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BACKGROUND: The provision of high-quality healthcare in rural Australian hospitals has necessitated general surgeons to take up the challenge and expand their expertise to advanced endoscopy techniques including endoscopic retrograde cholangiopancreatography (ERCP). This study examines the utility of ERCP in a regional setting especially in decreasing patient transfers and associated costs while achieving exceptional safety by measuring key indicators of safety and efficacy. METHODS: A single-centre retrospective cross-sectional cohort review in a rural Queensland hospital of patients who underwent ERCP (emergent and elective) from January 2019 until July 2022. Standardized international ERCP performance indicators were collected and compared to benchmark literature values including the rate of cannulation, stone extraction, successful stent placement, and post-ERCP pancreatitis. RESULTS: The majority of the ERCP performance indicator benchmarks were met. 100% of patients had an appropriate indication for the procedure and consent. 98.95% successful CBD cannulation with only 14.14% requiring multiple attempts. 92.22% successful stone retrieval with 100% stent placement, well above guideline targets. The post-procedural complication rate was 6.81% (2.09% pancreatitis; 1.05% pancreatitis; 1.05% duodenal perforation). Antibiotic prophylaxis adherence was identified to require improvement (12.57%). CONCLUSION: High-quality ERCP procedures can be performed in a regional hospital by general surgeons in a safe and cost-effective manner, significantly decreasing the costs associated with patient transfer. This study reflects strong evidence for consistently achieving international ERCP performance benchmarks and the provision of high-quality healthcare by a regional hospital and provides a strong argument for increasing access to ERCP in rural and remote hospitals.

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BACKGROUND: The complex and critically unwell upper gastrointestinal bleeding (UGIB) patient is a common emergency presentation in Australia. Managed medically and endoscopically by rural general surgeons in rural and remote Australian hospitals which lack a gastroenterology service, this can be ameliorated by clear evidence-based guidelines. METHODS: A single-centre retrospective review of adult patients who underwent emergency gastroscopy for UGIB at the Mackay Base Hospital, January 2019 to January 2022. Detailed patient data from the assessment, resuscitation, time to endoscopy, endoscopic intervention, and outcomes were compared against key international gastroenterology society safety and quality standards for UGIB. RESULTS: Two hundred patients had a comprehensive initial assessment and resuscitation with PRBC (39%), anticoagulation reversal (18%), pantoprazole infusion (81%), tranexamic acid (10.50%) and octreotide (16.50%). Risk scores were calculated retrospectively as none were documented. Time-to-endoscopy targets were achieved in over 70% of variceal or non-variceal UGIB patients. Bleeding was found in 59.50% of patients but 63% of patients did not require a manoeuvre to stop the bleeding. Post-operative complications were scarce. CONCLUSION: This study reflects on the need for a local multidisciplinary protocol to help expedite the current high-quality healthcare delivered by rural general surgeons in managing patients with UGIB. Implementing risk assessment scores would shorten the time to endoscopy in the initial assessment Guidelines would optimize resuscitation ensuring appropriate replacement, medication administration, anticoagulation reversal, and preventing unnecessary therapy. Despite these nuisances, the time to endoscopy, endoscopic intervention, and patient outcomes were largely in line with international quality assurance and safety targets.

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Background The need for chemotherapy treatment is increasing with the growing incidence of cancer worldwide. The insertion of totally implantable venous access devices (TIVADs) is commonly performed by surgeons and radiologists, but the procedures are not without complications. The primary outcome of this review outlines TIVAD insertion success and complication rates between general surgeons and radiologists. The secondary goal of this study is to help identify areas for improvement and consideration when performing TIVAD insertion. Methodology This was a descriptive, three-year, retrospective multicentre study of oncological patients who underwent TIVAD insertion by either general surgeons or radiologists at two peripheral Brisbane hospitals. Results Surgeons performed 61 percutaneous subclavian vein cannulations, 29 ultrasound-guided internal jugular veins, and seven open cephalic veins cut-down TIVAD insertions (n=97). Overall surgical success was 81.4%, with the internal jugular (89.7%) having the highest success rate followed by the open cut-down (85.7) and subclavian approaches (77.0%). The overall surgical complication rate was 16.4%, with five pneumothorax, five port malfunctions, three haemorrhages, two infections, one thrombus, and one mediastinal injury. Each pneumothorax was associated with subclavian cannulation attempts. Two haemorrhages were associated with both open cephalic and subclavian attempts. Radiologists performed 248 ultrasound-guided internal jugular vein TIVAD insertions (n=248) with 247 successful first attempts (99.5%). Within the radiology group, there was an overall complication rate of 15.3% with 22 infections, 14 port malfunctions, one haemorrhage, and 1 mediastinal injury. Conclusion Ultrasound-guided internal jugular vein TIVAD insertion had the highest first attempt success rate in both the surgical and radiology groups.

