INTRODUCTION:Breast spindle cell lesions (BrSCL) are rare pathologies encompassing a wide range of conditions, from benign reactive processes to aggressive malignancies. Their diverse and overlapping clinical, radiological and histological features pose significant diagnostic challenges. This study examines the clinical, radiological and histological characteristics of BrSCL to improve diagnostic accuracy and inform management strategies. METHODS:This retrospective, single-centre cohort study included all cases of BrSCL identified on core biopsy from 2008 to 2020, excluding fibroepithelial lesions and metaplastic cancers. It examined clinical presentations, imaging findings, formal excisional pathology and clinical outcomes. RESULTS:Thirty cases were analysed, with 70% (n = 21) presenting due to breast symptoms and 30% (n = 9) detected through breast screening or incidentally. Eligible cases were histologically subdivided into atypical (ASCL) (n = 10) and bland (BSCL) (n = 20) spindle cell lesion groups. Following formal excision, 80% of ASCLs were malignant (sarcoma: n = 1; malignant phyllodes tumour: n = 3; metaplastic cancer: n = 4), whilst 20% (n = 2) were benign. Eleven BSCLs underwent excisional biopsy, with no malignancy found (benign: n = 10; no lesion: n = 1). Nine patients underwent radiological and clinical surveillance. CONCLUSION:BrSCLs are rare and diagnostically complex entities. Lesions detected on core biopsy with features of ASCL carry a high risk of malignancy and should undergo surgical excision. In contrast, BSCL from core biopsy are frequently benign and those demonstrating low-risk imaging features and benign core biopsy findings may be considered for surveillance. A multidisciplinary approach is essential for optimising outcomes in this challenging and uncommon subset of breast pathology.
BACKGROUND:Heart valve replacement is associated with a high risk of respiratory dysfunction and postoperative pulmonary complications (PPCs). This meta-analysis of randomised controlled trials (RCTs) specifically aims to evaluate the effectiveness of perioperative inspiratory muscle training (IMT) in this patient population. METHODS:A systematic search was conducted on ClinicalTrials.gov, PubMed, ProQuest, and Scopus until October 2025. Data were synthesised using random-effects meta-analysis, with results reported as mean difference (MD), standardised mean difference (SMD), or risk ratio (RR), along with 95% confidence intervals (CI). RESULTS:A total of nine RCTs involving 1531 patients were included. IMT significantly improved primary outcomes: 6-min walk distance (6 MWD) (MD 49.91 m; 95% CI, 22.52-77.30), maximal inspiratory pressure (MIP) (MD 11.66 cm H2O; 95% CI, 3.15-20.16), and reduced the incidence of PPCs (RR 0.71; 95% CI, 0.56-0.90) compared to the control group. However, for secondary outcomes, including ICU and postoperative length of stay (LOS), forced vital capacity (FVC), and forced expiratory volume in 1 s (FEV1), no significant differences were observed. Subgroup analysis indicated greater clinical benefits of IMT in patients undergoing open surgery who received it postoperatively and integrated it into a rehabilitation bundle. CONCLUSIONS:IMT may improve 6 MWD and MIP and reduce the risk of PPCs in patients undergoing valve replacement. These findings suggest that IMT is a promising adjunct to perioperative cardiac rehabilitation (PROSPERO CRD420251172698).
INTRODUCTION:This narrative review covers a century of progress in the diagnosis, prevention, and treatment of pulmonary embolism (PE). DIAGNOSIS:Although the classic clinical presentation of PE was already well described, in the first half of the 20th century additional diagnostic support was limited to signs on a chest radiograph and evidence of right heart strain on ECG. From the 1960's, imaging accuracy improved through the introduction of pulmonary angiography (1963), ventilation perfusion scans (1964), CT (1978), and today's gold standard, CT Pulmonary Angiography (1990's). Echocardiographic signs of right ventricular dysfunction and pulmonary hypertension were described to help determine the physiological severity of PE. PREVENTION:Prophylaxis reduces the risk of venous thromboembolism (VTE) by 55%-70%. Heparin began to be used to prevent and treat PE from the 1930s, replaced by enoxaparin from 1993. In patients not suitable for anticoagulation, vena cava ligation and open clips were replaced by endovascularly-placed filters (now retrievable) from the 1970s. TREATMENT:Despite the first successful pulmonary embolectomy in 1924, subsequent success with massive PE was rare until embolectomy could be performed with the support of cardiopulmonary by-pass in the 1960's. Today, catheter-based thrombolysis or mechanical thrombectomy delivered by interventional radiology are the first choice for haemodynamically compromised patients. Pulmonary Embolism Response Teams (PERT) rapidly assess acute PE presentations to determine the optimal treatment based on patient risk. Enoxaparin is prescribed for lower risk cases, whilst Direct Oral Anticoagulants have largely replaced warfarin as the ambulant oral treatment of choice to prevent recurrent VTE.
