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Background: Sessile serrated lesions (SSL) account for up to 30% of colorectal carcinoma pathogenesis. With multiple classification changes and improvements in colonoscopy equipment and technique, historical reporting may have underestimated the true incidence of SSLs. This study aimed to determine the incidence of SSLs in patients undergoing colonoscopic investigation in Canterbury, New Zealand over a 1-year period and describe their clinical and pathological characteristics., Methods: Electronic records were searched to identify all lower endoscopy procedures with polypectomy performed from 1 January 2022 to 1 December 2022 (inclusive). Patients' electronic records were used to collect histological classification, location and size of each polyp removed during their procedure. The primary outcome was the number of procedures that had one or more SSL, adenoma or hyperplastic polyp identified. Secondary outcomes included histological classification, location and size of each polyp removed., Results: There were 4346 procedures completed during the study period. Of these, 64.1% (2786) had a polypectomy and 18.6% (808) had at least one SSL excised. Individual polyp analysis was completed on 9166 polyps and found that 24.0% of polyps removed were SSLs and they were found predominately in the right colon (65.1% right colon, 32.6% left colon, 2.3% rectum). SSLs were typically <10 mm (84.8%)., Conclusion: This study found a higher incidence of SSLs compared to previous research. These results raise questions regarding whether SLL rates have been historically underestimated, whether SSL detection rate should be included as a key performance indicator and raises further concerns regarding the use of computed tomography colonography as a screening tool., (© 2024 The Author(s). ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Healthcare systems globally face the issue of resource constraints and need for prioritization of elective surgery. Inclusive, explicit prioritization tools are important in improving consistency and equity of access to surgery across health systems. The General Surgical Prioritization Tool developed by New Zealand's Ministry of Health scores patients for elective non-cancer surgery based on surgeon's clinical judgement and patient derived Impact on Life (IoL) scores. This study aims to measure the changes in patient derived IoL scores after common general surgical procedures to enable direct comparison and inform future prioritization., Method: This longitudinal observational study enrolled 322 participants who had undergone elective general surgical procedures. Participants were contacted 3 to 9 months after their procedures and requested to complete the IoL questionnaire. The primary endpoint was the change in IoL scores after surgery among the different procedures., Results: Overall, 229/304 (75%) participants responded to the questionnaire and there were no significant baseline differences between responders and non-responders. Patients in the gallbladder treatment group had the greatest improvement in IoL scores. Patients across all ethnic groups had similar changes in IoL scores. Multivariate analysis showed that gallbladder surgery (relative to hernia surgery) and pre-surgery IoL scores significantly predicted improvement., Conclusion: The patient reported IoL score recorded at prioritization for surgery all reduced, albeit to varying amounts, after common general surgical procedures. This, combined with the fact that IoL scores predicted post-operative improvement support their inclusion in prioritization tools in addition to surgeon derived components., (© 2024 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Introduction: Anastomotic leak (AL) after colon cancer resection is feared by surgeons because of its associated morbidity and mortality. Considerable research has been directed at predictive factors for AL, but not the anatomic type of colonic resection. Anecdotally, certain types of resection are associated with higher leak rates although there remains a paucity of data on this. This study aimed to determine the AL rate for different types of colon cancer resection to inform decisions regarding the choice of operation., Methodology: Retrospective analysis of Bowel Cancer Outcome Registry (BCOR) for all colonic cancer resections with anastomosis between January 2007 and December 2020. Demographic, patient, tumour and outcome data were analysed. AL rates were compared among the different colonic procedures with both univariate and multivariate analysis., Results: 20 191 patients who underwent resection with anastomosis for cancer were included in this study. Of these 535 (2.6%) suffered ALs. While the univariate analysis found male sex, procedure type, symptomatic cancers, emergency surgery, unsupervised registrars, conversion to open surgery, medical complications and higher TNM staging were associated with AL, multivariate analysis, found only procedure type remained a significant predictor of AL (total colectomy (OR 4.049, P<0.001), subtotal colectomy (OR 2.477, P<0.001) and extended right hemicolectomy (OR 2.171, P < 0.001))., Conclusion: AL is more common in extended colonic resections. With growing evidence of similar oncological outcomes between subtotal colectomy and left hemicolectomy for splenic flexure cancers, more limited resections should be considered. The type of colonic resection should be integrated into prediction tools for AL., (© 2023 Royal Australasian College of Surgeons.)

