BACKGROUND: Common bile duct (CBD) stones are a common condition with high recurrence rates of stone and cholangitis. However, whether stone type influences recurrence remains unclear. METHODS: We retrospectively analyze...BACKGROUND: Common bile duct (CBD) stones are a common condition with high recurrence rates of stone and cholangitis. However, whether stone type influences recurrence remains unclear. METHODS: We retrospectively analyzed 190 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones between January 2014 and December 2023. Patients were categorized into two groups: brown pigment stone (n = 127) and black pigment stone (n = 63). Clinical characteristics were compared and recurrence risk factors were analyzed. This study was approved by the Institutional Review Board of Peking University Third Hospital (Approval No. M2024869) and conducted in accordance with the Declaration of Helsinki (2013 revision). RESULTS: Baseline characteristics were similar between groups, except the brown pigment group had higher rates of prior ERCP (33.1% vs. 17.5%), larger CBD diameter (15 mm vs. 12 mm), and more multiple stones (69.3% vs. 49.2%) (all p < 0.05). Recurrence of CBD stones (35.4% vs. 9.5%) and cholangitis (21.3% vs. 4.8%) was significantly higher in the brown pigment group (p < 0.05), with shorter median stone-free survival (67.0 vs. 82.0 months) and cholangitis-free survival (70.0 vs. 82.0 months). Multivariate analysis identified brown pigment stones (HR = 3.162, 95% CI: 1.337-7.482, p = 0.009) and prior ERCP (HR = 3.254, 95% CI: 1.798-5.888, p < 0.001) as independent risk factors for stone recurrence, while stone diameter ≤ 10 mm was protective (HR = 0.412, 95% CI: 0.220-0.773, p = 0.006). Brown pigment stones (HR = 3.434, 95% CI: 1.026-11.489, p = 0.045) and prior ERCP (HR = 2.398, 95% CI: 1.111-5.173, p = 0.026) also independently predicted cholangitis recurrence. CONCLUSION: Brown pigment stones carry higher risks of stone and cholangitis recurrence, and ERCP may not be the preferred treatment.
BACKGROUND: Surgeons undertake diverse roles in clinical practice, administration, education, research and innovation. These responsibilities can give rise to conflicts of interest when personal, financial, or profession...BACKGROUND: Surgeons undertake diverse roles in clinical practice, administration, education, research and innovation. These responsibilities can give rise to conflicts of interest when personal, financial, or professional interests intersect with the fundamental obligations to patient care, research integrity, and ethical conduct. While conflicts of interest are inherent in modern surgical practice, inadequate recognition and management risk undermining ethical decision-making and public confidence in the profession. METHODS: A structured literature search was conducted using the Ovid MEDLINE database to identify relevant publications addressing conflicts of interest in surgical practice. Conflict of interest policies from surgical specialty colleges in Australia, Canada, Ireland, the United Kingdom, and the United States of America were also reviewed. Findings were synthesised narratively. SUMMARY OF POLICIES: Existing policies demonstrate broad consistency in defining conflicts of interest and emphasising disclosure. However, substantial variability exists in the depth of guidance for identifying, evaluating and managing conflicts. Empirical evidence highlights underreporting of conflicts of interest and associations between industry relationships and favourable research outcomes. Practical, context-specific strategies for managing complex or evolving conflicts remain limited. CONCLUSIONS: Conflicts of interest are an inherent aspect of modern surgical practice. However, existing policies often lack practical, context-specific guidance to address these conflicts. A structured process incorporating identification, disclosure, risk assessment, management, monitoring, and ongoing transparency and accountability should be adopted to uphold professional integrity, support ethical decision-making, and maintain public trust within surgical practice.
