OBJECTIVE:Reflux within the superficial microvenous network may play a critical role in the development of skin changes associated with chronic venous insufficiency. This study aimed to extend previous ex vivo observations to determine the in vivo utility of near infrared fluorescence (NIRF) imaging to assess superficial venous reflux in the leg. METHODS:A total of 28 limbs were examined in 17 participants. These included limbs with (CEAP C2, n = 6; C3, n = 1; and C4, n = 15) and without (CEAP C0, n = 6) venous disease. Indocyanine green (5 mL at 0.1 mg/mL) was infused via an (antegrade) cannula in the distal great saphenous vein and the medial leg imaged using NIRF. Venous reflux was assessed using the Valsalva maneuver, with or without superficial outflow obstruction (thigh cuff inflated to 50 mmHg). RESULTS:Consistent with our previous ex vivo study, NIRF imaging visualized a wide range of different microvenous reflux patterns in vivo. These included focal and diffuse regions of fluorescence within the skin, the extent of which appeared to be associated with venous disease (CEAP C classification) severity. The observed reflux patterns also appeared to be functional correlates of perforator vein or saphenofemoral junctional incompetence. CONCLUSIONS:This preliminary in vivo study provides proof-of-principle observations suggesting a potential novel method for investigating microvenous reflux in superficial venous disease. CLINICAL RELEVANCE:This study reports the first in vivo use of near-infrared fluorescence (NIRF) imaging with indocyanine green to assess superficial microvenous reflux within intact limbs. This preliminary data suggests that the extent and distribution of skin fluorescence may be associated with venous disease severity (CEAP Clinical classification). It also provides potential mechanistic insight, identifying reflux patterns that appear to be functional correlates of venous incompetence. This study suggests that NIRF imaging could provide a novel tool for investigating microvenous contributions to chronic venous disease and its skin manifestations.

Background:Enhanced recovery after surgery (ERAS) significantly improves outcomes for colorectal surgery, but in publicly funded health services with resource constraints, some targets can be difficult to fully implement. eHealth interventions are increasingly used in surgery to improve outcomes. In 2020, we developed eHealth content to optimise prehabilitation, the delivery of an ERAS program, and postoperative care in a tertiary New Zealand hospital. Our objective was to summarise the clinical outcomes of implementing a patient-orientated eHealth intervention for patients undergoing elective colorectal surgery for neoplasia. Methods:We conducted a retrospective analysis of clinical outcomes with propensity score matching for patients undergoing elective colorectal resection for neoplastic disease between January 2020 and May 2024. Those using eHealth were compared to patients receiving standard care. Demographic and clinical data were extracted from the Otago Clinical Audit (OCA) database and from the eHealth platform. Complications, length of hospital stay (LOS), and readmission were compared using intention-to-treat (ITT) and per-protocol (PP) analyses. Results:We identified 333 patients; 102 using eHealth and 231 receiving standard care. For matched ITT analysis, 102 patients from the standard care group were included. The eHealth group had a significantly shorter LOS [median of 5 vs. 6 days; relative risk (RR) =0.79; 95% confidence interval (CI): 0.71, 0.88; P<0.001] and fewer total complications [27 vs. 51; odds ratio (OR) =0.60; 95% CI: 0.30, 1.22; P=0.03]. Readmissions were not significantly different between groups. The eHealth platform was well-liked, with 72% of interactions rated as "very helpful". Conclusions:Patient support through eHealth, with a focus on prehabilitation as well as postoperative recovery, can be used to effectively supplement ERAS pathways and improve clinical outcomes.