Background: Training pathways vary significantly after completion of the general surgery surgical education and training (SET) program due to increasing sub-specialization. Aotearoa New Zealand requires a diverse range of general surgeons. Appointment of new consultant surgeons can be an opaque process; trainees are often uncertain how to tailor their training to that required by potential employers. Heads of departments (HODs) are influential in new appointments, and their opinions on desirable candidate attributes are valuable., Methods: An online survey was conducted in March 2023. All public hospital general surgery HODs were invited to participate. The survey sought opinions on the importance of attributes, skills and experience when appointing a new consultant general surgeon., Results: The response rate was 70% (14/20) including 6 of 7 HODs from tertiary hospitals and 8 of 13 from secondary hospitals. The top three desirable factors were all personal attributes (being a team player, having a strong work ethic, and good interpersonal skills). 10 of 14 respondents disagreed that SET completion alone is sufficient without the need for further training. Most respondents preferred at least 2 years of fellowship training, except for trauma and endocrine surgery, where 1 year was frequently considered sufficient. Only one respondent agreed formal research training is highly valued., Conclusion: Trainees would be wise to obtain training desired by the majority of HODs while building an individualized profile of attributes, skills and experience tailored to hospitals they may wish to work in. The findings should be considered by organizations responsible for general surgical training and workforce planning., (© 2023 Royal Australasian College of Surgeons.)

Background: The 'weekend effect' is the term given to the observed discrepancy regarding patient care and outcomes on weekends compared to weekdays. This study aimed to determine whether the weekend effect exists within Aotearoa New Zealand (AoNZ) for patients undergoing emergency laparotomy (EL), given recent advances in management of EL patients., Methods: A cohort study was conducted across five hospitals, comparing the outcomes of weekend and weekday acute EL. A propensity-score matched analysis was used to remove potential confounding patient characteristics., Results: Of the 487 patients included, 132 received EL over the weekend. There was no statistically significant difference between patients undergoing EL over the weekend compared to weekdays. Mortality rates were comparable between the weekday and weekend cohorts (P = 0.464)., Conclusions: These results suggest that modern perioperative care practice in New Zealand obviates the 'weekend' effect., (© 2023 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Attenuation of the inflammatory response in patients undergoing colectomy with modern perioperative care and laparoscopic surgery has been a focus of research in recent years. Despite reported benefits, significant heterogeneity remains with studies including patients undergoing both rectal and colon surgery and including surgery with postoperative complications. Therefore, the aim of the study was to evaluate the inflammatory response in patients undergoing elective colectomy without complications, specifically comparing open and laparoscopic approaches., Methods: A multicenter prospective study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were included over a 3-year period. Perioperative blood samples were collected and analysed for the following inflammatory markers: IL-6, IL-1β, TNFα, IL-10, CRP, leucocyte and neutrophil count. Statistical analysis was performed using SPSS statistical software., Results: A total of 168 colectomy patients without complications were included in the analysis. Patients that underwent laparoscopy had significantly reduced IL-6, neutrophils and CRP on postoperative day (POD) 1 (p < 0.05) compared to an open approach. IL-10 and TNFα were significantly reduced on POD 2 (p < 0.05) in laparoscopic patients. Patients with a Body Mass Index (BMI) greater than 30 kg/m 2 had significantly higher levels of CRP regardless of operative approach. Statins altered both preoperative and postoperative inflammatory markers., Conclusion: The postoperative inflammatory response is influenced by surgical approach, perioperative medications, and patient factors. These findings have important implications in the utility of biomarkers in the diagnosis of postoperative surgical complications, in particular in the early diagnosis of anastomotic leak., (© 2022 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Background: Synoptic operative reports may improve reporting of key operative information. This study aimed to compare information included in synoptic reports with narrative notes following the introduction of a synoptic reporting system at a tertiary colorectal cancer referral centre., Methods: A standardized synoptic template incorporating the operative fields in the Australasian Bi-National Colorectal Cancer Audit (BCCA) was introduced for colorectal cancer surgery at the host institution in 2017. Colorectal cancer patients were identified from a prospectively collected database to collate samples of synoptic and narrative operative reports for comparison. The primary outcome was reporting of colon and rectal cancer-specific quality measures. Synoptic reporting of quality measures by clinician grade and uptake of synoptic reporting were also measured., Results: Five hundred and ninety-five operative reports were reviewed; 84% of all quality measures were included in synoptic reports and 43% in narrative reports describing colon cancer surgery (P <0.001). Synoptic reports describing rectal cancer surgery included 84% of quality measures with 40% reported in narrative reports (P <0.001). Reporting for most individual quality measures did not change depending on clinician experience. Synoptic reporting methods were used to document 80% of all colon cancer surgery and 84% of rectal cancer surgery., Conclusion: Synoptic operative reports were superior to narrative reports in documenting quality measures. Synoptic reporting facilitates simultaneous data capture and bulk upload for audits including the BCCA. Development of synoptic operative reports standardized across Australasian colorectal cancer centres should be further investigated as a tool to facilitate collaborative audit and research., (© 2022 Royal Australasian College of Surgeons.)

