INTRODUCTION: Based on opinion-based clinical guidelines, VAB Ex has been introduced into clinical practice in the UK, Europe, and New Zealand for subsets of borderline breast lesions (BBL) but to date has little uptake...INTRODUCTION: Based on opinion-based clinical guidelines, VAB Ex has been introduced into clinical practice in the UK, Europe, and New Zealand for subsets of borderline breast lesions (BBL) but to date has little uptake in Australia. AIMS: In the setting of a large Australian teaching hospital, our aims were to determine if VAB Ex is a feasible and effective alternative to surgical breast biopsy (SBB) for women with BBL and is acceptable to our patient population. METHODS: Following ethics approval, this is a prospective pilot of VAB Ex as an alternative to SBB for establishing the definitive diagnosis in women whose prior needle biopsies showed a specific range of BBL and a low risk of malignant upgrade. Surgeons at our centre identified potentially eligible candidates, and radiologists determined technical suitability. Eligible women were offered the choice of VAB Ex and surgical breast biopsy, and their decision was recorded. Radiologists performed VAB Ex at the medical imaging department. Following histologic evaluation, MDT review determined the next steps in patient care. RESULTS: A total of 31 women with 33 lesions (2 women each had 2 lesions) were eligible for VAB Ex. They all accepted the offer of VAB Ex instead of SBB. The mean patient age was 57.8 years. (range 35-85 years). Image guidance for VAB Ex was by ultrasound in 31 lesions any by stereotaxis in 2, all using 7G needles. Successful lesion removal was achieved in 100% cases. No adverse events requiring medical intervention were encountered. The mean specimen weight was 1.7 g, range (0.47-6.6 g). The mean lesion extent on VAB Ex was 6 mm (range 3-15 mm). Intraductal papilloma was the most common diagnosis (18 cases), radial scar (6), fibrocystic change (4), DCIS (3), adenomyoepithelioma (1) and granulomatous mastitis (1). Among 28 of 31 (90.3%) women had benign VAB Ex findings and did not require surgery. The three patients with DCIS on VAB Ex had breast conserving surgery, confirming DCIS and a 4.5 mm tubular carcinoma in one case. Patient feedback indicated little experience of pain or discomfort and return to usual duties within 24 h. A cost analysis found saving of AUS $2849.67 per patient. CONCLUSION: Australian women prefer VAB Ex to SBB and Australian breast surgeons are key supporters of this patient-centred innovation. Overall, 90% of our patients with low-risk BBL had benign results and did not require surgical biopsy. VAB Ex provides cost-effective care.
BACKGROUND: The American and European Societies of Gastrointestinal Endoscopy (ASGE and ESGE) have published diagnostic guidelines for the evaluation of choledocholithiasis. The applicability and feasibility of these gui...BACKGROUND: The American and European Societies of Gastrointestinal Endoscopy (ASGE and ESGE) have published diagnostic guidelines for the evaluation of choledocholithiasis. The applicability and feasibility of these guidelines in a publicly funded health care system, such as ours in Aotearoa New Zealand, are not known. This retrospective study compared the diagnostic performance and utility of these guidelines against our current approach to biliary investigations to explore the feasibility of their local implementation. METHODS: We identified patients with biliary diagnosis during 2017 from admission records. We retrospectively applied the diagnostic criteria of the ASGE 2010, ASGE 2019 and ESGE 2019 guidelines to classify patients as low, intermediate or high risk for choledocholithiasis, and to determine their management if the guidelines were followed. We estimated the diagnostic performance of the guidelines using ERCP or IOC as gold standard. The simulated volume and diagnostic yield of biliary investigations according to guidelines were compared to those observed with our current approach. RESULTS: We included 621 patients, of whom 18% had choledocholithiasis. For diagnosing choledocholithiasis, ASGE 2010, ASGE 2019 and ESGE 2019 guidelines had sensitivities of 79%, 68% and 57% and specificities of 93%, 96% and 97% respectively, if only patients classified as high risk were considered. If patients classified as high or intermediate risk were both considered, their sensitivities increased to > 99% at the expense of lower specificities of 20%-30%. The AUCs for the guidelines were 0.88, 0.85 and 0.83, respectively. When compared to our current approach to biliary investigations, guideline adoption would double MRCP utilisation with correspondingly decreased diagnostic yield. CONCLUSION: Both ASGE and ESGE guidelines for choledocholithiasis may increase the volume of biliary investigations without delivering better diagnostic performance than an ad hoc approach to biliary investigations. Guideline adoption in their current forms cannot be justified in our publicly funded system in Aotearoa New Zealand. Possible contributors to poor guideline performance have been proposed and these will require further research to guide adaptation of the guidelines for our local use.