BACKGROUND:To assess the clinical and financial impact of metachronous colorectal neoplasia (MCRN) requiring surgery after cessation of colonoscopic surveillance at age 75. METHODS:The Otago Clinical Audit database was interrogated to identify all colorectal neoplasia (CRN) resections between January 2020 and November 2022 and additional patients undergoing surgery for MCRN aged ≥ 75 (MCRN ≥ 75) between 2010 and 2020. The morbidity, hospital stay, and costs of surgery for MCRN ≥ 75 cases were compared to first colorectal neoplasia (FCRN) cases ≥ 75 and to all other colorectal resections, with and without propensity matching. RESULTS:MCRN was identified in 3.1% of patients < 75 and 13.1% of patients ≥ 75. Identifying a further 41 patients with surgery for MCRN ≥ 75 after 2010 resulted in 55 patients with MCRN aged ≥ 75, 93 with FCRN aged ≥ 75, and 130 with CRN aged < 75. The median(IQR) age for MCRN ≥ 75 was 81 (78-86). Surgery for MCRN ≥ 75 compared to FCRN ≥ 75 resulted in complication rates of 70.9% and 50.5% (p = 0.024), hospital stay nine versus seven days (p = 0.012), readmissions 20% versus 6.5% (p = 0.026) and cost of NZD 31 021 versus 24 157 (p = 0.028). When compared to all other resections, and adjusting for different approaches to rectal cancer in elderly patients, these differences all increased. The estimated annual hospital cost for MCRN ≥ 75 surgery was NZD 317 777. CONCLUSION:MCRN accounted for 13.1% of operations in patients aged ≥ 75. This resulted in more morbidity and cost than surgery for FCRN ≥ 75. Stopping surveillance of those with previous surgery for CRN at 75 years of age results in significant institutional cost and patient morbidity.

BackgroundLow cardiorespiratory fitness predicts worse postoperative outcomes, exacerbated by age and frailty. Preoperative High-Intensity Interval Training (HIIT) improves cardiorespiratory fitness and postoperative outcomes but is challenging to implement in frailty due to perceived risks.PurposeThe aim of this case report was to demonstrate feasibility of HIIT in a patient with frailty and multimorbidity.Case presentationAn 83-year-old frail male with atrial fibrillation and limited mobility presenting with locally advanced rectal cancer was assessed as unfit for major surgery unless his cardiorespiratory fitness improved. Initial cardiopulmonary exercise testing demonstrated low cardiorespiratory fitness (peak oxygen consumption ($\dot V$V(center dot)O2peak) of 11.45 mLmin-1kg-1). He subsequently underwent 15 supervised HIIT sessions targeting a Rating of Perceived Exertion >= 15.OutcomesThe patient demonstrated initial substantial improvements in his physical condition, increasing maximal work rate from 27.5 W to 55 W. However, there was no additional progress following session eight. At his post-exercise CPET he rapidly fatigued, resulting in a $\dot V$V(center dot)O2peak of 7.4 mLmin-1kg-1. Clinical investigations revealed a worsening anemia with a hemoglobin of 92 g/L caused by an undiagnosed synchronous cecal tumor which was corrected preoperatively. Postoperatively, the patient recovered without complications and was successfully discharged home.ConclusionPersonalized HIIT improved exercise duration and work rate and was associated with positive postoperative outcomes in this patient with frailty and multimorbidity. A unique feature of this case was the unexpected loss of training progress and $\dot V$V(center dot)O2peak deterioration post-HIIT, which prompted further clinical investigations. These identified a worsening anemia and resulted in important changes in both the preoperative and intraoperative treatment.

Hartmann’s procedure (sigmoid resection with end colostomy) is a commonly performed emergency procedure for diseases of the sigmoid colon. To determine the proportion of patients undergoing Hartmann’s reversal (restoration of GI continuity) following Hartmann’s procedure, the clinical and demographic factors associated with reversal, and the reasons for non-reversal. This is a single center, retrospective audit of patients undergoing Hartmann’s procedure between June 2011 and May 2020. Age, sex, American Society of Anesthesiologists classification (ASA), indication for Hartmann’s, surgical approach, specialty of responsible surgeon (General or Colorectal), 30-day reoperation, requirement for radiologically-guided drain, and reason for non-reversal were recorded. The association between these factors and reversal was determined with Fischer’s exact test and logistic regression. Cumulative reversal proportions were calculated with the Kaplan–Meier method. Data was obtained for 114/117 patients, of whom 31

