing the need for an evidence-based approach, close engagement with regulatory bodies, and education for surgical staff and patients. [Extracted from the article]

Health technology assessment (HTA) is an important part of healthcare decision-making globally. The key principles of HTA include transparency, reduction of bias, and consideration of economic value and health outcomes. Over time, the methods and tools for HTA have evolved, and international and regional HTA bodies have played a crucial role in developing best practices. In Australia, the Australian Safety and Efficacy Register of New Interventional Procedures–Surgical (ASERNIP–S) is a longstanding HTA service provider. However, challenges remain for HTA, particularly with the rise of novel and disruptive technologies. The recent HTAi meeting in Australia discussed these challenges and the need for HTA frameworks to adapt. The rapid evolution of digital health technology (DHT) is an example of the opportunities and challenges facing HTA. DHT allows for greater patient participation and personalized healthcare, but conventional HTA frameworks may not be equipped to assess these technologies. There is a need to review HTA methods, decision-making frameworks, and the role of governments in regulatory and funding decisions. Innovation in HTA and health policy, such as parallel reviewing processes and joint assessments, has occurred to improve efficiency. HTA agencies continue to work with governments to eliminate barriers and ensure patients have access to the latest medical technologies. [Extracted from the article]

Background: Although modern Australian healthcare systems provide patient‐centred care, the ability to predict and prevent suboptimal post‐procedural outcomes based on patient demographics at admission may improve health equity. This study aimed to identify patient demographic characteristics that might predict disparities in mortality, readmission, and discharge outcomes after either an operative or non‐operative procedural hospital admission. Methods: This retrospective cohort study included all surgical and non‐surgical procedural admissions at three of the four major metropolitan public hospitals in South Australia in 2022. Multivariable logistic regression, with backwards selection, evaluated association between patient demographic characteristics and outcomes up to 90 days post‐procedurally. Results: 40 882 admissions were included. Increased likelihood of all‐cause, post‐procedure mortality in‐hospital, at 30 days, and 90 days, were significantly associated with increased age (P < 0.001), increased comorbidity burden (P < 0.001), an emergency admission (P < 0.001), and male sex (P = 0.046, P = 0.03, P < 0.001, respectively). Identification as ATSI (P < 0.001) and being born in Australia (P = 0.03, P = 0.001, respectively) were associated with an increased likelihood of 30‐day hospital readmission and decreased likelihood of discharge directly home, as was increased comorbidity burden (P < 0.001) and emergency admission (P < 0.001). Being married (P < 0.001) and male sex (P = 0.003) were predictive of an increased likelihood of discharging directly home; in contrast to increased age (P < 0.001) which was predictive of decreased likelihood of this occurring. Conclusions: This study characterized several associations between patient demographic factors present on admission and outcomes after surgical and non‐surgical procedures, that can be integrated within patient flow pathways through the Australian healthcare system to improve healthcare equity. [ABSTRACT FROM AUTHOR]

Objective: To describe the economic and cost considerations of mobile X‐ray services (MXS) in residential aged care facilities (RACFs), according to stakeholders (involved in residents' healthcare), residents living in RACFs and informal carers (ICs) of residents. Methods: Semistructured interviews were conducted with 20 residents and 27 ICs recruited from six RACFs across metropolitan Adelaide (South Australia, Australia), and 22 stakeholders, on their perspectives of using MXS in RACFs. Data relating to economic and cost considerations were extracted and analysed using thematic analysis. Results: Residents' mean age was 85 years, 60% were women and 40% had experienced an MXS in the last 12 months. Most ICs were daughters (70%) and wives (11%) and 30% had a family member who had experienced an MXS in the last 12 months. Stakeholders included RACF staff, GPs, a hospital avoidance program clinician, paramedics, emergency department clinicians, MXS radiographers and manager, and a radiologist. Four themes were presented: (1) business considerations, where private providers found it necessary to charge residents a co‐payment to deliver MXS; (2) cost and payment process as a potential barrier to using MXS, with varied willingness and ability to pay for an MXS co‐payment, and equity concerns; (3) overcoming cost and payment barriers, with staff and consumers sometimes using strategies to overcome cost barriers; and (4) perceived cost benefits of MXS to the healthcare system, residents and ICs. Conclusions: Mobile X‐ray services providers charge residents an upfront co‐payment for business viability, which can be a barrier to some residents wishing to access MXS. [ABSTRACT FROM AUTHOR]

Objective: To investigate the incidence of occult appendiceal neoplasm in patients aged 40 years and over who underwent appendicectomy for appendicitis. Methods: The clinical coding electronic database was used to identify patients aged 40 years and over who were diagnosed with appendicitis from September 2010 to September 2022. Patients were included if they were managed operatively. Design: Retrospective cohort study. Setting: Modified Monash category 3 (large rural town). Participants: Patients aged 40 years and over undergoing appendicectomy for appendicitis. Main Outcome Measures: Incidence of appendiceal neoplasm within appendicectomy specimen. Results: A total of 279 patients aged 40 years and over underwent appendicectomy, with a median age of 53 years (range 40–95). Nineteen patients (7%) were found to have a primary neoplastic lesion within the appendix: seven neuroendocrine neoplasms (37%), six sessile serrated lesions (32%), two colonic‐type adenocarcinoma (11%), two goblet cell adenocarcinoma (11%) and two appendiceal mucinous neoplasms (11%). Additionally, one patient had a metastatic adenocarcinoma of pancreaticobiliary aetiology. Conclusions: Occult appendiceal neoplasm was higher than reported in the literature in our cohort. This would support appendicectomy as the treatment of choice for patients aged 40 years and over with acute appendicitis and caution against nonoperative management in this demographic. [ABSTRACT FROM AUTHOR]

Background: The frequency of oxycodone adverse reactions, subsequent opioid prescription, effect on pain and patient care in general surgery patients are not well known. This study aimed to determine prevalence of documented oxycodone allergy and intolerances (independent variables) in a general surgical cohort, and association with prescribing other analgesics (particularly opioids), subjective pain scores, and length of hospital stay (dependent variables). Methods: This retrospective cohort study included general surgery patients from two South Australian hospitals between April 2020 and March 2022. Multivariable logistic regression evaluated associations between previous oxycodone allergies and intolerances, prescription records, subjective pain scores, and length of hospital stay. Results: Of 12 846 patients, 216 (1.7%) had oxycodone allergies, and 84 (0.7%) oxycodone intolerances. The 216 oxycodone allergy patients had lower odds of receiving oxycodone (OR 0.17, P < 0.001), higher odds of tramadol (OR 3.01, P < 0.001) and tapentadol (OR 2.87, P = 0.001), but 91 (42.3%) still received oxycodone and 19 (8.8%) morphine. The 84 with oxycodone intolerance patients had lower odds of receiving oxycodone (OR 0.23, P < 0.001), higher odds of fentanyl (OR 3.6, P < 0.001) and tramadol (OR 3.35, P < 0.001), but 42 (50%) still received oxycodone. Patients with oxycodone allergies and intolerances had higher odds of elevated subjective pain (OR 1.60, P = 0.013; OR 2.36, P = 0.002, respectively) and longer length of stay (OR 1.36, P = 0.038; OR 2.24, P = 0.002, respectively) than patients without these. Conclusions: General surgery patients with oxycodone allergies and intolerances are at greater risk of worse postoperative pain and longer length of stay, compared to patients without. Many still receive oxycodone, and other opioids that could cause cross‐reactivity. [ABSTRACT FROM AUTHOR]