BACKGROUND: Adhesive small bowel obstruction (ASBO) accounts for 65%-75% of all reported small bowel obstructions, primarily occurring following abdominal surgery. Although conservative treatment is effective in most cas...BACKGROUND: Adhesive small bowel obstruction (ASBO) accounts for 65%-75% of all reported small bowel obstructions, primarily occurring following abdominal surgery. Although conservative treatment is effective in most cases, adhesions remain, which frequently recur. This systematic review and meta-analysis aimed to compare operative and non-operative management of ASBO with respect to recurrence rate and other clinical outcomes. METHODS: PubMed, Embase and Cochrane Library databases were searched for randomised and non-randomised studies (NRSs) comparing operative with non-operative management of ASBO in November 2025. The pooled results for recurrence, mortality, complications and length of hospital stay (LOS) were analysed. The Risk Of Bias In Non-randomized Studies-of Interventions was used to assess the risk of bias. RESULTS: One randomised controlled study and 26 NRSs were selected, with a total of 91 838 patients enrolled. Recurrence rate was significantly reduced with operative management across all study designs, including NRSs using clinical and administrative data analyses. No significant differences in mortality rates were observed between the two groups across all time periods and study designs, except for short-term mortality in NRSs using clinical data. Operative treatment was associated with significantly higher complication rates than non-operative treatment. LOS was generally longer and treatment costs were higher in the operative group than in the non-operative group. CONCLUSION: Operative management reduces the recurrence of ASBO compared with non-operative treatment; however, it is associated with higher complication rates, longer LOS and increased costs. Elective surgery may benefit patients with recurrent episodes.
This article describes a MIRP irrigation drainage system that facilitates saline or HO debridement of pancreatic necrosis using readily available equipment.This article describes a MIRP irrigation drainage system that facilitates saline or HO debridement of pancreatic necrosis using readily available equipment.
McCabe N, Clarnette N, Cabbabe K
… +15 more, Xi Y, Jarman A, Yin C, Fantenberg K, Ferguson E, Haege E, Thomas J, Hannan J, Arvanitis T, Wu V, Bowdler L, Dent L, Koutsofrigas L, Harding C, Hodgson R
BACKGROUND: Healthcare is a major contributor to greenhouse gas emissions, with operating theatres recognised as some of the most carbon-intensive areas of hospitals. Waste disposal practices substantially contribute to...BACKGROUND: Healthcare is a major contributor to greenhouse gas emissions, with operating theatres recognised as some of the most carbon-intensive areas of hospitals. Waste disposal practices substantially contribute to this footprint. Accurate quantification of operating theatre waste streams is essential to inform targeted sustainability interventions. METHODS: A prospective waste audit was conducted over 10 weekdays in April-May 2024 at a 400-bed tertiary hospital in Melbourne, Australia. Solid waste generated from 386 operations was intercepted and categorised into general, clinical, and recyclable streams. Waste generation was analysed overall, per operation, and by surgical specialty using descriptive statistics. RESULTS: A total of 2309 kg of solid operating theatre waste was generated, equating to 231 kg/day or 5.98 kg per operation. Clinical waste comprised the largest proportion (46%, 1055 kg), followed by general waste (40%, 923 kg) and recyclable waste (14%, 330 kg). Polypropylene, cardboard, and sterilisation wrap accounted for the majority of recycled materials. General Surgery, Orthopaedics and Plastic Surgery generated the highest total waste volumes. Adjusted for case numbers, Orthopaedics produced the greatest waste per case (7.15 kg). The clinical-to-general waste ratio varied substantially by specialty, with Vascular, Obstetric, and Orthopaedic surgery producing the highest proportions of clinical waste. CONCLUSIONS: This audit demonstrated a predominance of carbon-intensive clinical waste and low rates of recycling within operating theatres, with marked variation between surgical specialties. These findings highlight significant opportunities for improved waste segregation, targeted education, and specialty-specific sustainability interventions to reduce the environmental impact of surgical care.