Background: Globally, patients presenting with acute surgical disease in rural areas have poorer outcomes when compared to urban areas; little data are available regarding outcomes for New Zealand (NZ) rural patients. This study aimed to compare the surgical management of appendicitis in a large metropolitan centre with its regional referral centres., Methods: In this retrospective cohort study, patient data were collated from the studied centres between November 2014 and October 2019. In addition to patient demographics, patterns of referral and presentation, the primary outcome was time to the theatre; secondary outcomes were perforation rates, length of stay and complications. Data are presented as medians (interquartile range)., Results: A total of 3533 patients underwent appendicectomy over the period studied. For those presenting directly to the metropolitan centre, the median wait-time to the theatre was 16 h (9.2-23.2); if patients were transferred, they waited for 20.8 h (13.6-27). Patients presenting to regional centres waited for 7.6 h (4.5-15.4, P < 0.001). Perforation rates for transferred patients were 31% which was greater than for those presenting to the metropolitan (20%) or regional centres (17%, P = 0.014). Complications were also highest in transferred patients (20%) when compared to the metropolitan (17%) or regional centres (10%, P < 0.001)., Conclusion: Patients who were transferred to Christchurch Hospital from rural centres without surgical services had a longer wait-time than those who presented to Christchurch Hospital directly or were treated in regional centres. This was associated with higher rates of perforated appendicitis., (© 2021 Royal Australasian College of Surgeons.)

