ANZ Journal of Surgery

Background:  Because of specific methodological difficulties in conducting randomized trials, surgical research remains dependent predominantly on observational or non‐randomized studies. Few validated instruments are available to determine the methodological quality of such studies either from the reader's perspective or for the purpose of meta‐analysis. The aim of the present study was to develop and validate such an instrument.

Methods:  After an initial conceptualization phase of a methodological index for non‐randomized studies (MINORS), a list of 12 potential items was sent to 100 experts from different surgical specialities for evaluation and was also assessed by 10 clinical methodologists. Subsequent testing involved the assessment of inter‐reviewer agreement, test‐retest reliability at 2 months, internal consistency reliability and external validity.

Results:  The final version of MINORS contained 12 items, the first eight being specifically for non‐comparative studies. Reliability was established on the basis of good inter‐reviewer agreement, high test‐retest reliability by the κ‐coefficient and good internal consistency by a high Cronbach's α‐coefficient. External validity was established in terms of the ability of MINORS to identify excellent trials.

Conclusions:  MINORS is a valid instrument designed to assess the methodological quality of non‐randomized surgical studies, whether comparative or non‐comparative. The next step will be to determine its external validity when used in a large number of studies and to compare it with other existing instruments.

Background:  A surgical technique for closing skin defects following skin cancer (particularly melanoma) removal is described in the present paper. Its use is illustrated in five patients. The technique has been used in 300 cases over the past 7 years and is suitable for all areas of the body from scalp to foot.

We have coined the term Keystone Design Perforator Island Flap (KDPIF) because of its curvilinear shaped trapezoidal design borrowed from architectural terminology. It is essentially elliptical in shape with its long axis adjacent to the long axis of the defect. The flap is based on randomly located vascular perforators. The wound is closed directly, the mid‐line area is the line of maximum tension and by V‐Y advancement of each end of the flap, the ‘islanded’ flap fills the defect. This allows the secondary defect on the opposite side to be closed, exploiting the mobility of the adjacent surrounding tissue. The importance of blunt dissection is emphasized in raising these perforator island flaps as it preserves the vascular integrity of the musculocutaneous and fasciocutaneous perforators together with venous and neural connections. The keystone flap minimizes the need for skin grafting in the majority of cases and produces excellent aesthetic results. Four types of flaps are described: Type I (direct closure), Type II (with or without grafting), Type III (employs a double island flap technique), and Type IV (involves rotation and advancement with or without grafting). The patient is almost pain free in the postoperative phase. Early mobilization is possible, allowing this technique to be used in short stay patients.

Results:  In a series of 300 patients with flaps situated over the extremities, trunk and facial region, primary wound healing was achieved in 99.6% with one out of 300 developing partial necrosis of the flap.

Conclusions:  The technique described in the present article offers a simple and effective method of wound closure in situations that would otherwise have required complex flap closure or skin grafting particularly for melanoma.

Introduction:  Rapid reviews are being produced with greater frequency by health technology assessment (HTA) agencies in response to increased pressure from end‐user clinicians and policy‐makers for rapid, evidence‐based advice on health‐care technologies. This comparative study examines the differences in methodologies and essential conclusions between rapid and full reviews on the same topic, with the aim of determining the validity of rapid reviews in the clinical context and making recommendations for their future application.

Methods:  Rapid reviews were located by Internet searching of international HTA agency websites, with any ambiguities resolved by further communication with the agencies. Comparator full systematic reviews were identified using the University of York Centre for Reviews and Dissemination HTA database. Data on a number of review components were extracted using standardized data extraction tables, then analysed and reported narratively.

Results:  Axiomatic differences between all the rapid and full reviews were identified; however, the essential conclusions of the rapid and full reviews did not differ extensively across the topics. For each of the four topics examined, it was clear that the scope of the rapid reviews was substantially narrower than that of full reviews. The methodology underpinning the rapid reviews was often inadequately described.