BACKGROUND: Rural residents are more likely to suffer moderate and severe traumatic brain injury (TBI) and experience delay to definitive care than urban patients. Prior studies comparing these populations were based on...BACKGROUND: Rural residents are more likely to suffer moderate and severe traumatic brain injury (TBI) and experience delay to definitive care than urban patients. Prior studies comparing these populations were based on hospitalised patients only. We examined TBI outcomes incorporating pre-hospital mortality to determine the association between location of injury and mortality risk. METHODS: Twelve-month (2019) retrospective cohort study was performed on all adult patients with TBI within one Trauma System. Demographics, geographical location of injury, mechanism, scene vital parameters and interventions, injury severity, polytrauma status, TBI morphology and outcomes were collected for all hospital and prehospital deaths. Uni- and multivariate analysis was conducted including binary logistic regression to examine associations between mortality and potential confounders of mortality. RESULTS: 266 patients (145 hospitalised and 121 prehospital deaths) with median age 53.6 years (18-98), 72.6% males, scene Glasgow Coma Scale (GCS) < 14 (48.3%), were included. Ninety-four (36%) patients were urban and, 167 (64%) were regional, rural or remote. Rural compared to urban patients had higher risk of death (adjusted OR 1.934, 95% CI 1.07-3.49) without differences in GCS, pupillary status, injury pattern, radiological TBI severity or initial management. The strongest risk factor for mortality was polytrauma (adjusted OR 7.804, 95% CI 4.155-14.62, p < 0.01). CONCLUSIONS: Comprehensive assessment of TBI mortality indicates that rurality is associated with mortality and polytrauma status is a profound risk factor. These findings highlight that prehospital mortality is essential to monitor and optimisation of polytrauma care is a potential modifiable factor in TBI outcomes.
INTRODUCTION: Despite established ethical principles, a critical synthesis of how informed consent deficiencies, leading to costly malpractice lawsuits in elective orthopedic surgery, relate to medico-legal outcomes, doc...INTRODUCTION: Despite established ethical principles, a critical synthesis of how informed consent deficiencies, leading to costly malpractice lawsuits in elective orthopedic surgery, relate to medico-legal outcomes, documentation pitfalls, and team roles is lacking. This scoping review aimed to investigate the status of obtaining informed consent by the treatment team in elective orthopedic surgeries and the related legal consequences. METHODS: Following the Arksey & O'Malley framework update by Levac et al., we conducted a comprehensive search across PubMed, Scopus, Web of Science databases, and the Google Scholar search engine. Studies focusing on informed consent, legal factors, and the treatment team in elective orthopedic procedures were included in this review. Data were charted and analyzed using thematic analysis for qualitative synthesis, supplemented by quantitative summary statistics. RESULTS: Qualitative analysis identified four themes: documentation patterns, legal factors, cultural considerations, and risk mitigation strategies. Findings showed frequent documentation gaps (13%-32% of forms lacked specific complications). Nerve injury was the most common cause of lawsuits (46%-56%). In lumbar fusion, 24% of claims cited failure to obtain consent. US compensation averaged $871 093, vastly exceeding European figures. Patient recall of complications was poor (22.5%) but improved to 48% with written aids. CONCLUSION: The informed consent process in elective orthopedics faces systematic challenges, including inconsistent documentation, high litigation risk, and inadequate patient understanding. To reduce legal exposure and promote safety, implementing evidence-based, procedure-specific consent forms, interdisciplinary team training, and culturally competent communication is recommended. Addressing these requires coordinated policy reform at institutional and educational levels.
INTRODUCTION: Clinically significant infections (CSIs) are a common complication identified in cases of surgical mortality, associated with prolonged hospital stays, unplanned escalation of care and increased risk of dea...INTRODUCTION: Clinically significant infections (CSIs) are a common complication identified in cases of surgical mortality, associated with prolonged hospital stays, unplanned escalation of care and increased risk of death. This study aimed to examine the burden of CSIs in surgical deaths in the Australian Capital Territory and identify contributing factors and potential opportunities to improve surgical outcomes. METHODS: The Australian Capital Territory Audit of Surgical Mortality (ACTASM) collects data on in-hospital surgical mortality. This report compared cases with and without CSIs from 1 January 2015 to 31 December 2024. RESULTS: Of 1089 cases, 363 had CSIs. Cases with CSIs had a higher proportion of comorbidities and longer lengths of stay but underwent fewer procedures. More patients acquired infections during than before admission. Sepsis was the most common infection acquired before admission, whereas pneumonia was the most common infection acquired during admission. General surgery had the highest number of CSIs, while urology had the highest proportion of CSIs relative to case volume. Rates of unplanned readmissions to hospital, unplanned admissions to critical care unit, unplanned returns to theatre and postoperative complications were higher in cases with CSIs. CONCLUSION: Surgical patients with CSIs who died had more comorbidities and longer lengths of stay but were less likely to undergo an operation than those without CSIs. Unplanned events were higher in patients with CSIs. These findings underscore the significant impact of CSIs on patient outcomes, highlighting the need for effective preventive strategies and timely management to optimise patient outcomes.
