Surgery

Systematically offering cessation support is a low cost means for encouraging elective surgery patients to quit

Ashley R Webb · Lisa Coward · Darshana Meanger · Samuel Leong · Sarah L White · Ron Borland

Adjusted 30-day and 12-month rates declined for patients who underwent surgery

Lara Harvey · Ian A Harris · Rebecca J Mitchell · Adrian Webster · Ian D Cameron · Louisa Jorm · Hannah Seymour · Pooria Sarrami · Jacqueline Close

The optimal use of online risk tools in practice and barriers to patient access should be investigated

Australian Melanoma Centre of Research Excellence Study Group

Increasing same-day procedure rates will involve a complex interplay of pre-and post-operative decisions by hospitals, surgeons, and patients

Joanna MZ Mills · Georgina M Luscombe · Thomas J Hugh

Women with symptomatic macromastia need relief from a condition that can seriously impair their quality of life

Elisabeth Elder

Women who undergo bariatric surgery should be managed in the perinatal period with a multidisciplinary team to improve pregnancy-related outcomes

Sarah Cheah · Yijun Gao · Shirley Mo · Georgia Rigas · Oliver Fisher · Daniel L Chan · Michael G Chapman · Michael L Talbot

Bananas are not only healthy snacks during breaks, but also good for improving simple and vertical mattress suturing skills

Geoffrey Murphy · Muhammad A Khan · Adil Lathif · John Preddy

Healthcare systems in all Australian states should support access to surgery for both private and public patients

Tamara A Crittenden · Julie Ratcliffe · David I Watson · Christine Mpundu‐Kaambwa · Nicola R Dean

Early unplanned readmissions are often potentially preventable; averting them could improve clinical outcomes for people with PAD

Vanessa Woelk · Peter Speck · Billingsley Kaambwa · Robert A Fitridge · Isuru Ranasinghe

Evidence supports the establishment of a national TP-IAT program, delivered at sites with a concentration of expertise and experience

Jessica Eldredge · Michael R Couper · David J Moore · Sanjeev Khurana · John WC Chen · Jennifer J Couper · Christopher J Drogemuller · Toni Radford · Thomas W Kay · Tom Loudovaris · Michael Wilks · Patrick T Coates · Richard TL Couper

Rectal bleeding is common in pregnancy, with a reported prevalence of 10–43%

Ralley Prentice · Aysha Al‐Ani · Tiffany Cherry · Julia Dixon‐Douglas · Jade Eccles‐Smith · Julia Matheson · Jeanne Tie · Iniyaval Thevathasan · Jacob J McCormick · Britt Christensen

COPD is the fifth greatest contributor to burden of disease and fifth overall cause of death among Australians

Alan M Carew · Jonathan P Williamson · Claude S Farah · Tajalli Saghaie · Martin Phillips · Alvin Ing

▪ Obesity is reaching pandemic proportions globally, with overweight or obesity affecting at least two‐thirds of Australian adults. ▪ Bariatric surgery is an effective weight loss strategy but is constrained by high resource requirements and low patient acceptance. ▪ Multiple endoscopic bariatric therapies have matured, with well established and favourable safety and efficacy profiles in multiple randomised controlled trials (RCTs), and are best used within a multidisciplinary setting as an adjuvant to lifestyle intervention. ▪ Three types of intragastric balloon are currently in use in Australia offering average total weight loss ranging from 10% to 18%, with others available internationally. ▪ Endoscopic sleeve gastroplasty produces average total weight loss of 15–20% with low rates of severe complications, with RCT data anticipated in December 2021. ▪ Bariatric and metabolic endoscopy is rapidly evolving, with many novel, promising therapies currently under investigation.

Dominic A Staudenmann · Zhixian Sui · Payal Saxena · Arthur J Kaffes · George Marinos · Vivek Kumbhari · Patrick Aepli · Adrian Sartoretto