Background: The applicability of the vital signs prompting medical emergency response (MER) activation has not previously been examined specifically in a large general surgical cohort. This study aimed to characterize the distribution, and predictive performance, of four vital signs selected based on Australian guidelines (oxygen saturation, respiratory rate, systolic blood pressure and heart rate); with those of the MER activation criteria. Methods: A retrospective cohort study was conducted including patients admitted under general surgical services of two hospitals in South Australia over 2 years. Likelihood ratios for patients meeting MER activation criteria, or a vital sign in the most extreme 1% for general surgery inpatients (<0.5th percentile or > 99.5th percentile), were calculated to predict in‐hospital mortality. Results: 15 969 inpatient admissions were included comprising 2 254 617 total vital sign observations. The 0.5th and 99.5th centile for heart rate was 48 and 133, systolic blood pressure 85 and 184, respiratory rate 10 and 31, and oxygen saturations 89% and 100%, respectively. MER activation criteria with the highest positive likelihood ratio for in‐hospital mortality were heart rate ≤ 39 (37.65, 95% CI 27.71–49.51), respiratory rate ≥ 31 (15.79, 95% CI 12.82–19.07), and respiratory rate ≤ 7 (10.53, 95% CI 6.79–14.84). These MER activation criteria likelihood ratios were similar to those derived when applying a threshold of the most extreme 1% of vital signs. Conclusions: This study demonstrated that vital signs within Australian guidelines, and escalation to MER activation, appropriately predict in‐hospital mortality in a large cohort of patients admitted to general surgical services in South Australia. [ABSTRACT FROM AUTHOR]

Background: This study aimed to examine the performance of machine learning algorithms for the prediction of discharge within 12 and 24 h to produce a measure of readiness for discharge after general surgery. Methods: Consecutive general surgery patients at two tertiary hospitals, over a 2‐year period, were included. Observation and laboratory parameter data were stratified into training, testing and validation datasets. Random forest, XGBoost and logistic regression models were evaluated. Each ward round note time was taken as a different event. Primary outcome was classification accuracy of the algorithmic model able to predict discharge within the next 12 h on the validation data set. Results: 42 572 ward round note timings were included from 8826 general surgery patients. Discharge occurred within 12 h for 8800 times (20.7%), and within 24 h for 9885 (23.2%). For predicting discharge within 12 h, model classification accuracies for derivation and validation data sets were: 0.84 and 0.85 random forest, 0.84 and 0.83 XGBoost, 0.80 and 0.81 logistic regression. For predicting discharge within 24 h, model classification accuracies for derivation and validation data sets were: 0.83 and 0.84 random forest, 0.82 and 0.81 XGBoost, 0.78 and 0.79 logistic regression. Algorithms generated a continuous number between 0 and 1 (or 0 and 100), representing readiness for discharge after general surgery. Conclusions: A derived artificial intelligence measure (the Adelaide Score) successfully predicts discharge within the next 12 and 24 h in general surgery patients. This may be useful for both treating teams and allied health staff within surgical systems. [ABSTRACT FROM AUTHOR]

Glucagon‐like peptide 1 receptor agonists (GLP‐1 RAs) reduce elevated blood glucose levels and induce weight loss. Multiple GLP‐1 RAs and one combined GLP‐1/glucose‐dependent insulinotropic polypeptide agonist are currently available. This review was conducted with the aim of summarising direct comparisons between subcutaneous semaglutide and other GLP‐1 RAs in individuals with type 2 diabetes (T2D), particularly with respect to efficacy for inducing weight loss and improving other markers of metabolic health. This systematic review of PubMed and Embase from inception to early 2022 was registered on PROSPERO and was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses and Meta‐Analysis of Observational Studies in Epidemiology guidelines. Of the 740 records identified in the search, five studies fulfilled the inclusion criteria. Comparators included liraglutide, exenatide, dulaglutide and tirzepatide. In the identified studies, multiple dosing regimens were utilised for semaglutide. Randomised trials support the superior efficacy of semaglutide over other GLP‐1 RAs with respect to weight loss in T2D, but tirzepatide is more effective than semaglutide. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure worldwide. The aim of this study was to examine cases of mortality after ERCP to identify clinical incidents that are potentially preventable, to improve patient safety. Methods: The Australian and New Zealand Audit of Surgical Mortality provides an independent and externally peer‐reviewed audit of surgical mortality pertaining to potentially avoidable issues. A retrospective review of prospectively collected data within this database was performed for the 8‐year audit period from 1 January 2009 to 31 December 2016. Clinical incidents were identified by assessors through first‐ or second‐line review, and thematically coded into periprocedural stages. These themes were then qualitatively analysed. Results: There were 58 potentially avoidable deaths following ERCP, with 85 clinical incidents. Preprocedural incidents were most common (n = 37), followed by postprocedural (n = 32) and then intraprocedural (n = 8). Communication issues occurred across the periprocedural period (n = 8). Preprocedural incidents included delay to procedure, inadequate resuscitative management, decision to perform procedure and inadequate assessment. Intraprocedural incidents comprised technical factors and inadequate support. Postprocedural incidents involved inappropriate treatment, delay in definitive surgical treatment or in recognizing complications, inappropriate second‐line intervention and inadequate assessment. Communication incidents comprised inadequate documentation, failure to escalate care and poor inter‐clinician communication. Conclusion: Causes of mortality following ERCP are wide‐ranging, and reviewing clinical incidents associated with potentially avoidable mortality can serve to inform and educate practitioners. In collating a subset of cases in which procedure‐related mortality was deemed avoidable, a series of cautionary tales about ERCP is presented that may provide cues to practitioners on improving patient safety and inform future surgical practice. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer with synchronous liver‐only metastasis is managed with a multimodal approach, however, optimal sequencing of modalities remains unclear. Methods: A retrospective review of all consecutive rectal or colon cancer cases with synchronous liver‐only metastasis was conducted from the South Australian Colorectal Cancer Registry from 2006 to 2021. This study aimed to investigate how order and type of treatment modality affects overall survival. Results: Data of over 5000 cases were analysed (n = 5244), 1420 cases had liver‐only metastasis. There were a greater number of colon than rectal primaries (N = 1056 versus 364). Colonic resection was the preferred initial treatment for the colon cohort (60%). In the rectal cohort, 30% had upfront resection followed by 27% that had chemo‐radiotherapy as 1st line therapy. For the colon cohort, there was an improved 5‐year survival with surgical resection as initial treatment compared to chemotherapy (25% versus 9%, P < 0.001). In the rectal cohort, chemo‐radiotherapy as the initial treatment was associated with an improved 5‐year survival compared to surgery or chemotherapy (40% versus 26% versus 19%, P = 0.0015). Patients who were able to have liver resection had improved survival, with 50% surviving over 5 years compared to 12 months in the non‐resected group (P < 0.001). Primary rectal KRAS wildtype patients who underwent liver resection and received Cetuximab had significantly worse outcomes compared to KRAS wildtype patients who did not (P = 0.0007). Conclusions: Where surgery is possible, resection of liver metastasis and primary tumour improved overall survival. Further research is required on the use of targeted treatments in patients undergoing liver resection. [ABSTRACT FROM AUTHOR]

