Background
Autologous breast reconstruction services are logistically complex and challenging to implement but have better outcomes than implants. This study aimed to evaluate the effect of ...implementing a coordinated, low‐cost combined breast reconstruction service (0.8 FTE nurse liaison, 0.25 FTE plastic surgeon, two dedicated breast surgeons 0.05 FTE each and protected weekly all‐day oncoplastic theatre) on unit productivity and efficiency in reducing wait times for immediate autologous breast reconstruction.
Methods
A retrospective cohort study was conducted on all patients who underwent immediate autologous breast reconstruction at Fiona Stanley Hospital between two study periods, pre‐intervention – February 2016 to June 2019 and post‐intervention – November 2022. Data were analysed using SPSS v.27.
Results
One hundred twenty‐seven participants were included, with 49% (n = 62) in the post‐intervention group. Most procedures performed were therapeutic (n = 108, 85%). DIEP was the most common flap (84%), and the mean BMI was 26.9 (SD ± 4.2).
There was a statistically significant increase in the number of high‐risk gene carriers' prophylactic cases and bilateral cases performed post‐intervention (5% to 26%, P = 0.001) and (29% to 55%, P = 0.003), respectively.
Time to surgery on the waitlist did not significantly change after the intervention (therapeutic group: 3.1 to 3.5 weeks, P = 0.821; prophylactic group: 55.0 to 61.1 weeks, P = 1.000). Overall, there was a marked increase in the overall productivity of the breast service unit in terms of mastectomies, total reconstructions, and autologous reconstructions performed.
Conclusions
This single‐centre experience showed that implementing a coordinated service significantly increased the unit's productivity. This low‐cost intervention can be applied to other healthcare settings.
This study implemented a coordinated and combined breast reconstruction service, significantly increasing the unit's productivity. This low‐cost intervention can be applied to other healthcare settings.
Background
The closure of ileostomy is associated with significant morbidity, the most common being surgical site infection (SSI), ranging up to 41%. This study compared the stoma site SSI rates ...after either the conventional‐linear closure (CLC) or purse‐string closure (PSC).
Methods
The study conducted a single‐centre retrospective cohort study of elective loop‐ileostomy closures from June 2015 to January 2021. Patient demographics, surgical techniques and outcomes, including SSI rates, were analysed using SPSS ver.27.
Results
Hundred and six patients underwent loop‐ileostomy closure, 91.5% (n = 97) had CLC of which 67% (n = 65) were stapled. Male patients comprise 67.9%, with a median age of 62. The median BMI was 27. The median surgical time, LOS and interval time to closure were 66 min, 4.5 days and 5.5 months, respectively. The SSI rate was 19.6% (n = 19) for CLC and 11.1% (n = 1) for PSC. The SSI rate was significantly reduced to 3.7% (P < 0.001) in CLC when the site was washed with betadine. Multivariate logistic regression controlled for statistically insignificant confounders showed that stoma site betadine wash was significantly and independently associated with reduced SSI risk (P = 0.026). Other significant factors which reduced SSI risk were prophylactic antibiotic therapy (P = 0.004), operative time < 60 min (P = 0.021), and having the closure done >3 months post the formation surgery (P = 0.040).
Conclusions
This study found that stoma SSI risk was independently and significantly reduced when CLC stapled site was washed with betadine. This low‐cost intervention that significantly reduced skin closure site SSI rates is readily available and can easily be adopted into clinical practice.
The low‐cost intervention of washing the stoma closure site with betadine significantly reduced SSI rates and is readily available and can be adopted into clinical practice.
Background
The COVID‐19 pandemic led to a global shortage of iodinated contrast media (ICM) in early 2022. ICM is used in more than half of the computed tomography of the abdomen and pelvis (CTAP) ...performed to diagnose an acute abdomen (AA). In response to the shortage, the RANZCR published contrast‐conserving recommendations. This study aimed to compare AA diagnostic outcomes of non‐contrast CTs performed before and during the shortage.