BACKGROUND:Bladder cancer is responsible for considerable morbidity and mortality. Patients commonly present with haematuria to primary care for assessment. In Canterbury, New Zealand, the first-line investigations available to primary care were changed in 2018, from urine cytology to CxBladder Triage (CxBT) and upper urinary tract imaging. This retrospective study was performed to evaluate the impact of this change in diagnostics. METHODS:A retrospective audit of routinely collected electronic data from March 2013 to December 2021 from Christchurch Hospital, New Zealand, compared the traditional primary care haematuria pathway with the CxBT haematuria pathway. The primary outcome was waiting time from primary care referral to urological specialist appointment and waiting time to first operative treatment for bladder cancer. Waiting time was further analysed for ethnicity. The secondary outcome was monthly haematuria referrals for urological specialist appointment. RESULTS:There were 4512 haematuria referrals during the study period. Following the introduction of CxBT to the primary care haematuria pathway, waiting time from primary care referral to urological specialist review reduced by 14.8 days and time to surgery by 15.0 days. There was a greater reduction for Māori compared with that of non-Māori patients. The monthly haematuria referrals for urological specialist appointment reduced on average by 6.9 referrals per month. CONCLUSION:CxBT in primary care haematuria pathway reduces waiting time from primary care referral to urological specialist appointment and to first operative treatment for bladder cancer, whilst also reducing monthly referrals for urological specialist appointments and improving equity for Māori.
Acute necrotising pancreatitis with infected pancreatic necrosis has a significant mortality of up to 23.5%, with survival dependent on achieving a complete necrosectomy. In recent years, several minimally invasive techniques have been developed including laparoscopic and endoscopic approaches, which are feasible, well-tolerated and beneficial for the patient when compared with open surgery. Percutaneous drainage with radiologically guided drains has limited efficacy as pancreatic necrosis is mostly solid tissue, but these drains can guide the surgeon to areas of infected necrosis. We present our experience in utilising 10 mL syringes as ports for retroperitoneal access to perform staged pancreatic necrosectomies, allowing the operator to use both the nephroscope and the gastroscope to visually guide the removal of necrotic tissue, the drainage of infected fluid and the placement of drains. This is a cost-effective technique using widely available equipment and can be easily adopted.
BACKGROUND:Socioeconomic disadvantage, body mass index (BMI) and geographic location influence healthcare access and outcomes. This study examined associations between socioeconomic status, rurality and BMI with outcomes following total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a regional public referral centre. METHODS:A retrospective cohort study of all primary THA and TKA admissions between 2017 and 2024 was performed. Variables included socioeconomic indices (SEIFA), rurality (Modified Monash Model classification), age, sex and BMI. The primary outcome was unplanned 90-day readmission. Secondary outcomes were length of stay (LOS) and intensive care unit (ICU) admission. Multivariate regression was performed. LOS was analysed as a continuous variable, and BMI and socioeconomic indices were modelled continuously to assess dose-response relationships. RESULTS:A total of 3364 admissions were analysed (1862 THA; 1502 TKA). Mean age was 66.63 years (THA) and 69.22 years (TKA). Mean BMI was 30.87 and 34.02, respectively. Increasing BMI demonstrated a dose-response association with 90-day readmission, with a stronger effect in THA (OR 1.08, p < 0.01) than TKA (OR 1.03, p = 0.05). Increasing age and BMI were independently associated with longer LOS in both cohorts (all p < 0.01). Socioeconomic disadvantage was associated with longer LOS in THA (p < 0.01) but not TKA. Higher BMI was associated with ICU admission in both cohorts (THA p = 0.01; TKA p = 0.02). CONCLUSION:In this regional arthroplasty cohort, obesity was associated with increased readmission and longer LOS, while socioeconomic disadvantage was associated with longer LOS. Rurality was not associated with LOS or readmission.