Conclusions:  Rapid reviews do not adhere to any single validated methodology. They frequently provide adequate advice on which to base clinical and policy decisions; however, their scope is limited, which may compromise their appropriateness for evaluating technologies in certain circumstances.

Background:  Therapeutic lymph node dissection for melanoma aims to achieve regional disease control. Radical lymphadenectomy (RLND) can be a difficult procedure associated with significant postoperative morbidity.

The aims of the present study were to review regional disease control and morbidity in a series of lymphadenectomies performed within a specialist unit.

Methods:  The present study involved the analysis of 73 lymphadenectomies in 64 patients, from 1995 to 2001.

Results:  The overall wound complication rate after inguinal lymphadenectomy (71%) was higher than after axillary lymphadenectomy (47%; P = 0.05). After inguinal lymphadenectomy, the wound infection rate was higher (25.0%vs 5.9%; P = 0.03), delayed wound healing was more frequent (25.0%vs 5.9%; P = 0.03), and the mean time that drain tubes remained in situ was longer (12.5 vs 8.2 days; P = 0.05). There were no significant differences in seroma (46%vs 32%) rates. Lymphoedema was more common after inguinal lymphadenectomy (P < 0.02). Multivariate analysis identified inguinal RLND (P = 0.002) and increasing tumour size (P = 0.045) as predictors of wound morbidity. More patients received postoperative radiotherapy after neck RLND compared to inguinal or axilla RLND (P = 0.03). Six (8%) patients developed local recurrence after lymphadenectomy. At a median follow up of 22 months, 34 (53%) patients have died, from disseminated disease.

Conclusions:  Radical lymphadenectomy for melanoma is associated with significant morbidity. Inguinal node dissection has a higher rate of complications than axillary dissection. Low local recurrence rates can be achieved, limiting the potential morbidity of uncontrolled regional metastatic disease.

Background:  Signet ring cell (SRC) carcinoma of the stomach is characterized by its poor prognosis and potential to infiltrate the wall of stomach, although survival studies comparing carcinomas with and without SRC features have yielded inconsistent results. This study compared the clinicopathological features and prognosis of patients with SRC carcinoma with those with non‐signet ring cell carcinoma of the stomach (NSRC).

Methods:  We reviewed the records of 2358 patients diagnosed with gastric carcinoma who were treated surgically between January 1980 and December 1999 at the Department of Surgery, Chonnam National University Hospital. There were 204 patients (8.7%) with SRC carcinoma as compared to 2154 with NSRC.

Results:  Significant differences were noted in the mean patient age, mean tumour size, depth of invasion, prevalence of hepatic and regional lymph node metastases, tumour stage, and curability between the patients with SRC histology and NSRC. There were no statistically significant differences in patient gender, location, or peritoneal dissemination between patients with SRC carcinoma and NSRC. SRC carcinoma of the stomach had a higher prevalence of early gastric carcinoma (46.1%) than NSRC (21.7%). The overall 5‐year survival of all the patients with SRC carcinoma was 60.2% as compared with 48.9% for the patients with NSRC (P < 0.01). Using Cox proportional hazards model, lymph node metastasis and curability were significant factors affecting the outcome. Signet ring cell histology itself was not an independent prognostic factor.

Conclusions:  Patients with SRC histology do not have a worse prognosis than patients with other types of gastric carcinoma.

Background:  Ankle fractures form a high proportion of the total number of fractures treated in New Zealand. International studies show that there are mixed functional outcomes with differing fracture types and subsequently differing lifestyle outcomes.

Methods:  Fracture clinic records and orthopaedic admissions books for Wellington Public Hospital, Capital Coast Health, ­Wellington, were retrospectively reviewed to gain a population of patients who sustained ankle fractures for the period January−­December 1998. These patients were asked to fill in postal questionnaires detailing their current ankle function and lifestyle, two years after fracturing their ankle. The patients’ radiographs were reviewed to classify the types of ankle fractures sustained.