Australians have around 19 000 hip fractures each year,1 and the estimated cost to the health care system was $445 million in 2015–16.2 Surgery within 48 hours of initial presentation to hospital is widely accepted as a clinically meaningful indicator of best practice care, and is supported by the Australian Hip Fracture Care Clinical Care Standard when there are no clinical contraindications.3 However, timely access to emergency orthopaedic hip fracture surgery is difficult in a country as large and geographically diverse as Australia; patients admitted to remote or regional hospitals that do not provide orthopaedic surgery must be transferred to larger regional centres. In a retrospective population study, we evaluated the impact of pre‐surgery hospital transfer and time to surgery on 30‐day mortality for people aged 65 years or more who underwent surgical interventions for fall‐related hip fractures in NSW public hospitals during 1 January 2011 – 31 December 2018. Hospitalisation data from the NSW Admitted Patient Data Collection and deaths data from the NSW Registry of Births, Deaths and Marriages were linked to provide person‐level records. Time to surgery (in calendar days) was estimated from the date of admission for the first episode of care to the date of surgery. Comorbid conditions during the preceding year were identified with the Charlson Comorbidity Index (CCI). Multilevel multivariable logistic regression models were fitted to assess the influence of patient‐level factors (age, sex, comorbidity) and process factors (transfer status, time to surgery) on 30‐day mortality. Operating hospitals were included as a random effect to account for variation between hospitals. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated and residual variation (variance partition coefficient) assessed. All analyses were performed in SAS Enterprise Guide 7.1 and MLwiN 3.02 (http://www.bristol.ac.uk/cmm/software/mlwin). The NSW Population and Health Services Research Ethics Committee approved the study (HREC/17/CIPHS/45). Of 36 956 patients who underwent hip fracture repair procedures in 36 hospitals, 3916 (10.6%) were transferred from peripheral hospitals to operating hospitals for surgery; 1579 were transferred on the day of presentation (40.3%), 1875 the following day (47.9%), and 462 patients (11.8%) spent at least two days at the admitting hospital before being transferred. Larger proportions of transferred patients than of patients admitted directly to operating hospitals were men (29.4% v 27.8%), under 85 years of age (50.9% v 48.4%), or had CCI scores of 1 or more (60.2% v 56.3%). The proportion of transferred patients who underwent surgery within 48 hours of presentation was smaller than for directly admitted patients (53.9% v 72.4%) (Box). In multilevel models adjusted for inter‐hospital variation, transfer was associated with higher risk of 30‐day mortality than direct admission (aOR, 1.15; 95% CI, 1.01–1.32), but after adjusting for age, sex, and comorbidity, neither transfer (aOR, 1.10; 95% CI, 0.95–1.28) nor delayed surgery (> 2 days v ≤ 2 days: aOR, 0.99; 95% CI, 0.89–1.11) significantly influenced mortality. The most influential factor was comorbidity (CCI ≥ 3 v CCI < 3: aOR, 4.89; 95% CI, 4.32–5.54). The discrimination of our fully adjusted model was adequate (area under the curve, 0.73), and 1.8% of residual variation in 30‐day mortality was attributable to differences between hospitals. In our large study of NSW people with hip fractures, we found that transfer from non‐operating to operating hospitals, after adjusting for patient and hospital characteristics, was not associated with higher 30‐day mortality, despite increasing the time between initial presentation and surgery. This is contrary to the findings of earlier, single centre studies in Australia.4,5,6 However, our study was the first to control for several key person‐level factors that increase the risk of death, and our findings suggest that time to surgery may be less important for health outcomes than these factors when other dimensions of care quality are equal. More research is required to understand the interplay between the effects of patient demographic characteristics, pre‐injury health status, and the quality of hip fracture care on 30‐day mortality for patients. Box – Characteristics of patients with hip fractures, by pre‐surgery transfer, New South Wales, 2011–2018* table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Not transferred Transferred Number of people 33 040 (89.4%) 3916 (10.6%) Sex Women 23 866 (72.2%) 2766 (70.6%) Men 9174 (27.8%) 1150 (29.4%) Age at admission (years) 65–74 4684 (14.2%) 535 (13.7%) 75–84 11 311 (34.2%) 1458 (37.2%) ≥ 85 17 045 (51.6%) 1923 (49.1%) Weighted Charlson Comorbidity Index score 0 14 437 (43.7%) 1556 (39.7%) 1–2 12 667 (38.3%) 1595 (40.7%) ≥ 3 5936 (18.0%) 765 (19.5%) Time to transfer (days) 0 1579 (40.3%) 1 1875 (47.9%) ≥ 2 462 (11.8%) Time to surgery (days) 0 12 991 (39.3%) 739 (18.9%) 1 10 939 (33.1%) 1370 (35.0%) ≥ 2 9110 (27.6%) 1807 (46.1%) Length of stay (days), mean (SD) Total 27.5 (21.9) 26.8 (20.5) Acute care 11.9 (8.5) 12.8 (9.0) 30‐day deaths 2172 (6.6%) 288 (7.4%) SD = standard deviation. * Linked hospitalisation and deaths data.

Lara A Harvey · Ian A Harris · Rebecca J Mitchell · Adrian Webster · Ian D Cameron · Louisa R Jorm · Hannah Seymour · Pooria Sarrami · Jacqueline CT Close

Temporomandibular disorders are a major cause of orofacial pain resulting in significant morbidity and reduction in an individual’s perceived quality of life