Background: Ulcerative colitis (UC) is a risk factor in developing colorectal cancer (CRC). Surveillance programmes aim to identify premalignant lesions to facilitate improved treatment outcomes. Recent studies have suggested that the risk of CRC in UC has decreased. This study aims to characterize the risk of CRC in UC in a population-based New Zealand cohort., Methods: All patients in the Canterbury Inflammatory Bowel Disease Study, a comprehensive population-based cohort, were reviewed and cases of dysplasia and CRC identified. Demographic data and risk factors were assessed and standardized incidence ratios (SIRs) calculated comparing with the national population., Results: A total of 518 UC cases were analysed (46.3% female). Median follow-up was 17.5 years (interquartile range 12.2-25.1 years). Neoplasia developed in 42 (8.1%) patients, 14 (2.7%) of whom had CRC. The mean age at CRC diagnosis was 63.3 years, and mean duration with UC before CRC 18.4 years (0-36.8 years). The total incidence rate was 1.35/1000 person-year duration (95% confidence interval 0.74-2.27). The age-adjusted SIR was 1.74 (95% confidence interval 1.03-2.93) compared to the New Zealand population. Risk factors for any dysplasia included disease extent and male gender., Conclusion: In this population-based cohort with long-term follow-up, the SIR of CRC in UC patients was significantly lower than the initial epidemiological studies although similar to more recent studies. This increased risk still justifies ongoing screening in the UC population., (© 2020 Royal Australasian College of Surgeons.)

Background: Positron emission tomography/computed tomography (PET/CT) is used pre-operatively in patients with metastatic or recurrent colorectal cancer to identify those who have potentially curative disease. However, a recent randomized trial questioned the added benefit of PET/CT over conventional imaging in patients with liver metastases. The aim of this study was to determine the proportion of patients with colorectal cancer in whom PET/CT altered surgical management, in a single tertiary centre., Methods: This was a retrospective study of all patients with colorectal cancer who had a PET/CT for colorectal cancer, funded by the Canterbury District Health Board between 2010 and 2014., Results: Some 111 PET/CT scans were performed on 105 patients. A total of 38% of PET/CT were for patients with known or suspected liver metastases, 23% for suspected local recurrence and 18% for known or suspected lung metastases. Five scans were for post-operative patients with a rising carcinoembryonic antigen and no attributable source on conventional imaging. PET/CT identified additional extrahepatic sites of disease in 19 of 111 (17%) scans in patients deemed to have potentially operable disease. Overall, PET/CT altered surgical management following six of 42 (14%) scans for patients with liver metastases, four of 20 (20%) scans for patients with lung metastases and six of 26 (23%) scans for patients with local recurrence., Conclusion: PET/CT remains a useful adjunct to conventional imaging in the pre-operative workup of patients with colorectal cancer., (© 2016 Royal Australasian College of Surgeons.)

Background: Colorectal cancer is a common and often fatal malignancy. Currently, the modifications that alter disease outcome include early symptom recognition, population screening as well as improved surgical and adjuvant treatments. Preventative strategies have been limited with little evidence that lifestyle changes significantly alter risk. There is however a growing awareness of a potential role for chemoprevention in some patient groups. This study aimed to review the literature associated with chemoprevention in colorectal cancer., Methods: An electronic literature search of MEDLINE and Embase databases was performed on PubMed for studies detailing the use of chemoprevention agents in colon and rectal cancer. The search was limited to clinical trials on adult humans (>16 years of age) published in English since 1990., Results: The strongest evidence is for non-steroidal anti-inflammatory drugs slowing polyp progression, notably Sulindac and aspirin in patients with familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer, respectively. There is also increasing evidence that continuing use of low-dose aspirin reduces long-term incidence of colorectal cancers. Cyclooxygenase 2 inhibitors also have a potential role but cardiac toxicity currently limits their use. Folic acid, statins, antioxidants, calcium and 5-aminosalicylic acid lack evidence to support their use at present., Conclusions: Currently, there is not enough evidence to support the implementation of a chemopreventative agent for general use. However, there appears to be a role for aspirin in selected subgroups., (© 2015 Royal Australasian College of Surgeons.)

