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Surgery

Cancer Letters 16 March 2020 Free

The increasing use of shave biopsy for diagnosing invasive melanoma in Australia

To the Editor: De Menezes and colleagues1 report increasing use of shave biopsy for melanoma diagnosis in association with significant rates of base transection. They cite a wide range of base transection rates in the literature (7–68%), giving pause for thought: what is at play here besides the shave biopsy itself? This is an important question, as the incidence of invasive melanoma rose significantly over the study period along with a doubling of the frequency of shave biopsy. Particularly in Queensland, dubiously honoured with the title of “melanoma capital of the world,” we must be cautious about dismissing this efficient and low cost procedure. De Menezes and colleagues1 could not assess clinician intent regarding biopsy depth, and we do not know whether melanoma was the provisional diagnosis. There is an important distinction between superficial shave biopsies and saucerisation, which is acknowledged but not examined. Saucerisation would be expected to produce lower rates of base transection and tumour upstaging. The authors have not stratified the base transection rate by year. It would be useful to know whether better education, increasing use of dermoscopy and improved shave tools have influenced base transection over the 10‐year period. What is the standard of care for evaluating potential melanomas? Should more excisional biopsies be performed to increase microstaging accuracy when base transection has not been proven to reduce survival? We agree that excisional biopsy is the best way to evaluate a highly suspicious lesion. However, the role of the shave biopsy must be defended, particularly in patients with many lesions, in older and relatively immobile patients, and in rural populations. De Menezes and colleagues1 acknowledge the benefits of shave biopsy in terms of cost and reduced risk of missed or delayed diagnosis when the index of suspicion is low. Better training and improved shave equipment are the keys to ensuring better results.

Lachlan A Byth · Jenny Byth

Hematologic diseases Letters 16 September 2019 Free

Selecting and optimising patients for total knee arthroplasty

To the Editor: We read with interest the recent review by Adie and colleagues1 discussing the optimisation of patients planned for total knee arthroplasty (TKA) and the prevention of adverse post‐operative outcomes. However, anaemia, which is a common, major and modifiable risk factor for this patient cohort,2 was not addressed by the authors. A recent observational study found pre‐operative anaemia — defined as haemoglobin concentration < 130 g/L — in 32% of patients undergoing elective TKA, and, based on the results for the orthopaedic surgical cohort from this study, it is likely that most of these patients were iron depleted.3 A 2017 single‐centre retrospective study similarly reported anaemia in 24% of a similar cohort of patients, and found it was associated with an increased risk of hospital stay in excess of 6 days (unadjusted odds ratio [OR], 1.97; 95% confidence interval [CI], 1.53–2.53; P < 0.001), which escalated further and proportionally with decreasing haemoglobin cconcentration.4 In another observational study, anaemia was associated with an increased risk of post‐operative complications in aseptic revision joint arthroplasty (OR, 1.45; 95% CI, 1.24–1.70; P < 0.001), mortality (OR, 2.18; 95% CI, 1.09–4.36; P = 0.028), and increased hospital length of stay (adjusted coefficient, 1.02 days; 95% CI, 0.73–1.31; P < 0.001).5 Perhaps the most compelling argument for the recognition of anaemia in the pre‐operative TKA patient is that it is a risk factor that can be addressed even as little as 2–5 days pre‐operatively. A retrospective review of ultrashort term parenteral iron supplementation in major orthopaedic surgery suggested intravenous iron reduced allogeneic blood transfusion rates (8.9% v 30.1%; P = 0.001), which are a likely contributor to post‐operative outcome. Intravenous iron was also associated with reduced length of hospital stay (8.4 days v 10.7 days; P = 0.001).6 Newer parenteral iron preparations are widely used as pre‐operative rehabilitative interventions, are characterised by their ease of administration and favourable side‐effect profile, and are recommended as part of best practice patient blood management guidelines.7 At present, large scale prospective and randomised data assessing the safety and efficacy of iron supplementation for correction of anaemia before elective TKA remain lacking. The importance of this area and the potential capacity for clinical and economic effect warrant both further prospective research and consideration by clinicians practising perioperative medicine.

Lachlan F Miles · Kate L Burbury · David A Story

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Ophthalmology Narrative review 4 March 2019 Free

Current management of glaucoma

Glaucoma management varies depending on the underlying causative mechanism, with options trending towards earlier surgical intervention for both open‐angle and angle closure glaucoma. While the increased acceptance of SLT and the introduction of MIGS devices have started to change the face of glaucoma management, IOP‐lowering eye drops remain the foundation of treatment. Adherence is an ongoing treatment limitation and future therapies are being designed to diminish this.

Jed Lusthaus · Ivan Goldberg

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Surgery Letters 2 April 2018 Free

Untapped potential in Australian Hospitals for organ donation after circulatory death

To the Editor:We thank Rakhra and colleagues,1 whose report highlighted a group of potential donors yet to be fully exploited for organ transplantation. While this untapped potential appears to largely affect kidney and lung donor pools, we must not exclude the effect that relaxing donor suitability criteria may have on the heart. While not largely emphasised, the data collected for the heart are compelling, particularly for an organ so susceptible to ischaemic injury. Similar to the kidney and lungs, the data show that when including ideal and expanded criteria, potential donors more than doubled the number of donor hearts available for heart transplantation.1 This is an important finding, particularly if the authors have conservatively underestimated the actual potential for organ donation. In Australia, donation after circulatory death (DCD) kidney and lung donors comprise 25–30% of the total donor pool for these organs.2,3 Since 2014, the number of national and international hospitals now investigating DCD heart donation has increased, and we anticipate that DCD heart transplantation will follow the same trend as DCD lung and kidney transplant over time. The Critical Care Research Group at the Prince Charles Hospital has developed a clinically relevant 24-hour ovine model of brain stem death,4 and these donor hearts are being used to transplant into recipient animals. Transplant clinicians and researchers from the Prince Charles Hospital, the Alfred Hospital and St Vincent’s Hospital will collaboratively employ an ex vivo hypothermic perfusion system, capable of safely storing animal hearts up to 24 hours,5 together with novel cardioprotective therapeutics to increase the allowable ischaemic times for donor hearts without impairing graft function. This technology will hopefully extend to DCD donors in the future, which are currently only preserved using a warm blood perfusion system. By relaxing donor heart suitability criteria, and using novel machine perfusion technology to increase the storage time of the donor heart,5 thus eliminating time and travel distance constraints in Australia, the donor heart pool could be greatly increased. While the numbers may ultimately be modest, the positive effect on those recipients would be substantial.

Louise E See Hoe · David McGiffin · John F Fraser

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