aim: Ruptured abdominal aortic aneurysm (rAAA) is associated with a high mortality rate which, is especially significant in rural and provincial regions. In Aotearoa New Zealand, Māori experience higher rates of AAA and worse overall medium-term survival following AAA repair. This study aimed to understand the prevalence of incidental AAA on routine abdominal computed tomography (CT) scans over 12 months. method: A retrospective review of all abdominal CT scans performed on patients ≥50 years at Gisborne Hospital between 1 December 2018–1 December 2019 was performed. results: A total of 811 scans were reviewed, with 42 incidental AAA detected (5.2%). The majority of incidental AAA were in males aged ≥65 (65.8%), with a higher prevalence for Māori compared to New Zealand European (NZE) (16.2% vs 8.1%, p=0.052). This pattern was also seen in females, aged ≥65 (10.9% in Māori vs 3.8% in NZE, p=0.047). conclusion: The detection of AAA on routine abdominal CT scans appears to be a useful adjunct in lieu of targeted AAA screening in our region. A high prevalence of incidental AAA (5.2%) over 12 months, with a significantly higher prevalence noted in Māori males and females ≥65 years (16.2% and 10.9%), was observed.

INTRODUCTION:Compression stocking therapy is the gold standard of treatment for conditions associated with lower limb venous dysfunction. The benefits in symptom relief and preventing disease progression are well documented. Despite this, adherence to compression stocking therapy is poor. This project aimed to identify factors affecting compression stocking adherence in Aotearoa New Zealand through qualitative evaluation of interviews of patients with chronic venous insufficiency. METHODS:In this mixed-methods study, 25 participants were recruited, and semi-structured interviews were carried out until thematic saturation was reached. All participants also took part in surveys recording characteristics and Quality of Life questionnaires. Common interview themes were summarized and quality of life scores were compared between respondents. FINDINGS:Interview respondents were a median of 64 years old, and were prescribed compression therapy a median of 8 years prior. The cohort spent a median of 8 h a day standing. Qualitative interviews identified three main themes influencing compression stocking use: physical factors, psychological factors and external factors. Subthemes included the influence of age and sex on participant perceptions of the stockings' appearance, and how comorbidities contribute to donning difficulty. CONCLUSION:Understanding factors influencing patient adherence can enable clinicians to provide a multidimensional approach, mitigating barriers and emphasizing facilitators for the individual patient to improve adherence.

IMPORTANCE Preoperative high-intensity interval training (HIIT) is associated with improved cardiorespiratory fitness (CRF) and may improve surgical outcomes. OBJECTIVE To summarize data from studies comparing the association of preoperative HIIT vs standard hospital care with preoperative CRF and postoperative outcomes. DATA SOURCES Data sources included Medline, Embase, Cochrane Central Register of Controlled Trials Library, and Scopus databases with no language constraints, including abstracts and articles published before May 2023. STUDY SELECTION The databases were searched for randomized clinical trials and prospective cohort studies with HIIT protocols in adult patients undergoing major surgery. Thirty-four of 589 screened studiesmet initial selection criteria. DATA EXTRACTION AND SYNTHESIS Ameta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data were extracted by multiple independent observers and pooled in a random-effects model. MAIN OUTCOMES AND MEASURES The primary outcome was change in CRF, as measured by either peak oxygen consumption (V(over dot)O-2 peak) or 6-MinuteWalk Test (6MWT) distance. Secondary outcomes included postoperative complications; hospital length of stay (LOS); and changes in quality of life, anaerobic threshold, and peak power output. RESULTS Twelve eligible studies including 832 patients were identified. Pooled results indicated several positive associations for HIIT when compared with standard care either on CRF (V(over dot)O-2 peak, 6MWT, anaerobic threshold, or peak power output) or postoperative outcomes (complications, LOS, quality of life), although there was significant heterogeneity in study results. In 8 studies including 627 patients, there was moderate-quality evidence of significant improvement in V. O2 peak (cumulative mean difference, 2.59 mL/kg/min; 95% CI, 1.52-3.65 mL/kg/min; P <.001). In 8 studies including 770 patients, there was moderate-quality evidence of a significant reduction in complications (odds ratio, 0.44; 95% CI, 0.32-0.60; P <.001). There was no evidence that HIIT differed from standard care in hospital LOS (cumulative mean difference, -3.06 days; 95% CI, -6.41 to 0.29 days; P =.07). The analysis showed a high degree of heterogeneity in study outcomes and an overall low risk of bias. CONCLUSIONS AND RELEVANCE The results of this meta-analysis suggest that preoperative HIIT may be beneficial for surgical populations through the improvement of exercise capacity and reduced postoperative complications. These findings support including HIIT in prehabilitation programs before major surgery. The high degree of heterogeneity in both exercise protocols and study results supports the need for further prospective, well-designed studies.