Background: Unplanned return to theatre (URTT) is associated with longer hospital stay and higher mortality rates, placing extra burden on hospital resources. There is a lack of literature analysing causes of URTT in a rural general surgery department. This knowledge may be important to help identify patients at risk of URTT. This study aims to identify causes of URTT in rural general surgical patients. Methods: This is a retrospective multicenter cohort involving four rural South Australian (SA) hospitals: Mount Gambier (MGH), Whyalla (WH), Port Augusta (PAH), and Port Lincoln (PLH). All general surgical inpatients admitted from February 2014 to March 2020 were analysed to identify all‐cause of URTT. Results: Of the 44 191 surgical procedures performed, there were 67 (0.15%) URTT. The most common surgical subspecialty cases that resulted in URTT were Colorectal (47.1%), General surgery (33.2%) Plastics (9.8%), and Hepatopancreatico‐biliary (3.9%). The three commonest operations during URTT were washouts 22 (32.8%), interventions for haemostasis 11 (16.4%) and bowel resections 9 (13.4%). Sixteen (24%) of URTT followed emergency surgery. When comparing between elective and emergency admissions needing URTT, there were no statistical difference in age, gender, speciality type, types of surgery performed, and median number of days until URTT. Conclusion: Rates of URTT are low in South Australian rural hospitals when compared to our overseas counterpart. A wide range of surgery is being performed in rural centres, further supporting the need for rural surgical trainees to have a tailored curriculum encompassing subspecialities and being competent in managing any potential complications. [ABSTRACT FROM AUTHOR]

Introduction: Non-technical skills complement technical skills in surgeons to provide best possible care for patients. The former is essential to promote patient engagement. Coaching has been introduced to surgeons as a method to improve non-technical skills. We aimed to investigate the impact of coaching for surgeons on patient engagement in the outpatient consultation setting. Methods: This was a single-centre cohort study conducted in South Australia. Consultant surgeons, suitable coaches, and patients were recruited. Coaches underwent further training by a human factors psychologist on being an effective coach. Outpatient consultations were recorded in an audio-visual format and analysed by investigators. Patient talking time, mutual eye gaze between surgeon and patient, and number of questions asked by the patient were measured as outcomes for patient engagement. Results: 182 patients, 12 surgeons, and 4 coaches participated in the study. Each surgeon underwent 3 coaching sessions, 5 to 6 weeks apart. There were 62 pre-coaching patient consultations, 63 patient consultations after one coaching session, and 57 patient consultations after two coaching sessions. The mean talking time of the patient increased significantly after a single coaching session (P < 0.05) without making significant difference to the total consultation time (p = 0.76). Coaching sessions did not have a significant effect on mutual eye gaze or mean number of questions asked by the patient. Conclusion: Coaching of non-technical skills for surgeons appears to objectively improve patient engagement during the outpatient consultation. This would suggest that tailored coaching programs should be developed and delivered to surgeons to improve care delivery. [ABSTRACT FROM AUTHOR]

Background: There is some evidence of the association between acute appendicitis and colorectal neoplasm in patients over the age of 40 years. Despite this, few centres routinely evaluate the colon endoscopically following an episode of appendicitis in these patients. Our aim was to investigate the incidence of colorectal neoplasm in patients aged 40 years and over who underwent screening colonoscopy following acute appendicitis. Methods: Retrospective cohort study of patients aged 40 years and over who were diagnosed with acute appendicitis via imaging or histology between January 2015 and May 2022. Findings on subsequent screening colonoscopy were evaluated and classified according to adenomatous and non‐adenomatous lesions. Results: A total of 176 patients met inclusion criteria, with a median age of 54 years (range 40–92) and female to male ratio of 1:1.3. One hundred patients (56%) had a colonoscopy following their admission, at a mean duration of 3.5 months post discharge. 15% of patients had an adenomatous polyp detected (10 adenomas, 4 advanced adenomas, and 1 sessile serrated adenoma), and 9% had a non‐adenomatous lesion detected (8 hyperplastic polyps and 1 lipoma). Conclusion: Adenoma detection rate in patients aged 40 years and over undergoing colonoscopy after acute appendicitis was 15% in our cohort. This high adenoma detection rate supports the view of appendicitis as an indication for screening faecal immunochemical testing or colonoscopy in patients above 40 years. [ABSTRACT FROM AUTHOR]

Background: There is a shortage of surgeons caring for the 33% of Australians residing in rural and regional areas. In order to help appreciate what rural general surgery entails and optimize training for aspiring rural surgeons, the aim of this study was to analyse the general surgical departments' procedural caseload and casemix in four rural South Australian hospitals. Methods: This is a retrospective multi‐centre study involving four rural surgical centres in South Australia (Mt Gambier, Whyalla, Port Augusta, and Port Lincoln). Surgical procedures performed from 2014–2020 were extracted from departmental audits. To identify trends of surgical procedure over time, the data was divided into three time periods (Period 1: February 2014–December 2015, Period 2: January 2016–December 2017, Period 3: January 2018–March 2020). Results: A total of 44 191 surgical procedures were performed, 70.2% being day procedures. 54% were endoscopic procedures, 46% were operative procedures. 60.6% of the operative procedures were general surgery procedures. 28.5% were general surgery‐based subspecialty (colorectal, hepato‐pancreato‐biliary, upper gastrointestinal, and breast). 10.9% were non‐general surgery‐based subspecialty (urology, plastics, vascular, orthopaedics, head and neck, and obstetrics and gynaecology). There were no statistically significant fluctuations in procedure caseload in all aspects (endoscopic and operative procedures) over the three time periods. Conclusion: The majority of a rural Australian general surgeon's procedures are endoscopic. Operative procedures are mainly general surgery based. It may be beneficial to equip aspiring rural general surgeons to manage basic non‐general surgery procedures (urological, vascular, and orthopaedic). [ABSTRACT FROM AUTHOR]

Background: High‐quality colonoscopy is vital for the detection and removal of adenomatous polyps and early diagnosis of colorectal cancer. The aim of this study was to prospectively assess the quality and safety of colonoscopies performed in the non‐metropolitan setting. Key performance indicators measured include completion, polypectomy and adenoma/serrated polyp detection rates, rate of adequate bowel preparation, withdrawal time and complications. Methods: Prospective data collection for all colonoscopies performed over a one‐year period in seven non‐metropolitan South Australian hospitals. Two general surgeons and twelve registrars working in rural South Australian hospitals (Mount Gambier, Millicent, Naracoorte, Port Lincoln, Port Augusta, Whyalla and Berri) contributed to this study. Results: In total 3497 colonoscopies were analysed. Complete colonoscopy was achieved in 96.1%. The adenoma detection and serrated polyp detection rates were 25.6% and 5.4% respectively. Cancer was detected in 71 patients (2%). Colonic perforation occurred in five patients (0.1%). There was no procedure‐related mortality. Conclusions: Colonoscopy performed in the non‐metropolitan Australian setting outperforms key performance indicators set by national institutions. This is the first Australian prospective multi‐centre study investigating the quality and safety of endoscopic procedures. [ABSTRACT FROM AUTHOR]