BACKGROUND:Negative pressure wound therapy (NPWT) reduces wound complications following oncoplastic breast surgery, yet there is limited evidence supporting its use in mastectomy without reconstruction. This study evaluated the effect of NPWT on post-mastectomy wound complications in a rural Australian centre. METHODS:A single centre retrospective cohort study assessed simple mastectomy outcomes between 2020 and 2025. Wounds were grouped by post-operative dressing type (NPWT vs. no NPWT). The primary outcome was a composite of aspirated seroma, haematoma, wound dehiscence, and surgical site infection (SSI). Secondary outcomes were individual wound complications and intervention-related outcomes. RESULTS:The 131 mastectomy wounds were included (NPWT = 59). There was no significant difference in the composite wound outcome between NPWT and no NPWT (62.71% vs. 47.22%; p = 0.077). NPWT had significantly more aspirated seromas (59.32% vs. 40.28%; p = 0.030) but multivariate analysis did not identify a significant association (Multivariate Exp (β) (95% CI): 2.021 (0.958-4.265); p = 0.065). No significant difference was identified in the other secondary outcomes. Diabetes mellitus was independently associated with the composite wound complication (Multivariate Exp (β) (95% CI): 3.349 (1.242-9.031); p = 0.017) and increasing body mass index was associated with SSI (Multivariate Exp (β) (95% CI): 1.064 (1.012-1.119); p = 0.015). CONCLUSION:NPWT was not associated with reduced wound complications following simple mastectomy. Aspirated seroma was more common for NPWT, but regression analysis found no significant association. A high rate of wound complications poses a significant burden for patients and this regional centre; prospective data is required to determine optimal the way to prevent and manage said complications.
BACKGROUND:Preoperative mental wellbeing is an important determinant of postoperative recovery, yet psychological care is frequently overlooked within multidisciplinary prehabilitation programmes. When included, psychological interventions are fragmented and inconsistently delivered. This study aimed to establish international multidisciplinary consensus on preferred psychological prehabilitation interventions for patients undergoing urogenital, thoracic or gastrointestinal cancer surgery, and to describe current practice. METHODS:A three-round Delphi was conducted between February and September 2025. An international multidisciplinary expert panel rated the perceived effectiveness of each intervention for urogenital, thoracic and gastrointestinal cancer surgery using a 5-point Likert scale. Predefined criteria classified interventions as effective, ineffective, contested or indeterminate. Round 1 also captured current models of psychological prehabilitation delivery. RESULTS:In total, 439 participants completed Round 1, with 191 and 234 completing Rounds 2 and 3, respectively. Nine interventions reached consensus as endorsed across all tumour types, with supportive counselling, personalised coping strategies, cognitive behavioural therapy and mindfulness-based techniques reaching the strongest agreement. Sexual health counselling was endorsed only for urogenital cancers. No interventions reached consensus as ineffective; however, hypnotherapy and eye movement desensitisation and reprocessing were contested in specific cancer groups, whilst metacognitive therapy remained indeterminate. International practice was heterogeneous, with limited routine screening, variable access to psychological services and funding/resource constraints as common barriers. CONCLUSION:This international Delphi study identified a core set of consensus-based psychological prehabilitation interventions for cancer surgery, providing a foundation for clinical implementation. Future research should prioritise hybrid effectiveness-implementation designs, generating data on optimal providers, delivery formats and patient characteristics.
