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Purpose: The aim of this study is to make an objective assessment of whether multidisciplinary meetings (MDM) improve the management of patients requiring surgery for colorectal cancer as this has never been examined. Methodology: This retrospective study analyzed patients from the Geelong Hospital mandatory Colorectal Database between 1/1/2006 and 31/12/2007. MDM were implemented on 3/10/2006. To be included in the study patients had to have had an operation for colorectal adenocarcinoma. Each patient's management was determined to have conformed, or not conformed, to meet the best practice guidelines according to the 2005 Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer. Those patients who had been discussed in an MDM were compared with those pre-MDM to ascertain if there was any difference in patient treatment. Results: 182 patients had surgery for colorectal cancer. In the period where an MDM was available, 46% (53 of 116) patients were discussed in an MDM and all conformed to best practice guidelines. Of the 130 patients where no MDM review occurred, 98.5% conformed to best practice guidelines. This was consistent in both the pre MDM period (98.5%) and MDM available period (98.4%). Conclusion: The implementation of MDM at Geelong Hospital has marginally improved management of colorectal cancer. Few clinicians would dispute the benefits of such meetings but where an already high standard of care exists it is difficult to objectively demonstrate these improvements. We support using MDM but look to the less tangible benefits such as improved consistency and coordination of care, communication between health professionals and educational opportunities that MDM provide. [ABSTRACT FROM AUTHOR]

Background: Complications of diverticular disease commonly cause urgent admission yet there are no standard guidelines of the role of surgery. We aimed to review the management and outcome of patients with acute diverticular disease. Patients were managed by general surgeons with a conservative approach to diverticular disease. Methods: Emergency presentations for diverticular disease were identified in the period of Jan03–Aug08. Electronic databases provided discharge diagnosis, details of management, mortality and multiple admissions. Subgroup analysis compared surgical and conservative management subdivided for presentation type. Results: 435 admissions with a diagnosis of diverticular disease were identified. This constituted 8% (435/5069) of all emergency admissions for general surgery. Presentation types: Diverticulitis (57%), Haemorrhage (25%), Perforation (10%), Abscess (5%), Obstruction (2%) and Fistula (1%). 21% of admissions required urgent surgery while 8% were multiple admissions. Surgical management: Hartmann's Procedure (74%), Right Hemicolectomy (9%), High Anterior Resection (4%), Subtotal Colectomy (3%), Sigmoid Colectomy (2%), Total Colectomy (2%), Low Anterior Resection (1%), Laparoscopy (1%), Laparotomy & Washout/Abscess Drainage (2%). Mortality: Surgical group 5%, Conservative group 1.2%, Overall mortality 2%. Conclusion: Diverticulitis and Haemorrhage form most of the presentations. Conservative management is successful in these cases (93% and 89%) but less so for the complication of Abscess (36%), Perforation (22%), Obstruction (22%) and Fistula (0%). Here a conservative approach to surgical management of acute diverticular disease results in a low mortality of 5%, which is favourable compared to other series. [ABSTRACT FROM AUTHOR]

