Participation in Australian health quality improvement programmes is highly variable and often poor. Overseas guides suggest medical professionals, healthcare organisations and patients have an ethical and perhaps legal...Participation in Australian health quality improvement programmes is highly variable and often poor. Overseas guides suggest medical professionals, healthcare organisations and patients have an ethical and perhaps legal responsibility to participate in quality improvement programmes. There appear to be no similar Australian recommendations. With the increasing development of quality improvement programmes in Australia there is an urgent need to recognise that resistance to quality improvement participation is inconsistent with professional ethical and legal obligations to provide best care.
A novel analgesic framework for minimally invasive oesophagectomy to facilitate functional recovery.A novel analgesic framework for minimally invasive oesophagectomy to facilitate functional recovery.
BACKGROUND AND AIMS: Medicine and surgery have been practised by women since the earliest of times, but as these activities became professionalised, they became excluded by various barriers. The aims of this review are t...BACKGROUND AND AIMS: Medicine and surgery have been practised by women since the earliest of times, but as these activities became professionalised, they became excluded by various barriers. The aims of this review are to identify these obstacles and how they were overcome. METHODS: An analysis was undertaken of the history of women's education and of female surgeons, and of the contemporary factors which influenced their development. RESULTS: Victorian assumptions about gender differences and societal roles resulted in a lack of educational opportunities for girls and women, their exclusion from university and medical college examinations, and from opportunities to train in hospitals. Claims that the anatomy dissection room and the operating theatre were unsuitable environments for women were further obstacles for those who wished to become surgeons. Examination of the lives of those women who led the changes in education, and of the first females to obtain the Fellowship of the different Royal Colleges of Surgeons by examination, or to become Board Certified in the US, illustrates the challenges they overcame and the important roles they played in health care and medical research. Despite their success and that of the countless female surgeons who have since followed them, challenges remain. CONCLUSION: Analysis of the history of the education of young women and of the first female surgeons demonstrates the barriers and unfounded biases they overcame. To achieve the satisfactory recruitment, education, training, career success and retention of women surgeons, lessons must be learned from history and the remaining obstacles overcome.
BACKGROUND: Breast angiosarcoma is a rare, aggressive malignancy that can be primary (PAS) or secondary (SAS). This study evaluates the management and outcomes of breast angiosarcoma in a single-center breast/surgical on...BACKGROUND: Breast angiosarcoma is a rare, aggressive malignancy that can be primary (PAS) or secondary (SAS). This study evaluates the management and outcomes of breast angiosarcoma in a single-center breast/surgical oncology unit. METHODS: A retrospective review was conducted on patients with histologically confirmed PAS or SAS who underwent surgical resection at Mater Hospital Brisbane between 2009 and 2024. Patient characteristics, clinical features, treatment, complications, and survival outcomes were analyzed. RESULTS: Fifteen patients were included-4 with PAS and 11 with SAS. SAS patients were significantly older, all had a history of breast cancer treated with adjuvant radiotherapy, and commonly presented with skin discoloration (bruising or violaceous rash). There was a trend toward a shorter duration from presentation to diagnosis and fewer investigations required in PAS patients. Management did not differ between PAS and SAS groups; all patients underwent surgical resection and less than half received adjuvant radiotherapy or chemotherapy. Median follow-up was 27 months for PAS patients and 12 months for SAS patients. The local recurrence rate in the SAS group was 9.1%, with no local recurrence observed in the PAS group (p = 0.53). Mortality rates were 25% in the PAS group and 18.2% in the SAS group (p = 0.77). CONCLUSION: Breast angiosarcoma has a poor prognosis with high recurrence and mortality. Diagnosis is difficult due to its rarity, subtle symptoms, and non-specific imaging. Clinicians should maintain a high index of suspicion to facilitate early diagnosis and referral to dedicated sarcoma/breast units for optimal management of this rare malignancy.
