Dr Peter Pockney

© 2020 Royal Australasian College of Surgeons Background: Opioid over-prescription following surgery is a significant public health issue in most developed countries. Multiple studies have been conducted in the USA demonstrating and investigating the issue; however, there is a lack of literature addressing this topic in the Australian setting. The aim of this study is to review prescribing practices at an Australian tertiary referral hospital on discharge in patients having undergone laparoscopic cholecystectomy (LC) or laparoscopic appendicetomy (LA). Additionally, to identify potential factors which influence medical officer prescribing practices. Methods: A retrospective observational study on opioid prescribing practice on all patients who underwent LC or LA over a 12-month period at an Australian tertiary referral hospital. Results: A total of 435 patients (223 LC, 214 LA) were prescribed a mean opioid dose on discharge of 25 oral morphine milli-equivalents (range 0¿180 morphine milli-equivalents). Less opioids were prescribed following elective procedures (42% versus 10%, P < 0.001). There is a downward trend of opioid prescribing on discharge as the Junior Medical Officer clinical year progresses (P < 0.001). Conclusions: This study demonstrates a lower rate of opiate prescription on discharge for LC and LA in an Australian setting when compared to the US data. There is a wide diversity of prescribing demonstrated. This indicates the need for better training of opioid prescribers to reduce over-prescribing.

© 2020 BJS Society Ltd Published by John Wiley & Sons Ltd Background: Ileus is common after colorectal surgery and is associated with an increased risk of postoperative complications. Identifying features of normal bowel recovery and the appropriateness for hospital discharge is challenging. This study explored the safety of hospital discharge before the return of bowel function. Methods: A prospective, multicentre cohort study was undertaken across an international collaborative network. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The main outcome of interest was readmission to hospital within 30 days of surgery. The impact of discharge timing according to the return of bowel function was explored using multivariable regression analysis. Other outcomes were postoperative complications within 30 days of surgery, measured using the Clavien¿Dindo classification system. Results: A total of 3288 patients were included in the analysis, of whom 301 (9·2 per cent) were discharged before the return of bowel function. The median duration of hospital stay for patients discharged before and after return of bowel function was 5 (i.q.r. 4¿7) and 7 (6¿8) days respectively (P < 0·001). There were no significant differences in rates of readmission between these groups (6·6 versus 8·0 per cent; P = 0·499), and this remained the case after multivariable adjustment for baseline differences (odds ratio 0·90, 95 per cent c.i. 0·55 to 1·46; P = 0·659). Rates of postoperative complications were also similar in those discharged before versus after return of bowel function (minor: 34·7 versus 39·5 per cent; major 3·3 versus 3·4 per cent; P = 0·110). Conclusion: Discharge before return of bowel function after elective colorectal surgery appears to be safe in appropriately selected patients.

© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians) We conducted a systematic review of the literature to establish the prevalence of and predictive factors for parental decision regret in hypospadias surgery. A search strategy without language restrictions was developed with expert help, and two reviewers undertook independent study selection. Five studies were included in this review (four for quantitative analysis) with a total of 783 participants. The mean overall prevalence of parental decision regret was 65.2% (moderate to severe ¿ 20.3%). Although significant predictors of regret were identified (post-operative complications, small size glans, meatal location, decision conflict between parents, parental educational level and others), they had unexplained discordance between studies. Parental decision regret after proximal hypospadias surgery and refusing surgery was inadequately reported. In conclusion, even though the prevalence of parental decision regret after consenting for the hypospadias repair appears to be high, risk factors associated with it were discordant suggesting imprecision in estimates due to unknown confounders.

© 2019 BJS Society Ltd Published by John Wiley & Sons Ltd Background: Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non-steroidal anti-inflammatory drugs (NSAIDs) for reducing ileus after surgery. Methods: A prospective multicentre cohort study was delivered by an international, student- and trainee-led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre-specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury. Results: A total of 4164 patients were included, with a median age of 68 (i.q.r. 57¿75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1¿3, of whom 1061 (92·0 per cent) received non-selective cyclo-oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001). Conclusion: NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.