BACKGROUND: The Nuss procedure, also known as minimally invasive repair of pectus excavatum (MIRPE), is recognised to cause high levels of post-operative pain, requiring regional techniques and inpatient and outpatient o...BACKGROUND: The Nuss procedure, also known as minimally invasive repair of pectus excavatum (MIRPE), is recognised to cause high levels of post-operative pain, requiring regional techniques and inpatient and outpatient opioid use. Intercostal nerve cryoablation during MIRPE is a new technique that results in extended analgesia for up to 3-6 months after surgery. This multisite comparative analysis is the first to present the use of cryoanalgesia in Australasia. METHODS: Retrospective chart reviews were conducted of 17 consecutive patients who underwent cryoanalgesia for MIRPE and 17 patients who underwent MIRPE without cryoanalgesia immediately before its introduction to two sites. Oral morphine equivalents were calculated for opiate medications administered and dispensed. The two cohorts were compared using unpaired t-tests for normally distributed data and Mann-Whitney U tests for non-normally distributed data. RESULTS: Cryoanalgesia significantly shortened the length of stay-median length of stay 3 days in patients who had cryoanalgesia compared to 5 days in patients with no cryoanalgesia (p < 0.05). Cryoanalgesia also significantly reduced inpatient opiate use-average oral morphine equivalent 110 mg in patients who received cryoanalgesia compared to 489 mg in those who did not (p < 0.05). CONCLUSION: Use of cryoanalgesia significantly reduced inpatient opioid use and reduced length of stay. Ongoing research is required to establish the safety of this technique and study the long-term effects.
BACKGROUNDS: Micro-nanoplastics (MNPs) are increasingly detected in human cardiovascular tissues and have been linked to higher rates of adverse cardiovascular events. However, the clinical and economic implications of M...BACKGROUNDS: Micro-nanoplastics (MNPs) are increasingly detected in human cardiovascular tissues and have been linked to higher rates of adverse cardiovascular events. However, the clinical and economic implications of MNP contamination for vascular surgery populations remain unclear. We aimed to model the potential impact of MNPs on outcomes and healthcare costs among Australian patients undergoing carotid endarterectomy. METHODS: We performed a modelling study using secondary data. Rates of carotid plaque MNP contamination and associated risks of stroke, myocardial infarction, and death were derived from international cohort data, while procedure numbers and costs were obtained from Australian national sources. A cohort of 1900 patients undergoing carotid endarterectomy in 2020-2021 was modelled across MNP contamination scenarios from 0% to 100%, estimating additional adverse events, healthcare costs, and years of life lost (YLL). RESULTS: At the current reported contamination rate of 58.4%, MNPs were estimated to contribute to 139 additional adverse events, including 52 strokes, 53 myocardial infarctions, and 34 deaths, among 1900 Australian carotid endarterectomy patients. This corresponded to an additional AUD$25.5 million in healthcare costs and 441 YLL. A hypothetical 100% contamination rate increased the incremental burden to AUD$43.6 million and 881 YLL. CONCLUSION: MNP contamination may substantially increase the clinical and economic burden associated with carotid endarterectomy in Australia. Although model-based and subject to uncertainty arising from potential false positives of MNPs due to challenges with analysis in tissue matrices, these findings highlight MNPs as a plausible, previously unrecognised contributor to adverse vascular outcomes and healthcare expenditure.