Methods
A single‐centre retrospective observational cohort study of all adult patients presenting with an AA who underwent a CTAP was conducted during the contrast shortage period from May to July 2022. The pre‐shortage control comparison group was from January to March 2022; key demographics, imaging modality indication and diagnostic outcomes were collected and analysed using SPSS v27.
Results
Nine hundred and sixty‐two cases met the inclusion criteria, of which n = 502, 52.2% were in the shortage period group. There was a significant increase of 464% in the number of non‐contrast CTAPs performed during the shortage period (P < 0.001). For the six AA pathologies, only n = 3, 1.8% of non‐contrast CTAPs had equivocal findings requiring further imaging with a contrast CTAP. Of the total CTs performed, n = 464, 48.2% were negative.
Conclusion
This study showed that when non‐contrast CTs are selected appropriately, they appear to be non‐inferior to contrast‐enhanced CTAPs in diagnosing acute appendicitis, colitis, diverticulitis, hernia, collection, and obstruction. This study highlights the need for further research into utilizing non‐contrast scans for assessing the AA to minimize contrast‐associated complications.
The utilization of non‐contrast computer tomography imaging to diagnose the acute abdomen during the global contrast shortage.
Background
To investigate the value of routine colonoscopy, post-computed tomography (CT) confirmed diverticulitis. The current practice is to scope patients 6–8 weeks post an episode of acute ...diverticulitis. We hypothesise that this practice has a relatively low value.
Methods
A retrospective cohort study was conducted on adult patients presenting acute diverticulitis
n
= 1680 (uncomplicated = 1005, complicated = 675) between January 2017 and July 2019 at three tertiary hospitals in Perth. The National Bowel Cancer Screening Program (NBCSP) positive cases were the reference group (
n
= 1800). Data were analysed using SPSS v.27.
Results
One thousand two hundred seventy-two patients had a subsequent colonoscopy during the follow-up period, of which 24% (
n
= 306) were uncomplicated diverticulitis, 34% (
n
= 432) complicated diverticulitis, and 42% (
n
= 534) as the reference cohort. Patient demographics were similar between centres and subgroups. Incidence of primary colorectal cancer (CRC) was
n
= 3 (1.0%),
n
= 9 (2.1%), and
n
= 10 (1.9%) for uncomplicated diverticulitis, complicated diverticulitis, and NBCSP, respectively (
p
= 0.50). Subgroup analysis by age revealed a statistically significant higher rate of negative colonoscopy in uncomplicated diverticulitis patients aged over 50.
Conclusion
Routine colonoscopy for patients with uncomplicated diverticulitis is not a cost-effective strategy for colorectal cancer screening patients over 50 years. These patients should participate in the NBCSP with biennial FOBT instead. We suggest continuing routine endoscopic evaluation for patients with uncomplicated diverticulitis under 50 years and all patients admitted with complicated diverticulitis.