Background: Effective pain control is crucial to postoperative recovery and is affected by biopsychosocial factors. This study aimed to evaluate how non-English primary language, gender, and marital status may influence pain, length of stay, and mortality after general surgery. Methods: Consecutive general surgical admissions over a two-year period to two tertiary hospitals were included. Multivariable logistic regression analyses were conducted to evaluate the relationship between non-English primary language, gender, and marital status, and pain scores, length of stay, and in-hospital mortality. Explanatory variables that were controlled for in these analyses included age, birth country, whether a religion was specified, socioeconomic percentile, Charlson comorbidity index, and time of admission. Results: A total of 12 846 general surgery patients were included. When controlling for the aforementioned variables, including having a specified religion and being born overseas, having a non-English primary language was significantly independently associated with lower pain scores (odds ratio 0.61, 95% CI 0.52–0.71, P < 0.001). Female gender was independently associated with an increased likelihood of higher pain scores (odds ratio 1.09, 95% CI 1.01–1.18, P = 0.024) and a lower likelihood of prolonged length of stay (odds ratio 0.88, 95% CI 0. 80–0.95, P = 0.002). None of the evaluated variables had a statistically significant association with in-hospital mortality. Conclusions: This study is the first to characterize an association between general surgery patients with a non-English primary language and lower levels of postoperative pain. It was also found that female gender was associated with higher postoperative pain but lower length of hospital sta [ABSTRACT FROM AUTHOR]

Background: Laparoscopic colorectal cancer surgery has been shown to produce comparable oncological long‐term results as well as improved short‐term outcomes compared to open surgery in multicentre trials. Limited information is available whether these results are reproduced in non‐metropolitan surgery. Methods: Audit of prospectively collected follow‐up data in a rural surgical centre in South Australia. Short‐ and long‐term results of colorectal cancer patients undergoing elective laparoscopic surgery for cure. Outcomes are compared with results of open surgery. Results: Survival and clinical data of 120 patients after laparoscopic resection were analysed and then benchmarked against results of 157 open resections. Conversion rate was 10.8% (N = 13). Mean patient age was 69.9 years. Mean number of lymph nodes analysed was 15.5. Mean follow‐up is 53.0 months. Thirty‐day mortality was 0.36% (n = 1) and 90‐day mortality was 0.72% (n = 2). No differences in complications rates, long term survival or procedures performed were observed. This is a single centre audit of clinical and oncological outcomes and a number of exclusion criteria were applied. Patient gender, cancer stages as well as number of patients undergoing neoadjuvant radio‐chemotherapy differ significantly between the study and the benchmarking group. Patients were not randomized and the benchmarking group is in part a historical control. Conclusions: This audit of clinical outcomes and survival after laparoscopic CRC resection for cure indicates that minimal invasive surgery may be suitable for adequately staffed and equipped rural centres. [ABSTRACT FROM AUTHOR]

The article discusses the translational benefits of space medicine for rural and remote perioperative medicine. Topics include ways high-quality perioperative medicine improves the patient experience of surgery, considerations that need to be made regarding the requirements needed to allow remote perioperative medicine to mirror the advancements in space medicine, and significance of the delivery of high-qualitative perioperative care in Australian rural and remote medicine.

Background: There are limited opportunities for surgeons to engage in active learning programs once they achieve Fellowship, especially for non‐technical skills such as communication. This study aims to address this gap by evaluating a peer‐based coaching program in non‐technical skill using video‐recorded patient consultations from a routine outpatient clinic. Methods: Standard outpatient consultations between consultant surgeons and patients were video recorded. The surgeon viewed the videos with a peer‐coach (senior surgeon) who helped identify areas of strength and areas for improvement. To test the effect of the coaching session, outpatient consultations were recorded roughly 1 month later. Pre and post‐coaching videos were assessed using the Maastricht History‐Taking and Advice Scoring – Global Rating List (MAAS), a common tool for evaluating non‐technical skills in clinicians. Results: A total of 12 surgeons consented to participate. Coaching significantly improved MAAS scores (mean difference = −0.61; 95% CI (−0.88, −0.33); P < 0.0001). Surgeons were generally positive about the experience. All found the method of learning suitable, and most thought the process improved their skills. Most thought that coaching would improve patient outcomes and the majority thought they would participate in ongoing coaching as part of their employment. Conclusion: This supports the concept of surgical coaching as an effective tool to improve communication skills and the quality of surgical consultation. The next step is to expand beyond a voluntary cohort and link surgical coaching to improved patient outcomes. We sought to understand if a peer‐based coaching program can better the non‐technical skills of surgeons in the outpatient clinic environment. This interventional pilot study assessed 12 surgeons and was conducted at The Queen Elizabeth Hospital (TQEH) in Adelaide, Australia. Our results support the concept that a video‐based peer‐coaching program can act as an effective tool to improve the communication skills of consultant surgeons and improve the quality of surgical consultation. [ABSTRACT FROM AUTHOR]

Background: Accurate and thorough surgical ward round documentation is crucial for maintaining quality clinical care. Accordingly, checklists have been proposed to improve ward round documentation. This systematic review aimed to evaluate the literature investigating the use of checklists to improve surgical ward round documentation. Methods: MEDLINE, EMBASE, and PsycINFO were searched on August 16, 2021. Study selection, data extraction, and risk of bias assessment were performed in duplicate. We included English studies that investigated the use of checklists during ward rounds in various surgical subspecialties compared to routine care, where the rates of documentation were reported as outcomes. We excluded studies that used checklists in outpatient, non-surgical, or pediatric settings. Due to heterogeneity of outcome measures, meta-analysis was precluded. This study was registered with PROSPERO (ID: CRD42021273735) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 (PRISMA 2020) reporting guidelines. Results: A total of 206 studies were identified, only 9 were suitable for inclusion. All included studies were single-center observational studies, spanning across seven surgical specialties. Rates of documentation on 4–23 parameters were reported. Documentation for all measured outcomes improved in 8/9 studies; however, statistical analyses were not included. There was a high risk of bias due to the nature of observational studies. Conclusion: Ward round checklists can serve as a useful tool to improve inpatient care and safety. Currently, there is no high-level evidence showing the effectiveness of checklists on ward round documentation. The synthesis of results indicates that further high-quality research is imperative. [ABSTRACT FROM AUTHOR]

Background: Mesh is frequently utilized intraoperatively for the repair of groin hernias. However, patients may request non‐mesh hernia repairs owing to adverse events reported in other mesh procedures. To inform surgical safety, this study aimed to compare postoperative complications between mesh and non‐mesh groin hernia repairs and identify other operative and patient‐related risk factors associated with poor postoperative outcomes. Methods: Ovid MEDLINE and grey literature were searched to 9 June 2021 for studies comparing mesh to non‐mesh techniques for primary groin hernia repair. Outcomes of interest were postoperative complications, recurrence of hernia, pain and risk factors associated with poorer surgical outcomes. Methodological quality was appraised using the AMSTAR 2 tool. Results: The systematic search returned 4268 results, which included seven systematic reviews and five registry analyses. Mesh repair techniques resulted in lower hernia recurrence rates, with no difference in chronic pain, seroma, haematoma or wound infection, compared to non‐mesh techniques. Risk factors associated with increased risk of hernia recurrence were increased body mass index (BMI), positive smoking status and direct hernia. These were independent of surgical technique. Patients under 40 years of age were at increased risk of postoperative pain. Conclusions: Surgical repair of primary groin hernias using mesh achieves lower recurrence rates, with no difference in safety outcomes, compared with non‐mesh repairs. Additional risk factors associated with increased recurrence include increased BMI, history of smoking and hernia subtype. [ABSTRACT FROM AUTHOR]

