Introduction: Incidental common bile duct (CBD) calculi is found in approximately 11% of routine intra-operative cholangiograms (IOC) during laparoscopic cholecystectomy (LC). An uncertain proportion of these may remain asymptomatic or pass spontaneously, and therefore not require invasive intervention. We aim to explore the natural history of retained CBD calculi in asymptomatic patients to guide management for this common incidental operative finding. Methods: Retrospective analysis of LC performed at an Australian tertiary hospital from 2014 to 2018 was undertaken. Records of patients with filling defects noted on IOC were reviewed. Incidental patients were defined by preoperative bilirubin< 40μmol/L and gamma-glutamyl transferase< 500U/L. The main endpoint was the passage of CBD calculus, determined by the absence of choledocholithiasis on postoperative magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP). Results: 1453(87%) patients underwent IOC with LC and filling defects were noted in 116(8%) of these. 75 incidental patients underwent postoperative cholangiography within 30 days at a median of 3(IQR=2-6) days following LC. 32(43%) patients had no residual choledocholithiasis. The median time to stone passage was estimated at 10(95%CI 5.6-14.3) days. Retained choledocholithiasis was detected in 72% of patients where no contrast passed into the duodenum and 48% with duodenal contrast passage but filling defects on IOC (p=0.049). Conclusion: A significant proportion of incidental CBD calculi pass spontaneously within 14 days from LC. Expectant management with follow-up non-invasive imaging may reduce unnecessary ERCP and minimise its associated complications. However, failure of contrast passage into the duodenum on IOC may predict non-passage of choledocholithiasis.

BACKGROUND:Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) is well validated in the staging of pre-treatment head and neck squamous cell carcinoma (HNSCC), although the impact of human papilloma virus (HPV) status and node size on accuracy remains unclear. The aim of this study was to assess the diagnostic accuracy of PET/CT based on HPV status and node size and determine the effects of maximum standardized uptake value thresholds on sensitivity, specificity and positive predictive value.METHODS:A total of 38 patients with primary HNSCC were recruited. All patients underwent primary tumour resection and cervical node dissection following FDG-PET/CT.RESULTS:A total of 38 patients including 68 dissected necks, representing 353 nodal levels and a total of 2701 lymph nodes were included. Histopathological analysis revealed lymph node metastases in 4.3% (116/2701) of dissected lymph nodes. Forty-four percent of patients had HPV-positive tumours. Sixty-four percent of involved lymph nodes were <1 cm. The sensitivity and specificity for HPV-positive nodes were 67.2% and 99.3% versus 35.6% and 98.2% in HPV-negative nodes, respectively (P < 0.001). Mean maximum standardized uptake value in HPV-positive nodes was 6.3 versus 3.5 in HPV-negative nodes (P < 0.001). Sensitivity and specificity were 30.7% and 99.2% in <1 cm nodes versus 90.2% and 84.8% in ≥1 cm nodes, respectively (P < 0.001).CONCLUSION:FDG-PET/CT has significantly higher diagnostic accuracy in determining nodal metastases in HPV-positive HNSCC versus HPV-negative disease. Accuracy was lower in <1 versus ≥1 cm nodes.