BACKGROUND:Transanal endoscopic microsurgery (TEM) is an established technique for the resection of rectal adenomas and selected malignant tumours. It avoids the morbidity of radical resection for tumours not amenable to endoscopic resection. An important marker of quality is the local recurrence rate. The primary objective was to determine local recurrence rates for benign and malignant rectal tumours. METHODS:We identified index TEM excisions of rectal adenomas and adenocarcinomas in patients age 18 and over at Dunedin Hospital, New Zealand, between 2000 and 2020, from a prospective database. Surveillance data were collected via chart review. The primary outcome was recurrence rate for adenomas and adenocarcinomas. Secondary outcomes included time to recurrence, association of recurrence with recognized risk factors, and adverse event rates. RESULTS:We identified 100 patients for analysis. Of 75 benign cases, 11 (14.7%) developed local recurrence, with 63.6% identified within 1 year. Of the 25 malignant cases (19 T1, 5 T2, 1 T3), 9 (36%) developed recurrence, with 77.8% identified within 2 years. Adverse events occurred in 26% of patients, with no reoperations or deaths. CONCLUSION:Our adenoma recurrence rate was at the higher end of the reported range of 2.4-16%. Minor complications were common, but not major morbidity. The propensity for rectal tumours to recur commonly and early reinforces the importance of regular standardized endoscopic surveillance.

Background Supracondylar humeral fractures (SCHF) are a common cause of orthopedic morbidity in pediatric populations across the world. The treatment of this fracture is likely one of the first procedures involving x-ray–guided wire insertion that trainee orthopedic surgeons will encounter in their career. Traditional surgical training methods of “see one, do one, teach one” are reliant on the presence of real-world cases and must be conducted within an operative environment. We have developed an augmented reality simulator that allows trainees to practice this procedure in a radiation-free environment at no extra risk to patients. Objective This study aims to examine whether training on a simulator in addition to traditional surgical training improves the in-theater performance of trainees. Methods This multicenter, interventional cohort study will involve orthopedic trainees from New Zealand in their first year of advanced training between 2019 and 2023. Advanced trainees with no simulator exposure who were in their first year in 2019-2021 will form the comparator cohort, while those in the years 2022-2023 will receive additional regular simulator training as the intervention cohort. The comparator cohort’s performance in pediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a 6-month period. Data on the performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to determine whether additional training with an augmented reality training shows improved real-world surgical outcomes compared to traditional surgical training. Results As of February 2022, a total of 8 retrospective comparator trainees have been recruited by email. The study is financially supported through an external grant from the Wishbone Orthopaedic Research Foundation of New Zealand (September 2021) and an internal research grant from the University of Otago (July 2021). Conclusions This protocol has been approved by the University of Otago Health Ethics committee (reference HD21/087), and the study is due for completion in 2024. This protocol may assist other researchers conducting similar studies in the field. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12623000816651; https://tinyurl.com/mtdkecwb International Registered Report Identifier (IRRID) DERR1-10.2196/38282