BACKGROUND: Temporary loop ileostomy formation is a routine procedure performed to protect distal colorectal anastomosis. Traditionally, the ideal timing of ileostomy reversal is believed to fall between 3 and 6 months....BACKGROUND: Temporary loop ileostomy formation is a routine procedure performed to protect distal colorectal anastomosis. Traditionally, the ideal timing of ileostomy reversal is believed to fall between 3 and 6 months. It has been suggested that delayed reversal increases the risk of complications. Our study looks to demonstrate the relationship between delayed reversal and its associated risks in a real-world setting. METHODS: This is a retrospective cohort study conducted at Monash Health, analysing patients who underwent loop ileostomy reversal from May 2016 to December 2023. Main outcome measures include incidence of post-reversal complications, including colitis, Clostridium difficile infection, anastomotic leak, ileus, wound infection and acute kidney injury. Secondary outcome is to investigate the impact of COVID-19 on ileostomy reversal timing. RESULTS: A total of 223 patients were included. The primary indications for initial surgery included cancer (n = 134), inflammatory bowel disease (n = 19) and diverticular disease (n = 29). The median time between initial surgery and ileostomy reversal was 341 days (IQR = 211-530). Post-reversal complications occurred in 65 patients (29.1%). Patients reversed after the pandemic experienced a delay between surgeries (median: 411, IQR = 276-660) compared with those prior (median: 294, IQR = 196-408, p < 0.0001). A statistically significant association was seen between delayed reversal and post-operative complications (OR 1.11, p = 0.020, ROC AUC = 0.588). Ileostomy reversal occurring beyond 134 days (based on the Youden's Index with 90% sensitivity-based cutoff) is associated with increased risk of complications. CONCLUSION: Delayed loop ileostomy reversal is associated with post-operative complications specifically colitis and C. difficile colitis.
BACKGROUND: A rare and serious adverse outcome of sepsis is surgical amputation. Limited research has examined the prevalence and risk factors associated with amputations among sepsis patients. AIMS: To (i) assess the ra...BACKGROUND: A rare and serious adverse outcome of sepsis is surgical amputation. Limited research has examined the prevalence and risk factors associated with amputations among sepsis patients. AIMS: To (i) assess the rate of sepsis-related amputations in hospitals and (ii) identify associated risk factors. METHODS: A retrospective cohort study of sepsis patients admitted to any hospital in New South Wales, Australia, from 1 January 2015, to 31 January 2021. The primary outcome was the rate of amputations in sepsis patients. The secondary outcome was amputation risk factors, identified using multivariable logistic regression. RESULTS: There were 158 842 sepsis patients hospitalised during the study period. The amputation rate was 1.11% (1637/148061) in non-maternal adult patients, 0% (0/3656) in maternal sepsis patients, and < 0.15% (< 10/7125) in paediatric patients. In adult patients with septic shock (n = 20 354), 283 (1.39%) had an amputation. After adjustment for sex, age group, socioeconomic status, geographical remoteness, diabetes and peripheral arterial disease (PAD), factors associated with a higher odds of amputation in adult patients (n = 148 061) were being male (adjusted Odds Ratio [aOR] 2.16, 95% CI: 1.93-2.43; p < 0.001), having diabetes (aOR 9.06, 95% CI: 8.01-10.23; p < 0.001) or having PAD (aOR 19.29, 95% CI: 17.01-21.88; p < 0.001). Compared to patients aged ≥ 85 years, those 16 to 59 years (aOR 3.65, 95% CI: 3.00-4.44; p < 0.001) and 60 to 84 years (aOR 2.19, 95% CI: 1.83-2.63; p < 0.001) also had higher odds of amputation. CONCLUSIONS: This large population study provides much-needed evidence on the burden and risk factors of amputations in sepsis patients.