ObjectivesPrimary objectives: To determine the additive value of gallium‐68 prostate‐specific membrane antigen (PSMA) positron emission topography (PET)/computed tomography (CT) when combined with multiparametric magnetic resonance imaging (mpMRI) detecting clinically significant prostate cancer (csPCa) in men undergoing initial biopsy for suspicion of PCa, and to determine the proportion of men who could have avoided prostate biopsy with positive mpMRI (PI‐RADS ≥3) but negative PSMA‐PET/CT. Secondary objectives: To determine the proportion of men who had csPCa detected only by PSMA‐PET/CT or only by systematic prostate biopsy; to compare index lesions by template biopsies vs targeted lesions identified on mpMRI or PSMA‐PET/CT; to assess whether there may be health economic benefit or harm if PSMA‐PET/CT is incorporated into the diagnostic algorithm; and to develop a nomogram which combines clinical, imaging and biomarker data to predict the likelihood of csPCa. Patients and MethodsThe PRIMARY trial is a multicentre, prospective, cross‐sectional study that meets the criteria for level 1 evidence in diagnostic test evaluation. PRIMARY will investigate if a limited (pelvic‐only) PSMA‐PET/CT in combination with routine mpMRI can reliably discriminate men with csPCa from those without csPCa. We conducted a power calculation based on pilot data and will recruit up to 600 men who will undergo PSMA‐PET/CT (the index test), mpMRI (standard test) and transperineal template + targeted (PSMA‐PET/CT and/or mpMRI) biopsies (reference test). The conduct and reporting of the mpMRI and PSMA‐PET/CT will be blinded to each other.ResultsThe PRIMARY trial will measure and compare sensitivity, specificity, positive predictive value and negative predictive value of both mpMRI and PSMA‐PET/CT vs targeted prostrate biopsy. The results will be used to determine the proportion of men who could safely avoid biopsy without compromising detection of csPCa. Furthermore, we will assess whether there is a health economic benefit in incorporating PSMA‐PET/CT into the diagnostic algorithm.ConclusionsThis trial will provide robust prospective data to determine the diagnostic ability of PSMA‐PET/CT used in addition to mpMRI. It will establish if certain patients can avoid biopsy in the investigation of PCa.

68Ga-labeled prostate-specific membrane antigen (PSMA) PET/CT is increasingly used in men with biochemical recurrence (BCR) after radical prostatectomy (RP), but its longer-term prognostic or predictive potential in these men is unknown. The aim of this study was to evaluate the predictive value of PSMA PET for a 3-y freedom from progression (FFP) in men with BCR after RP undergoing salvage radiotherapy (sRT). Methods: This prospective multicenter study enrolled 260 men between 2015 and 2017. Eligible patients were referred for PSMA PET with a rising level of prostate-specific antigen (PSA) after RP. Management after PSMA PET was recorded but not mandated. PSMA PET protocols were standardized across sites and reported prospectively. Clinical, pathologic, and surgical information; sRT; timing and duration of androgen deprivation; 3-y PSA results; and clinical events were documented. FFP was defined as a PSA rise of no more than 0.2 ng/mL above nadir after sRT, with no additional treatment. Results: The median PSA was 0.26 ng/mL (interquartile range, 0.15–0.59 ng/mL), and follow-up was 38 mo (interquartile range, 31–43 mo). PSMA PET had negative results in 34.6% (90/260), showed disease confined to the prostatic fossa in 21.5% (56/260), showed disease in the pelvic nodes in 26.2% (68/260), and showed distant disease in 17.7% (46/260). Of the patients, 71.5% (186/260) received sRT: 38.2% (71/186) to the fossa only, 49.4% (92/186) to the fossa plus the pelvic nodes, and 12.4% (23/186) to the nodes alone or stereotactic body radiation therapy. PSMA PET was highly predictive of FFP at 3 y after sRT. Overall, FFP was achieved in 64.5% (120/186) of those who received sRT, 81% (81/100) with negative results or fossa-confined findings versus 45% (39/86) with extrafossa disease (P < 0.0001). On logistic regression, PSMA PET was more independently predictive of FFP than established clinical predictors, including PSA, T stage, surgical margin status, or Gleason score (P < 0.002). Thirty-two percent of men with a negative PSMA PET result did not receive treatment. Of these, 66% (19/29) progressed, with a mean rise in PSA of 1.59 ng/mL over the 3 y. Conclusion: PSMA PET results are highly predictive of FFP at 3 y in men undergoing sRT for BCR after RP. In particular, men with negative PSMA PET results or disease identified as still confined to the prostatic fossa demonstrate high FFP, despite receiving less extensive radiotherapy and lower rates of additional androgen deprivation therapy than those with extrafossa disease.

Surgical resection for Bismuth‐Corlette type IV (BC‐IV) hilar cholangiocarcinomas, also termed Klatskin tumours are technically challenging and were once considered unresectable tumours. Following advances in hepatobiliary imaging and surgical techniques, emerging evidence suggests that surgical resection is a viable avenue for long‐term survival. We aimed to identify factors affecting survival outcomes of hepatic resections for BC‐IV cholangiocarcinomas.