BACKGROUND: Nephron-sparing surgery is standard for localised renal cell carcinoma, while microwave ablation (MWA) is increasingly used in older and comorbid patients. Comparative data on local recurrence between laparos...BACKGROUND: Nephron-sparing surgery is standard for localised renal cell carcinoma, while microwave ablation (MWA) is increasingly used in older and comorbid patients. Comparative data on local recurrence between laparoscopic partial nephrectomy (LPN) and MWA remain inconsistent. We aimed to compare local recurrence rates and identify patient and tumour factors favouring either modality. METHODS: A 5-year retrospective study was conducted at a regional centre in Queensland, Australia. The study included 158 adults with localised renal cancer treated with curative intent using LPN or MWA. It excluded metastatic disease, palliative treatment or alternative focal therapies. Demographics, tumour and renal function data were analysed. Statistical analyses were performed using R version 4.4.1, with significance set at p < 0.05. RESULTS: MWA was associated with significantly higher odds of local recurrence compared with LPN (OR 5.73, 95% CI 1.51-37.5, p = 0.02). A Charlson Comorbidity Index > 5 showed a trend towards higher odds of recurrence (OR 3.26, 95% CI 1.06-12.2, p = 0.05), as did age > 65 years (OR 4.31, 95% CI 1.13-28.2, p = 0.06). Patients undergoing MWA were significantly older, more comorbid and more likely to have tumours < 4 cm. The change in creatinine level was significantly higher post-LPN. Salvage therapy achieved local tumour control in 60% of cases at a mean follow-up of 21.4 months. CONCLUSION: MWA demonstrated higher local recurrence rates than LPN but was predominantly used in older, comorbid patients and provided superior nephron preservation. MWA remains an effective primary and salvage treatment option in appropriately selected patients.
BACKGROUND: Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous neuroendocrine malignancy with a high risk of nodal metastasis. Sentinel lymph node biopsy (SLNB) is used to stage clinically node-negative disease...BACKGROUND: Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous neuroendocrine malignancy with a high risk of nodal metastasis. Sentinel lymph node biopsy (SLNB) is used to stage clinically node-negative disease and to guide adjuvant therapy decisions. This study updates the Westmead Hospital experience with an expanded cohort and extended follow-up. METHODS: Patients with clinically node-negative MCC who underwent SLNB between 1998 and 2024 were identified from an institutional database. Demographic, tumour, treatment and outcome data were reviewed. RESULTS: A total of 75 patients (57 men, 18 women; median age 74 years) underwent SLNB. A total of 28 (37%) had a positive SLNB and 47 (63%) a negative SLNB. Seven patients with a negative SLNB developed nodal recurrence, for a false-negative rate of 20%. Among patients with head and neck primaries, the false-negative rate was 12% (3/31). Overall recurrence occurred in 11 of 47 (23%) SLNB-negative and 11 of 28 (39%) SLNB-positive patients (p = 0.23). Distant recurrence was more frequent after a positive SLNB (18% vs. 6%). Overall survival did not differ significantly by SLNB status (p = 0.11). CONCLUSION: MCC demonstrates a high rate of subclinical nodal metastases, with a SLNB positivity rate of nearly 40% in our series. These findings support the use of SLNB in the management of clinically node-negative MCC to improve staging accuracy, prognostication and guide management decisions, with an acceptable false-negative rate under close surveillance.
BACKGROUND: Metabolic bariatric surgery (MBS) is a safe and effective treatment for severe obesity and type 2 diabetes. However, access to MBS in Australia, remains largely confined to the private healthcare sector. We e...BACKGROUND: Metabolic bariatric surgery (MBS) is a safe and effective treatment for severe obesity and type 2 diabetes. However, access to MBS in Australia, remains largely confined to the private healthcare sector. We examined 2-year safety and efficacy outcomes of MBS performed in adults affected by obesity and diabetes, within a high-volume, public hospital in Queensland, Australia. METHODS: A retrospective review of a prospectively collated database encompassing all patients who underwent MBS at the Royal Brisbane and Women's Hospital's Statewide Bariatric Service between 5 December 2017 and 31 December 2021 was performed. Eligibility for MBS required a BMI ≥ 35 kg/m and diagnosis of type 2 diabetes. Patient demographics, 90-day postoperative complications, and 1- and 2-year weight and diabetes outcomes were collated. RESULTS: A total of 226 patients (61.5% female; mean age 52.5 (SD: 9.2) years; mean BMI 46.0 (6.9) kg/m) underwent MBS. Preoperatively, mean HbA1c was 9.0 (1.5) % and 65% of patients required insulin. Procedures included Roux-en-Y gastric bypass (78.8%), sleeve gastrectomy (15.7%) and one-anastomosis gastric bypass (5.3%). All patients were followed up to 1 year, and 219 patients (96.9%) were followed up to 2 years. Median length of stay was 2 days (range: 2-18). Seven patients (3.1%) developed a clinically significant postoperative complication within 90 days. There was no mortality. Mean percentage total body weight loss was 29.6 (8.2) % and 31 (11.4) % at 1 and 2 years. 120 patients (54.8%) achieved complete diabetes remission at 2 years. CONCLUSION: Public MBS is safe and effective, producing significant and sustained weight loss and improvements in diabetes at 2 years.
