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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. High but decreasing rates of reconstruction after total proctocolectomy for ulcerative colitis, and evidence of a direct volume outcome relationship. ANZ J Surg 2024. [PMID: 38525855 DOI: 10.1111/ans.18986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/19/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Total (procto)colectomy is indicated in 15%-20% of ulcerative colitis(UC) patients during their disease course. Reconstruction options to avoid a permanent ileostomy include an ileoanal pouch anastomosis (IPAA) or ileorectal anastomosis (IRA). This study aimed to investigate reconstruction rates using Australian-based population-level data, and factors influencing reconstruction. METHODS A retrospective data linkage study of the NSW population over a 19-year period was performed. Patients with UC who underwent total (procto)colectomy with a minimum of 1-year follow up were included. The main outcome was reconstruction with either IPAA or IRA. The influence of hospital and patient factors on reconstruction rates was assessed by Cox regression. RESULTS Overall, 1047 patients underwent a (procto)colectomy for UC (mean age 45.9 years [SD ± 18.3], 640 [61.1%] male). The 5-year reconstruction rate was 55% (IPAA 89%). Advanced age, emergent colectomy, higher comorbidity burden, and geographical remoteness were significantly associated with lower reconstruction rates. A lower reconstruction rate was also observed in the most recent time-period (2014-2019) (aHR 0.68[95% CI 0.54-0.86]), and where index (procto)colectomy was performed in low-volume (<1 pouch/year) pouch hospitals (aHR 0.60 [95% CI 0.43-0.82]). CONCLUSIONS NSW Australia has the highest reported rate of reconstruction following UC (procto)colectomy globally. However, rates reduced in the most recent time-period. There was variation in reconstruction rates across centres, with primary and overall reconstruction rates proportionate to hospital pouch volume. Reconstruction rates were also lower for patients living outside major cities. To ensure equitable opportunities for reconstruction, patients being considered for IBD pouch surgery should be centralized to a limited number of specialist pouch centres.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joe Van Buskirk
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. Reducing rate of total colectomies for ulcerative colitis but higher morbidity in the biologic era: an 18-year linked data study from New South Wales Australia. ANZ J Surg 2023; 93:2928-2938. [PMID: 37795917 DOI: 10.1111/ans.18713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND This study aims to investigate the trends in UC surgery in New South Wales (NSW) at a population level. METHODS A retrospective data linkage study of the NSW population was performed. Patients of any age with a diagnosis of UC who underwent a total abdominal colectomy (TAC) ± proctectomy between Jul-2001 and Jun-2019 were included. The age adjusted population rate was calculated using Australian Bureau of Statistics data. Multivariable linear regression modelled the trend of TAC rates, and assessed the effect of infliximab (listed on the Pharmaceutical Benefits Scheme for UC in Apr-2014). RESULTS A total of 1365 patients underwent a TAC ± proctectomy (mean age 47.0 years (±18.6), 59% Male). Controlling for differences between age groups, the annual rate of UC TACs decreased by 2.4% each year (95% CI 1.4%-3.4%) over the 18-year period from 1.30/100000 (2002) to 0.84/100000 (2019). An additional incremental decrease in the rate of TACs was observed after 2014 (OR 0.83, 95% CI 0.69-1.00). There was no change in the proportion of TACs performed emergently over the study period (OR 1.02, 95% CI 0.998-1.04). The odds of experiencing any perioperative surgical complication (aOR 1.54, 95% CI 1.01-2.33, P = 0.043), and requiring ICU admission (aOR 1.85, 95% CI 1.24-2.76, P = 0.003) significantly increased in 2014-2019 compared to 2002-2007. CONCLUSIONS The rate of TACs for UC has declined over the past two decades. This rate decrease may have been further influenced by the introduction of biologics. Higher rates of complications and ICU admissions in the biologic era may indicate poorer patient physiological status at the time of surgery.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joe Van Buskirk
- Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Giddings HL, Ng KS, Solomon MJ, Steffens D, Van Buskirk J, Young J. Population outcomes, trends and the future of pouch surgery for ulcerative colitis: a 19-year New South Wales data linkage study. ANZ J Surg 2023; 93:2686-2696. [PMID: 37449791 DOI: 10.1111/ans.18588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Ileal pouch-anal anastomosis (IPAA) is considered the gold standard reconstructive option in ulcerative colitis (UC). Recent efforts to improve pouch outcomes have seen a push towards centralisation of surgery. This study aimed to document outcomes following pouch surgery at a population level within New South Wales (NSW), and identify factors associated with, and temporal trends of these outcomes. METHODS A retrospective data linkage study of the NSW population over a 19-year period was performed. The primary outcome was pouch failure in patients with UC who underwent IPAA. The influence of hospital level factors (including annual volume) and patient demographic variables on this outcome were assessed using Cox proportional hazards modelling. Temporal trends in annual volume and evidence for centralisation over the studied period were assessed using Poisson regression analysis. RESULTS The annual volume of UC pouches reduced over the study period. The pouch failure rates were 8.6% (95% CI 6.3-10.8%) and 10.6% (95% CI 8.0-13.1%) at 5- and 10-years, respectively. Increasing age and non-elective admission were associated with higher failure rates. One-third of UC pouches (31.6%) were performed in a single institution, which averaged 6.5 pouches/year throughout the study period. Three-quarters (19/25) of NSW public hospitals who performed pouches performed less than one UC pouch annually. CONCLUSIONS The outcomes following UC pouch surgery in NSW are comparable with global standards. Concentrating IBD pouch surgery with the aim of producing specialist surgical teams may be a reasonable way forward in NSW and would ensure equity of access and facilitate research and training collaboration.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, New South Wales, Australia
| | - Joe Van Buskirk
- Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, New South Wales, Australia
- Public Health Research Analytics and Methods for Evidence, Sydney Local Health District, New South Wales, Australia
| | - Jane Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Giddings HL, McNeill J, Rahman B, Meagher AP, Gett R, Lord RV. Effectiveness of an Oral Gastrografin Regimen for Complete Distal Intestinal Obstruction Syndrome. Ann Surg Open 2023; 4:e279. [PMID: 37601469 PMCID: PMC10431405 DOI: 10.1097/as9.0000000000000279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/12/2023] [Indexed: 08/22/2023] Open
Abstract
Objectives To assess the effectiveness of oral Gastrografin treatment and outcomes in adult patients with complete distal intestinal obstruction syndrome (cDIOS). Background DIOS is an important gastrointestinal complication of cystic fibrosis (CF). Conservative treatment options for cDIOS are largely empirical, and the optimal management remains unclear. Surgery should be reserved for patients who have failed nonoperative treatment or have immediate indications for surgery. Methods A retrospective single-institution cohort study was undertaken of adults with CF who had undergone lung transplantation and were admitted with an episode of cDIOS between 2004 and 2020. The outcomes of treatment in a high-volume CF transplant center with routine oral Gastrografin-based therapy were assessed. Results Forty-seven episodes of cDIOS were recorded in 29 (23.3%) of 124 patients who had undergone lung transplantation for CF, and mean age at cDIOS was 30.3 years (SD ±11.2). Mean follow-up post cDIOS was 75.6 months (SD ±45.5). Twelve patients had >1 cDIOS episode. One episode occurred during recovery after transplantation, and 5 patients were readmitted within 30 days posttransplant with cDIOS. A history of previous abdominal surgery was associated with the development of cDIOS (P < 0.001). Oral Gastrografin therapy was used in 95.7% of the episodes, at varying doses. Three patients (7.0%) were resistant to oral Gastrografin treatment, requiring laparotomy. There were no deaths due to DIOS. Conclusions Oral Gastrografin is effective and safe for the treatment of cDIOS, with low treatment failure rates. It should be considered as a first-line treatment option for patients with CF presenting with complete distal intestinal obstruction.