The increasing number of prehabilitation randomised controlled trials (RCTs) for cancer surgery patients emphasises the need for high-quality evidence. Therefore, this study aims to assess reporting quality and risk of bias in prehabilitation RCTs. A comprehensive search was conducted across multiple databases, including MEDLINE, Embase, The Cochrane Library, CINAHL, AMED, and PsycINFO to identify RCTs evaluating the effectiveness of exercise, nutrition, and/or psychological interventions on postoperative complications and/or length of hospital stay in adult patients undergoing cancer surgery. Trials were assessed for risk of bias, reporting quality and other relevant metrics. Of the 74 included RCTs, 55 had a high risk of bias. Deviations from intended interventions (55%) and missing outcome data (32%) were the most frequently identified items with a high risk of bias. Only nine of 13 TIDieR items were adequately reported, and just nine RCTs provided information on intervention modifications. 55% of trials provided a protocol, with 68% altering primary and/or secondary aims. Prehabilitation RCTs exhibit poor reporting quality and high risk of bias. More transparent trials are needed to assess the effectiveness of prehabilitation programs. Identifying barriers to improving the quality would assist in enhancing the reliability of future trials.

Fibroblast-activation protein is a promising target for oncologic molecular imaging. Studies show that fibroblast activation protein inhibitor (FAPI) radiotracers are accurate diagnostics with favorable tumor-to background ratios across various cancers. Therefore, we performed a systematic review and metaanalysis to assess the diagnostic performance of FAPI PET/CT in comparison with [18F]FDG PET/CT, the most widely used radiotracer in oncology. Methods: We conducted a systematic search in MEDLINE, Embase, Scopus, PubMed, Cochrane Central Register of Controlled Trials, relevant trial registries, and bibliographies. The search consisted of combinations of terms for 3 topics: neoplasia, PET/CT, and FAPI. Two authors independently screened retrieved articles using predefined inclusion and exclusion criteria and extracted the data. Study quality was assessed using the criteria of QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2). For each study, the sensitivity, specificity, and 95% CIs were calculated to determine diagnostic accuracy for primary, nodal, and metastatic lesions. A random-effects metaanalysis was used for pooling the data, and heterogeneity was assessed (I2 index). Results: Thirtynine studies (1,259 patients) investigating the use of FAPI PET/CT were included. On a patient-based analysis, pooled sensitivity was 0.99 (95% CI, 0.97-1.0) for the detection of primary lesions. Pooled sensitivity for nodal and distant metastases was 0.91 (95% CI, 0.81-0.96) and 0.99 (95% CI, 0.96-1.0), respectively. On a paired analysis between FAPI and [18F]FDG PET/CT, FAPI had a higher sensitivity in the detection of primary, nodal, and metastatic lesions (all P, 0.001). The differences in sensitivities between FAPI and [18F]FDG were statistically significant. In terms of heterogeneity, analyses on primary lesions were moderately affected, distant metastatic lesions were highly affected, and the nodal metastatic analyses had negligible heterogeneity. Conclusion: The diagnostic performance of FAPI PET/CT is superior to that of [18F]FDG in the detection of primary, nodal, and distant metastases. However, further studies are needed to better evaluate its utility and indication in specific cancer types and clinical settings.