BACKGROUND: Gastro-oesophageal reflux disease (GORD) is common, and surgery can benefit patients with refractory symptoms. However, the uptake and effectiveness of surgery vary between patient subgroups. Understanding lo...BACKGROUND: Gastro-oesophageal reflux disease (GORD) is common, and surgery can benefit patients with refractory symptoms. However, the uptake and effectiveness of surgery vary between patient subgroups. Understanding long-term national trends is essential to inform clinical practice and service planning. METHODS: This population-based study analysed age-adjusted national data on anti-reflux procedures, paraoesophageal hiatal hernia (POH) repair, and gastroscopies in Australian adults (≥ 18 years) from 2000 to 2024. Age-standardised and age-sex-specific rates were calculated to examine trends. RESULTS: Rates for POH and reflux surgery increased by 245.6% (p < 0.001) over the study. POH repair accounted for 57.9% of procedures, increasing by 4924.7% (6.1 to 304.3 procedures/million/year, p < 0.001). Fundoplasty without POH repair declined by 65.9% (100.4 to 34.3 procedures/million/year, p < 0.001), but the less common cardiopexy increased by 3395.8% (1.4 to 49.5 procedures/million/year, p < 0.001). CONCLUSION: Over two decades, Australia experienced a substantial shift in the surgical management of GORD, characterised by increasing utilisation of POH repair and a decline in isolated fundoplasty. Females had higher rates than males and increased most markedly in older individuals. These findings outline evolving operative patterns in GORD management and highlight the need for further research into the factors underlying these sex and age-related disparities, which may have important implications for clinical decision-making and patient outcomes.
INTRODUCTION: For many patients, liver transplantation (LT) is not feasible due to a shortfall of suitable organs. In Australia, almost all grafts come from deceased donors, a pool not easily expanded, and many potential...INTRODUCTION: For many patients, liver transplantation (LT) is not feasible due to a shortfall of suitable organs. In Australia, almost all grafts come from deceased donors, a pool not easily expanded, and many potentially useable grafts are declined for viability concerns. Despite this, referral utilisation is incompletely understood. The objective of this paper was to characterise deceased donor liver utilisation and referral patterns at a major Australian LT unit. METHODS: All deceased donor referrals made to the Australian National Liver Transplantation Unit (ANLTU) from 2014 to 2024 were included. The primary endpoint was the utilisation rate of referrals made to the ANLTU. Secondary endpoints included the effect of referring hospital location on utilisation, reason for decline and donor characteristics. RESULTS: A total of 1649 referrals were included. During the study period, out-of-network referral volume increased significantly, from 23 to 77 annually (p = 0.044). Overall, utilisation fell from 61.3% to 43.2% (p = 0.045), due to falling utilisation of out-of-network referrals. In-network donation after neurological determination of death (DNDD) and circulatory determination of death (DCDD) referral utilisation was stable at 65.3% (p = 0.979) and 30.0% (p = 0.621), respectively. In-network referrals were increasingly declined due to an absence of a suitable potential recipient (p = 0.003) and out-of-network due to the graft being unsuitable for the urgently listed patient (p = 0.038). CONCLUSION: Utilisation of in-network referrals has remained unchanged since 2014. Out-of-network referral volume is increasing, with reduced utilisation of grafts amongst this cohort. Techniques to improve organ utilisation will be critical to expand access to LT in Australia.