BACKGROUND: Preoperative anxiety affects a substantial proportion of surgical patients and may adversely influence perioperative outcomes. Virtual reality (VR) technology offers an innovative approach for anxiety managem...BACKGROUND: Preoperative anxiety affects a substantial proportion of surgical patients and may adversely influence perioperative outcomes. Virtual reality (VR) technology offers an innovative approach for anxiety management, yet evidence regarding its efficacy in surgical settings remains limited. OBJECTIVE: This study aimed to evaluate the effectiveness of an immersive VR-based intervention for reducing preoperative anxiety among adult patients undergoing elective abdominal surgery. METHODS: A prospective, single-center, randomized controlled trial was conducted from March 2023 to December 2024. Three hundred eight patients scheduled for elective abdominal surgery were randomly allocated to either the VR intervention group (n = 155) or the standard care control group (n = 153). The VR group received a 10-15 min immersive relaxation experience prior to anesthesia induction. The primary outcome was pre-induction anxiety measured using the State-Trait Anxiety Inventory, State subscale (STAI-S). Secondary outcomes included intraoperative cooperation scores, physiological stress markers, and patient satisfaction. RESULTS: Patients in the VR group demonstrated significantly lower pre-induction STAI-S scores compared to controls (36.5 ± 10.5 vs. 48.0 ± 10.9, mean difference -11.5, 95% CI -13.9 to -9.2, Cohen's d = 1.08, p < 0.001). The VR group also exhibited higher intraoperative cooperation scores (82.8 ± 9.3 vs. 74.8 ± 11.8, mean difference 8.0, Cohen's d = 0.75, p < 0.001) and attenuated physiological stress responses including heart rate (82.5 ± 12.8 vs. 89.5 ± 12.4 bpm, mean difference -7.0, Cohen's d = 0.56, p < 0.001), systolic blood pressure (133.3 ± 15.0 vs. 142.0 ± 14.5 mmHg, mean difference -8.7, Cohen's d = 0.59, p < 0.001), and serum cortisol (14.9 ± 4.3 vs. 20.1 ± 4.8 μg/dL, mean difference -5.2, Cohen's d = 1.14, p < 0.001). The VR group reported higher satisfaction scores (8.1 ± 1.1 vs. 7.4 ± 1.3, p < 0.001). Subgroup analyses revealed consistent benefits across surgery types, anesthesia modalities, and demographic characteristics. Adverse events were minimal, with only 4.5% of VR participants reporting mild transient symptoms including dizziness (n = 3, 1.9%), headache (n = 3, 1.9%), and eye strain (n = 1, 0.6%), all of which resolved spontaneously within minutes. CONCLUSIONS: Immersive VR-based intervention effectively reduces preoperative anxiety and improves patient cooperation in adults undergoing elective abdominal surgery. This non-pharmacological approach represents a promising adjunct to standard perioperative care protocols.
BACKGROUND: The symptomatology of large hiatus hernia (LHH) has been historically poorly understood, with cardiorespiratory symptoms caused by LHH being underappreciated by clinicians. This study reports on the mechanism...BACKGROUND: The symptomatology of large hiatus hernia (LHH) has been historically poorly understood, with cardiorespiratory symptoms caused by LHH being underappreciated by clinicians. This study reports on the mechanisms of dyspnoea in LHH through a historical review of symptoms and evolved physiological literature, discussing likely causation. METHODS: The physiological abnormalities contributing to the development of dyspnoea in LHH were identified through a search of PubMed, Medline, Embase and Cochrane using keywords hiatus (hiatal) hernia, dyspnoea and pulmonary symptoms. A literature review was conducted to identify symptom patterns associated with LHH over time. The established physiological mechanisms have been described. RESULTS: Multiple mechanisms of dyspnoea were identified over passage of time, including pulmonary gas trapping, cardiac inflow obstruction, pulmonary microaspiration, reduction in pulmonary volumes, parenchymal lung disease and iron deficiency anaemia. Early symptomatic literature was found to infrequently report dyspnoea preoperatively in LHH; however, in recent decades, the frequency of dyspnoea has 'apparently' increased, suggesting improved clinical recognition of the association of LHH and cardio-respiratory symptoms. CONCLUSION: Dyspnoea appears to be causally associated with LHH and is likely physiologically multifactorial in individual patients when other causes are excluded as the primary cause.