Importance There are discrepancies in guidelines on preparation for colorectal surgery. While intravenous (IV) antibiotics are usually administered, the use of mechanical bowel preparation (MBP), enemas, and/or oral antibiotics (OA) is controversial. Objective To summarize all data from randomized clinical trials (RCTs) that met selection criteria using network meta-analysis (NMA) to determine the ranking of different bowel preparation treatment strategies for their associations with postoperative outcomes. Data Sources Data sources included MEDLINE, Embase, Cochrane, and Scopus databases with no language constraints, including abstracts and articles published prior to 2021. Study Selection Randomized studies of adults undergoing elective colorectal surgery with appropriate aerobic and anaerobic antibiotic cover that reported on incisional surgical site infection (SSI) or anastomotic leak were selected for inclusion in the analysis. These were selected by multiple reviewers and adjudicated by a separate lead investigator. A total of 167 of 6833 screened studies met initial selection criteria. Data Extraction and Synthesis NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data were extracted by multiple independent observers and pooled in a random-effects model. Main Outcomes and Measures Primary outcomes were incisional SSI and anastomotic leak. Secondary outcomes included other infections, mortality, ileus, and adverse effects of preparation. Results A total of 35 RCTs that included 8377 patients were identified. Treatments compared IV antibiotics (2762 patients [33%]), IV antibiotics with enema (222 patients [3%]), IV antibiotics with OA with or without enema (628 patients [7%]), MBP with IV antibiotics (2712 patients [32%]), MBP with IV antibiotics with OA (with good IV antibiotic cover in 925 patients [11%] and with good overall antibiotic cover in 375 patients [4%]), MBP with OA (267 patients [3%]), and OA (486 patients [6%]). The likelihood of incisional SSI was significantly lower for those receiving IV antibiotics with OA with or without enema (rank 1) and MBP with adequate IV antibiotics with OA (rank 2) compared with all other treatment options. The addition of OA to IV antibiotics, both with and without MBP, was associated with a reduction in incisional SSI by greater than 50%. There were minimal differences between treatments in anastomotic leak and in any of the secondary outcomes. Conclusions and Relevance This NMA demonstrated that the addition of OA to IV antibiotics were associated with a reduction in incisional SSI by greater than 50%. The results support the addition of OA to IV antibiotics to reduce incisional SSI among patients undergoing elective colorectal surgery.

AIM:There are discrepancies in the guidelines on preparation for colorectal surgery. While intravenous antibiotics (IV) are usually administered, the use of mechanical bowel preparation (MBP) and/or oral antibiotics (OA) is controversial. A recent network meta-analysis (NMA) demonstrated that the addition of OA reduced incisional surgical site infections (iSSIs) by more than 50%. We aimed to perform a NMA including only the highest quality randomized clinical trials (RCTs) in order to determine the ranking of different treatment strategies and assess these RCTs for methodological problems that may affect the conclusions of the NMAs. METHOD:A NMA was performed according to PRISMA guidelines. RCTs of adult patients undergoing elective colorectal surgery with appropriate antibiotic cover and with at least 250 participants recruited, clear definition of endpoints and duration of follow-up extending beyond discharge from hospital were included. The search included Medline, Embase, Cochrane and SCOPUS databases. Primary outcomes were iSSI and anastomotic leak (AL). Statistical analysis was performed in Stata v.15.1 using frequentist routines. RESULTS:Ten RCTs including 5107 patients were identified. Treatments compared IV (2218 patients), IV + OA (460 patients), MBP + IV (1405 patients), MBP + IV + OA (538 patients) and OA (486 patients). The likelihood of iSSI was significantly lower for IV + OA (rank 1) and MBP + IVA + OA (rank 2), reducing iSSIs by more than 50%. There were no differences between treatments for AL. Methodological issues included differences in definition, assessment and frequency of primary endpoint infections and the limited number of participants included in some treatment options. CONCLUSION:While this NMA supports the addition of OA to IV to reduce iSSI it also highlights unanswered questions and the need for well-designed pragmatic RCTs.

