Objectives To perform a systematic review on the use of magnetic resonance imaging (MRI) of the abdomen to evaluate clinically suspected appendicitis in the general adult population. We examined the diagnostic accuracy, the reported trends of MRI use, and the factors that affect the utility of MRI abdomen, including study duration and cost-benefits. Methods We conducted a systematic literature search on PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library databases. We enrolled primary studies investigating the use of MRI in diagnosing appendicitis in the general adult population, excluding studies that predominantly reported on populations not representative of typical adult appendicitis presentations, such as those focusing on paediatric or pregnant populations. Results Twenty-seven eligible primary studies and 6 secondary studies were included, totaling 2,044 patients from eight countries. The sensitivity and specificity of MRI for diagnosing appendicitis were 96% (95% CI: 93–97%) and 93% (95% CI: 80–98%), respectively. MRI can identify complicated appendicitis and accurately propose alternative diagnoses. The duration of MRI protocols in each primary study ranged between 2.26 and 30 minutes, and only one study used intravenous contrast agents in addition to the non-contrast sequences. Decision analysis suggests significant benefits for replacing computed tomography (CT) with MRI and a potential for cost reduction. Reported trends in MRI usage showed minimal utilisation in diagnostic settings even when MRI was available. Conclusions MRI accurately diagnoses appendicitis in the general adult population and improves the identification of complicated appendicitis or alternative diagnoses compared to other modalities using a single, rapid investigation.

Objective: This systematic review aims to identify causes of increased risk for and location and mechanism of gastric injury at laparoscopy for gynecologic indications and determine optimal management.Data Sources: A prospectively registered systematic review (PROSPERO: CRD42021237999) was undertaken and per-formed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases searched included Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Medline, Embase, Web of Science, SCOPUS, and Google Scholar from 1960 to 2021.Methods of Study Selection: All study types were included involving female patients of any age with gastric injury at lapa-roscopy for gynecologic indication.Tabulation, Integration, and Results: A total of 6294 articles were screened, from which 67 studies were selected for a full-text review. Twenty-eight articles were included, which contained 42 cases drawn from 7 observational studies, 4 case series, and 17 case reports. Of these, 93% (39/42) were at the time of laparoscopic entry, with Veress entry technique used in 79% of these cases (31/39). Eighteen cases reported an entry point, with 77% (14/18) occurring at the periumbilical entry point and 11% (2/18) occurring at Palmer's point. Of the cases with reported etiology for gastric distention or displacement, 64% (9/14) were owing to anesthetic cause. The most common sites of gastric injury were on the anterior stomach wall (n = 8) and the greater curvature (n = 5). Among patients with reported management (32/42), a similar proportion were managed conservatively (11) when compared with repair through laparotomy (13) or laparoscopy (8). All injuries were detected intraoperatively with no reported short-term sequelae. Conclusion: This systematic review of the literature reveals that gastric injury at laparoscopy for gynecologic indications is a rare complication predominantly occurring during laparoscopic entry, most commonly at the periumbilical entry point. When detected intraoperatively, conservative management, laparoscopic, or open repair in the appropriate patient has been performed with no short-term sequelae. The limitations of this review include paucity of cases, detail, and timeline of publi-cations.(c) 2022 AAGL. All rights reserved.

BACKGROUND:This study aimed to assess the risk factors, management, imaging validity, Laboratory Risk Indicator for Necrotising infection (LRINEC) score and outcomes of necrotising soft tissue infection (NSTI) at a western Sydney tertiary hospital.METHODS:A retrospective study was conducted of all patients with NSTI from 2012 to 2019 at our institution. Patient characteristics, imaging, microbiology and site, LRINEC score, surgical management and outcomes/disposition were collected.RESULTS:Thirty-six patients met the inclusion criteria with mean age of 52 years and body mass index of 38.1; 55.6% were male, 48% of Polynesian descent and 55.6% were diabetic. The most frequent sites of NSTI were perineal (30.6%), lower limb (30.6%), perianal (19.3%) and trunk (11.1%). A total of 64% of patients underwent computed tomography radiological imaging with diagnostic accuracy of 50%. The mean LRINEC score was 7 (1-20). A total of 52.8% were transferred from another facility or non-surgical teams which delayed surgical review by 11.4 h (P < 0.03) and operating time by 12.4 h (P < 0.04) compared with direct emergency department referrals to the on-call surgical team. There was no statistical difference in outcomes in both groups. The overall average time to surgical debridement was 16.2 h (standard deviation 19.6, range 3.4-105.1). The mean hospital length of stay was 20.9 days; 44.4% of patients were transferred for rehabilitation or plastic reconstruction with a single mortality from multi-organ failure.CONCLUSION:The optimal management of NSTI requires a high index of suspicion and LRINEC score is a useful adjunct in aiding a clinician's decision. Early surgical debridement within 24 h of diagnosis and a multidisciplinary approach is associated with a lower mortality rate.