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Situs inversus is described as exact mirroring of the normal anatomical arrangement of the major visceral organs. Polysplenia is a congenital anomaly associated with situs inversus and causes various splenic abnormalities. This case discusses a 62-year-old female who presented to the emergency department with hypotension and abdominal pain. Commuted tomography reveals situs inversus and a lobulated mass in the right upper quadrant consistent with a splenic rupture intraoperatively. This is the first reported case of a spontaneous splenic rupture in a patient with situs inversus. This case highlights the rarity of splenic injuries in situs inversus and the unique anatomical challenges that surgeons are faced with intraoperatively in a high-pressure environment.

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BACKGROUND: The incidence of colonic diverticulitis is increasing. In Australia the majority of diverticulitis occurs in the left colon and patients typically undergo colonoscopy following an attack. At present debate exists regarding the utility of this costly procedure and a flexible sigmoidoscopy has been proposed as a cheaper, less invasive alternative. This paper seeks to examine whether significant pathology is being detected in the right and transverse colon to warrant colonoscopy, as opposed to a flexible sigmoidoscopy. METHODS: A retrospective review of colonoscopies performed between August 2016 and August 2018, indicated by diverticulitis alone, performed in a single Australian metropolitan hospital. RESULTS: 189 patient colonoscopies were reviewed in combination with the pathology forms. Only 1 primary colonic malignancy was detected, found in the left colon. 110 traditional adenomas and 35 sessile serrated adenomas were detected. 41.8% of patients had a polyp detected with an average of 1.9 polyps per patient. 38.6% of polyps were resected from the left colon while 61.4% were removed from the right and transverse colon. In total 30 polyps > 10 mm or with high-risk histological features were resected, 18 (60%) from the left colon and 12 (40%) from the right and transverse. 20 patients (10.6%) met the criteria for high-risk adenomas and 50% of those had > 40% of their polyps in the right and transverse colon. There was no significant difference in age between patients with polyps and those without. CONCLUSION: Despite over half the patients having no polyps and only one left sided malignancy. This study demonstrates that the right and transverse colon is responsible for over 50% of the polyps removed and similar proportion of the advanced polyps. Where endoscopic surveillance after acute colonic diverticulitis is performed, this study supports the use of colonoscopy and cautions against flexible sigmoidoscopy alone.

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BACKGROUND: Patient complaints are an underutilized and under-addressed issue in general surgery. They represent a unique sphere of interaction for surgeons and patients to understand motivations and failures in the delivery of healthcare. The aims of this study were to identify motivators of patient complaints and understand surgeon's awareness of this issue. METHODS: A retrospective review of patient complaint data in a single regional general surgical department was undertaken between the periods October 2017 to June 2020 and June 2018 to October 2020 relating to patient demographics and subject of complaint. Secondly, an anonymous survey was conducted across the same department and results tabulated by seniority. RESULTS: Two hundred and nineteen complaints were received during the study period. One hundred and thirteen were made by patients, while 56 were made by family members. One hundred and fifty-nine complaints were related to an inpatient episode of care, and 152 were made in writing. The majority of complainants were female, with a mean age of 52. The most common reason for complaint was "treatment" (n = 102), followed by communication (n = 48), and humaneness/caring (n = 44). Consultant surgeons and surgical trainees placed communication, humaneness/caring, and professionalism as most likely to incite complaints, while interns were more likely to prioritize other measures such as patient healthcare rights and medications. CONCLUSION: Patient complaints remain a relatively under-utilized resource in addressing the downfalls of general surgical departments. This study reports patient demographics that are congruent with the literature and highlights that surgeons prioritize many non-technical skills in the maintenance of the doctor-patient relationship, in contrast to preconceptions.