INTRODUCTION: Recurrent inguinal hernia repair presents unique clinical challenges. While minimally invasive surgery (MIS) is often preferred, open anterior mesh repair is a valid approach particularly when requiring mes...INTRODUCTION: Recurrent inguinal hernia repair presents unique clinical challenges. While minimally invasive surgery (MIS) is often preferred, open anterior mesh repair is a valid approach particularly when requiring mesh, suture, or tack removal. This study evaluates the outcomes of a small incision open anterior mesh repair, including foreign body (FB) removal, in an Australian cohort. METHODS: Retrospective analysis of patients who underwent open anterior mesh repair for a clinically detectable recurrent inguinal hernia at a tertiary centre. Demographics, hernia history, intraoperative findings, anaesthetic technique, complications, and follow-up symptoms were analysed. RESULTS: From 2001 to 2024, 173 patients were included (97.7% male, median age of 66). Swelling (54.9%) was the most common symptoms. 82.7% had a prior open repair, same-day procedures occurred in 40% and 13.3% were treated under local anaesthesia with sedation. FB removal was done in 15.6% of patients. The overall complication rate was 10.4%, wound or spermatic cord haematoma (5.2%) was the most common. At median follow-up of 35.7 months, (range 9.7-163 months), 92.3% were pain-free. Minor discomfort occurred in 7.6%, no patient reported moderate or severe pain and re-recurrence is 5.2%. No major complications occurred during FB removal. Subgroup analysis showed no significant difference in outcomes based on the prior repair approach, FB removal, or nerve management. CONCLUSION: Open anterior mesh repair for recurrent inguinal hernia is safe and effective, even after prior anterior repairs, and enables safe removal of FBs. Maintaining proficiency in open techniques is important given the increasing use of MIS in primary hernia repair.
BACKGROUND: Non-intubated video-assisted thoracoscopic surgery (VATS) with sedation anesthesia (SA) has emerged as an alternative to general anesthesia (GA) with tracheal intubation for pulmonary spontaneous ventilation...BACKGROUND: Non-intubated video-assisted thoracoscopic surgery (VATS) with sedation anesthesia (SA) has emerged as an alternative to general anesthesia (GA) with tracheal intubation for pulmonary spontaneous ventilation anesthesia. Its safety and perioperative efficacy remain incompletely defined. We also considered oncologic quality metrics, including margins and nodal evaluation, when spontaneous ventilation anesthesia was performed for suspected or confirmed malignancy. METHODS: PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) were systematically searched through June 2025. Eligible studies compared SA (nonintubated, spontaneous ventilation) with GA using either double-lumen or single-lumen tubes with bronchial blockers (pooled as "intubated GA"). Primary outcomes were overall procedural time (induction + operation + emergence), postoperative length of stay (LOS), and perioperative complications. Secondary outcomes included operative duration. Random-effects models were applied. RESULTS: Seventy-five studies were screened; five comparative studies (112 SA; 119 GA) met criteria. Overall procedural time favored SA (SMD -0.39, 95% CI -0.68 to -0.09), whereas induction time showed no significant difference (SMD -0.11, 95% CI -0.37 to 0.15). LOS was shorter with SA (SMD -1.41, 93% CI -2.65 to -0.16) but showed high heterogeneity across enhanced recovery adoption and discharge policies. Complication rates were comparable, and operative duration showed a nonsignificant trend favoring SA. Stratification by indication or GA technique was not feasible. CONCLUSIONS: SA is a feasible alternative to intubated GA for VATS spontaneous ventilation anesthesia, potentially reducing procedural time and LOS without raising complication risk. Applicability to U.S. practice requires caution, given oncologic standards and lower adoption. Prospective randomized trials with standardized endpoints remain necessary.