Postoperative pancreatic fistula remains one of the most consequential complications after pancreaticoduodenectomy, particularly when it triggers post-pancreatectomy haemorrhage, sepsis, reoperation and failure to rescue. Current fistula risk models mainly capture local pancreatic factors, but they incompletely reflect systemic vascular frailty and the patient's capacity to tolerate major complications. Abdominal aortic calcification is frequently visible on routine preoperative computed tomography and may provide an opportunistic marker of systemic atherosclerosis, impaired microvascular reserve, sarcopenia, frailty and reduced physiological resilience. Emerging evidence suggests that severe abdominal aortic calcification, particularly when quantified by CT-based scores or volumetric methods, is associated with clinically relevant postoperative pancreatic fistula, major complications and poorer outcomes after pancreatic surgery. In parallel, contemporary data suggest that planned total pancreatectomy, although metabolically demanding, may be feasible in selected high-risk patients when supported by modern diabetes care, pancreatic enzyme replacement and structured follow-up. This narrative review examines whether severe abdominal aortic calcification should be integrated into risk stratification before pancreaticoduodenectomy and whether, in carefully selected patients with very high fistula risk and limited rescue capacity, it may contribute to the discussion between pancreatic reconstruction and planned total pancreatectomy.
Clinical quality registries (CQRs) are central to improving surgical safety and quality by enabling systematic monitoring of outcomes and proactive identification of outliers. Published guidelines provide important advice on methods and activities for CQRs. Guideline flexibility allows for the varied and unique requirements of each CQR, but some aspects around guideline implementation are less certain, particularly for outlier management. In order to describe activities in Australia and the UK, searches were undertaken for published examples of CQR analysis and reporting of outliers and the subsequent management of outlier surgeons. There are many examples of high quality CQRs which actively report relevant performance indicators, with dashboards that show inter-hospital variation including unwarranted (outlier) variance. A small number of reports from the UK provide insight to local responses to suspected outlier status, commonly identifying data errors or systemic failures of local care processes. In Australia, challenges include voluntary participation, incomplete datasets, varied benchmarks, complex governance across public and private systems, and in some the restrictions imposed by qualified privilege. Worryingly, no single body is responsible for the management of the outlier surgeon. Outlier management can build on existing governance practices such as morbidity and mortality meetings and professional development activities. The publication of outlier processes and outcomes provides transparency to participants and closes the feedback loop. Active participation in CQRs and effective local outlier management actions should be encouraged as part of quality improvement, to learn from mistakes, celebrate excellence, and improve patient outcomes.
BACKGROUND:Outcomes in aesthetic breast surgery are dependent on accurate pre-operative breast measurements. The accuracy of large scale 3-dimentional scanners has been reported, the use of handheld scanners has not been described. OBJECTIVES:The authors aimed to determine the trueness of anthropometric measurements of breasts obtained from a handheld 3D scan compared to direct measurements. METHODS:Three raters measured the breasts of 19 women using three anthropometric measurements (direct) measurements: sternal notch to nipple (Sn-N), nipple to inframammary fold (N-IMF), base width (BW). The measurements were taken directly by two raters using a measuring tape, and digitally by one rater using the software on 3D scans acquired with the Artec Leo handheld 3D scanner. Statistical analysis was completed with Bland-Altman plots as well as scatter plots to identify bias between the two methods. RESULTS:The study found that the 3D scanner showed varying levels of bias when compared to direct breast measurements. Sn-N measurement showed smaller differences, while the N-IMF and BW measurements exhibited larger discrepancies. The 3D scanning process was significantly faster, taking only 30 s per scan, compared to roughly 5 min for direct measurements, with an additional 10 min for image processing and digital measurements. CONCLUSION:Three-dimensional scanning is most accurate for Sn-N and is more variable when measuring BW and N-IMF due to obscured landmarks on frontal imaging. The BW and N-IMF measurements also showed the most inter-rater variability. Consistent with previous research 3D scanning has limited trueness when measuring N-IMF as it is a dynamic measurement.