Samuel V Thambar · Sachin Kulkarni · Joshua Tesar · Scott Armstrong

Objective: To assess the association between having a serious mental illness and surgical outcomes for adults, including in‐hospital and 30‐day mortality, post‐operative complications, and hospital length of stay. Study design: Systematic review and meta‐analysis of publications in English to 30 July 2018 of studies that examined associations between having a serious mental illness and surgical outcomes for adults who underwent elective surgery. Primary outcomes were in‐hospital and 30‐day mortality, post‐operative complications, and length of hospital stay. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. Studies were grouped by serious mental illness diagnosis and outcome measures. Odds ratios (ORs) or mean differences (MDs), with 95% confidence intervals (CIs), were calculated in random effects models to provide pooled effect estimates. Data sources: MEDLINE, EMBASE, PsychINFO, and the Cochrane Library. Data synthesis: Of the 3824 publications identified by our search, 26 (including 6 129 806 unique patients) were included in our analysis. The associations between having any serious mental illness diagnosis and having any post‐operative complication (ten studies, 125 624 patients; pooled effect: OR, 1.44; 95% CI, 1.15–1.79) and a longer stay in hospital (ten studies, 5 385 970 patients; MD, 2.6 days; 95% CI, 0.8–4.4 days) were statistically significant, but not those for in‐hospital mortality (three studies, 42 926 patients; OR, 1.21; 95% CI, 0.69–2.12) or 30‐day mortality (six studies, 83 013 patients; OR, 1.85; 95% CI, 0.86–3.99). Conclusions: Having a serious mental illness is associated with higher rates of post‐operative complications and longer stays in hospital, but not with higher in‐hospital or 30‐day mortality. Targeted pre‐operative interventions may improve surgical outcomes for these vulnerable patients. Systematic review registration: PROSPERO, CRD42018080114 (prospective).

Kate E McBride · Michael J Solomon · Paul G Bannon · Nicholas Glozier · Daniel Steffens

A 73-year-old man underwent a right total right knee replacement for osteoarthritis

Suran L Fernando · Marc J Capon · Sarah L Green · Michael J Boyle

Objective: To describe the clinical and procedural outcomes of per‐oral endoscopic myotomy (POEM) for achalasia in Australia. Design, setting: Prospective observational study in three Australian tertiary referral centres, 5 May 2014 – 27 October 2019 (66 months). Participants: Patients who had undergone POEM for achalasia. Major outcome measures: Eckardt scores calculated prior to POEM and six months, one year, and two years after POEM. The primary outcome was clinical success, defined as an Eckardt score of 3 or less without a second intervention. Results: 142 patients underwent POEM for achalasia; their mean age was 52 years (SD, 18 years), 83 were men (58%), and the median length of hospital stay two days (IQR, 1–3 days). Their mean Eckardt score before POEM was 8.0 (SD, 2.4) and 1.1 (SD, 1.6) six months after POEM; it did not change significantly between six months and two years after POEM (mean monthly increase, 0.014 points; 95% CI, –0.001 to 0.029). A total of 127 patients (89%) improved clinically after POEM. Intra‐procedural capnoperitoneum was the only risk factor associated with treatment failure (adjusted hazard ratio, 2.85; 95% CI, 1.08–7.51). Previous treatments — botulinum toxin injection (25 patients, 18%), endoscopic balloon dilatation (69, 49%), and Heller myotomy (14, 10%) — did not affect POEM outcomes. Five patients (4%) experienced major adverse events, including pneumonia, oesophageal leak, empyema and melaena, that were managed during admission and without sequelae. Conclusions: POEM is an effective treatment for achalasia. Significant reductions in Eckardt scores achieved by six months are sustained at two years. POEM can be both a first line definitive therapy and a salvage therapy for patients not helped by other treatments.

Sunil Gupta · Mayenaaz Sidhu · Xuan Banh · Joseph Bradbear · Karen Byth · Luke F Hourigan · Spiro Raftopoulos · Michael J Bourke

Although VTE risk in minor gynaecological procedures is low, a systematic approach to prophylaxis is necessary