INTRODUCTION: With the advent of more minimally invasive procedures like endoscopic sleeve gastroplasty (ESG) for weight loss and metabolic disorders, we are seeing more cases of patients presenting with sub-optimal results for consideration of alternative weight loss surgery. The report aims to describe our experience in converting ESG to laparoscopic sleeve gastrectomy and highlight our suggested technique, challenges and pitfalls. PRESENTATION OF CASES: We described two bariatrics cases detailing our findings on initial endoscopy along with methods used to reverse ESG hardware, followed by issues encountered during sleeve gastrectomy 1 month later. Case 1 being of a 33 year old female (BMI - 50.7) with previous laparoscopic band removal and 2 ESG attempts, while case 2 is a 31 year old female (BMI 44.6) with previously failed gastric balloon and ESG. DISCUSSION: ESG reversal was performed without difficulty via endoscopy with visible sutures cut and hardware removed with snares. In both cases, the stomach was easily endoscopically distensible. During sleeve gastrectomy, extra-gastric adhesions along with more gastro-gastric sutures were encountered in case 1. In case 2, ESG hardware was noted on the external surface of stomach with misfiring of 3rd stapler reload during sleeve gastrectomy likely related to unidentified retained hardware. No post-operative complications occurred in either of the cases with adequate weight loss on one month follow up. CONCLUSION: In our experience, ESG conversion to sleeve gastrectomy is feasible and for the most part, uncomplicated. In our case series, we described a two staged approach to conversion although a single staged conversion is theoretically feasible. (C) 2020 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd.

Purpose Endoscopic sleeve gastroplasty (ESG) has grown in popularity as a potential minimally invasive bariatric procedure with acceptable short- and medium-term outcomes. This review aims to assess the safety and weight loss outcomes of ESG and compare it with laparoscopic sleeve gastrectomy (LSG). Material and Methods A comprehensive search of MEDLINE, EMBASE, Cochrane and World Wide Web was conducted. Results Five studies were reviewed, three ESG cohort studies and two case-matched cohort studies comparing ESG with LSG. Total unique ESG and LSG patients were 1451 and 203, respectively. All papers demonstrated a modest short-term total body weight loss (TBWL%) at 6 months ranging from 13.7 to 15.2% for ESG. Comparably, the two LSG papers demonstrated a superior TBWL% of 23.5 and 23.6% at 6 months, with one paper reporting a 12-month TBWL% of 29.3%. Two ESG papers reported medium-term results at 18 and 24 months of 14.8% and 18.6%, respectively. Excluding Clavien-Dindo 1 complications, ESG had a complication rate between 2.0 and 2.7%, while comparatively, LSG had a complication rate between 9.2 and 16.9% (current literature reported as 8.7%). In both procedures, there were no grade IV or V complications. Conclusion ESG when compared with LSG has lower short-term weight loss outcomes with fewer complications. Weight loss results for ESG appear to plateau after the 1-year mark. The future and uptake of ESG as a minimally invasive bariatric procedure will be determined by its long-term data on potential weight loss sustainability.

1.Intussusception after LRYGB surgery is a rare complication, may be more common in pregnant subjects, and can be difficult to diagnose clinically.2.The diagnosis is generally based on axial CT imaging, although this may not be possible in pregnant patients.3.Here a presentation and suggested management approach is provided to contribute to the literature and inspire further research in this area.

Background Electronic health records (EHR) systems have been utilized in New South Wales for more than a decade; however, there is no agreement as to what clinical benefits they provide. This study aims at determining whether the introduction of EHR systems resulted in changes in documentation quality and other markers of clinical performance such as post‐operative length of stay (PO LOS), use of imaging modality, rates of readmission and morbidity. Methods A before and after study was conducted utilizing both written and electronic patient documentation in a single surgical ward. Patients who underwent appendicectomy at Blacktown Hospital had inpatient documentation collated at three distinct time‐points. Documentation was then assessed against the QNOTE assessment criteria. Other markers of clinical performance assessed included PO LOS, ultrasound use, computed tomography use, rate of readmission, rate of morbidity and rate of positive histological findings. Results There was a significant ( P = 0.001) improvement in QNOTE score between group 1 (6 months prior to the implementation of EHR) and group 3 (12 months after the implementation of EHR) of 9 points. PO LOS was reduced following the implementation of EHR from 1.94 to 1.37 days ( P = 0.001). Conclusion This study demonstrated that following the implementation of EHR system in an inpatient surgical ward, notation quality improved. It was also found that the implementation of EHR was associated with a decrease in PO LOS.