Background: Superior patient outcomes rely on surgical training being optimized. Accordingly, we conducted an international, prospective, cross‐sectional study determining relative impacts of COVID‐19, gender, race, specialty and seniority on mental health of surgical trainees. Method: Trainees across Australia, New Zealand and UK enrolled in surgical training accredited by the Royal Australasian College of Surgeons or Royal College of Surgeons were included. Outcomes included the short version of the Perceived Stress Scale, Oxford Happiness Questionnaire short scale, Patient Health Questionnaire‐2 and the effect on individual stress levels of training experiences affected by COVID‐19. Predictors included trainee characteristics and local COVID‐19 prevalence. Multivariable linear regression analyses were conducted to assess association between outcomes and predictors. Results: Two hundred and five surgical trainees were included. Increased stress was associated with number of COVID‐19 patients treated (P = 0.0127), female gender (P = 0.0293), minority race (P = 0.0012), less seniority (P = 0.001), and greater COVID‐19 prevalence (P = 0.0122). Lower happiness was associated with training country (P = 0.0026), minority race (P = 0.0258) and more seniority (P < 0.0001). Greater depression was associated with more seniority (P < 0.0001). Greater COVID‐19 prevalence was associated with greater reported loss of training opportunities (P = 0.0038), poor working conditions (P = 0.0079), personal protective equipment availability (P = 0.0008), relocation to areas of little experience (P < 0.0001), difficulties with career progression (P = 0.0172), loss of supervision (P = 0.0211), difficulties with pay (P = 0.0034), and difficulties with leave (P = 0.0002). Conclusion: This is the first study to specifically describe the relative impacts of COVID‐19 community prevalence, gender, race, surgical specialty and level of seniority on stress, happiness and depression of surgical trainees on an international scale. [ABSTRACT FROM AUTHOR]

Introduction: The burden of complex abdominal wall hernia (CAWH) is increasing, with associated high morbidity and healthcare costs. This study evaluates current evidenoptce regarding multidisciplinary care for CAWH patients to improve patient outcomes. Methods: A systematic review of Scopus, MEDLINE, Embase, PubMed, Web of Knowledge and Cochrane Library was conducted to identify proposed or established multidisciplinary team (MDT) pathways, necessary MDT constituents, and to evaluate patient outcomes. The pre‐optimization pathways were then compared with a recent Delphi consensus statement. Results: Seven articles matched the relevant search criteria. Three were concept articles, without prospective data analysis. Four were case series that applied multidisciplinary care and included limited data analyses with outcomes reported up to 50 months. The consensus was that CAWH MDT requires multiple clinical specialties, including hernia, upper gastrointestinal, colorectal and/or plastic and reconstructive surgeons, along with allied health specialists, radiologists, anaesthetists/pain specialists and infectious diseases consultants. A successful MDT should aim to achieve pre‐optimization and plan the definitive repair. These pre‐optimization pathways were similar to the recent Delphi consensus by international hernia experts. Using these data, we propose a CAWH multidisciplinary pathway model in an Australian tertiary hospital involving a stepwise approach with well‐defined referral criteria, perioperative high‐risk management with pre‐optimization, surgical planning, postoperative care and follow‐up protocols. This pathway incorporates prospective data collection in a Clinical Quality Registry (CQR) to validate its appropriateness. Conclusions: CAWH MDT can provide comprehensive, patient‐centred care with improved postoperative outcomes. CQR are important to better evaluate long‐term outcomes and ensure rigorous quality control. The increasing burden of complex abdominal wall hernia (CAWH) has inspired the application of multidisciplinary care principles; however, this remains a relatively novel concept. The aim of this study is to perform a systematic review of the literature on multidisciplinary care for patients with CAWH, and to determine the necessary constituents of the multidisciplinary team for this patient cohort. Based on our results, we propose a suitable multidisciplinary pathway that can be applied in an Australian tertiary centre. [ABSTRACT FROM AUTHOR]

Background: Despite advances in medical management and endoscopic therapy, gastrectomy remains an important yet high‐risk procedure for a range of benign and malignant upper gastrointestinal pathologies. No study has previously analysed Australian gastrectomy perioperative mortality rate (POMR). This retrospective, population‐based cohort study was conducted to determine the Australian national gastrectomy POMR, allowing state‐based and regional trends and outcomes to be assessed. Methods: Logistic regression models were compared using de‐identified procedural data between 1 July 2005 and 30 June 2017 from the Australian Institute of Health and Welfare. Codes relating to total and subtotal gastrectomy contained in the Australian Classification of Health Interventions were used to extract patient data. Mortality rates were risk adjusted for age and gender. Temporal trends and differences between states/territories and regions were investigated. Results: The national average POMR throughout the study period was 2.1%. For subtotal gastrectomy, the national mean POMR was 1.1%, decreasing from 2.7% (2005) to 1.3% (2017). For total gastrectomy, the national mean POMR was 2.8%, decreasing from 3.3% (2005) to 1.7% (2017). POMR significantly reduced over time without variation between states or regions. Procedure volume steadily reduced in rural centres with a concomitant increase in metropolitan centres over time. Conclusion: Pleasingly, the Australian gastrectomy POMR is favourable when compared to international cohorts. Improved outcomes were consistent between states and territories, and metropolitan and regional centres. Progressive metropolitan centralization of gastrectomy was demonstrated without evidence of improved outcomes. [ABSTRACT FROM AUTHOR]

Aim: Reviewing outcomes of regorafenib use in metastatic colorectal cancer using real‐world data from the South Australian Metastatic Colorectal Cancer Registry. Methods: A retrospective review of the characteristics and outcomes of patients who received regorafenib in the Registry up to December 2018. The registry started in February 2006. Results: Fifty‐three patients received regorafenib therapy since approved by the therapeutic goods administration in November 2013. The median age was 66 (range 34–82). 66% were male, 66% had stage IV disease at diagnosis, 53% had liver only involvement, whereas 13% had liver and lung disease and 6% had lung only involvement. 75% had left‐sided primary. KRAS was available in 35/53 patients with 49% of them being WT. BRAF status was known in 8/53 with 25% of them having a mutated variant. MSI testing was known in 14 patients in whom 21% of them had MSI‐High tumors. Prior lines of treatment received: one line 4%, two 9%, three 23%, four 26%, >four 37%. Prior biological use: bevacizumab 72%, anti‐EGFR 100% (for RAS WT). Median survival from diagnosis was 3.3 years (95% CI, 2.8–3.8 years). Median survival from the start of regorafenib was 7.1 months (95% CI, 4.8–9.4 months) and the 12‐month survival rate was 28%. Conclusion: The survival outcome for those patients from our population‐based registry who access regorafenib is in keeping with reports from large, randomized trials. Thus, clinicians can quote local real world data when discussing efficacy and access to regorafenib therapy for mCRC patients. [ABSTRACT FROM AUTHOR]

Objective: The objective of this review is to examine the reliability and measurement error of devices that measure transepidermal water loss (TEWL). Introduction: TEWL is a physiological property of skin which increases when the epidermis is damaged. It is, therefore, a commonly utilised measure of skin barrier integrity. Devices measuring TEWL are available as open, semi‐open or closed chamber. Studies of reliability examine the consistency of measurement, and/or responsiveness whereas measurement error scores in absolute terms the amount of error due to sources of variation. Inclusion criteria: Studies examining the reliability and/or measurement error of TEWL measurement devices were included. Studies that only report on measurement of TEWL outcomes without examination of reliability and/or measurement error were excluded. Methods: The search strategy aimed to locate published and unpublished studies. Databases searched included PubMed, Embase, CINAHL and Web of Science, utilising identified keywords and limited to studies in English. Grey literature sources were searched to identify any unpublished documents. Study selection using the inclusion criteria was then assessed by two reviewers for methodological quality utilising the COnsensus‐based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias tool to assess the reliability and measurement error of outcome measurement instruments. Results: A total of 22 devices were examined in the 38 included studies. The quality of study design was on average rated as 'Adequate' however reliability and measurement error statistical methods were on average rated as 'Doubtful'. Discussion and conclusion: TEWL measurement devices were found to demonstrate good reliability and frequently correlated with other devices. However, measurement error was highly variable but improves under in vitro conditions. Future research should consider risk of bias factors when designing studies. [ABSTRACT FROM AUTHOR]