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BACKGROUND: Keratinocyte skin cancers are common in Australia, incurring disproportionately high health expenditure in comparison with mortality. General surgeons often excise these lesions as day-surgery. Balancing individual complexities of these cancers with trainee supervision and health expenditure is key to deliver efficacious care and maintain day-surgery volume for patients during a pandemic. METHODS: A retrospective, cross-sectional study was performed, examining 414 procedures from January 2019 to December 2020. Pathology was reviewed, and benign lesions excluded. Complete excision was based on 5 mm margins for squamous cell carcinoma (SCC), 0.5 mm microscopic margins for low-risk basal cell carcinoma (BCC) subtypes, and 3 mm for high-risk. Results of trainee-performed local anesthetic (LA) excision and general anesthetic (GA) excision (consultant scrubbed) were compared. RESULTS: 288 excisions were reviewed for completeness, location, and reconstruction modality. 69% were BCC (199), and 31% were SCC (89). These were excised under GA (72.5%) and LA (27.5%). 25.6% of BCC excisions were "close," and 22.6% were "positive" under GA, whilst 31% were "close" and 15.5% were "positive" under LA. 52.8% of SCC excisions were "close," and 7.8% were "positive" under GA, compared with 42.8% "close" and 9.5% "positive" under LA. Complex reconstruction (skin graft, flap) was more common under GA (38% SCC and 36.1% BCC), but occurred at a modest rate under LA (22% BCC and 28.5% SCC). CONCLUSIONS: The results confirm that comparable margins and reconstruction options are achievable when excising keratinocyte cancers under LA by surgical trainees. This is fundamental in cost and timesaving, as well as reducing risk of aerosolisation of virus during GA, in a pandemic.

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Leiomyosarcomas are rare, primary malignancies that can be found in the small bowel in a minority of cases. The management of these visceral sarcomas remains controversial, with surgical resection forming the mainstay, being optimally achieved in a unit familiar with the management of sarcomas. These tumours are difficult to diagnose based on history and are challenging to localize on conventional imaging modalities. We report a case of a 61-year-old female who proceeded to emergent laparotomy with imaging suggestive of small bowel ischaemia secondary to portal venous thrombosis. Incidental leiomyosarcoma was noted on histology and was discussed at local multidisciplinary meeting regarding further management.

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Fire or combustion occurring during laparotomy is an uncommon and potentially hazardous event that can be precipitated by the use of surgical energy devices in the presence of enteric gases or exogenous materials present in the abdomen such as alcohol. Oxygen necessary for a combustive event can be increased in the setting of a proximal enteric injury and with higher concentrations of inspired oxygen during anaesthesia. We report on a case of combustion on entry to the abdomen using monopolar diathermy during exploratory laparotomy for gastric antral perforation in the presence of alcohol and enteric gases.

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Cutaneous metastases are rare and often late signs of an internal malignancy; however, this can be the presenting sign in very rare cases. These typically have a characteristic appearance and distribution based on the underlying malignancy but can be difficult to distinguish from other malignant or benign dermatoses. We report a case of a 69-year-old female who presented for elective excision of two cutaneous, fast-growing lesions on the chest wall. The patient's past medical history is significant for a 45-pack-year smoking history. Pre-operative chest radiograph revealed a right upper lobe mass, with the lesions ultimately representing cutaneous metastases of a non-small-cell lung cancer. Although cutaneous metastases have been reported, difficulty remains in distinguishing other causes of cutaneous lesions from cutaneous metastases in the predominantly asymptomatic patient.

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BACKGROUND: Diverticular disease and its spectrum of complications are increasingly encountered in the Australian population. Accurate management of patients before and after an acute episode entails extension beyond the acute event to include dietary advice and colonoscopy. OBJECTIVE: The objectives of this article are to evaluate the literature regarding dietary factors and diverticular disease, routine colonoscopy and antibiotic treatment in acute diverticulitis, to enable primary care physicians to manage patients and provide sound advice after hospital admission. DISCUSSION: Diverticulitis can often be managed in the community by general practitioners, but the necessity of antibiotics may not be definitive. When patients do require hospital admission, advice and management of patient lifestyle factors after admission, and investigations to rule out red flags are crucial. These elements of patient management are the subject of debate, as it appears that standard dietary advice does not alter a patient's clinical course, and colonoscopy is not always necessary and should be used judiciously.

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