Three patients with severe Clostridium difficile infection (CDI) caused by an unusual strain of C. difficile, PCR ribotype (RT) 251, were identified in New South Wales, Australia. All cases presented with severe diarrhoea, two had multiple recurrences and one died following a colectomy. C difficile RT251 strains were isolated by toxigenic culture. Genetic characterisation was performed using techniques including toxin gene profiling, PCR ribotyping, whole genome sequencing (WGS), in-silico multi-locus-sequence-typing (MLST) and core-genome single nucleotide variant (SNV) analyses. Antimicrobial susceptibility was determined using an agar incorporation method. In vitro toxin production was confirmed by Vero cell cytotoxicity assay and pathogenicity was assessed in a murine model of CDI. All RT251 isolates contained toxin A (tcdA), toxin B (tcdB) and binary toxin (cdtA and cdtB) genes. Core-genome analyses revealed the RT251 strains were clonal, with 0-5 SNVs between isolates. WGS and MLST clustered RT251 in the same evolutionary Glade (Glade 2) as RT027. Despite comparatively lower levels of in vitro toxin production, in the murine model RT251 infection resembled RT027 infection. Mice showed marked weight loss, severe disease within 48 h post-infection and death. All isolates were susceptible to metronidazole and vancomycin. Our observations suggest C difficile RT251 causes severe disease and emphasise the importance of ongoing surveillance for new and emerging strains of C. difficile with enhanced virulence. (C) 2018 Elsevier Ltd. All rights reserved.

Repair of complex ventral hernia can be very challenging for surgeons. Closure of large defects can have serious pathophysiological consequences. Botulinum toxin A (BTA) has recently been described to provide flaccid paralysis to abdominal muscles prior to surgery, facilitating closure and repair.

BACKGROUND:High rates of inappropriate use of prophylactic antibiotics in surgery continue to be reported in the literature, with many institutions designing interventions aimed at improving prescription. This study evaluates the surgical arm of a clinician-focused educational antimicrobial stewardship program implemented in February 2014 at Blacktown Hospital, Australia.METHODS:A before-after analysis of the surgical antibiotic prophylaxis intervention was conducted at Blacktown Hospital, New South Wales, Australia. Two hundred abdominal general surgical patients were selected via simple random sampling and categorized into pre-intervention (n = 100) and post-intervention (n = 100) groups. Antibiotic prophylaxis regimens were compared with the Australian guideline, Therapeutic Guidelines: Antibiotic (v14) with respect to drug choice, dosage, timing of administration, and duration of administration.RESULTS:Overall adherence rates in the pre- and post-intervention periods were 18% and 15% respectively, demonstrating no substantial change (p = 0.568). No patients in either group were administered antibiotics without an appropriate indication. There were no substantial decreases in error rates across any category, including drug choice, dosage, timing of administration, duration of administration, or re-dosing. The apparent decrease in the rate of inappropriate broad-spectrum cephalosporin usage was not statistically significant (29.3% vs. 18.8%; p = 0.16).CONCLUSIONS:The educational intervention studied demonstrated no substantial change to overall adherence. Given the frequent failure of such interventions, stronger and more directly mandated adoption of prescribing guidelines is recommended for surgical services. Future consideration should be given to focused computer-based solutions, integrated with electronic medical records where possible.

BACKGROUND:Interhospital transfer of patients requiring emergency surgery is common practice. It has the potential to delay surgical intervention, increase rate of complications and thus length of hospital stay.METHODS:A retrospective cohort study was conducted of adult patients who underwent emergency surgery for abdominal pain at a large metropolitan hospital in New South Wales (Hospital A) in 2013. The impact of interhospital transfer on time to surgical intervention, post-operative length of stay and overall length of stay was assessed.RESULTS:Of the 910 adult patients who underwent emergency surgery for abdominal pain at Hospital A in 2013, 31.9% (n = 290) were transferred by road ambulance from a local district hospital (Hospital B). The leading surgical procedures performed were appendicectomy (n = 299, 32.9%), cholecystectomy (n = 174, 19.1%), gastrointestinal endoscopy (n = 95, 10.4%), cystoscopy (n = 86, 9.5%), hernia repair (n = 45, 4.9%), salpingectomy (n = 19, 2.1%) and oversewing of perforated peptic ulcer (n = 13, 1.4%). Overall, interhospital transfer (n = 290, 31.9%) was associated with increases in mean time to surgical intervention (14.2 h, P < 0.001), post-operative length of stay (1.1 days, P = 0.001) and overall length of stay (1.6 days, P < 0.001). Delayed surgical intervention was observed across all procedure types except surgery for perforated peptic ulcer, where transferred patients underwent surgery within a comparable timeframe to direct admissions.CONCLUSION:Interhospital transfer delays surgical intervention and increases length of hospital stay. This mandates attention due to the implications for patient outcomes and added burden to the healthcare system. The system did, however, show capability to appropriately expedite surgery for acutely life-threatening cases.