Results:  Of 141 patients that sustained ankle fractures, 74 were followed up 2 years after their ankle fracture. All fracture types averaged Olerud‐Molander ankle scores of 71.1. Weber A fractures averaged ankle function scores of 90, Weber B fractures 80, and Weber C fractures 78. Four patients (5%) achieved ‘poor’ results, 12 (16%) patients achieved a ‘fair’ result, 30 (41%) patients gained a ‘good’ result, 27 (36%) patients attained ‘excellent’ results. Lifestyle outcomes were reflected in the patient’s ankle function outcomes (P < 0.05).

Conclusion:  Patients who sustain ankle fractures can be expected to be still experiencing functional difficulties two years post‐treatment.

Background:  Bile duct injury following cholecystectomy is an iatrogenic catastrophe which is associated with significant perioperative morbidity and mortality, reduced long‐term survival and quality of life, and high rates of subsequent litigation. The aim of this article was to review the management of bile duct injury after cholecystectomy.

Methods:  Medline and PubMed database search was undertaken to identify articles in English from 1970 to 2008 using the key words ‘bile duct injury’, ‘cholecystectomy’ and ‘classification’. Additional papers were identified by a manual search of the references from the key articles. Case report was excluded.

Results:  Early recognition of bile duct injury is of paramount importance. Only 25%–32.4% of injuries are recognized during operation. The majority of patients present initially with non‐specific symptoms. Management depends on the timing of recognition, the type, extent and level of the injury. Immediate recognition and repair are associated with improved outcome, and the minimum standard of care after recognition of bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair. There is a growing body of literature supporting the importance of early referral to a tertiary care hospital which can provide a multidisciplinary approach to treat bile duct injury. Inadequate management may lead to severe complications.

Conclusions:  None of the classification system is universally accepted as each has its own limitation. The optimal management depends on the timing of recognition of injury, the extent of bile duct injury, the patient's condition and the availability of experienced hepatobiliary surgeons.

Background:  Phyllodes tumours (PT) of the breast are fibro‐epithelial neoplasms that are known to recur locally in up to 19% of patients. The failure to achieve adequate surgical margins is an important risk factor for local recurrence. This, however, is a common problem as PT are clinically similar to the more common fibro‐adenoma and are therefore often locally excised without any gross surgical margins. It is still debatable as to whether it is necessary to subject the patient to repeat surgery to obtain pathologically negative margins after a diagnosis of a benign or borderline PT is made. Although the majority of recurrences are histologically similar to the initial tumour, a malignant recurrence is possible. Malignant tumours can metastasize through the haematogenous route and metastases are associated with a poor prognosis as they are poorly responsive to conventional chemotherapy.

Methods:  We retrospectively reviewed 37 women who presented with local recurrence over a 10‐year period to the Singapore General Hospital. Data, including age at the time of diagnosis, clinical presentation, histological features, type of surgery carried out, clinical progression and characteristics of locally recurrent disease, were analysed. Comparisons were made between those with benign, borderline and malignant tumours, as well as between those who developed a malignant recurrence and those who did not.

Results:  The mean age at the time of diagnosis was 39.6 ± 7.4 years and the mean tumour size was 6.0 ± 5.1 cm. A total of 22 patients were classified as having benign tumour, 9 as having borderline tumour and 6 as having malignant tumour. Tumour grade did not influence the tumour size, the adequacy of surgical margins or the time interval to local recurrence or the number of recurrences. Local recurrence occurred after a median interval of 20 months. Although malignant tumours tended to recur earlier, this was not found to be statistically significant. The majority of recurrent tumours were histologically similar to the initial tumour; however, seven patients (19%) developed a malignant recurrence from an initially benign or borderline tumour. Although these tumours were larger, recurred more frequently and within a shorter interval, no significant predictive factor was found on multivariate analysis. Distant metastasis developed only in patients with malignant tumours and accounted for all three mortalities in the study.

Conclusions:  It may be acceptable to use an expectant management towards benign and borderline tumours that are excised without adequate surgical margins. However, surgery for locally recurrent tumours, as well as malignant tumours, should aim to achieve adequate surgical margins to reduce the risk of local recurrence, particularly that of a malignant recurrence.