© 2019 Background: The National Emergency Laparotomy Audit (NELA) highlights the importance of identifying high-risk patients due to the potential for significant morbidity and mortality. The NELA risk prediction calculator (NRPC) was developed from data in England and Wales and is one of several calculators available. We seek to determine the utility of NRPC in the Australian population and compare it with Portsmouth Physiological and Operative Severity Score for the enumeration of mortality and Morbidity (P-POSSUM) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) calculators. Methods: A retrospective review of all emergency laparotomies undertaken at four Australian centers was performed between January 2016 and December 2017. Data extracted from patient records were used to calculate NRPC, ACS-NSQIP, and P-POSSUM scores for 30-day mortality risk. The sensitivity of NRPC was assessed using the NELA high-risk cohort score of =10% and this was compared with the other two calculators. Results: There were 562 (M = 261, mean age = 66 [±17] y) patient charts reviewed in the study period. 59 patients died within 30 d (10.5%). NRPC was able to identify 52 (sensitivity = 88.1%) of these as being within the high-risk group. Using the NELA high-risk cutoff, NRPC identified 52 deaths of 205 (25.4%) high-risk patients, P-POSSUM identified 46 of 245 (18.8%), and ACS-NSQIP identified 46 of 201 (22.9%). Using the McNemar test, no significant difference was noted between NRPC and P-POSSUM (P = 0.07) or NRPC and ACS-NSQIP (P = 0.18). Conclusions: In the Australian context, the NRPC is a highly sensitive and useful tool for predicting 30-day mortality in high-risk emergency laparotomy patients and is comparable with P-POSSUM and ACS-NSQIP calculators.

© 2020 The Association of Coloproctology of Great Britain and Ireland Aim: Aspiration is a common cause of pneumonia in patients with postoperative ileus. Insertion of a nasogastric tube (NGT) is often performed, but this can be distressing. The aim of this study was to determine whether the timing of NGT insertion after surgery (before versus after vomiting) was associated with reduced rates of pneumonia in patients undergoing elective colorectal surgery. Method: This was a preplanned secondary analysis of a multicentre, prospective cohort study. Patients undergoing elective colorectal surgery between January 2018 and April 2018 were eligible. Those receiving a NGT were divided into three groups, based on the timing of the insertion: routine NGT (inserted at the time of surgery), prophylactic NGT (inserted after surgery but before vomiting) and reactive NGT (inserted after surgery and after vomiting). The primary outcome was the development of pneumonia within 30¿days of surgery, which was compared between the prophylactic and reactive NGT groups using multivariable regression analysis. Results: A total of 4715 patients were included in the analysis and 1536 (32.6%) received a NGT. These were classified as routine in 926 (60.3%), reactive in 461 (30.0%) and prophylactic in 149 (9.7%). Two hundred patients (4.2%) developed pneumonia (no NGT 2.7%; routine NGT 5.2%; reactive NGT 10.6%; prophylactic NGT 11.4%). After adjustment for confounding factors, no significant difference in pneumonia rates was detected between the prophylactic and reactive NGT groups (odds ratio 1.03, 95% CI 0.56¿1.87, P¿=¿0.932). Conclusion: In patients who required the insertion of a NGT after surgery, prophylactic insertion was not associated with fewer cases of pneumonia within 30¿days of surgery compared with reactive insertion.

© 2018 Royal Australasian College of Physicians Background: A direct access colonoscopy service (DACS) for the National Bowel Cancer Screening Program has become standard of care in Newcastle public hospitals because of the effect it has on time to colonoscopy. Cost-effectiveness has not been studied to date. Aim: The aim of this retrospective study was to analyse the cost-effectiveness of a DACS. Methods: Data were collected for patients referred to DACS between January 2014 and June 2016, and patients who were treated on the normal service pathway in 2013 prior to the introduction of the process. A cost-benefit analysis from the patient¿s and local health district¿s perspective was undertaken. Results: Introduction of the DACS produces a direct financial gain to patients in the form of reduced direct costs. It produces an indirect financial gain in terms of increased productivity if the patient is in work, and of increased leisure time if not in work. The DACS is modest income generating for the local health district, an evaluation which is sensitive to internal policies for distribution of government funding within a district. The DACS increases the availability of outpatient consultations to other patients, which is not a quantifiable economic benefit, but is likely to be an overall health benefit. Conclusion: The introduction of DACS in the public system in Australia is of financial benefit to patients and to the local health service provider. It is likely to produce health benefits to non-screening patients, by means of freeing consultations to be used for other indications.