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Affiliation(s)
- Hugh L Giddings
- From the Department of General Surgery, St Vincent's Hospital, Sydney, Australia
- Department of Surgery, School of Medicine, University of Notre Dame Australia, Sydney, Australia
| | - Jared McNeill
- From the Department of General Surgery, St Vincent's Hospital, Sydney, Australia
| | - Bayzidur Rahman
- Department of Epidemiology and Biostatistics, School of Medicine, University of Notre Dame Australia, Sydney, Australia
- The Kirby Institute, Faculty of Medicine and Health, UNSW Sydney, Australia
| | - Alan P Meagher
- From the Department of General Surgery, St Vincent's Hospital, Sydney, Australia
- Department of Surgery, School of Medicine, University of Notre Dame Australia, Sydney, Australia
| | - Rohan Gett
- From the Department of General Surgery, St Vincent's Hospital, Sydney, Australia
- Department of Surgery, School of Medicine, UNSW Australia, Sydney, Australia
| | - Reginald V Lord
- From the Department of General Surgery, St Vincent's Hospital, Sydney, Australia
- Department of Surgery, School of Medicine, University of Notre Dame Australia, Sydney, Australia
- St. Vincent's Centre for Applied Medical Research, Sydney, Australia
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Giddings HL, Wong J, Meagher AP. Should we inform women about the recognised risks of childbirth? Aust N Z J Obstet Gynaecol 2021; 62:37-39. [PMID: 34328214 DOI: 10.1111/ajo.13411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND At present in Australia women are not routinely, systematically informed of the risks of childbirth. AIMS It is hoped this presentation of the perspective of some women who suffer unexpected obstetric complications will encourage change. MATERIALS AND METHODS The experience of women involved in obstetric medicolegal reports prepared by a colorectal surgeon over ten years is analysed. RESULTS Twenty women were identified. Sixteen had vaginal deliveries. All 16 suffered third or fourth-degree tears, six developed rectovaginal fistulae, six required stomas and 11 developed faecal incontinence. Of the four women who delivered by caesarean section, there were two post-operative caecal perforations, one unrecognised small bowel enterotomy, and one patient developed sepsis due to an infected haematoma. Seventeen of the 20 women were noted to suffer psychological sequalae. None of the women recollected being warned of the complication they suffered, and there was no record of such warnings in their medical records. CONCLUSION Informed written 'consent' for natural vaginal delivery is, understandably, a contentious topic. Although learning from medicolegal cases may go against the grain, as medical professionals it is very difficult to ethically justify the status quo, where women are not routinely simply informed of the risks of childbirth. This is not fair. Even if informing women does not decrease the incidence of complications, the women who subsequently suffer these complications may well handle them much better, recognising they could occur.
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Affiliation(s)
- Hugh L Giddings
- Department of Colorectal Surgery, St Vincent's Hospital, Sydney, Australia
| | - Jean Wong
- Department of Colorectal Surgery, St Vincent's Hospital, Sydney, Australia
| | - Alan P Meagher
- Department of Colorectal Surgery, St Vincent's Hospital, Sydney, Australia
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Giddings HL, Fenton-Lee D. Australian general surgical trainee experience with inguinal hernia surgery: a review of international training programmes and the learning curve. ANZ J Surg 2021; 91:1138-1142. [PMID: 33908142 DOI: 10.1111/ans.16897] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/12/2021] [Accepted: 04/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are no publications addressing the level of experience Australian surgical trainees achieve in inguinal hernia surgery. Internationally, some training boards have set minimum competency requirements, but this is not true in Australia. The longer learning curve for laparoscopic inguinal hernia repairs (LIHRs) compared to open inguinal hernia repairs (OIHRs) has placed greater demands on trainees. METHODS Logbook data on OIHR and LIHR for Australian surgical trainees who graduated as fellows between 2013 and 2018 were obtained. A literature review was performed to analyse international published logbook numbers for surgical trainees from the past decade. International training board requirements, estimations of the learning curve and hernia society guidelines for each procedure were reviewed. RESULTS In total, 7946 operations were recorded from 58 trainees. On average 49.2 OIHRs (range 13-101), 21.5 LIHRs (range 1-94) and 71.1 inguinal hernia repairs overall (range 25-129) were performed during training. The European Hernia Society recommends that at least 30-50 of each procedure be performed during training. The learning curves for LIHRs (50-100 procedures) have been shown to be longer than for OIHRs (40-64 procedures). CONCLUSION Australian general surgical trainees are achieving adequate primary operator logbook numbers for OIHRs but are not completing the required number of LIHRs. The tailored approach to inguinal hernia repair requires skill in both open and laparoscopic repairs. This may not be possible with the current training structure in Australia.
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Affiliation(s)
- Hugh L Giddings
- Department of General Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Douglas Fenton-Lee
- Department of General Surgery, St Vincent's Hospital, Sydney, New South Wales, Australia
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Seccombe LM, Giddings HL, Rogers PG, Corbett AJ, Hayes MW, Peters MJ, Veitch EM. Abnormal ventilatory control in Parkinson's disease—Further evidence for non-motor dysfunction. Respir Physiol Neurobiol 2011; 179:300-4. [DOI: 10.1016/j.resp.2011.09.012] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 09/02/2011] [Accepted: 09/21/2011] [Indexed: 10/17/2022]
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