SAINTS IN SURGERY

There are nearly 300 saints whose names are associated with diseases or the cure of the sick and this relationship has come about either by some miracle attributed to them or by some aspect of their martyrdom. Some diseases have a number of saints as patrons and some saints have many different patronages. A selection has been made of some that have an association with surgical conditions.     

UNPLANNED ADMISSIONS IN DAY‐CASE SURGERY AS A CLINICAL INDICATOR FOR QUALITY ASSURANCE

Background : Day surgery is a modern, effective and economical way to treat patients while maintaining the same level of quality of patient care. Quality improvement in day surgery units, however, continues to be an issue due to high rates of unplanned admissions. The aim of the present retrospective study was to investigate reasons for and methods of preventing unplanned postoperative admissions in a day surgical unit over a 12‐month period in respect to different surgical specialties. Methods : The study was based on an audit from the Endoscopy and Day Surgery Unit (EDSU) at Launceston General Hospital, which provides health care to a population of more than 120 000. Results : For the accounted period 920 outpatients had elective day surgical procedures. Overall the unplanned admission rate was 4.7%, and surgical, anaesthetic and social reasons accounted for 58.2, 37.2 and 4.6% of the unplanned admissions, respectively. The highest rate of unplanned admissions was for plastic and reconstructive surgery (12.8%) and orthopaedic surgery (7.5%) despite the relatively small number of patients who underwent such procedures in the day surgery unit. The results also showed a correlation between age group, pre‐operative medical status of the patients found suitable for the day surgical procedure and unplanned admissions. Conclusions : Strategies to reduce the unplanned admission rate which include patient selection and pre‐operative assessment, patient waiting time and education, pre‐operative anaesthesia, follow‐up with nursing care and postoperative analgesia are discussed.     

IN‐HOSPITAL MORTALITY AND ASSOCIATED COMPLICATIONS AFTER BOWEL SURGERY IN VICTORIAN PUBLIC HOSPITALS

Background : The purpose of the present paper was to determine the mortality rate and associated complications after large bowel resection and anastomosis in Victorian public hospitals. Methods : A retrospective analysis of data from the Victorian Inpatient Minimum Database (VIMD) was undertaken. The data were collected from all Victorian public hospitals performing hemicolectomy and anterior resection (resection of the rectum with anastomosis) from 1987/88 to 1995/96. Results : A total of 11 036 patients underwent hemicolectomy or anterior resection in the time period studied, there being a 7% increase in the rate of operations performed over the 9 years. Two‐thirds of these operations were for carcinoma of the large bowel. The anastomotic leak rate of 4.5% fell slightly but the in‐hospital mortality rate of 6.5% did not change over the study period. The total morbidity recorded (mainly major complications) was 24.6%. The patients most at risk of death were the elderly with pre‐existing cardiac or respiratory disease undergoing an emergency operation. Conclusions : Notwithstanding some inaccuracies of coding and reporting, the morbidity and mortality for surgery of the large intestine remains high, largely due to the comorbidities of the patients, although certain technical complications such as leakage of an anastomosis after anterior resection are still associated with a significantly increased risk of death. Consideration should be given to the routine use of high‐dependency nursing units for these high‐risk patients after major colorectal surgery, and support from physicians to reduce morbidity and mortality from associated medical conditions worsened by surgery.     