© 2018 Royal Australasian College of Physicians Background: The 2017 National Bowel Cancer Screening Program report records a median time from positive faecal occult blood test to colonoscopy of 53 days. There is some intrinsic delay in accessing specialist medical opinion prior to colonoscopy. Aim: To examine the effect of the introduction of a Direct Access Colonoscopy Service (DACS). Methods: Using prospectively maintained databases, patients undergoing normal service (NS) colonoscopy and those referred to DACS were compared. The primary outcome measure was the time from general practitioner (GP) referral to colonoscopy. Secondary outcome measures included the proportion of patients who met the current recommended 30 days from GP referral to colonoscopy, and the proportion of patients who waited longer than 90 days. Results: There were 289 patients in the NS group, and 601 patients who progressed on the DACS pathway. The demographics of both groups were comparable. DACS patients had a median waiting time of 49 days, significantly shorter than NS patients whose median wait was 79 days (P < 0.0001). Approximately 15.1% patients in the DACS group had their colonoscopy within 30 days from GP referral, significantly better than in the NS group (4.5%, P < 0.001). In the NS group, 41.2% patients waited longer than 90 days from GP referral to colonoscopy, compared with 16.3% in the DACS group (P < 0.001). Conclusion: DACS reduces waiting times to colonoscopy and is associated with an increased proportion of patients undergoing colonoscopy in a timely manner.

© 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland Introduction: Previous studies have shown single CRP measurements at time of presentation to have limited predictive benefit for appendicitis. Our objective was to determine the diagnostic utility of serial CRP measurements (to determine CRP velocity [CRPv]) in patients with right iliac fossa (RIF) pain. Methods: A single-centre prospective observational study was conducted on adult patients admitted with RIF pain. CRP was measured on admission, at midnight, and the following morning. Appendicitis was diagnosed on histopathology, or diagnostic imaging in non-operatively managed patients. Therapeutic interventions included all appropriate operative procedures and effective non-operative treatment with antibiotics. Logistic regression was used to generate predictors of therapeutic intervention, and then used to create a new risk score incorporating CRPv. Results: 98 of 112 (87.5%) participants had complete CRP data. 58 patients met the criteria for appendicitis (59.2%). Most patients presented with intermediate Modified Alvarado Scores (MAS) 5¿6 (40.8%) or Appendicitis Inflammatory Response Scores (AIRS) 5¿8 (49%). Our risk score had an AUROC of 0.88 (95% CI 0.81¿0.96) in predicting therapeutic intervention. This score was superior to MAS, AIRS, and single admission biomarker measurements. Patients with an increasing CRPv had 14 times the odds (OR 14.07, 95% CI 0.63¿315.2) of complicated appendicitis, and no cases of complicated appendicitis were observed in patients with a flat CRPv. Conclusions: CRP velocity is superior to single CRP at predicting intervention. Our v-Score shows promise as a decision making-aide by predicting the need for surgical intervention in RIF pain. A flat CRPv identifies a group of patients with a very low risk of complicated appendicitis.

© 2018 Elsevier Inc. Background: Circulating tumour DNA (ctDNA) has emerged as an excellent candidate for the future of liquid biopsies for many cancers. There has been growing interest in blood-based liquid biopsy because of the potential of ctDNA to produce a noninvasive test that can be used for: the diagnosis of colorectal cancer, monitoring therapy response, and providing information on overall prognosis. The aim of this review was to collate and explore the current evidence regarding ctDNA as a screening tool for colorectal cancer (CRC). Methods: A systematic review of published articles in English over the past 20 y was performed using Medline, Embase, and Cochrane databases on May 23, 2017. After a full-text review, a total of 69 studies were included. Two assessment tools were used to review and compare the methodological quality of these studies. Results: Among the 69 studies included, 17 studies reviewed total cfDNA, whereas six studies looked at the DNA integrity index and 15 focused on ctDNA. There were a total of 40 studies that reviewed methylated cfDNA with 19 of these focussing specifically on SEPT9. Conclusions: The results of this review indicate that methylated epigenetic ctDNA markers are perhaps the most promising candidates for a blood-based CRC-screening modality using cell-free (cf) DNA. Methylated cfDNA appears to be less specific for CRC compared to ctDNA; however, they have demonstrated good sensitivity for early-stage CRC. Further research is required to determine which methylated cfDNA markers are the most accurate when applied to large cohorts of patients. In addition, reliable comparison of results across multiple studies would benefit from standardization of methodology for DNA extraction and PCR techniques in the future.