Esther MC Johns · Alex Ades · Pavitra Nanayakkara

In Australia, colorectal cancer is the second most frequently diagnosed cancer and one of the most common causes of cancer‐related death.1 Evidence that bowel cancer screening reduces mortality through early detection and treatment2 led to the introduction in 2006 of the Australian National Bowel Cancer Screening Program (NBCSP), offering faecal occult blood testing. The NBCSP has been progressively rolled out, from covering those aged 55 or 65 years in 2006 to screening every two years for all Australians aged 50–74 years by 2020.3 During 2016–17, 41% of people invited to participate in screening did so.4 A recent review of the NBCSP found that the risk of death from colorectal cancer was lower for invitees, and that those who had cancer were diagnosed at an earlier stage of disease.5 In Australia, jurisdictional cancer registries do not collect data on surgery‐related morbidity. However, the Binational Colorectal Cancer Audit (BCCA) (https://www.bowelcanceraudit.com) has collected information since 2007 on the diagnosis, management, and outcomes of surgically managed Australian and New Zealand patients with colorectal cancer, as well as whether patients were identified by the NBCSP. BCCA data are voluntarily collected by 435 registered surgeons at 138 participating hospitals across Australia and New Zealand, covering about 24% of newly diagnosed cases of colorectal cancer in 2019.6 We sought to determine whether patients with surgically managed colorectal cancer diagnosed through the NBCSP have better post‐operative outcomes than those diagnosed in other pathways. We undertook a cross‐sectional analysis of de‐identified BCCA data for patients aged 18 years or over who underwent surgery in Australia for colorectal cancer during January 2007 – December 2018. Outcome measures were inpatient and 30‐day mortality; surgical complications; medical complications; return to theatre; and hospital length of stay. We undertook binary logistic regression to assess associations between screening and binary outcomes. The association with length of stay was assessed in ordinary least squares linear regression models. The Monash University Human Research Ethics Committee (project, 19327) and the BCCA Operations Committee provided ethics approval for our study. Of 23 310 cases of colorectal cancer in the database, we could include 15 630 cases with data on cancer type and screening status in our comparison of demographic and clinical characteristics. A larger proportion of patients identified by the NBSCP than of otherwise identified patients were men (58% v 54%); their mean age (64 years, standard deviation [SD], 7 years v 69 years; SD, 14 years) was lower, and larger proportions had American Society of Anesthesiologists (ASA) scores in the low risk range (77% v 59%), were from lower socio‐economic status areas, had presented for elective surgery (96% v 85%), had less advanced cancer stage disease (stages 0–II: 69% v 63%), and underwent minimally invasive surgery (80% v 66%) (Box 1). Data on adjusting variables and outcomes were available for the 11 366 cases included in our logistic regression models. NBSCP‐detected patients were less likely to have post‐operative surgical (adjusted odds ratio [aOR], 0.83; 95% confidence interval [CI], 0.69–0.99) or medical complications (aOR, 0.75; 95% CI, 0.59–0.94); their length of stay was also briefer (adjusted mean difference, –1.56 days; 95% CI, –2.06 to –1.06 days). Post‐operative mortality and return to theatre rates were similar for screened and other patients (Box 2). Our analysis of BCCA data indicates that, in addition to the lower long term mortality associated with the NBCSP,5 short term post‐operative benefits are also evident that should be taken into account