Background: One‐third of Australia's population reside in rural and remote areas. This audit aims to describe all‐causes of mortality in rural general surgical patients, and identify areas of improvement. Methods: This is a retrospective multi‐centre study involving four South Australian hospitals (Mt Gambier, Whyalla, Port Augusta, and Port Lincoln). All general surgical inpatients admitted from June 2014 to September 2019 were analysed to identify all‐cause of mortality. Results: A total of 80 mortalities were recorded out of 26 996 admissions. The overall mortality rate of 0.3% was the same as the 2020 Victorian state‐wide Audit of Surgical Mortality. No mortality was secondary to trauma. Mean age was 79 ± 11 years and ASA was 3.9 ± 1. Malignancy was associated in over a third of cases (41.2%), mostly colorectal and pancreatic. Most cases were related to general surgical subspecialties: colorectal (51.3%), upper gastrointestinal (21.3%), hepatopancreaticobiliary (13.8%); however, there were also vascular (6.3%) and urology (3.8%) cases. The most common causes of mortality were large bowel obstruction (13.4%), ischemic bowel (10.4%), and small bowel obstruction (7.5%). Majority of mortality were beyond the surgeon's control (73.8%). Of the 21 potentially preventable mortalities, 42.9% were attributed to aspiration pneumonia and decompensated heart failure. Only one (1.3%) mortality case was due to pulmonary embolism. Conclusion: Rural general surgical mortalities occur in older, comorbid patients. Rural surgeons should be equipped to manage basic subspeciality conditions. To further reduce mortalities, clear protocols to prevent aspiration pneumonia and resuscitation associated fluid overload are needed. [ABSTRACT FROM AUTHOR]

The article describes the indications and illustrates the technique of skin flaps, including the snail, rhomboid or Limberg flap and keystone, which can be learned and adapted by a general surgeon in the rural and remote setting. It also discusses the uses of the bilobed, helical rim advancement and preauricular transposition flaps. It also points out that local flap reconstructions can often be done under local anaesthetic.

Background: Emergency general surgery is an emerging public health issue globally, with substantial healthcare burden. Interhospital transfer of critically unwell surgical patients has been the mainstay of bridging gaps in surgical coverage in regional and rural locations, despite evidence of greater morbidity and mortality. Delays in transfer invariably occurs and compounds the situation. Our aim was to examine the factors influencing interhospital transfer delays in emergency general surgical patients. Methods: A systematic search of PubMED and EmBase, was performed by two researchers from 2020 to 23rd Feb 2021, for English articles related to interhospital transfer delays in emergency general surgical patients, with an age of >16. Articles were critically appraised and data were extracted into a pre‐specified data extraction form. No data was suitable for statistical analysis and a narrative synthesis was performed instead. Results: Six relevant articles were identified from the search. All studies were retrospective cohort studies with moderate to high risk of bias. Lack of consultant surgeon input, after hours transfer, need for intensive care bed and poor transfer documentation may have a role in interhospital transfer delays. Patients with public health insurance, multiple comorbidities and non‐emergency medical conditions experience longer transfer request time and may be at risk of precipitating interhospital transfer delays. Transfer delays are seen in transfers over longer distances. Conclusion: There is a paucity of knowledge on what and how factors influence interhospital transfer delays in emergency general surgical patients. Well‐designed prospective cohort studies are required to bridge this knowledge gap. [ABSTRACT FROM AUTHOR]

Background: Interhospital transfers in Australia facilitate access to acute surgical services, however transfer delays can occur. The aims of this study were to examine Australian mortality audit data on acute surgical patients who were transferred after presenting with a surgical emergency, and to identify modifiable predictors of transfer delay. Methods: Surgical admissions between 1 January 2001 and 18 August 2020 were retrospectively extracted from the Australian and New Zealand Audit of Surgical Mortality database. Relevant factors and themes of interest were collated. Results were presented as odds ratios (OR) and 95% confidence intervals (CI), with statistical significance defined as P <0.05. Results: After exclusion, a final 8270 cases were analysed. Non‐modifiable predictors identified were female gender (OR 1.34, 95% CI 1.05–1.70, P = 0.0184), comorbidities (OR 1.50, 95% CI 1.40–161, P <0.0001) and major non‐trauma non‐vascular specialty (OR 1.54 to 7.77, depending on specialty, P < 0.05). Modifiable predictors were inadequate clinical assessment (OR 49.48, 95% CI 32.91–74.38, P <0.0001), poor communication (OR 6.62, 95% CI 3.70–11.85, P <0.0001) and multiple transfers (OR 6.30, OR 95% 4.31–9.21, P <0.0001). Age, lack of bed and after‐hours transfer did not predict transfer delays. Metropolitan transfers was protective against transfer delays (OR 0.64, 95% CI 0.47–0.86, P = 0.0035). Conclusion: In the view of the receiving surgeon or assessor, all transfer delays potentially contributed to patient deaths, and may have been preventable. Strategies directed at modifiable factors could minimize delays. Increased surgical services in non‐metropolitan regions could reduce need for transfer. Prospective data is required to examine if the same predictors are observed in surgical patients who survive. [ABSTRACT FROM AUTHOR]

Background: Patient centred communication ensures patients are well informed and educated, which is vital to providing the best care possible. By asking questions, patients can better understand their disease and make informed decisions regarding their health journey. We aimed to investigate factors that affect question asking behaviours in surgical outpatient consultations and to determine the typical question‐asking by doctors, patients, and their companions. Methods: This is an observational cross‐sectional study, where 182 video recordings of surgical consultations in the surgical outpatient setting at The Queen Elizabeth Hospital, Adelaide, South Australia were reviewed. Results: A total of 3472 questions were asked. Most questions were asked by the surgeon, followed by the patient, and if present, their companion. Pre‐surgical consultations resulted in the most questions asked by the patients, compared to post‐surgical or follow‐up consultations. When companions were present, patients asked more questions in consultants regarding malignant conditions. Interruptions increased the number of questions asked by the patient and their companion. Questions were commonly asked to clarify information given by the surgeon and often regarded the cause of the illness and the timing of the next step in disease management. Conclusion: Patients are generally interested in their health and ask questions during consultations. Companions have a positive effect on patient question asking behaviour and their presence in surgical consultations should be encouraged. Surgeons should develop strategies to encourage question asking and could review their own behaviours via surgical coaching and video review. [ABSTRACT FROM AUTHOR]

The article presents a prospective study which aims to assess the quality of rural colonoscopy service at the Mount Gambier and Districts Health Service in South Australia. The hospital provides outreach endoscopy and colonoscopy service to neighboring towns. Topics include the low incidence of mortality among colorectal cancer (CRC) patients in the country due to programs like the colonoscopy service and the National Bowel Cancer Screening Program (NBCSP).