© 2017 The American Society of Colon and Rectal Surgeons, Inc. BACKGROUND: Lower GI hemorrhage is a common source of morbidity and mortality. Tranexamic acid is an antifibrinolytic that has been shown to reduce blood loss in a variety of clinical conditions. Information regarding the use of tranexamic acid in treating lower GI hemorrhage is lacking. OBJECTIVE: The aim of this trial was to determine the clinical efficacy of tranexamic acid when used for lower GI hemorrhage. DESIGN: This was a prospective, double-blind, placebo-controlled, randomized clinical trial. SETTINGS: The study was conducted at a tertiary referral university hospital in Australia. PATIENTS: Consecutive patients aged >18 years with lower GI hemorrhage requiring hospital admission from November 2011 to January 2014 were screened for trial eligibility (N = 265). INTERVENTIONS: A total of 100 patients were recruited after exclusions and were randomly assigned 1:1 to either tranexamic acid or placebo. MAIN OUTCOME MEASURES: The primary outcome was blood loss as determined by reduction in hemoglobin levels. The secondary outcomes were transfusion rates, transfusion volume, intervention rates for bleeding, length of hospital stay, readmission, and complication rates. RESULTS: There was no difference between groups with respect to hemoglobin drop (11 g/L of tranexamic acid vs 13 g/L of placebo; p = 0.9445). There was no difference with respect to transfusion rates (14/49 tranexamic acid vs 16/47 placebo; p = 0.661), mean transfusion volume (1.27 vs 1.93 units; p = 0.355), intervention rates (7/49 vs 13/47; p = 0.134), length of hospital stay (4.67 vs 4.74 d; p = 0.934), readmission, or complication rates. No complications occurred as a direct result of tranexamic acid use. LIMITATIONS: A larger multicenter trial may be required to determine whether there are more subtle advantages with tranexamic acid use in some of the secondary outcomes. CONCLUSIONS: Tranexamic acid does not appear to decrease blood loss or improve clinical outcomes in patients presenting with lower GI hemorrhage in the context of this trial. see Video Abstract at http://links.lww.com/DCR/A453.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. Objective: This study aims to report short-term clinical and oncological outcomes from the international transanal Total Mesorectal Excision (taTME) registry for benign and malignant rectal pathology. Background: TaTME is the latest minimally invasive transanal technique pioneered to facilitate difficult pelvic dissections. Outcomes have been published from small cohorts, but larger series can further assess the safety and efficacy of taTME in the wider surgical population. Methods: Data were analyzed from 66 registered units in 23 countries. The primary endpoint was "good-quality TME surgery." Secondary endpoints were short-term adverse events. Univariate and multivariate regression analyses were used to identify independent predictors of poor specimen outcome. Results: A total of 720 consecutively registered cases were analyzed comprising 634 patients with rectal cancer and 86 with benign pathology. Approximately, 67% were males with mean BMI 26.5 kg/m 2. Abdominal or perineal conversion was 6.3% and 2.8%, respectively. Intact TME specimens were achieved in 85%, with minor defects in 11% and major defects in 4%. R1 resection rate was 2.7%. Postoperative mortality and morbidity were 0.5% and 32.6% respectively. Risk factors for poor specimen outcome (suboptimal TME specimen, perforation, and/or R1 resection) on multivariate analysis were positive CRM on staging MRI, low rectal tumor <2 cm from anorectal junction, and laparoscopic transabdominal posterior dissection to <4 cm from anal verge. Conclusions: TaTME appears to be an oncologically safe and effective technique for distal mesorectal dissection with acceptable short-term patient outcomes and good specimen quality. Ongoing structured training and the upcoming randomized controlled trials are needed to assess the technique further.