Background The clinical diagnosis of acute appendicitis (AA) can be challenging. This study aimed to evaluate the significance of this diagnosis amidst technological progress. It compared clinical ...diagnosis to radiology-aided diagnostic outcomes and negative appendicectomy rates (NAR). Methodology This study conducted a single-center retrospective and prospective cohort observational study on all adult patients presenting with suspected AA in 2018 at a major tertiary teaching hospital in Perth, Western Australia. Key demographics, clinicopathological, radiology, and operative reports were reviewed. Data were analyzed using SPSS v.27. Results Of 418 patients with suspected AA, 234 (56%) were in the retrospective group. The median age was 35 (IQR=26), and 224 (54%) were female. The overall NAR was 18.6% (95% CI (14.8-22.4)) and 20.8% for clinical diagnosis. Notably, the NAR for ultrasound (USS)-reported AA (false positive) was 17.6% (95% CI (10.6-27.4)). Three-quarters of the patients, 298 (71.3%), had radiological imaging. The most common modality was CT 176 (59.1%), and 33 (7.9%) had both CT and USS imaging performed. Compared with final histopathology, no significant difference was found in the accuracy of clinically diagnosed and USS-diagnosed cases, with rates of 83.5% and 82.5%, respectively (p=0.230). CT had the best positive predictive value at 82.1%. Single-modality imaging did not cause a significant surgical delay (p=0.914), but multi-modal imaging showed a non-significant trend toward delay (p=0.065). When surgeons assessed an appendix as normal, 54 (12.9%), the histopathological assessment revealed pathology in 28 (51.9%). The inter-observer agreement was only fair to moderate, Kappa=0.46 (95% CI (0.33-0.58); p<0.001). The intraoperative identification of a normal appendix inversely correlated to the grade of the primary surgeon, which was likely related to the number of surgical personnel in the theater (p<0.001). Conclusion This study showed that clinical diagnosis matches the diagnostic accuracy of imaging technologies. Utilizing diagnostic imaging methods promptly and appropriately did not lead to considerable delays in surgery. Surgeons' capability to diagnose appendicitis during surgery is moderately accurate. Most patients underwent imaging, with CT scans being the most common. Moving forward, practitioners must minimize excessive reliance on imaging techniques as this can be resource-intensive, especially in developing countries. Future clinical practice should balance embracing technological advancements and preserving essential clinical diagnostic expertise, for medicine is both a science and an art.Background The clinical diagnosis of acute appendicitis (AA) can be challenging. This study aimed to evaluate the significance of this diagnosis amidst technological progress. It compared clinical diagnosis to radiology-aided diagnostic outcomes and negative appendicectomy rates (NAR). Methodology This study conducted a single-center retrospective and prospective cohort observational study on all adult patients presenting with suspected AA in 2018 at a major tertiary teaching hospital in Perth, Western Australia. Key demographics, clinicopathological, radiology, and operative reports were reviewed. Data were analyzed using SPSS v.27. Results Of 418 patients with suspected AA, 234 (56%) were in the retrospective group. The median age was 35 (IQR=26), and 224 (54%) were female. The overall NAR was 18.6% (95% CI (14.8-22.4)) and 20.8% for clinical diagnosis. Notably, the NAR for ultrasound (USS)-reported AA (false positive) was 17.6% (95% CI (10.6-27.4)). Three-quarters of the patients, 298 (71.3%), had radiological imaging. The most common modality was CT 176 (59.1%), and 33 (7.9%) had both CT and USS imaging performed. Compared with final histopathology, no significant difference was found in the accuracy of clinically diagnosed and USS-diagnosed cases, with rates of 83.5% and 82.5%, respectively (p=0.230). CT had the best positive predictive value at 82.1%. Single-modality imaging did not cause a significant surgical delay (p=0.914), but multi-modal imaging showed a non-significant trend toward delay (p=0.065). When surgeons assessed an appendix as normal, 54 (12.9%), the histopathological assessment revealed pathology in 28 (51.9%). The inter-observer agreement was only fair to moderate, Kappa=0.46 (95% CI (0.33-0.58); p<0.001). The intraoperative identification of a normal appendix inversely correlated to the grade of the primary surgeon, which was likely related to the number of surgical personnel in the theater (p<0.001). Conclusion This study showed that clinical diagnosis matches the diagnostic accuracy of imaging technologies. Utilizing diagnostic imaging methods promptly and appropriately did not lead to considerable delays in surgery. Surgeons' capability to diagnose appendicitis during surgery is moderately accurate. Most patients underwent imaging, with CT scans being the most common. Moving forward, practitioners must minimize excessive reliance on imaging techniques as this can be resource-intensive, especially in developing countries. Future clinical practice should balance embracing technological advancements and preserving essential clinical diagnostic expertise, for medicine is both a science and an art.