INTRODUCTION: Older patients undergoing emergency laparotomy are overrepresented and are at risk of poor postoperative outcomes that may not align with their goals. Goals of care (GOC) documentation remains low in older...INTRODUCTION: Older patients undergoing emergency laparotomy are overrepresented and are at risk of poor postoperative outcomes that may not align with their goals. Goals of care (GOC) documentation remains low in older emergency laparotomy patients. METHODS: We conducted a prospective cohort study of emergency laparotomy patients aged ≥ 70 years between February 2024 and April 2025. Participants received phone follow-up 30 days after index surgery, assessing postoperative outcomes, EQ-5D-5L quality of life and decision satisfaction. If patients lacked capacity, next of kin were consented. Our primary aim was to assess recall of a preoperative GOC discussion. Our secondary aims were to correlate GOC recall with postoperative quality of life and decision satisfaction, and to determine rates of documented GOC conversations and GOC form completion. RESULTS: We recruited 80 participants and completed follow-up in 75. Twenty-nine (39%) participants recalled discussing GOC preoperatively. Next of kin had higher recall than patients (n = 13, 59% and n = 16, 30% respectively). GOC recall was not associated with quality of life or decision satisfaction questionnaire scores. Most patients (n = 31, 89%) in the "GOC recall" group reported that the GOC conversation was worthwhile. Although 89% (n = 71) of participants had a completed GOC form preoperatively, 49% (n = 39) had a documented GOC discussion. We observed documentation inconsistencies, as participants with no GOC documentation recalled GOC discussions. CONCLUSIONS: GOC recall by older patients and their next of kin was low following emergency abdominal surgery. GOC discussions were valued by patients and next of kin, supporting further research.
BACKGROUND: Microvascular free flap surgery is a cornerstone of modern reconstructive surgery, providing robust coverage for complex defects. While studies have examined outcomes in specific anatomical sites, few have ev...BACKGROUND: Microvascular free flap surgery is a cornerstone of modern reconstructive surgery, providing robust coverage for complex defects. While studies have examined outcomes in specific anatomical sites, few have evaluated long-term institutional trends across all indications. This study aimed to assess temporal changes in microvascular free flap reconstructive surgery at a tertiary plastic surgery unit over 12 years. METHODS: A retrospective review was conducted of free and locoregional flap reconstructions performed between 2012 and 2023 at a single tertiary centre. Data collected included patient demographics, flap type, anatomical region, surgical indication and complication rates. RESULTS: A total of 912 free flaps and 628 locoregional flaps were performed during the study period. The volume of free flaps increased by 2.6-fold, from 4.7 procedures per month in 2012 to 12.2 in 2023 (p < 0.0001), whereas locoregional flap rates remained stable. Head and neck reconstruction accounted for the majority of cases (58%), followed by lower limb (29%) and breast (6.3%), with breast and lower limb demonstrating the greatest proportional growth. Malignancy was the most frequent indication, although trauma and infection-related reconstructions increased in later years. Takeback rates declined from 25.6% in 2012 to 17.1% in 2023, with flap loss rates consistently below 5%. CONCLUSION: This 12-year review demonstrates a significant rise in free tissue reconstructions without a corresponding decline in locoregional procedures, indicating a genuine growth in microsurgical activity. These findings highlight increasing demand, improved outcomes, and the ongoing need for investment in microsurgical services, training, and infrastructure.
BACKGROUND: Although laparoscopic common bile duct exploration with primary duct suture (LCBDE + PDC) is recognized as a feasible and safe approach for treating cholecystocholedocholithiasis, there is a paucity of studie...BACKGROUND: Although laparoscopic common bile duct exploration with primary duct suture (LCBDE + PDC) is recognized as a feasible and safe approach for treating cholecystocholedocholithiasis, there is a paucity of studies examining its applicability in elderly patients. This study aims to investigate the safety and feasibility of primary suture in patients aged ≥ 65 years and older following LCBDE. METHODS: A total of 219 patients diagnosed with cholecystocholedocholithiasis who underwent LCBDE + PDC treatment were categorized into two groups: Group A (age ≥ 65 years, n = 86) and Group B (age < 65 years, n = 133). This study aims to compare the demographic characteristics and clinical outcomes between the two groups. RESULTS: This study reported no mortality cases. Compared to Group B, Group A had a longer duration of abdominal drainage placement (p = 0.008), longer postoperative hospital stay (p = 0.008), and longer total hospital stay (p < 0.001). In addition, the total costs in the elderly group were significantly higher (p < 0.001). The incidence of postoperative pneumonia in Group A was significantly higher than in Group B (5.81% vs. 0.75%, p = 0.036). There were no significant differences between the two groups in terms of operation time, estimated blood loss, holmium laser lithotripsy usage rate, and incidence of severe complications. CONCLUSIONS: For elderly patients who meet the surgical indications, laparoscopic common bile duct exploration with primary duct closure is considered safe and feasible. Nevertheless, surgeons should remain vigilant regarding the potential occurrence of postoperative pneumonia in the elderly population.