Background: Recent guidelines published by the Australian Endocrine Surgeons AES06/01 Group recommend a parathormone (PTH) measurement >1.0 ρmol/L drawn 4 hrs following total or completion thyroidectomy predicts those patients not requiring treatment (92.6% sensitivity, 70.7% specificity). This study evaluated the ability of single PTH and calcium levels in the early prediction of which patients need treatment for hypocalcaemia and so facilitating earlier discharge. Method: Clinical details and pathology results of patients undergoing total or completion thyroidectomy from 2001–2008 were retrieved electronically. PTH and calcium levels at 6–8 hrs and at 18–24 hrs were assessed by Receiver-Operating Characteristic curve analyses. Results: 180 patients (151 females, 29 males) underwent total (145) or completion (35) thyroidectomy; 66 required postoperative calcium supplements. A PTH measurement drawn at 6–8 hrs post-surgery ≤1.1 ρmol/L identified all patients requiring treatment (100% sensitivity), ruling out 86% of patients not requiring treatment. A PTH measurement ≤1.1 ρmol/L drawn at 18–24 hrs predicted those patients requiring treatment (91% sensitivity, 93% specificity). Calcium measurements at 6–8 hrs (81% sensitivity, 51% specificity) and 18–24 hrs (80% sensitivity, 68% specificity) proved poor predictors. There was no benefit in plotting a calcium slope over the first postoperative day (73% sensitivity, 65% specificity). Conclusion: In our series a PTH of <1.1 ρmol/L at 6–8 hrs was the most accurate at identifying those patients requiring calcium supplements to enable earlier discharge from hospital. These results are certainly consistent with the recently published AES guidelines and validate their findings. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the anaesthesia care of an enhanced recovery after surgery (ERAS) program for patients having abdominal surgical in Victorian hospitals. The main outcome measure was the number of ERAS items implemented following introduction of the ERAS program. Secondary endpoints included process of care measures, outcomes and hospital stay. We used a before-and-after design; the control group was a prospective cohort (n=154) representing pre-existing practice for elective abdominal surgical patients from July 2009. The introduction of a comprehensive ERAS program took place over two months and included the education of surgeons, anaesthetists, nurses and allied health professionals. A post-implementation cohort (n=169) was enrolled in early 2010. From a total of 14 ERAS-recommended items, there were significantly more implemented in the post-ERAS period, median 8 (interquartile range 7 to 9) vs 9 (8 to 10), P <0.0001. There were, however, persistent low rates of intravenous fluid restriction (25%) and early removal of urinary catheter (31%) in the post-ERAS period. ERAS patients had less pain and faster recovery parameters, and this was associated with a reduced hospital stay, geometric mean (SD) 5.7 (2.5) vs 7.4 (2.1) days, P=0.006. We found that perioperative anaesthesia practices can be readily modified to incorporate an enhanced recovery program in Victorian hospitals. [ABSTRACT FROM AUTHOR]

In Australia 61% of elective surgery takes place in private hospitals where current opportunities for surgical education and training (SET) are limited. The situation will shortly be compounded because of the large increase in local medical graduates, many of whom will aspire to be surgeons. How and where to train these extra surgeons to meet the expanding needs of the community must be addressed. Two models of private sector training are reviewed both of which involved combined training in both private and public sectors. Two second-year (SET 2) positions were created from one public hospital SET position by using the private sector for 3.5 days per week for 3 months of a 6-month rotation. The second model was applicable to post-fellowship training with a fairly even split between public and private sector responsibilities. In the first year, four registrars shared the two 6-month rotations for the SET 2 position. Trainees did the required minimum procedures (range 109–139) with primary operating targets of 20–25% (range 21–32%). The post-fellowship position in colorectal surgery was greatly enhanced by the private sector involvement with regard to operating experience as well as meeting part of the remuneration of the trainee. Successful models for training within the private sector in Australia can be found. To expand training in the private sector there will need to be a cultural shift in the perceptions of surgeons, patients, administrators, and trainees. Funding for posts may be available to those private hospitals that can meet the Royal Australasian College of Surgeons’ accreditation standards for posts and hospitals. [ABSTRACT FROM AUTHOR]

Diabetes mellitus is a frequent long-term complication of infantile nephropathic cystinosis. We studied 44 cystinotic patients, aged 22.1±5.4 years, transplanted at a mean age of 11.3±2.5 years: 25% were treated with insulin at 20 years of age or 10 years after transplantation, and over half required insulin at latest follow-up. In comparison, diabetes mellitus occurred in only 1% of non-cystinotic transplanted patients. Sequential oral glucose tolerance tests (OGTTs) in these patients showed the progressive deterioration of glucose metabolism. All but 2 patients had an abnormal response at latest follow-up. The high doses of corticosteroid given after transplantation or during rejection episodes were responsible for transient insulin dependency. However, the development of impaired glucose tolerance and diabetes mellitus depended mainly on the cystinotic process, which developed slowly with time. The deterioration of glucose tolerance was correlated with a decreased early phase of insulin secretion, estimated from the plasma insulin level at 30 min of the OGTT, while there was no evidence of insulin resistance. The occurrence of diabetes mellitus correlated with a worsening of the vital prognosis. [ABSTRACT FROM AUTHOR]