BACKGROUND:Surgical repair of recurrent abdominal incisional hernia(s) can be challenging due to complex operative conditions, intense post-operative pain, potential respiratory compromise and lateral muscle traction predisposing to early recurrence. We report our preliminary results with botulinum toxin A (BTA) injection causing flaccid paralysis (relaxation) of the lateral abdominal wall muscles prior to surgery.METHODS:A prospective pilot study measured the effect of preoperative BTA prior to elective repair of recurrent abdominal hernias. Under ultrasound control, 2 weeks prior to surgery, 50 units of BTA was injected into the external oblique, internal oblique and transversus abdominis muscles at three sites on each side of the lateral abdominal wall (total dose 300 units). Pre- and post-BTA abdominal computed tomography measured changes in abdominal wall muscle thickness and length. All hernias were repaired with laparoscopic or laparoscopic-assisted mesh techniques in a single or two-staged procedure.RESULTS:Eight patients received BTA injections which were tolerated with no complications. Post-BTA preoperative computed tomography showed a significant increase in mean length of lateral abdominal wall from 18.5 cm pre-BTA to 21.3 cm post-BTA (P = 0.017) with a mean unstretched length gain of 2.8 cm per side (range 0.8-6.0 cm). All hernias were surgically reduced with mesh with no early recurrence.CONCLUSION:Preoperative BTA injection prior to complex abdominal hernia repair is a safe procedure that causes flaccid relaxation, elongation and thinning of the lateral abdominal muscles and decrease in hernia defect. Although further evaluation is required, BTA injections may be a useful adjunct to surgical repair of complex incisional hernias.

BACKGROUND Surgical antibiotic prophylaxis is frequently reported in the literature to be suboptimal, a finding having both clinical and public health implications. This study aimed to calculate rates and patterns of adherence to guidelines at two sites and identify extrinsic contributing factors. METHODS A retrospective analysis was conducted over two 12-mo periods during 2013-2014 at the metropolitan Blacktown Hospital and regional Lismore Base Hospital, New South Wales, Australia. A group of 400 patients undergoing abdominal general surgery was selected via simple random sampling (n = 200 per site). Medical records were reviewed, and prophylactic antibiotic regimens were compared with the Australian guideline, Therapeutic Guidelines: Antibiotic (v. 14) with respect to drug choice, dosage, timing of administration, and duration of administration. RESULTS The overall rate of adherence to the guidelines was 16.5% at Blacktown Hospital and 19.5% at Lismore Base Hospital. At each site, prophylaxis was administered to more than 95% of patients and was inappropriately withheld in 4%. Drug choice was the most frequent error type, specifically involving inappropriate omission of metronidazole and use of newer-generation cephalosporins. Errors in the timing of administration also were frequent, with prophylaxis typically occurring excessively early. Logistic regression identified emergency surgery as independently associated with prophylactic errors in both the Blacktown Hospital (p < 0.001) and the Lismore Base Hospital cohorts (p = 0.020). CONCLUSIONS Adherence to antibiotic prophylactic guidelines was poor at both the metropolitan and regional sites. Choice of antibiotic and timing of administration were identified as major error types. Consideration should be given to multidisciplinary involvement of anesthetists, implementation of focused interventions with an emphasis on emergency settings, and further research correlating antibiotic use with clinical significance.