BACKGROUND:Ischaemic optic neuropathy (ION) is the most common cause of perioperative visual loss, with the highest incidence reported after cardiac surgery involving cardiopulmonary bypass (CPB). Despite devastating complications, the overall incidence and risk factors for patients with ION in the setting of cardiac surgery remain contentious. We performed a systematic review and meta-analysis to evaluate the pooled incidence and risk factors for ION after cardiac surgery. METHODS:This review conformed to PRISMA guidelines. PubMed, MEDLINE, Web of Science and Cochrane were searched up to 24 March 2024 for multivariable-adjusted and propensity-matched observational studies assessing the incidence of ION exclusively in patients undergoing cardiac surgery. Odds ratios (ORs) with 95% confidence intervals (CIs) for each risk factor were pooled from the selected studies using a random-effects model. RESULTS:Eleven studies totalling 6 471 577 patients were included. The pooled incidence of ION was approximately 1.50 per 10 000 cardiac surgeries. Significant risk factors for developing ION included coronary artery disease (OR 1.81, 95% CI 1.17-2.79), peripheral vascular disease (OR 1.67, 95% CI 1.10-2.54) and anaemia (OR 1.06, 95% CI 1.00-1.13). Notably, the incidence varied widely between studies, reflecting differences in diagnostic criteria and reporting standards. Newcastle-Ottawa risk of bias assessment found the studies to be of overall moderate methodological quality, with a high risk of bias. CONCLUSION:This study demonstrates a relatively low overall pooled incidence of ION following cardiac surgery, with identifiable risk factors such as pre-existing coronary artery disease, peripheral vascular disease and perioperative anaemia.
BACKGROUND:Iatrogenic vascular injuries (IVIs) are increasingly encountered in clinical practice. Contemporary population-level data describing these injuries in Australia and New Zealand are limited. METHODS:A retrospective observational study was performed using prospectively collected data from the Australasian Vascular Audit. All cases coded as 'trauma (iatrogenic)' requiring operative or endovascular intervention between January 2010 and December 2024 were included. Patient demographics, anatomical sites of injury, operative procedures, urgency, and in-hospital outcomes were analysed. Temporal trends were assessed using negative binomial regression and Cochran-Armitage trend testing. RESULTS:A total of 4559 iatrogenic vascular injuries were identified over the 15-year study period. Median patient age was 66 years, with a slight male predominance (54.0%). The most frequently injured vessels were the common femoral artery (20.6%), external iliac artery (8.6%), and brachial artery (5.6%). Local repair without bypass was the most common operative strategy (43.5%). Overall in-hospital mortality was 6.5%, while major limb amputation was uncommon (0.44%). A significant increase in annual case numbers was observed, corresponding to an approximate 1.5% increase per year (p < 0.001). Common femoral, radial and brachial artery injuries increased significantly over time, whereas carotid artery injuries declined. CONCLUSION:Iatrogenic vascular injuries requiring surgical intervention are increasing in Australia and New Zealand and represent a growing component of acute vascular surgical workload. Despite low amputation rates, associated mortality remains substantial, highlighting the need for ongoing surveillance, preventive strategies, and appropriate vascular workforce planning.
BACKGROUND:Pelvic exenteration is an extensive procedure for advanced or recurrent pelvic malignancies, associated with high morbidity and mortality. Malnutrition is common in this cohort and may affect postoperative outcomes, but the current evidence remains inconsistent. MATERIALS AND METHODS:A systematic review was performed following PRISMA guidelines. Pooled analyses were used to assess the relationship between preoperative nutritional status (serum albumin, BMI, and Subjective Global Assessment (SGA)) and postoperative outcomes, with results shown as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS:Nine retrospective cohorts comprising 1057 patients were included. The median age across studies was 56 years. Primary tumour types included colorectal, gynaecological, bladder, and soft tissue sarcoma. All studies reported complications, most of which were classified using the Clavien-Dindo system. Low BMI was linked to increased postoperative morbidity (OR 1.12, 95% CI 1.02-1.23, *p = 0.02). Hypoalbuminemia (< 35 g/L) (OR 1.38, 95% CI 0.62-3.08, p = 0.44) and SGA-defined malnutrition (OR 1.24, 95% CI 0.24-6.48, p = 0.09) showed non-significant but consistent trends towards higher complications in malnourished patients. Secondary outcomes were statistically significant, with malnourished patients experiencing longer hospital stays (SMD 0.44, 95% CI 0.26-0.62, *p < 0.00001) and more reoperations (OR 1.82, 95% CI 1.08-3.09, *p = 0.03). CONCLUSION:Pre-operative malnutrition is linked to increased morbidity after pelvic exenteration. Low BMI was associated with increased postoperative morbidity following pelvic exenteration, while hypoalbuminaemia and SGA-defined malnutrition demonstrated consistent but non-significant associations. These findings support routine nutritional screening and preoperative optimisation in this high-risk patient group.