Background: Transanal total mesorectal excision (taTME) aims to overcome some of the technical challenges faced when operating on mid and low rectal cancers. Specimen quality has been confirmed previously, but recent concerns have been raised about oncological safety. This multicentre prospective study aimed to evaluate the safety of taTME among early adopters in Australia and New Zealand. Methods: Data from all consecutive patients who had taTME for rectal cancer from July 2014 to February 2020 at six tertiary referral centres in Australasia were recorded and analysed. Results: A total of 308 patients of median age of 64 years underwent taTME. Some 75.6 per cent of patients were men, and the median BMI was 26.8 kg/m². The median distance of tumour from anal verge was 7 cm. Neoadjuvant chemoradiotherapy was administered to 57.8 per cent of patients. The anastomotic leak rate was 8.1 per cent and there was no mortality within 30 days of surgery. Pathological examination found a complete mesorectum in 295 patients (95.8 per cent), a near-complete mesorectum in seven patients (2.3 per cent), and an incomplete mesorectum in six patients (1.9 per cent). The circumferential resection margin and distal resection margin was involved in nine patients (2.9 per cent), and two patients (0.6 per cent) respectively. Over a median follow-up of 22 months, the local recurrence rate was 1.9 per cent and median time to local recurrence was 30.5 months. Conclusion: This study showed that, with appropriate training and supervision, skilled minimally invasive rectal cancer surgeons can perform taTME with similar pathological and oncological results to open and laparoscopic surgery. !! [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Patients with methylmalonic acidemia (MMA) may develop many complications despite medical treatment, in particular, severe central nervous system damage and chronic kidney disease (CKD). A kidney transplant may partially correct the metabolic dysfunctions. Liver, kidney and combined liver–kidney transplantations have been advocated but no guidelines are available to identify the most suitable organ to transplant. Patients and methods: Four patients with MMA (mut° phenotype) received a kidney graft because of repeated metabolic decompensations, with progression to CKD in 3 patients (end-stage kidney disease in two patients and CKD stage III in one patient with an estimated glomerular filtration rate [eGFR] of 40ml/min/1.73m2) but normal renal function in one (eGFR of 93ml/min/1.73m2) before transplantation. Results: The medium age at transplantation was 7.9y (5–10.2) and the median follow-up was 2.8years (1.8–4.6). Renal transplantation improved the relevant metabolic parameters in 4/4 patients and renal function in the patients with CKD. Plasma and urinary MMA levels immediately decreased and remained normal or subnormal (mean values of plasma MMA before transplantation 1530μmol/L versus 240μmol/L after transplantation, and mean values of urine MMA before transplantation 4700mmol/mol creatinine versus 2300mmol/mol creatinine after transplantation). No further acute metabolic decompensation was observed and protein-intake was increased from 0.60 to 0.83g/Kg/day. One patient transplanted at age 9.7years developed a hepatoblastoma at age 11years with subsequent neurological complications and eventually died. The three other patients are alive. Two of them remained neurologically stable. The 3rd patient who displayed choreoathetosis transiently improved his neurological condition immediately after transplantation and then remained stable. Conclusion: Kidney transplantation represents an interesting alternative therapeutic option in methylmalonic aciduria, for renal complications but also as a “cellular therapy” that may significantly reduce metabolic decompensations and hospitalizations. However, further neurological impairment remains possible. [Copyright &y& Elsevier]

Objectif: Présentation des résultats de la greffe rénale pédiatrique dans 8 centres français grâce au registre DIVAT pédiatrique. Patients et Méthodes: DIVAT (Données Informatiques VAlidées en Transplantation rénale) pédiatrique est un registre informatique recueillant les données cliniques et biologiques des enfants greffés rénaux. L’étude porte sur les greffes rénales pédiatriques réalisées dans 8 centres, entre le 01/01/1995 et le 31/12/2007, chez des enfants âgés de 1 à 16 ans. Les greffes combinées (rein – foie) sont exclues. Les comparaisons de survie sont effectuées par un test non paramétrique (Khi 2), p < 0.05 est considéré comme significatif. Résultats: 748 greffes rénales ont été réalisées chez 720 enfants au cours de cette période. Il s’agit d’une première greffe dans 93 % des cas. La transplantation est préemptive dans 16 % des cas. 86 % des greffes sont effectuées avec un donneur cadavérique, 12.8 % avec un donneur vivant apparenté. L’âge et le poids moyen du receveur lors de la greffe est 10.7 +/−4,3 ans et 28.3 +/−13,5 kg. Il n’y a aucune incompatibilité DR dans 24 % des cas, alors qu’il existe 1 et 2 incompatibilités DR dans 64 % et 11 % des cas. Les receveurs sont séropositifs pour le cmV et l’EBV dans 34 % et 64 % des cas respectivement. Il existe un mismatch non favorable (donneur positif, receveur négatif) pour le cmV et l’EBV dans 23 % et 20 % des cas respectivement. La survie du patient est de 99 %, 97 % et 96 % à 1, 5 et 10 ans respectivement. La survie du greffon est de 94 %, 86 % et 77 % à 1, 5 et 10 ans respectivement. La survie du greffon est signifi cativement meilleure avec un donneur vivant par rapport à un donneur cadavérique (96 % versus 85 % à 5 ans et 85 % versus 76 % à 10 ans, p < 0.05). Discussion et Conclusion: On observe une survie des greffons rénaux satisfaisante et une mortalité faible. On peut remarquer le faible pourcentage de greffes préemptives et de greffes issues de donneur vivant apparenté. Le registre DIVAT Pédiatrique permet une analyse descriptive d’une importante cohorte d’enfants greffés rénaux en France, et est un outil intéressant pour des études descriptives et prospectives concernant de nombreux paramètres intervenant dans la greffe rénale pédiatrique. [Copyright &y& Elsevier]