Medical Journal of AustraliaVolume 201, Issue 9 p. 502-503 Editorial Inequalities of access to bariatric surgery in Australia Michael Edye MB BS, FRACS, FACS, Corresponding Author Michael Edye MB BS, FRACS, FACS Professor of Surgery [email protected] Blacktown/Mt Druitt Clinical School, University of Western Sydney, Sydney, NSW.Correspondence: [email protected]Search for more papers by this authorMichael L Talbot MB ChB, FRACS, Michael L Talbot MB ChB, FRACS Senior Lecturer Department of Surgery, St George Hospital, Sydney, NSW.Search for more papers by this author Michael Edye MB BS, FRACS, FACS, Corresponding Author Michael Edye MB BS, FRACS, FACS Professor of Surgery [email protected] Blacktown/Mt Druitt Clinical School, University of Western Sydney, Sydney, NSW.Correspondence: [email protected]Search for more papers by this authorMichael L Talbot MB ChB, FRACS, Michael L Talbot MB ChB, FRACS Senior Lecturer Department of Surgery, St George Hospital, Sydney, NSW.Search for more papers by this author First published: 03 November 2014 https://doi.org/10.5694/mja14.01169Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Lukas N, Franklin J, Lee CMY, et al. The efficacy of bariatric surgery performed in the public sector for obese patients with comorbid conditions. Med J Aust 2014; 201: 218–222. https://www.mja.com.au/journal/2014/201/4/efficacy-bariatric-surgery-performed-public-sector-obese-patients-comorbid 10.5694/mja13.00046 PubMedWeb of Science®Google Scholar 2Talbot ML, Jorgensen JO, Loi KW. Difficulties in provision of bariatric surgical services to the morbidly obese. Med J Aust 2005; 182: 344–347. https://www.mja.com.au/journal/2005/182/7/difficulties-provision-bariatric-surgical-services-morbidly-obese 10.5694/j.1326-5377.2005.tb06733.x PubMedWeb of Science®Google Scholar 3Dixon JB, O'Brien PE, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA 2008; 299: 316–323. 10.1001/jama.299.3.316 CASPubMedWeb of Science®Google Scholar 4Brethauer SA, Aminian A, Romero-Talamás H, et al. Can diabetes be surgically cured? Long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus. Ann Surg 2013; 258: 628–636. 10.1097/SLA.0b013e3182a5034b PubMedWeb of Science®Google Scholar 5Zingmond DS, McGory ML, Ko CY. Hospitalization before and after gastric bypass surgery. JAMA 2005; 294: 1918–1924. 10.1001/jama.294.15.1918 CASPubMedWeb of Science®Google Scholar 6Hamdan K, Somers S, Chand M. Management of late postoperative complications of bariatric surgery. Br J Surg 2011; 98: 1345–1355. 10.1002/bjs.7568 CASPubMedWeb of Science®Google Scholar 7 Second report of the pilot bariatric surgery registry. Melbourne: Monash University, 2014. http://www.med.monash.edu.au/assets/docs/sphpm/second-report.pdf (accessed Sep 2014). Google Scholar 8Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes — 3-year outcomes. N Engl J Med 2014; 370: 2002–2013. 10.1056/NEJMoa1401329 CASPubMedWeb of Science®Google Scholar 9Sjöström L. Review of the key results from the Swedish Obese Subjects (SOS) trial — a prospective controlled intervention study of bariatric surgery. J Intern Med 2013; 273: 219–234. 10.1111/joim.12012 CASPubMedWeb of Science®Google Scholar 10Prospective Studies Collaboration; Whitlock G, Lewington S, Sherliker P, et al. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet 2009; 373: 1083–1096. Google Scholar Citing Literature Volume201, Issue9November 2014Pages 502-503 ReferencesRelatedInformation

ANZ Journal of SurgeryVolume 84, Issue 12 p. 993-993 LETTER TO THE EDITOR Re: Utility of inguinal incision in retroperitoneoscopic live donor nephrectomy Michael Edye MBBS, FRACS, Michael Edye MBBS, FRACS Blacktown Mount Druitt Clinical School, University of Western Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this author Michael Edye MBBS, FRACS, Michael Edye MBBS, FRACS Blacktown Mount Druitt Clinical School, University of Western Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this author First published: 01 December 2014 https://doi.org/10.1111/ans.12918 Selected letters will be published on ANZJSurg.com before they appear in the print journal Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Yu S, Men C, Liu L et al. Utility of inguinal incision in retroperitoneoscopic live donor nephrectomy. ANZ J. Surg. 2014; 84: 649–652. 10.1111/ans.12561 PubMedWeb of Science®Google Scholar 2 Recalls.org. July 2006. [Cited 16 Sept 2014.] Available from URL: http://www.recalls.org/medical07-06.htm Google Scholar 3 U.S. Food and Drug Administration. Weck Hem-o-lok ligating clips contraindicated for ligation of renal artery during laparoscopic living-donor nephrectomy: FDA and HRSA joint safety communication. [Cited 16 Sept 2014.] Available from URL: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm253237.htm Google Scholar Volume84, Issue12December 2014Pages 993-993 ReferencesRelatedInformation