BACKGROUND: Acute uncomplicated diverticulitis is commonly managed in hospital in Australia. Virtual care may offer reassurance to clinicians and enable out-of-hospital management by providing remote monitoring. This stu...BACKGROUND: Acute uncomplicated diverticulitis is commonly managed in hospital in Australia. Virtual care may offer reassurance to clinicians and enable out-of-hospital management by providing remote monitoring. This study evaluated the feasibility, safety and acceptability of a virtual care pathway for acute diverticulitis (iCAD). METHODS: This Phase I/II trial comprised a single-centre pilot of patients managed via the iCAD pathway, followed by a multicentre randomised trial comparing iCAD with conventional inpatient care. The iCAD model involved initial in-person assessment and intravenous antibiotics, followed by daily medical/nursing videoconferencing, supported by wearable devices and a mobile app for vital signs monitoring. Outcomes included treatment retention (defined as the proportion of patients who remained on the iCAD pathway without crossover to inpatient care), rate of major complications and patient-reported acceptability. RESULTS: In Phase I, 10 participants were treated on the iCAD pathway with no withdrawals, crossovers or major complications. In Phase II, 40 patients were randomised and no major complications occurred in either group. Two iCAD patients crossed over to inpatient care for clinical reasons. The treatment retention rate for the virtual care group across both phases of the trial was 93%. Patient-reported experiences favoured the iCAD group, with more participants rating their care as 'excellent' (88% vs. 40%, p = 0.03) and felt their healthcare needs were 'always' met (88% vs. 47%, p = 0.02). CONCLUSIONS: Virtual care for acute uncomplicated diverticulitis appears feasible, safe and acceptable, with potential advantages over inpatient care, including superior patient-reported experience.
Intrathyroid parathyroid adenomas can be difficult to detect on imaging and may be missed intraoperatively. 18F-fluorocholine positron emission tomography/computed tomography (FCH PET/CT) is a relatively new imaging moda...Intrathyroid parathyroid adenomas can be difficult to detect on imaging and may be missed intraoperatively. 18F-fluorocholine positron emission tomography/computed tomography (FCH PET/CT) is a relatively new imaging modality used to evaluate patients with hyperparathyroidism preoperatively. We present the case of an intrathyroid parathyroid adenoma visualised on FCH PET/CT but not identified on the current conventional imaging modalities preoperatively, which subsequently underwent successful surgical removal. Trial Registration: ACTRN12625000509460.
BACKGROUND: Emergency general surgery (EGS) services are under increasing pressure in New Zealand and internationally. This study examined trends in EGS volume, incidence, patient complexity, and system performance over...BACKGROUND: Emergency general surgery (EGS) services are under increasing pressure in New Zealand and internationally. This study examined trends in EGS volume, incidence, patient complexity, and system performance over 15 years at North Shore Hospital, Waitematā, New Zealand. METHODS: We conducted a retrospective cohort study of adult patients (≥ 16 years) undergoing emergency general surgical procedures at North Shore Hospital between 2010 and 2024. Annual procedure volumes, incidence rates using census-derived catchment populations, patient demographics, procedure type and key system performance indicators were analysed over time. RESULTS: A total of 39 996 emergency general surgical procedures were performed. Case volume increased by 32.3% over the study period, with a corresponding rise in total operative minutes. The overall population of Waitemata increased from 524 610 to 670 174 people (a 27.8% increase, 1.65% per year). The overall procedure incidence rate increased modestly (453.1 vs. 469.1 per 100 000 person-years) but did not reach statistical significance. The median age of surgical patients increased more rapidly than the underlying population. The proportion of patients with ASA ≥ 3 rose from 23.4% to 34.5%. Median time from booking to surgery increased from 7 to 16 h, while length of stay remained stable. CONCLUSION: This study demonstrated a significant increase in the emergency general surgical workload at a large metropolitan hospital in New Zealand, with population growth as the primary driver. It also demonstrates that the patients are ageing and becoming increasingly medically complex. These findings highlight the need for proactive workforce planning and service design.