Over the past four decades, there has been significant debate as to whether mechanical bowel preparation (MBP) and oral antibiotics (OAB) should be prescribed preoperatively prior to elective colorectal surgery. With the widespread implementation of enhanced recovery after surgery (ERAS) protocols as well as the findings of the Cochrane review in 2011 (n=5,805) concluding that MBP did not provide any statistically significant benefit (1), there was a paradigm shift away from mechanical bowel preparation.

Purpose 18F-FDG PET/CT is a valuable diagnostic tool in the evaluation of cardiac sarcoidosis. Appropriate patient preparation is important because the diagnostic accuracy of this procedure depends on adequate suppression of physiologic glucose uptake. This systematic review and meta-analysis aims to assess the effect of different patient preparations on the diagnostic accuracy of 18F-FDG PET/CT in cardiac sarcoidosis. Patients and Methods We searched the PubMed/MEDLINE, Embase, and Cinicaltrials.gov databases. Sixteen studies (n = 559) were identified to be suitable for this systemic review. Studies were stratified according to fasting duration and means of physiologic suppression of 18F-FDG by cardiac tissue, which involves the use of heparin infusion or high-fat, low-carbohydrate diet before imaging. Study quality was assessed using the QUADAS-2 tool. Forest plots of sensitivity and specificity were calculated in Review Manager 5.3, and a random-effects hierarchical summary receiver operating characteristic model was created using MetaDiSc. Meta-regression was performed to investigate sources of heterogeneity. Results PET/CT had an overall Specificity of 0.75 (95% confidence interval [CI], 0.69–0.80) and specificity of 0.81 (95% CI, 0.76–0.85) for the diagnosis of cardiac sarcoidosis. This modest diagnostic accuracy was attributed to the inclusion of large single study in which a short fasting duration before scanning likely influenced its sensitivity. Its exclusion resulted in an overall sensitivity of 0.81 (95% CI, 0.76–0.86) and specificity of 0.82 (95% CI, 0.77–0.86). Meta-regression showed that the diagnostic odds ratio was significantly affected by fasting time and heparin administration before scanning (P = 0.01, 0.02) but not with high-fat, low-carbohydrate diet (P = 0.17). Conclusions 18F-FDG PET/CT plays an integral role in the diagnosis of cardiac sarcoidosis. Diagnostic accuracy is affected by fasting duration and means of cardiomyocyte glucose uptake suppression before scanning.