Objective and Methods: To assess patient survival in pediatric renal transplantation, we retrospectively reviewed 573 transplants in 553 patients, registered from 1995 to 2005. Results: Mean age at transplantation was 9.9 years. Patient survival at 1, 5 and 10 years was respectively 99%, 97% and 96%. Death occurred at a median time of 2.6 years after transplantation. Long-term patient survival was significantly lower in recipients younger than 5 years old. Seventeen patients (3.1%) died. Two deaths occurred while under maintenance dialysis. Among the remaining patients, the two main causes of death were infections (33%) and malignancies (27%). Interestingly, initial disease-related complications were a major cause of death (34%). Conclusion: A low mortality rate was observed, with the majority of deaths due to malignancies and infections, and with a notable participation of complications related to the initial disease. No impact of cardiovascular disease was noted with the given follow-up period. Improvements in managing immunosuppression may contribute to reducing mortality in pediatric renal transplantation. [ABSTRACT FROM AUTHOR]

From 1990 to 2000, we performed eight liver-kidney transplants in eight children, aged 1–16 years, with end-stage renal failure (ESRF) due to primary hyperoxaluria (PH1). The duration of dialysis before transplantation ranged from 2 to 42 months (mean 14 months) and was <1 year in four patients. Only the first patient underwent postoperative hemodialysis; in the other five, we chose to induce maximal diuresis from the first hours with intravenous and intragastric hyperhydration (≥3 l/m[sup 2] per day). High water intake with nocturnal tube hydration was maintained for 6 months to 5 years, as long as oxaluria exceeded 0.5 mmol/day. A quadruple sequential immunosuppressive regimen was used. Two patients died during liver graft surgery. The other six patients are alive and well, with a mean follow-up of 7.4 years (range 5–11 years). Patient and graft survival is 75% at 5 years. At latest follow-up, liver tests were normal in all six patients; creatinine clearance ranged from 55 to 95 ml/min per 1.73 m[sup 2] (mean=74). Oxaluria was lower than 0.4 mmol/day in all patients (mean=0.22). The six patients underwent 15 renal biopsies, 1–11 years after transplantation. Chronic transplant nephropathy was present in four patients and mild cyclosporin nephrotoxicity in another. No oxalate crystals were seen and repeat ultrasonography has been consistently normal in all patients. The three patients with bone oxalosis showed progressive complete healing of bone lesions. All six children or adolescents now live a normal life. From this series, we conclude that early combined liver-kidney transplantation is the treatment of choice for children with ESRF due to primary hyperoxaluria. [ABSTRACT FROM AUTHOR]

Abstract: A boy who was diagnosed with methylmalonic aciduria (MMA) at the age of 10 days developed persistent hepatomegaly and raised transaminases from the age of 4 years. He was subsequently diagnosed with Leigh syndrome and required a kidney transplantation for end-stage renal failure. A massive hepatoblastoma led to his death by the age of 11 years. Methylmalonyl-CoA mutase activity was undetectable on both cultured skin fibroblasts and kidney biopsy and multiple respiratory chain deficiency was demonstrated in the kidney. Mitochondrial dysfunction and/or post-transplant immunosuppressive therapy should be considered as a possible cause of liver cancer in this patient. [Copyright &y& Elsevier]