when promoting the program. Our study reinforces calls to improve participation rates in the national screening program by eligible participants to optimise the value of this critically important initiative. Box 1 – Demographic and clinical features of 15 730 patients who underwent surgery for colorectal cancer in Australia, 2007–2018, by diagnostic pathway Identification of patients Characteristic Total NBSCP Other P Number of patients 15 730 1357 14 373 Age at surgery (years) Mean (SD) 69 (13) 64 (7) 69 (14) < 0.001 Range 18–100 50–75 18–100 50 or under* 1556 (10%) 77 (6%) 1479 (10%) 51–60 2433 (15%) 385 (28%) 2048 (14%) 61–70 4192 (27%) 651 (48%) 3541 (25%) 71–80 4473 (28%) 244 (18%) 4229 (29%) over 80 3073 (20%) 0 3073 (21%) Missing data 3 0 3 Sex 0.003 Women 7142 (45%) 563 (42%) 6579 (46%) Men 8586 (55%) 792 (58%) 7794 (54%) Missing data 2 2 0 American Society of Anesthesiologists score < 0.001 1–2 (low risk) 9205 (60%) 1000 (77%) 8205 (59%) 3–5 (high risk) 6033 (40%) 294 (23%) 5739 (41%) Missing data 492 63 429 Socio‐economic status (IRSD quintile) < 0.001 1 (most disadvantaged) 2470 (16%) 224 (17%) 2246 (16%) 2 2385 (16%) 221 (17%) 2164 (16%) 3 2957 (20%) 278 (22%) 2679 (19%) 4 3107 (21%) 288 (22%) 2819 (20%) 5 (least disadvantaged) 4153 (28%) 282 (22%) 3871 (28%) Missing data 658 64 594 Cancer type 0.50 Colon 11 287 (72%) 963 (71%) 10 324 (72%) Rectal 4443 (28%) 394 (29%) 4049 (28%) Operative urgency < 0.001 Elective 13 457 (86%) 1310 (96%) 12 147 (85%) Emergency 999 (6%) 11 (1%) 988 (7%) Urgent 1248 (8%) 36 (2%) 1212 (8%) Missing data 26 0 26 Cancer stage < 0.001 0 (cancer in situ) 699 (5%) 92 (7%) 607 (4%) I (local disease) 3728 (24%) 535 (41%) 3193 (23%) II (local disease) 4689 (31%) 278 (21%) 4411 (32%) III (nodal spread) 4437 (29%) 347 (26%) 4090 (29%) IV (metastatic disease) 1625 (11%) 42 (3%) 1583 (11%) X (not identifiable) 121 (1%) 16 (1%) 105 (1%) Missing data 431 47 384 Operative approach < 0.001 Minimally invasive surgery† 10 498 (67%) 1082 (80%) 9416 (66%) Open 5140 (33%) 269 (20%) 4871 (34%) Missing data 92 6 86 IRSD = Index of Relative Socioeconomic Disadvantage (Australian Bureau of Statistics); NBSCP = National Bowel Cancer Screening Program; SD = standard deviation. * National screening program participants are aged 50 years or more. † Laparoscopic, hybrid, conversion of laparoscopic, robotic and transanal total mesorectal excision. table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Box 2 – Logistic and linear regression analysis of the association between screening and outcomes for 11 366 patients with colorectal cancer, Australia, 2007–2018 Identification of patients NBSCP v other Outcome NBSCP Other Univariate regression: OR (95% CI) Multivariate regression: aOR* (95% CI) Number of patients 843 10 523 30‐day mortality† 2 175 0.14 (0.02–0.44) 0.31 (0.05–1.01) Surgical complications‡ 171 2494 0.82 (0.69–0.97) 0.83 (0.69–0.99) Medical complications§ 89 1889 0.54 (0.43–0.67) 0.75 (0.59–0.94) Returned to theatre 52 658 0.99 (0.73–1.31) 1.02 (0.75–1.37) Mean difference (95% CI) Adjusted mean difference* (95% CI) Length of stay (days), mean (SD) 7.27 (6.17) 9.62 (8.02) –2.34 (–2.90 to –1.79) –1.56 (–2.06 to –1.06) aOR = adjusted odds ratio; CI = confidence interval; NBSCP = National Bowel Cancer Screening Program; OR = odds ratio; SD = standard deviation. * Adjusted for age, sex, socio‐economic status, screen category, cancer type, American Society of Anesthesiologists score. † Within 30 days of surgery. ‡ Abdominal/pelvic collection, anastomotic leak, entero‐cutaneous fistula, wound dehiscence, wound infection, sepsis, ileus, small bowel obstruction, urinary retention, ureteric injury, splenectomy, post‐operative haemorrhage. § Including chest infection, cardiac complications, deep vein thrombosis, pulmonary embolus.