THYROID SURGERY AND VOICE‐RELATED OUTCOMES

Background : Vocal dysfunction in patients with thyroid pathology has been poorly documented, and dysfunction after thyroid surgery is generally reported in terms of recurrent laryngeal nerve or external laryngeal nerve palsy. But voice dysfunction is more complex than simply nerve integrity. The present study reports the incidence of dysphonia in patients presenting for thyroid surgery, and relates postoperative changes in vocal function to recurrent and external laryngeal nerve function, and the surgical handling of the strap muscles. Methods : Fifty patients were assessed by Visipitch before and after thyroidectomy. Following surgery the patients filled out a questionnaire. Results : Overall 26 of 44 patients had no subjective postoperative voice change, while 10 reported subjective deterioration and eight reported subjective improvement in voicing. Postoperative objective assessment of these patients found that 17 were the same, eight refused to come for testing because they felt their voice had not changed, 13 were better and six were worse. Following surgery two patients (4.5%) had temporary recurrent laryngeal nerve palsies (2.5% of nerves at risk), and four patients (10%) suffered external laryngeal nerve palsies. Division of strap muscles was not detrimental to voicing. Six patients were lost to follow‐up. Fifteen patients (34%) presented with vocal abnormalities, six (40%) of whom improved postoperatively. Conclusions : Patients may have voicing abnormalities before thyroid surgery is performed. Surgery may improve or worsen the voice irrespective of the pre‐operative voice status.     

LAPAROSCOPIC ANTI‐REFLUX SURGERY IN NEW ZEALAND: A TREND TOWARDS PARTIAL FUNDOPLICATION

Background : The advent of laparoscopic anti‐reflux surgery has generated considerable debate regarding the best technique. The present study was undertaken to determine the trends and current technique in laparoscopic anti‐reflux surgery in New Zealand. Methods : A confidential nationwide postal survey was sent to all general surgeons in New Zealand; it was repeated after a month, and followed up with a telephone prompt, if necessary. Results : Of the 146 questionnaires sent out, 126 were returned (response rate: 86%), and 104 were excluded (no anti‐reflux surgery performed (n = 96); surgeon retired (n = 5); paediatric surgeon (n = 3)). The number of operations performed by the 22 (16%) adult general surgeons who had performed laparoscopic anti‐reflux surgery increased 4.6 times from 1991 to 1997 (474 open and 1218 laparoscopic operations). The median number of cases per surgeon was 30 (range: 5–300). In 1997 there were 208 (60%) total fundoplications (TF) and 135 (40%) partial fundoplications (PF) performed. Variations in the technique of TF included the Nissen–DeMeester (10 surgeons), the Nissen–Rosetti (nine surgeons), division of short gastric vessels (10 surgeons), and routine cruroplasty (14 surgeons). A PF had never been perfomed by six surgeons, was preferred by six surgeons, and four other surgeons were performing it more often. Variations in the technique of PF included posterior (12 surgeons) and anterior (four surgeons) forms. Conclusion : There is significant variation in the technique of laparoscopic anti‐reflux surgery in New Zealand. A TF is preferred by 16 surgeons, but there appears to be a trend towards PF among the more experienced surgeons.     

SINGLE‐ VERSUS MULTIPLE‐DOSE ANTIBIOTICS PROPHYLAXIS FOR CARDIAC SURGERY

Background : This study was carried out to determine if single‐dose antimicrobial prophylaxis is sufficient for cardiac surgery. Methods : The study was a prospective non‐randomized trial of 353 consecutive patients undergoing cardiac surgery. Group A (n = 151) received 48 h of prophylaxis and Group B (n = 202) received a single dose. Cephazolin was used in all patients except those at high risk from methicillin‐resistant Staphylococcus aureus (MRSA) who received teicoplanin and timentin. Results : There was an overall in‐hospital infection rate of 2.8%. There was no significant difference in rate or type of infection between the two groups. Conclusions : An in‐hospital infection rate of 2.8% compares favourably with other reported series. Single‐dose antimicrobial prophylaxis is as effective as a 48‐h regimen. Targeting high‐risk groups is effective.     

WHAT’S NEW IN PLASTIC SURGERY?

A review is made of the latest developments in the field of plastic and reconstructive surgery. The subspecialty divisions are more pronounced in the modern era, but are still linked by a unified approach to soft-tissue management. Although cornerstone areas such as microsurgery have seen refinement, other fields, including aesthetic surgery, have been totally redefined by laser technology and the spread of endoscopic techniques.