BACKGROUND: Postoperative pancreatic fistula (POPF) complicates 10%-25% of pancreatoduodenectomies (PDs). This study sought to validate the recent Auditing Fistula Risk Score (Auditing-FRS). METHODS: PDs recorded in the...BACKGROUND: Postoperative pancreatic fistula (POPF) complicates 10%-25% of pancreatoduodenectomies (PDs). This study sought to validate the recent Auditing Fistula Risk Score (Auditing-FRS). METHODS: PDs recorded in the 2015-2023 National Surgical Quality Improvement Program (NSQIP) were analyzed. Multivariable logistic regression confirmed independent predictors. Discrimination was quantified using the area under the receiver operating characteristic curve (AUC). Calibration was assessed using the Brier score, and decision-curve analysis (DCA) evaluated clinical utility across overall, open (OPD), laparoscopic (LPD), and robotic (RPD) subgroups. RESULTS: Among 25 250 PDs, POPF occurred in 12.6% of cases. All Auditing-FRS predictors remained independently associated with POPF. The AUC was 0.694 (95% confidence interval [CI] 0.684-0.704) for the overall cohort, with comparable performance across operative subgroups: OPD 0.693 (95% CI 0.683-0.703), LPD 0.708 (95% CI 0.672-0.745), and RPD 0.701 (95% CI 0.657-0.744). Predicted and observed POPF probabilities were closely aligned. DCA demonstrated that within the clinically relevant threshold range of 5%-30%, the Auditing-FRS consistently offered greater net benefit than treating all or no patients. CONCLUSION: The Auditing-FRS demonstrates acceptable discrimination and good calibration in a large NSQIP cohort across open, laparoscopic, and robotic approaches, supporting its use for institutional benchmarking and perioperative risk stratification.
BACKGROUND: Colonic diverticulitis is a common diagnosis at emergency presentation, and traditional management includes admission, bowel rest and intravenous antibiotics. We investigated the management of patients who pr...BACKGROUND: Colonic diverticulitis is a common diagnosis at emergency presentation, and traditional management includes admission, bowel rest and intravenous antibiotics. We investigated the management of patients who presented to two centres over a 2-year period with acute uncomplicated diverticulitis (AUD) in the context of evidence and recent guidelines suggesting that select patients can be managed safely in the outpatient setting and without antibiotics. METHODS: Data was collected for all patients who presented to two metropolitan emergency departments from January 2023 to December 2024 with AUD. Each case was then assessed against predetermined criteria for admission, based on recent guidelines and randomised controlled trials. The primary outcome was use of antibiotics in those eligible for management without them. Secondary outcomes included IV antibiotic use and reasons for admission. RESULTS: A total of 564 patients across the two centres were included. 229 patients were deemed eligible for nonantibiotic therapy +/- discharge. 130 of these patients were admitted; all received antibiotics. Only eight of 229 did not receive antibiotics. Outside of these 130 patients admitted without clear indication, the most common reasons for admission were sepsis, failure of outpatient therapy and age. CONCLUSION: Most eligible patients with AUD still receive antibiotics, in both inpatient and outpatient settings, which highlights a major discrepancy between evidence-based guidelines and real-world practice.
PURPOSE: Sir Charles Gairdner Hospital (SCGH) commenced an observation strategy in patients with a complete clinical response, Watch and Wait (W&W), for rectal adenocarcinoma in 2017 using a rigorous surveillance protoco...PURPOSE: Sir Charles Gairdner Hospital (SCGH) commenced an observation strategy in patients with a complete clinical response, Watch and Wait (W&W), for rectal adenocarcinoma in 2017 using a rigorous surveillance protocol. Our earlier results (2017-2019) have been published. We report updated results and present a revised treatment pathway and surveillance protocol. METHODOLOGY: A retrospective review of a prospectively maintained database and medical records was performed. All patients from 2017 to 2023 referred for long-course chemoradiotherapy (LCCRT) as part of rectal adenocarcinoma treatment with curative intent were included. RESULTS: A total of 142 patients were referred for induction LCCRT for rectal cancer. Consolidation chemotherapy usually followed. Six patients did not complete treatment; 31 had a complete or near-complete clinical response and were enrolled in W&W. Six patients declined surgery and were offered W&W. Of the 31 patients in W&W, 5 patients had suspected local regrowth and underwent surgical resection. Two of five had pCR on histopathology. Regrowth cases were identified within 9 months by flexible sigmoidoscopy and sometimes on imaging (PET or MRI). A total of 95 patients did not have cCR and had surgical resection; of these, 20 had pCR. CONCLUSION: A total of 24% of patients referred for LCCRT at SCGH achieved cCR, and this was sustained in 84%. Sixteen percent of W&W patients had suspected local regrowth. Our surveillance protocol detected regrowth early, and surgical salvage was always possible. Twenty percent of patients undergoing surgery having pCR despite not having cCR highlights the difficulty of avoiding TME in all patients who have a pCR but suggests optimisations of our practice are possible. We propose a reduction in the length and intensity of our current protocol.