In prostate cancer with biochemical failure after therapy, current imaging techniques have a low detection rate at the prostate-specific antigen (PSA) levels at which targeted salvage therapy is effective. 11C-choline and 18F-fluoromethylcholine, though widely used, have poor sensitivity at low PSA levels. 68Ga-PSMA (Glu-NH-CO-NH-Lys-(Ahx)-[68Ga-N,N′-bis[2-hydroxy-5-(carboxyethyl)benzyl]ethylenediamine-N,N′-diacetic acid]) has shown promising results in retrospective trials. Our aim was to prospectively compare the detection rates of 68Ga-PSMA versus 18F-fluoromethylcholine PET/CT in men who were initially managed with radical prostatectomy, radiation treatment, or both and were being considered for targeted therapy. Methods: A sample of men with a rising PSA level after treatment, eligible for targeted treatment, was prospectively included. Patients on systemic treatment were excluded. 68Ga-PSMA, 18F-fluoromethylcholine PET/CT, and diagnostic CT were performed sequentially on all patients between January and April 2015, and the images were assessed by masked, experienced interpreters. The findings and their impact on management were documented, together with the results of histologic follow-up when feasible. Results: In total, 38 patients were enrolled. Of these, 34 (89%) had undergone radical prostatectomy and 4 (11%) had undergone radiation treatment. Twelve (32%) had undergone salvage radiation treatment after primary radical prostatectomy. The mean PSA level was 1.74 ± 2.54 ng/mL. The scan results were positive in 26 patients (68%) and negative with both tracers in 12 patients (32%). Of the 26 positive scans, 14 (54%) were positive with 68Ga-PSMA alone, 11 (42%) with both 18F-fluoromethylcholine and 68Ga-PSMA, and only 1 (4%) with 18F-fluoromethylcholine alone. When PSA was below 0.5 ng/mL, the detection rate was 50% for 68Ga-PSMA versus 12.5% for 18F-fluoromethylcholine. When PSA was 0.5–2.0 ng/mL, the detection rate was 69% for 68Ga-PSMA versus 31% for 18F-fluoromethylcholine, and when PSA was above 2.0, the detection rate was 86% for 68Ga-PSMA versus 57% for 18F-fluoromethylcholine. On lesion-based analysis, 68Ga-PSMA detected more lesions than 18F-fluoromethylcholine (59 vs. 29, P < 0.001). The tumor-to-background ratio in positive scans was higher for 68Ga-PSMA than for 18F-fluoromethylcholine (28.6 for 68Ga-PSMA vs. 9.4 for 18F-fluoromethylcholine, P < 0.001). There was a 63% (24/38 patients) management impact, with 54% (13/24 patients) being due to 68Ga-PSMA imaging alone. Histologic follow-up was available for 9 of 38 patients (24%), and 9 of 9 68Ga-PSMA–positive lesions were consistent with prostate cancer (68Ga-PSMA was true-positive). The lesion positive on 18F-fluoromethylcholine imaging and negative on 68Ga-PSMA imaging was shown at biopsy to be a false-positive 18F-fluoromethylcholine finding (68Ga-PSMA was true-negative). Conclusion: In patients with biochemical failure and a low PSA level, 68Ga-PSMA demonstrated a significantly higher detection rate than 18F-fluoromethylcholine and a high overall impact on management.

Objective: This article synthesises evidence for calcium supplementation in preeclampsia prevention. Methods: Major databases and trial registries were searched, and comparisons were made against other meta-analyses. Results: Calcium supplementation reduced the overall risk of preeclampsia in 10 trials (n = 24 787; risk ratio (RR) 0.62; 95% confidence interval [CI] 0.47-0.81). Its effect was larger in two subgroups: low-baseline calcium intake (RR 0.42 [0.23-0.76]) and increased risk of developing hypertensive disorders (RR 0.36 [0.10-0.98]). This effect was not significant amongst larger studies (RR 0.93 [0.83-1.04]). Funnel plotting suggested possible publication bias. Conclusion: Some evidence for calcium supplementation exists, but its utility is limited by the possibility of publication bias and a lack of large trials.

BACKGROUND:Surgical checklists are designed to improve patient outcomes following surgery. While such checklists have been widely implemented worldwide, few studies examine surgical checklists within an Australian context. For this purpose, we have performed a literature review using data from OECD member nations to determine the effectiveness of surgical checklists in improving patient outcomes and factors that contribute to their successful implementation.METHOD:The databases, Pubmed, Medline, EMBASE, Cochrane and CINAHL were searched using the keywords ('surgical' AND 'checklist') and ( (surgical) AND checklist) AND ( (implementation) OR (utilization) OR (usage) ). Studies were limited to those written in the English language, peer-reviewed, published between January 2000 and December 2012, and including an abstract.RESULTS:Our search yielded 2242 papers, of which 72 papers were identified for their potential relevance and selected for full text review. Of these, nine papers met the inclusion criteria and were reviewed in detail. Evidence that supports the use of surgical checklists in countries with a large number of protocols already in place is limited. Adequate checklist implementation plays a central role in checklist effectiveness, which in turn is dependent on multiple factors.CONCLUSION:Although evidence from OECD member countries is non-conclusive, it does suggest that surgical checklists, when effectively implemented, have the potential to be effective at reducing complication and mortality rates following surgery. Within an Australian context, more studies are needed to fully establish the potential effectiveness of surgical checklists and to monitor checklist use compliance in order to ensure greater patient safety.