Ultrasound measurements of the aorta are typically taken in the axial plane, with the transducer perpendicular to the aorta, and diameter measurements are obtained by placing the callipers from the anterior to the posterior wall and the transverse right to the left side of the aorta. While the ‘conventional’ anteroposterior walls in both sagittal and transverse plains may be suitable for aneurysms with less complicated geometry, there is controversy regarding the suitability of this approach for complicated, particularly tortuous aneurysms, as they may offer a more challenging situation. Previous work undertaken within our research group found that when training inexperienced users of ultrasound, they demonstrated more optimal calliper placement to the abdominal aorta when approached from a decubitus window to obtain a coronal image compared to the traditional ultrasound approach.

Objectives To determine the association between suprarenal aortic diameters and complications that may be attributed to a dilating phenotype following endovascular abdominal aortic aneurysm repair. Design This study is a retrospective review. Methods We measured the abdominal aortas of 147 consecutive patients with a mean age of 78.5 (range 60-93) years, who had a mean Endovascular aneurysm repair (EVAR) follow-up of 3 years (6 months to 8 years) at a public Hospital. Aortic calibres measured 5 mm above the highest renal artery were recorded, patients were categorised according to suprarenal diameter; Group A: greater than 25 mm, Group B: less than or equal to 25 mm. Stent migration, aneurysmal sac growth, presence of an endoleak and its type, occlusion events, rupture, interventions and mortality, as well as clinical history and demographic data were compared between groups. Results There was a significantly higher occurrence of stent migration (11% v 0%; P = .01) in patients with larger suprarenal aortas (Group A). The occurrence of any endoleak did not differ between the groups, however, significantly more complications resulting in secondary intervention, excluding occlusions, were noted in Group A (34% vs 17%, P = .04). Conclusions The results from this study suggest that patients with above-average suprarenal diameters (categorised as dilators) may have a higher occurrence of specific complications following EVAR. A more detailed study to establish the association of suprarenal calibre with types of complications following EVAR is warranted.

Objective: Reflux within the superficial microvenous network may play a critical role in the development of skin changes which can be associated with chronic venous insufficiency. This study aimed to determine if near infrared fluorescence (NIRF) imaging could be used to accurately determine superficial venous reflux in the leg. Methods: A total of nine limbs were examined ex vivo from patients undergoing limb amputation for peripheral arterial disease. Cannulation of the distal great saphenous vein was used to sequentially perform Xray contrast enhanced venography, NIRF imaging, and venous corrosion casts. Results: Fluorescence imaging visualised a range of different microvenous reflux patterns ex vivo, which were generally not evident by Xray venography but were consistent with retrograde resin vascular casts. These included both focal and diffuse regions of fluorescence within the skin and, consistent with previous observations, the vascular casts indicated that regions of venous reflux were typically associated with incompetent valves. Conclusion: The findings from this study suggest a potential method for investigating early stage superficial venous disease, prior to the appearance of visible signs of advanced venous disease, such as skin changes. However, further studies are required to confirm the in vivo clinical utility of these observations.

Aim There is increasing evidence that delayed loop ileostomy closure is associated with an increase in postoperative morbidity. In the context of a publicly funded health service with constrained theatre access, we review the impact of delay in loop ileostomy closure. Method A retrospective cohort study of patients undergoing loop ileostomy closure at the Dunedin Public Hospital between 2000-2017 was performed. Cases and complications were identified from the prospectively maintained Otago Clinical Audit database. Patient demographics, ASA score, indications for ileostomy, reasons for delay in closure, length of stay (LOS) after ileostomy closure and complications were collected. LOS and overall complication rate were assessed using univariable and multivariable analyses. Results A total of 292 patients were included in the study, of whom 74 (25.3%) were waiting for longer than 12 months for ileostomy closure. The overall complication rate was 21.5%. This was 8% up to 90 days, 20% between 90-360 days, 28% between 360-720 days and 54% after 720 days. Delay was associated with an increased risk of any complication (RR 1.06 for every 30 days with stoma, p < 0.001), including Ileus (OR [95% CI] 1.06 [1.00-1.11], p = 0.024). Overall mean LOS was 5.9 days (range 1-63), being 4.6 days up to 180 days, 5.6 between 180-720 days and 8.7 after 720 days. LOS significantly increased with increasing stoma duration (p = 0.04). Conclusion Increasing time with loop ileostomy is detrimental for patients, being associated with an increase in complication rates, and is detrimental for hospitals due to increased length of stay. Resources should be allocated for timely closure of loop ileostomies.