Sasha Taylor · Farhad Salimi · Arul Earnest · Alexander G Heriot · John R Zalcberg · Susannah Ahern

The incidence of colorectal cancer in Australia is among the highest in the world.1 About 29% of Australians live in rural or remote areas. We have previously reported that colorectal cancer surgery in rural hospitals is safe and that short term outcomes are good.2 This report is based on prospectively collected data for 311 patients treated for stages 1 to 3 colorectal cancer by four surgeons in rural South Australia (Mount Gambier Hospital, with 110 beds and a six‐bed high dependency unit) during 1 February 2006 – 31 January 2020. The follow‐up parameters, intervals between follow‐up examinations, and data analysis tools have been reported previously.2 Briefly, data were analysed in SigmaStat 3.5 (Systat). Survival was analysed by single‐group and log‐rank testing; survival differences between groups were assessed by pairwise multiple comparison (Holm–Šídák). Group data were compared in t, rank sum, and χ2 tests; correlations of covariates and cancer‐specific survival were assessed by multiple logistic regression. The Central Adelaide Local Health Network Human Research Ethics Committee approved our study (reference, 12041). One hundred of 311 patients (32%) had Union for International Cancer Control (UICC) stage 1, 110 (35%) stage 2, and 101 (33%) stage 3 colorectal cancer. The median age of the patients was 71 years (interquartile range [IQR], 63–78 years); 172 (55%) were men. Of the 311 procedures, 277 were elective (89%); 113 were laparoscopic (36%) and 198 laparotomies (64%). Median hospital length of stay was 7 days (IQR, 4–10 days); 30‐day mortality was 1.3% (four deaths), 90‐day mortality 1.6% (five deaths). The proportion of deaths at 30 days after emergency colorectal cancer surgery (three of 34 patients, 9%) was significantly greater than following elective surgery (one of 277, 0.4%; P = 0.002). Leakage occurred in 13 of 259 procedures with anastomosis (5%). The median number of lymph nodes resected was 14 (IQR, 10–20). Overall 5‐year survival of patients (stages 1–3) was 79%, 10‐year survival was 45%. Cancer‐specific 5‐year survival was 86% and 10‐year survival 79% (Box). Multivariate analysis included patient sex, age, intra‐operative blood loss, laparoscopic surgery, American Society of Anesthesiologists (ASA) score, and UICC stage as covariates. More advanced tumour stage (stages 1/2 v stage 3: odds ratio [OR], 2.01; 95% confidence interval [CI], 1.39–2.90) and higher age (< 70 years v ≥ 70 years: OR, 2.28; 95% CI, 1.11–4.71) were significantly associated with lower overall survival. Cancer‐specific survival was significantly reduced by more advanced tumour stage stages 1/2 v stage 3: OR, 4.76; 95% CI, 2.53–8.94). Our follow‐up program included quarterly blood tests (carcino‐embryogenic antigen, carbohydrate antigen 19.9, full blood cell count) and clinical examination during the first two years, semi‐annual tests during the next three years, and annual blood tests and clinical examinations thereafter. Throughout follow‐up, annual computed tomography and colonoscopy were offered to all patients, and additional investigations initiated in response to changes in clinical or laboratory findings. This intense follow‐up program, based on that used at the University of Munich in Germany, was adopted when the current surgical unit was established in Mount Gambier. It is being reviewed and will be adjusted to current Australian recommendations. Recurrent disease was detected in a total of 52 patients (17%), and 13 patients (4%) underwent curative resection. The primary treatment for colorectal cancer is surgical removal. Surgical care should be provided in an adequately staffed and equipped hospital. We found that such surgery can be provided safely and with good long term oncological outcomes in a rural centre. Overall 5‐year survival in our study exceeded the most recent reported value for Australia (2011–2015: 69.9%),3 and contrasts with a Californian study which found that rural residence was associated with poorer cancer‐specific mortality.4 Published data on outcomes beyond 10 years after colorectal cancer surgery are limited. Our overall 10‐year survival rate of 45% is similar to that reported by an earlier study in Fremantle (44%).5 Our findings confirm that tumour stage and age at diagnosis are significant predictors of death following curative surgery for colorectal cancer. We found that colorectal cancer surgery in a non‐metropolitan surgical centre is safe and associated with low 30‐ and 90‐day mortality rates. Oncological results at 5 and 10 years compare well with the results of other groups. Surgery can be provided close to the patients’ homes and families in adequately staffed and equipped centres and can match outcomes in capital city hospitals. Box – Five‐ and 10‐year survival of patients undergoing curative resection for colorectal cancer at Mount Gambier Hospital, February 2006 – January 2020 5‐year survival 10‐year survival Overall Cancer‐specific Overall Cancer‐specific All 79% 86% 45% 79% Union for International Cancer Control (UICC) stage Stage 1 (pT1/pT2) 91% 99% 58% 99% Stage 2 (pT3/pT4) 82% 87% 51% 85% Stage 3 (any T, node positive) 55% 74% 39% 55% American Society of Anesthesiologists (ASA) physical status classification 1 100% — 100% — 2 84% — 58% — 3 70% — 32% — 4 62% — 0 — Age < 70 years 86% — 72% — 70–79 years 76% — 32% — ≥ 80 years 60% — 7% — pT = primary tumour staging. table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; }