BACKGROUND: Hip fracture is a common, high-risk condition over-represented in surgical mortality audits, yet the contribution of non-technical errors has not been examined. This study aimed to determine the number, chara...BACKGROUND: Hip fracture is a common, high-risk condition over-represented in surgical mortality audits, yet the contribution of non-technical errors has not been examined. This study aimed to determine the number, characteristics and clinical context of non-technical errors associated with patient death in hip fracture mortality to identify targets for improvement. METHODS: A retrospective cohort study analysed all inpatient hip fracture mortalities reported to the Australian and New Zealand Audit of Surgical Mortality (ANZASM) between 2012 and 2019. Patient mortalities flagged with an adverse event or area of concern were independently reviewed using a validated non-technical error classification tool. Outcomes included number and proportion of errors within this cohort, error type, temporal trends, clinical phase of occurrence and team responsibility. RESULTS: Of 8414 orthopaedic mortalities, 510 were flagged with an adverse event or area of concern, including 255 hip fracture patients. Non-technical errors associated with death were identified in 116/255 (45.5%) patients, with no meaningful change over time. Decision making errors were most common (47.9%), followed by situational awareness (35.2%), communication/teamwork (10.3%) and leadership errors (6.7%). Most errors occurred outside the operating theatre, with 60.6% pre-operative and 28.5% post-operative. Orthopaedics were responsible for 86% of single-team errors and contributed to all multi-team errors. Other specialties were responsible for 14% of single-team errors and contributed to multi-team errors. CONCLUSION: In this cohort non-technical errors associated with death are common. Distinct patterns by clinical phase, error type and team involvement highlight actionable targets for interventions to improve surgical safety and reduce future errors associated with death.
BACKGROUND: Early laparoscopic cholecystectomy is recommended for acute cholecystitis, yet delivery is often constrained by emergency theatre access. We examined whether delay occurred mainly before or after the decision...BACKGROUND: Early laparoscopic cholecystectomy is recommended for acute cholecystitis, yet delivery is often constrained by emergency theatre access. We examined whether delay occurred mainly before or after the decision to operate. METHODS: Retrospective single-centre cohort of adults undergoing emergency laparoscopic cholecystectomy for coded acute cholecystitis at Cairns Hospital (July 2021-June 2025). Primary outcomes were time to theatre, pathway decomposition, preoperative bed-days and cost. RESULTS: Among 122 patients, median preoperative wait was 2 days (IQR: 1-3) and preoperative waiting accounted for 260/482 bed-days (53.9%). The decision to operate was made on the admission day in 102 patients (83.6%), yet 29 (28.4%) still underwent surgery after > 2 days. Across recorded pathway intervals, 148/185 days (80.0%) accrued between decision and operation. In the same-day decision subgroup, waiting > 2 days was associated with similar postoperative length of stay (1 vs. 1 day, p = 0.496) and operative duration (108 vs. 112 min, p = 0.285), but longer total stay (5 vs. 3 days, p < 0.001). Weekend admission was associated with lower odds of delay > 2 days (OR: 0.20, 95% CI: 0.07-0.54). CONCLUSION: Delay appeared to represent post-booking inpatient queueing rather than delayed decision-making or clinically useful optimisation. The findings suggest a policy-capacity mismatch: early-surgery standards have expanded in a setting of population growth without matching resource allocation to theatre, ward and staffing capacity, a problem likely relevant to many Australian public hospitals.
PURPOSE: Patient reported outcome measures (PROMs) following colorectal cancer (CRC) treatment have been gaining prominence in addition to oncological outcomes. We have integrated PROMs collection through our nurse-led f...PURPOSE: Patient reported outcome measures (PROMs) following colorectal cancer (CRC) treatment have been gaining prominence in addition to oncological outcomes. We have integrated PROMs collection through our nurse-led follow-up (NLFU) clinic of patients undergoing surgical/endoscopic treatment of CRC and report our real-world results. METHODS: PROMs were collected using the EORTC 29 Questionnaire using a pre-appointment link via NLFU clinic over a period of 18 months since April 2023. The reported outcomes were analysed and correlated with patient demographics, tumour stage, type of procedure and duration since procedure. RESULTS: Tumour site did not influence functional (FS) or symptom (SS) scores. Age demonstrated selective effects: older patients reported better overall functional outcomes but worse urinary-frequency symptoms. Gender did not significantly affect FS or SS. Symptomatic presentation was associated with higher symptom burden, particularly abdominal pain, buttock pain and urinary frequency, while FS remained comparable to screen-detected cases. Most operative approaches produced similar PROMs; however, body image, faecal incontinence and embarrassment differed between specific procedures. Neoadjuvant chemotherapy and tumour stage showed no significant relationships with FS or SS outcomes. Symptom trajectories improved over time, with stool frequency, urinary incontinence, body image and male sexual function varying significantly across follow-up durations, while FS remained stable. Sphincter preservation versus resection revealed worse body image, male sexual function and buttock pain in patients undergoing Abdominoperineal resections (APR). Organ preservation and surgical resection showed broadly comparable PROMs despite differing symptom patterns. CONCLUSION: PROMs collection is feasible, and outcomes are largely stable across treatments, though symptom burden varies with patient and procedural factors.