Background: In under-resourced settings, general surgeons may be called upon to perform emergency operations within other specialties. Accordingly, we aimed to characterise patient outcomes after emergency neurosurgery performed by a general surgeon or general surgery trainee. Methods: PubMed, Embase and the Cochrane Library were searched to 30 May 2021 for observational studies reporting outcomes after emergency neurosurgery performed by a general surgeon. Study screening, data extraction, and risk of bias using the Downs and Black checklist were performed in duplicate. Data on setting, operation undertaken, mortality rates and complications were extracted. Meta-analysis was planned but not possible due to heterogeneity. This study is registered with PROSPERO, CRD42021258097. Results: From 632 records, 14 retrospective observational studies were included, covering a total sample of 1,988 operations. Four studies were from Australia, and the remaining 10 were, respectively, from 10 other countries. Most common operations performed were decompressive surgery with burr holes or craniectomy for head trauma and insertion of intracranial pressure monitors. Rural hospitals were the most common settings. Mortality rates for procedures performed by general surgeons at latest follow-up were heterogenous, ranging from 5% for evacuation of chronic subdural haematoma in Kenya to 81% in head injured patients in a Hong Kong study. Conclusions: This is the first systematic review that synthesises the literature to characterise patient outcomes after neurosurgical operations performed by a general surgeon. Findings from this study may benefit global surgery performed in rural, remote, military or humanitarian settings. [ABSTRACT FROM AUTHOR]

Background: Variation in cut‐off values for what is considered a high volume (HV) hospital has made assessments of volume‐outcome relationships for pancreaticoduodenectomy (PD) challenging. Accordingly, we performed a systematic review and meta‐analysis comparing in‐hospital mortality after PD in hospitals above and below HV thresholds of various cut‐off values. Method: PubMed/MEDLINE, Embase and Cochrane Library were searched to 4 January 2021 for studies comparing in‐hospital mortality after PD in hospitals above and below defined HV thresholds. After data extraction, risk of bias was assessed using the Downs and Black checklist. A random‐effects model was used for meta‐analysis, including meta‐regressions. Registration: PROSPERO, CRD42021224432. Results: From 1855 records, 17 observational studies of moderate quality were included. Median HV cut‐off was 25 PDs/year (IQR: 20–32). Overall relative risk of in‐hospital mortality was 0.37 (95% CI: 0.30, 0.45), that is, 63% less in HV hospitals. All subgroup analyses found an in‐hospital survival benefit in performing PDs at HV hospitals. Meta‐regressions from included studies found no statistically significant associations between relative risk of in‐hospital mortality and region (USA vs. non‐USA; p = 0.396); or 25th percentile (p = 0.231), median (p = 0.822) or 75th percentile (p = 0.469) HV cut‐off values. Significant inverse relationships were found between PD hospital volume and other outcomes. Conclusion: In‐hospital survival was significantly greater for patients undergoing PDs at HV hospitals, regardless of HV cut‐off value or region. Future research is required to investigate regions where low‐volume centres have specialized PD infrastructure and the potential impact on mortality. [ABSTRACT FROM AUTHOR]

Background: Surgical outpatient consultations are demanding for the surgeon and patients without a definite formula for success. Various factors have been identified regarding factors that influence patient satisfaction and engagement. We aimed to examine the modern-day surgical outpatient consultation and report on these factors. Methods: An observational cross-sectional study was performed by reviewing video recordings of 182 surgical consultations by 12 surgeons at The Queen Elizabeth Hospital, South Australia, Australia. Results: The mean consultation time was 12.3 min, with pre-surgical consultations being the longest. There were 107 consultations for benign conditions (58%). Proportionally, the consultant spoke most (51.9% of total consultation time), followed by the patient (19.5%) and then companion (8.2%). Forty-eight (26.4%) patients brought a companion to the clinic but monopolisation of the consultation by the companion was rare. When a companion was present, there was more mutual eye gaze between the consultant and the patient. Interruptions were present in 23.6% of consultations and were associated with a significant increase of the length of the consultation. Table positioning did not seem to affect the dynamics of the outpatient consultation. Conclusion: Companions are highly valuable for promoting patient engagement and their presence should be encouraged in surgical outpatients. Interruptions should be kept to a minimum to avoid unnecessary delays. Further studies should be conducted to investigate the effect of companions, interruptions and table positioning during a consultation on patient outcomes. [ABSTRACT FROM AUTHOR]

Background: This study systematically reviewed the literature regarding perioperative mortality in human adults undergoing elective surgical abdominal wall hernia repair, including an audit of the Royal Australasian College of Surgeons (RACS) Australian and New Zealand Audit of Surgical Mortality (ANZASM) database. Methods: A systematic review was conducted in accordance with PRISMA guidelines for the reporting of systematic reviews and meta‐analysis of observational studies. Cochrane Library, PubMed, MEDLINE and Embase database searches and data extraction were conducted from June 1979 to October 2019. Statistical analysis was undertaken utilising denominator values for elective hernia procedures derived from the Australian Institute of Health and Welfare (AIHW) data. Risk‐adjusted perioperative mortality rates for the relevant procedures were also produced, using a binary logistic regression for the risk adjustment. Results: Through systematic review of the literature, it was established that the overall reported perioperative mortality in human adults undergoing elective surgical abdominal wall hernia repair was low (0.1%–0.5%). Using ANZASM and AIHW data, the calculated risk‐adjusted mortality rate for Australian patients was found to be significantly lower (0.04%–0.06%, p < 0.001). Conclusion: The risk‐adjusted mortality rate for elective abdominal wall hernia surgery in Australia is very low and compares favourably to international cohorts. Despite low absolute numbers, the factors which were most significantly associated with increased perioperative mortality in patients undergoing elective surgical abdominal wall hernia repair were increased age, cardiorespiratory co‐morbidity and incisional hernia repair. [ABSTRACT FROM AUTHOR]

Background: Long‐term effects after COVID‐19 may affect surgical safety. This study aimed to evaluate the literature and produce evidence‐based guidance regarding the period of delay necessary for adequate recovery of patients following COVID‐19 infection before undergoing surgery. Methods: A rapid review was combined with advice from a working group of 10 clinical experts across Australia and New Zealand. MEDLINE, medRxiv and grey literature were searched to 4 October 2020. The level of evidence was stratified according to the National Health and Medical Research Council evidence hierarchy. Results: A total of 1020 records were identified, from which 20 studies (12 peer‐reviewed) were included. None were randomized trials. The studies comprised one case–control study (level III‐2 evidence), one prospective cohort study (level III‐2) and 18 case‐series studies (level IV). Follow‐up periods containing observable clinical characteristics ranged from 3 to 16 weeks. New or excessive fatigue and breathlessness were the most frequently reported symptoms. SARS‐CoV‐2 may impact the immune system for multiple months after laboratory confirmation of infection. For patients with past COVID‐19 undergoing elective curative surgery for cancer, risks of pulmonary complications and mortality may be lowest at 4 weeks or later after a positive swab. Conclusion: After laboratory confirmation of SARS‐CoV‐2 infection, minor surgery should be delayed for at least 4 weeks and major surgery for 8–12 weeks, if patient outcome is not compromised. Comprehensive preoperative and ongoing assessment must be carried out to ensure optimal clinical decision‐making. [ABSTRACT FROM AUTHOR]