PurposeImproving cardiopulmonary reserve, or peak oxygen consumption( O2peak), may reduce postoperative complications; however, this may be difficult to achieve between diagnosis and surgery. Our primary aim was to assess the efficacy of an approximate 14‐session, preoperative high‐intensity interval training(HIIT) program to increase O2peak by a clinically relevant 2 ml·kg−1·min−1. Our secondary aim was to document clinical outcomes.MethodologyIn this prospective study, participants aged 45–85 undergoing major abdominal surgery were randomized to standard care or 14 sessions of HIIT over 4 weeks. HIIT sessions involved approximately 30 min of stationary cycling. Interval training alternated 1 min of high (with the goal of reaching 90% max heart rate at least once during the session) and low/moderate‐intensity cycling. Cardiopulmonary exercise testing(CPET) measured the change in O2peak from baseline to surgery. Clinical outcomes included postoperative complications, length of stay(LOS), and Short Form 36 quality of life questionnaire(SF‐36).ResultsOf 63 participants, 46 completed both CPETs and 50 completed clinical follow‐up. There was a significant improvement in the HIIT group's mean ± SD O2peak (HIIT 2.87 ± 1.94 ml·kg1·min−1 vs standard care 0.15 ± 1.93, with an overall difference of 2.73 ml·kg1·min−1 95%CI [1.53, 3.93] p < 0.001). There were no statistically significant differences between groups for clinical outcomes, although the observed differences consistently favored the exercise group. This was most notable for total number of complications (0.64 v 1.16 per patient, p = 0.07), SF‐36 physical component score (p = 0.06), and LOS (mean 5.5 v 7.4 days, p = 0.07).ConclusionsThere was a significant improvement in O2peak with a four‐week preoperative HIIT program. Further appropriately powered work is required to explore the impact of preoperative HIIT on postoperative clinical outcomes.

Background To identify whether compliance with Enhanced Recovery After Surgery (ERAS) Society recommendations is associated with length of stay (LOS) in a New Zealand hospital for patients undergoing segmental colectomy in mixed acute and elective general surgery wards. Methods Consecutive elective colorectal surgeries (n = 770) between October 2012 and February 2019 were audited. Patients with non-segmental colectomies, multi-organ surgeries, LOS > 14 days, and those who died were excluded. Logistic regression was used to determine the relationship between patient demographics, compliance with ERAS guidelines, and suboptimal LOS (> 4 days). Results Analysis included 376 patients. Age, surgery prior to 2014, surgical approach, non-colorectal surgical team, operation type, and complications were significantly associated with suboptimal LOS. Non-compliance with ERAS recommendations for laparoscopy [OR 8.9, 95% CI (4.52, 19.67)], removal of indwelling catheters (IDC) [OR 3.14, 95% CI (1.85, 5.51)], use of abdominal drains [OR 4.27, 95% CI (0.99, 18.35)], and removal of PCA [OR 8.71, 95% CI (1.78, 157.27)], were associated with suboptimal LOS (univariable analysis). Multivariable analysis showed that age, surgical team, late removal of IDC, and open approach were independent predictors of suboptimal LOS. Conclusions Non-compliance with ERAS guidelines for laparoscopic approach and early removal of IDC was higher among procedures performed by non-colorectal surgery teams, and was also associated with adverse postoperative events and suboptimal LOS. This study demonstrates the importance of the surgical team’s expertise in affecting surgical outcomes, and did not find significant independent associations between most individual ERAS guidelines and suboptimal LOS once adjusting for other factors.