Background: Poor documentation of medical notes and plans not only adversely affects patient management but also has medico-legal implications. A standardized ward round checklist (adhesive proforma sticker, PFS) was introduced at our institution in 2013 to improve documentation by junior doctors. We aimed to examine the current pattern of PFS documentation (2 years after its introduction) and to identify which fields, if any, have been the most problematic to complete., Methods: Notes of all current general surgical inpatients admitted to Christchurch Public Hospital on or before the two study days were reviewed. All information written in the PFS, regardless of accuracy, authorship or completeness, was recorded. Documentation of the various PFS fields was classified as well documented (completed in >80% of PFS), inadequate (40-80%) or minimal (<40%)., Results: Four hundred and seventy-nine PFS were reviewed. Most fields in the PFS were documented to an adequate level (i.e. >80%). Problematic fields identified were dietary plans, diagnosis, national health index number, estimated date of discharge and the patient's first name. Notes of patients on outlying ward contained significantly fewer PFS compared with home-ward patients' notes (0.71 PFS/day versus 1.21 PFS/day, respectively, P < 0.001)., Conclusion: Our study has shown generally adequate patterns of medical note documentation in the General Surgery service. Certain fields remain challenging to document accurately. The proposed modified PFS was designed to help rectify this; electronic data record may be the step forward, however. It is hoped that other institutions in Australasia would benefit from our experience., (© 2016 Royal Australasian College of Surgeons.)

Introduction: Enhanced recovery after surgery (ERAS) programmes have been shown to improve outcomes after colonic surgery. However, there is less evidence supporting ERAS in rectal surgery. The aim of this study was to compare outcomes of conventional perioperative care with those of an ERAS pathway including both colonic and rectal surgery patients., Methods: Outcomes of patients undergoing elective colorectal surgery at Christchurch Hospital within the ERAS pathway were compared with patients receiving conventional perioperative care over a 2-year period. A retrospective analysis was conducted, including primary and total length of stay (LOS), readmission, complication and mortality rate., Results: A total of 240 patients undergoing colorectal surgery were included; 160 patients received conventional perioperative care and 80 patients were managed within the ERAS pathway. Primary and total LOS were shorter in the ERAS group (6 versus 7 days, P = 0.0004, 7 versus 10 days, P = 0.0003, respectively). Re-admission and complication rates were not significantly different between the groups. There was one death (in the conventional care group) within 30 days. Patients undergoing rectal surgery within the ERAS pathway did not show any difference in primary LOS, readmission or complication rate although median total LOS was significantly reduced (7 versus 10 days, P = 0.0457)., Conclusion: Patients undergoing elective colorectal surgery managed within the ERAS pathway had shorter hospital stays without increased morbidity or mortality. Differences were less pronounced in the rectal surgery subgroup and further research is needed to investigate the use of ERAS pathways for patients undergoing elective rectal surgery., (© 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.)

Background: Diaphragmatic hernias complicating pregnancy are not a common problem but they can have catastrophic consequences. They can present to the surgeon as a life-threatening emergency or pose a management dilemma when detected incidentally. In this paper, recommendations for the management of non-hiatal maternal diaphragmatic hernias are made based on our experience and the available published reports., Methods: The presentation, management and outcomes of a series of three recent cases are described. A review of all other reported cases of diaphragmatic hernias complicating pregnancy was also carried out., Results: All three cases were emergency presentations in the third trimester of pregnancy, resulting from compression of thoracic contents. All cases required emergency laparotomy and one also required thoracotomy. Delivery was by Caesarean section at the time of emergency surgery in two cases and was delayed in the third case. There was one fetal and no maternal deaths. One mother suffered persistent pleural infection. One baby also had a diaphragmatic hernia requiring postnatal repair. Published reports showed only 36 previously reported cases of diaphragmatic hernias identified in pregnancy. There is a consensus that hernias presenting with evidence of strangulation represent a surgical emergency and mandate operative management, irrespective of fetal maturity. Elective management of asymptomatic hernias is more controversial and both conservative and operative approaches have been suggested., Conclusion: Diaphragmatic hernias can cause life-threatening complications in pregnancy. Consideration should be given to operative repair in the second trimester if asymptomatic hernias are identified during pregnancy. If vaginal delivery is attempted in the presence of a hernia, this should only be carried out under closely monitored conditions.