OBJECTIVE: Axillary management in early-stage breast cancer has shifted from routine clearance to selective, biology-driven intervention. Advances in systemic therapy, imaging, and radiotherapy have reduced the need for...OBJECTIVE: Axillary management in early-stage breast cancer has shifted from routine clearance to selective, biology-driven intervention. Advances in systemic therapy, imaging, and radiotherapy have reduced the need for axillary lymph node dissection (ALND), limiting morbidity without compromising oncologic outcomes. METHODS: This narrative review summarizes evidence supporting surgical de-escalation, targeted axillary dissection (TAD), and regional nodal irradiation (RNI), drawing on randomized trials, prospective cohorts, and international guidelines. RESULTS: Randomized trials show that completion ALND can be safely omitted in patients with limited sentinel lymph node (SLN) involvement, with equivalent survival and lower lymphedema rates. Noninferiority studies indicate that SLN biopsy itself may be omitted in selected low-risk patients with negative axillary imaging. In biopsy-proven node-positive disease treated with neoadjuvant therapy, TAD-retrieving the clipped node together with SLNs-reduces false-negative rates to ≤ 5%, allowing omission of ALND in responders. CONCLUSION: Axillary treatment has evolved toward individualized, minimally invasive strategies guided by tumor biology, treatment response, and patient priorities, requiring multidisciplinary decision-making to optimize outcomes.
Luo Y, Zhang Y, Nestel D
… +15 more, King S, Dixon BJ, Royse A, Mohan H, Allen P, Jackson A, Gould D, Green C, Stevens S, de Steiger R, Eppich W, Hodgson R, Martinez LA, Perini M, Duchi S
BACKGROUND: The 2025 University of Melbourne Department of Surgery Research Showcase, held on 18 November 2025, brought together surgeons, researchers, educators, and trainees from across seven clinical precincts to exam...BACKGROUND: The 2025 University of Melbourne Department of Surgery Research Showcase, held on 18 November 2025, brought together surgeons, researchers, educators, and trainees from across seven clinical precincts to examine emerging directions in surgical education research. The event aimed to facilitate knowledge exchange, interdisciplinary collaboration, and critical reflection on evolving training paradigms. METHODS: The Showcase was delivered in a hybrid format, combining in-person and virtual participation to maximize accessibility and engagement. The program comprised keynote presentations and precinct-led talks, alongside thematic discussions addressing contemporary issues in surgical education. Contributions were drawn from multiple disciplines, including engineering, data science, ophthalmology, oncology, and general surgery. RESULTS: Presentations highlighted innovations in simulation-based learning, robotic and technology-enhanced training, Artificial Intelligence-enabled assessment, large-scale online education, and real-time intraoperative performance monitoring. Additional themes included curriculum reform, competency-based assessment, trainee underperformance, gender equity in surgical training, and the transition from trainee to consultant. The Showcase demonstrated the increasing prominence of educational scholarship within surgical disciplines and illustrated how multidisciplinary approaches can strengthen training frameworks and support workforce sustainability. CONCLUSION: The Research Showcase provides a model for fostering regional academic communities in surgery through accessible, collaborative platforms. Its findings offer valuable insights for educators, academic surgeons, and policymakers addressing current challenges in surgical training. The reflections arising from the event contribute to the broader discourse in surgical education research and have important implications for the design of future curricula, assessment strategies, and professional development pathways.