Matthias W Wichmann · Timothy K McCullough · Eben Beukes · Thomas Gunning · Guy J Maddern

The increasing use of split livers for in children has effectively increased the donor organ supply

James Neuberger

Prostate cancer continues to be the most commonly diagnosed cancer, and the second leading cause of cancer death among Australian men

Xuan Rui S Ong · Dominic Bagguley · John W Yaxley · Arun A Azad · Declan G Murphy · Nathan Lawrentschuk

Clinical record A 40‐year‐old woman of Karen ethnicity presented with 5 days of generalised abdominal pain. The pain was worsening and associated with vomiting in the 12 hours preceding presentation. She had been constipated for 5 weeks. There was no diarrhoea, no blood or mucous in the stool and no haematemesis. There were no sick family, friends or colleagues and no recent travel. She had an omnivorous diet, which had not changed recently, and worked casually at a vegetable farm. In the emergency department, vital signs were normal and the abdomen was mildly distended and tender. Initial blood tests showed a neutrophil count of 9.6 × 109/L (reference range [RR], 2.0–8.0 × 109/L), serum bicarbonate 22 mmol/L (RR, 22–32 mmol/L), normal renal function, and C‐reactive protein below 2.9 mg/L (RR, < 3.0 mg/L). Computed tomography of the abdomen and pelvis was consistent with colitis of the descending colon and ileus (Box 1). She was admitted for observation under the general surgical team. Five hours after admission, her condition rapidly deteriorated. Blood pressure was 80/40 mmHg, heart rate 129 beats per minute in sinus rhythm, and there was severe abdominal tenderness with generalised guarding. Repeat tests showed serum creatinine 175 μmol/L (RR, 60–110 μmol/L), bicarbonate below 10 mmol/L (RR, 22–32 mmol/L), blood pH 6.97 (RR, 7.35–7.45), and lactate 14.8 mmol/L (RR, < 1.5 mmol/L). At emergency surgery, colonoscopy and ileoscopy revealed mucosal inflammation affecting the distal 20 cm of terminal ileum, caecum, transverse and sigmoid colon, with patches of frank mucosal necrosis (Box 2). The bowel was grossly dilated, with small patches of full thickness caecal necrosis but no perforation. Subtotal colectomy, terminal ileectomy, and formation of an end ileostomy were performed, with resultant resolution of circulatory shock. Pathological examination demonstrated severe acute pancolitis and extensive mucosal necrosis (Box 3). Clostridium perfringens infection was suspected, due to a striking similarity to published cases.1,2C. perfringens was isolated from biopsy specimens of the necrotic colonic mucosa using selective culture media. The isolate expressed C. perfringens enterotoxin and α‐toxin, defined as toxinotype F.3 Postoperative management included vancomycin both orally and per rectum. Three months after the operation, she was pain‐free, with a normal appetite and functional state. Reversal of ileostomy is planned in coming months. Discussion C. perfringens is a gram‐positive bacillus that forms hardy spores, is ubiquitous in environmental soil and water, and can be part of normal bowel flora. Toxigenic strains commonly cause both foodborne and sporadic cases of acute, self‐limiting diarrhoea. The typical foodborne strain F produces C. perfringens enterotoxin and α‐toxin and was found in our patient.3 The organism exhibits the shortest known doubling time of any cell when grown at 42°C in cooked minced beef.4 Exposure to large inocula of toxigenic organisms may arise when meat is kept lukewarm before consumption. Enteric infections are characterised by adherence of organisms to small bowel mucosa before concurrent sporulation and release of toxin. This typically induces self‐limiting diarrhoea 10–12 hours after eating. Necrotising enterocolitis is a manifestation of C. perfringens enteric infection that is rare in high income countries. Some reported cases associate the condition with constipation, either pre‐existing due to medication side effects or induced by the high protein content of ingested contaminated meat. Constipation has been proposed to impair the usual expulsion of C. perfringens bacteria and spores, leading to mucosal necrosis and shock as opposed to the usual syndrome of transient diarrhoea. Mortality in case series is greater than 50%.1,2 Despite thorough assessment, the cause of our patient's constipation and means of exposure remain unclear. She most likely contracted the infection hours before the onset of her pain, 5 days before presentation. Exposure could have occurred during food preparation at home, meals with social groups, or via soil at her workplace. While rare in Australia, a type of C. perfringens necrotising enteritis was endemic throughout the 20th century in the Papua New Guinea highlands, caused by β‐toxin‐producing strains. Called “pigbel” in Tok Pisin, the disease is closely associated with traditional pig feasts. In the 1960s and 1970s, pigbel accounted for almost a quarter of paediatric deaths in highlands hospitals. Implementation of a β‐toxoid vaccine in 1979 resulted in an eightfold reduction in incidence and an even greater reduction in disease‐specific mortality.5 C. perfringens infection is an important differential diagnosis in cases of acute severe enteritis or colitis, particularly if accompanied by circulatory shock. Prompt operative intervention is necessary in such situations. In Papua New Guinea, toxoid vaccination has proven very successful. In Australia, food safety practices likely play the greatest role in controlling disease burden. Lessons from practice Toxigenic Clostridium perfringens type F commonly causes acute diarrhoea, with illness typically commencing hours after meat consumption. Cases are usually self‐limiting, and require symptomatic management only. Very rarely, toxigenic C. perfringens strains can cause fulminant bowel necrosis requiring emergency bowel resection, which may be associated with pre‐existing constipation. In the highlands of Papua New Guinea, necrotising enteritis has been a common cause of paediatric morbidity and mortality, where it is caused by a locally endemic strain of toxigenic C. perfringens. Box 1 – Coronal computed tomography image of the abdomen and pelvis with portal venous phase contrast, demonstrating mural thickening of the descending colon in the left lower quadrant and fluid‐filled distension of the transverse colon, ascending colon, and ileum Box 2 – Endoscopy images obtained immediately before laparotomy, showing mucosal necrosis of the ascending colon Box 3 – Macroscopic appearance of resected colon, demonstrating extensive mucosal necrosis and oedema

Harry N Walker · Kwee‐Chin Liew · Vicki Adams · Sarah Larcombe · Sonal S Nagra · Glenn Guest · Eugene Athan