Background: With an ageing population, it is paramount for surgeons to comprehend the implications of age on surgical outcomes. This study aims to identify the effects of age on perioperative outcomes post-hepatectomy. Methods: Between 2001 and 2017, 357 hepatectomies were performed in our centre for malignancy. Data recorded include demographic, histopathology and perioperative outcomes. Patients were divided into three age groups (Group 1 < 65 years, Group 2 65–74 years, Group 3 ≥ 75 years). Results: With increasing age, there was a trend towards patient having: ASA ≥ 3 (from 32.1% to 60.9%, p < 0.0001), clear margins (from 80.4% to 88.3%, p = 0.2256), days of hospitalisation (from 9.5 ± 6.9 to 12 ± 8.0, p = 0.0003), days of ICU admission (from 2.3 ± 2.8 to 2.8 ± 12.9, p = 0.0790) and morbidity (from 39% to 58.5%, p = 0.0073). Cardiovascular complications and postoperative delirium increase with age. There was no significant difference in mortality across the three groups. Univariate and bivariate binary logistic regressions found no association between mortality and age. When adjusted for age, 30- and 90-day mortality was significantly associated with Clavien–Dindo ≥ 3, length of hospital and cardiac complications. Additionally, 90-day mortality was significantly associated with ASA score ≥3, mass of liver resected, length of ICU stay and hepatobiliary, pulmonary and genitourinary complications. Conclusion: Increased age is associated with increased post-hepatectomy complications, prolonged hospital stay and ICU admission. However, age itself is not a contraindication for hepatectomy and is not associated with increased mortality. Good histopathology outcomes and low mortality rates are achievable with careful patient selection and appropriate perioperative management. [ABSTRACT FROM AUTHOR]

Background: Cholecystectomy is a commonly performed procedure; however, it is not without risks. It is crucial to constantly audit surgical outcomes in order to improve quality of care. The aim of this retrospective population-based cohort study is to identify preventable issues of clinical management associated with adverse occurrences in order to reduce mortality of cholecystectomy patients. Methods: Data were obtained from the Australian and New Zealand Audit of Surgical Mortality (ANZASM). It encompasses peer-reviewed first and second line assessments of management of cholecystectomy patients who died from 2005 to 2015 in Australia. Clinical Management Issues (CMIs) were identified from text in assessments and grouped into communication failures, pre-operative, intra-operative and post-operative categories. These were further classified into subthemes using thematic analysis with a data-driven approach. Results: There were 359 deaths in the study period. CMIs were present in 71 cases, with a reported total of 124 concerns or adverse events. Post-operative CMIs were the most prevalent issue [50% (62/124)], with the most common theme being delay to recognise complications (19/124). Pre-operative concerns were the second most common (n = 34). Decision to operate was questioned in 14 cases, and delay to surgery was reported in 12 cases. Conclusion: ANZASM analysis has allowed us to identify modifiable adverse occurrences. This audit shows that delay to recognise complications is the most common assessment recorded. Preventive measures should be taken to improve outcomes and reduce peri-operative mortality, with an emphasis on post-operative management and enhancing communication between members of the multidisciplinary team. [ABSTRACT FROM AUTHOR]

Background: Studies have reported significant differences in baseline characteristics and outcomes of metastatic colorectal cancer (mCRC) patients when managed in private versus public hospitals. Aims: To compare disease, treatment and survival outcomes of patients with mCRC in public versus private hospitals in South Australia (SA). Methods: Analysis of prospectively collected data from the SA mCRC Registry. Patterns of care and outcome data according to location of care and socioeconomic status based on Index of Relative Socio‐Economic Advantage and Disadvantage were analysed. Results: A total of 3470 patients' data was analysed during February 2006–January 2015. The majority (70%) of patients received treatment in public hospitals. Patients in the upper 50% for Index of Relative Socio‐Economic Advantage and Disadvantage score were more likely to receive treatment at a private hospital (41.2% vs 21.56%) compared to <50%. Public patients had higher burden of disease (10.49% vs 7.41%, P = 0.005). Public patients received less treatment compared to the private patients (odds ratio = 0.48 (0.38–0.61), P = 0.01) and rates of surgical resections were lower in public patients. After adjusting for the covariates, public patients survive 1.33 months (P = 0.025) shorter than private patients with follow‐up time of 5 years. Patients receiving metastasectomy and more than three lines of treatment were shown to have the greatest survival benefit. Conclusion: Public patients have a higher burden of disease and in comparison are less likely to receive systemic therapy and have lower survival than patients treated in private hospitals. [ABSTRACT FROM AUTHOR]

Background: Oral squamous cell carcinoma (OSCC) is a significant public health issue. Australia had 448 deaths from lip and oral cavity cancer in 2018, some of which could be prevented. Consideration of the factors contributing to mortality after OSCC resection can provide a greater insight into how deaths can be prevented. Methods: This paper used data from the Australia and New Zealand Audit of Surgical Mortality from the last 10 years from 1 January 2009 to 31 December 2018 for analysis. All surgical deaths were captured as the treating surgeons were mandated to complete a surgical case form for assessment by an independent surgeon from the same specialty. Results: This study found 25 cases of death after OSCC resection. In 44% of cases, death was related to cardiac causes and 40% was related to respiratory causes. Fourteen cases were found to have issues with management, and 25 issues were raised. In 36% of issues, it was found to be related to decision to operate. There were no obvious differences between the patients who had neck dissections and those who did not. Conclusion: The decision to operate on high‐risk patients, cardiovascular and respiratory causes were the major contributors to surgical mortality. The small number of deaths and the limitation of using existing data limited statistical analysis and conclusions. Changes could be made to the Australia and New Zealand Audit of Surgical Mortality to improve the results for analysis. [ABSTRACT FROM AUTHOR]

Blockchain technology in health care. Blockchain technology is one of the many disruptive technologies of the Fourth Industrial Revolution that will irrevocably change the way we live and work. These technologies are well embedded in the areas of global finance, health care and defence, to name a few. This review focuses on the relevance of blockchain technology to health care. Blockchain technology will be the unifying platform for sharing patient data currently inaccessible due to the siloed architecture of legacy software systems, and as a result potentially be the basis for precision or individualized patient treatment. It will also strengthen digital security of sensitive patient data that is presently a lucrative target for cyber criminals. In the current COVID‐19 environment, clinicians will rely more on telehealth to reduce person‐to‐person contact. This service can be delivered by the clinical team with confidence in the veracity of the patient data made accessible through the blockchain platform. Smart contracts written on the blockchain platform will reduce the possibility of international humanitarian aid to low‐ and middle‐income countries being misspent. The pharmaceutical supply chain industry is adopting blockchain technology to ensure supply chain provenance. Similarly, the health insurance industry recognizes how the blockchain ecosystem can improve services to its members and expedite reimbursements to clinicians. [ABSTRACT FROM AUTHOR]

Artificial intelligence technology in surgery. Artificial intelligence (AI) is one of the disruptive technologies of the fourth Industrial Revolution that is changing our work practices. This technology is in use in highly diverse industries including health care, defence, insurance and e‐commerce. This review focuses on the relevance of AI to surgery. AI will aid surgeons with diagnostic decision‐making, patient selection for surgery as well as improve patient pre‐ and post‐operative care and management. Ethical considerations of AI with respect to patient rights and data privacy are highlighted. A further challenge is how best to present to national regulators a pragmatic way to assess AI as 'software as a medical device'. This relates to the ramifications for the adoption of AI technology in clinical practice, and its subsequent public funding support and reimbursement. It is evident that AI technology has important applications in surgery in the 21st century. The establishment of a key work programme in this area will be important if surgeons are to fully utilize AI in surgery. [ABSTRACT FROM AUTHOR]