BACKGROUND: Erythropoietin (EPO) has emerging tissue-protective roles, including anti-apoptotic, anti-inflammatory, and pro-angiogenic effects. In reconstructive surgery, where flap necrosis remains a significant challen...BACKGROUND: Erythropoietin (EPO) has emerging tissue-protective roles, including anti-apoptotic, anti-inflammatory, and pro-angiogenic effects. In reconstructive surgery, where flap necrosis remains a significant challenge, EPO has been investigated as an agent to enhance flap survival. Currently, no pharmacological agent has consistently improved flap survival, underscoring the need for novel therapeutics. METHODS: A systematic review was conducted in accordance with PRISMA guidelines. PubMed, Embase, and CENTRAL databases were searched from inception to September 2025. Eligible studies investigated the effect of EPO on surgical flap survival in animal or human models compared with placebo/no treatment, reporting percentage flap necrosis. Secondary outcomes included perfusion, histological and molecular parameters, and safety. RESULTS: Nine animal studies met the pre-defined inclusion criteria (mice, n = 139; rats, n = 196) using random-pattern dorsal, musculocutaneous, and TRAM flap models. All studies evaluated the effect of recombinant human EPO with a variety of different doses, routes, and time applications. Across all studies, EPO was associated with reduced flap necrosis versus controls, with the greatest benefit observed from short-course, low-dose peri-operative regimes. High-dose or prolonged schedules were less effective and occasionally detrimental. EPO improved perfusion (capillary density, arteriolar flow), enhanced microvascularity and tissue preservation, and upregulated vascular endothelial growth factor (VEGF) and endothelial nitric oxide synthase (NOS) with reduced oxidative stress. No thrombotic events or treatment-related mortality were reported. CONCLUSION: EPO improves flap survival in experimental animal models. Short-term, low-dose preconditioning appears most effective, while higher doses raise safety concerns. Translation to clinical practice requires optimization of dosing strategies and rigorous clinical trials.
BACKGROUND: In Europe, the lowest perioperative mortality is seen when oesophagectomies are performed in high-volume hospitals. In Australia, the optimum annual volume for the lowest mortality has been shown to be 21+. T...BACKGROUND: In Europe, the lowest perioperative mortality is seen when oesophagectomies are performed in high-volume hospitals. In Australia, the optimum annual volume for the lowest mortality has been shown to be 21+. The objective was to evaluate regional variation in hospital mortality following oesophagectomy from a prospective database using univariate and multivariable logistic regression models. METHODS: The Australia and New Zealand Intensive Care Society Adult Patient Database was used to identify patients undergoing oesophagectomy for cancer in Australia from 2012 to 2021. The hospital mortality for each jurisdiction per year was determined, and a three-level mixed-effects logistic model was used to assess hospital volume versus hospital mortality. RESULTS: 4189 patients underwent oesophagectomy in 124 hospitals. Regions with the highest number of hospitals performing oesophagectomies were NSW/ACT (44) and VIC/TAS (38). The jurisdiction with the highest proportion of operations in high-volume hospitals (21+ operations per year) was Queensland (39.7%), followed by Western Australia (39.6%) and South Australia (31.8%). Mortality rates were 1.4% in Queensland, 2.5% in South Australia, 3.3% in Western Australia, 3.8% in VIC/TAS and 5.4% in NSW/ACT. The differences in mortality between jurisdictions were primarily driven by differences in surgical volume across hospitals within each jurisdiction, accounting for 73.9% of the between-hospital variance, with higher volume associated with lower mortality. CONCLUSIONS: Differences exist between jurisdictions in Australia for outcomes following oesophagectomy. Perioperative mortality was lower in regions where surgery was more commonly undertaken in a higher-volume hospital. Hospital mortality in Australia might be reduced if oesophagectomies are uniformly centralised to high-volume hospitals.