The conventional treatment for brain metastases is whole brain radiotherapy (WBRT).1 But there has been a gradual move to managing limited brain metastases with stereotactic radiosurgery (SRS),2 and delaying or avoiding WBRT because of its effects on cognition and quality of life. Data on contemporary SRS practice for managing brain metastases in Australia are, however, very limited.3 We performed a population‐based linkage study, analysing data from the Victorian Cancer Registry and the Victorian Radiotherapy Minimum Data Set (VRMDS). We included all patients with solid tumours (ICD‐10 codes C00–C80), but excluding primary central nervous systems malignancies (ICD‐10 codes C69–72), who received brain radiotherapy in Victoria between 1 January 2012 and 31 December 2017. The primary outcome was the proportion of patients treated with SRS. Although SRS refers to large single fraction radiotherapy, patients treated with fractionated “stereotactic radiotherapy” were also classified as receiving SRS. In addition, because of potential coding inconsistencies, patients who had no more than four fractions of radiotherapy and were treated with “volumetric modulated arc therapy” or “intensity modulated radiation therapy” were also classified as receiving SRS. Differences in factors of interest by SRS use were assessed in Pearson χ2 (categorical variables) and Student t or Mann–Whitney U tests (continuous variables). Temporal changes were assessed with the Cochran–Armitage test for trend. Factors associated with SRS use were assessed by logistic regression, with year as an ordinal categorical variable; variables for which P < 0.10 in univariate analyses were included in the multivariate model. The study was approved by the Austin Health Human Research Ethics Committee (reference, LNR/18/Austin/34). A total of 3961 patients who received radiotherapy for brain metastases were included, of whom 1116 (28%) received SRS. The proportion of patients receiving SRS increased from 27% (105 of 388) in 2012 to 35% (287 of 821) in 2017 (for trend: P < 0.001). The mean age of patients who received SRS (63.5 years; standard deviation [SD], 12.5 years) was lower than for those who did not (65.2 years; SD, 12.5 years). Factors that influenced SRS use included socio‐economic status, primary cancer type (about half the patients with melanoma received SRS, and about one‐quarter of patients with other cancer types), treatment institution type (public institutions, 31%; private institutions, 24%), and location (metropolitan centres, 34%; regional centres, 5%). Remoteness of patients’ area of residence was not a significant factor. In multivariate analyses, age, primary cancer type, treatment centre type, and location were significant factors for SRS use (Box). While the VRMDS captures all radiotherapy delivered in Victoria, it does not include data on patients’ performance status, numbers of brain metastases, the extent of extracranial disease, and other factors that would allow evaluation of the appropriateness of SRS for individual patients. Another limitation is potential misclassification of radiotherapy classified as “SRS”, as the VRMDS did not include data on radiotherapy dose. As evidence supporting the use of SRS for managing brain metastases grows, we would expect SRS rates to rise.6,7 While SRS was less frequently used in regional centres, patients living in regional areas were as likely to receive SRS as patients living in metropolitan areas. It is nevertheless important to ensure easy and convenient access to SRS services for all cancer patients in Victoria. Box – Baseline characteristics of 3961 patients who received radiotherapy for brain metastases, Victoria, 2012–2017 Stereotactic radiosurgery Multivariable analysis: odds ratio (95%CI) P Received Not received Number of patients 1116 (28%) 2845 (72%) Age at first treatment for brain metastases (years) < 55 266 (33%) 543 (67%) 1 55–59 157 (32%) 331 (68%) 1.11 (0.86–1.44) 0.42 60–64 161 (28%) 419 (72%) 0.89 (0.69–1.14) 0.35 65–69 177 (26%) 502 (74%) 0.85 (0.67–1.08) 0.19 70–74 153 (25%) 448 (75%) 0.88 (0.68–1.14) 0.33 75 or more 202 (25%) 602 (75%) 0.78 (0.62–0.99) 0.045 Mean (SD) 63.5 (12.5) 65.2 (12.5) — — Sex Men 528 (28%) 1373 (72%) — — Women 588 (29%) 1472 (71%) — — Primary cancer type Lung 419 (24%) 1344 (76%) 1 Breast 203 (28%) 512 (72%) 1.24 (1.00–1.53) 0.05 Melanoma 252 (47%) 277 (52%) 2.89 (2.32–3.59) < 0.001 Gastrointestinal 93 (28%) 235 (72%) 1.37 (1.03–1.80) 0.028 Genitourinary 73 (28%) 189 (72%) 1.33 (0.97–1.80) 0.07 Other 76 (21%) 288 (79%) 0.80 (0.60–1.06) 0.12 Socio‐economic status (quintile) 1st (most disadvantaged) 188 (24%) 612 (77%) 1 2nd 189 (27%) 501 (73%) 1.12 (0.87–1.44) 0.39 3rd 202 (26%) 572 (74%) 1.02 (0.79–1.30) 0.90 4th 220 (26%) 618 (74%) 0.90 (0.70–1.14) 0.38 5th (least disadvantaged) 317 (37%) 542 (63%) 1.19 (0.94–1.50) 0.14 Remoteness classification5 Major city 780 (29%) 1949 (71%) — — Inner regional 261 (26%) 732 (73%) — — Outer regional/remote/very remote 75 (31%) 164 (69%) — — Treatment institution type Public 744 (31%) 1656 (69%) 1 Private 372 (24%) 1189 (76%) 0.10 (0.07–0.14) < 0.001 Treatment institution location Metropolitan 1071 (34%) 2071 (66%) 1 Regional 45 (5%) 774 (95%) 0.58 (0.49–0.68) < 0.001 Year of first brain metastasis treatment 2012 105 (27%) 283 (73%) 1 2013 111 (25%) 342 (76%) 1.01 (0.72–1.41) 0.95 2014 147 (25%) 439 (75%) 0.86 (0.63–1.18) 0.35 2015 207 (25%) 633 (75%) 0.79 (0.59–1.06) 0.12 2016 259 (30%) 614 (70%) 1.10 (0.83–1.47) 0.50 2017 287 (35%) 534 (65%) 1.41 (1.06–1.88) 0.017 CI = confidence interval; SD = standard deviation. * Index of Relative Socio‐Economic Disadvantage.4

Wee Loon Ong · Therese Ming Jung Kang · Gishan Ratnayake · Morikatsu Wada · Jeremy Ruben · Sashendra Senthi · Roger L Milne · Jeremy L Millar · Farshad Foroudi