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Biomedical subjects

Guy Maddern

Publications and source records attributed to Guy Maddern.

At least 19 recordsLinked to original sources
PubMed2006

Living donor liver transplantation--adult donor outcomes: a systematic review.

The objective of this study was to evaluate the safety and efficacy of adult-to-adult living donor liver transplantation, specifically donor outcomes. A systematic review, with searches of the literature up to January 2004, was undertaken. Two hundred and fourteen studies provided information on donor outcomes. The majority of these were case series studies, although there were also studies comparing living donor liver transplantation with deceased donor liver transplantation. Both underreporting and duplicate reporting is likely to have occurred, and so caution is required in interpretation of these results. Overall reported donor mortality was 12 to 13 in about 6,000 procedures (0.2%) (117 studies). Mortality for right lobe donors to adult recipients is estimated to be 2 to 8 out of 3,800 (0.23 to 0.5%). The donor morbidity rate ranged from 0% to 100% with a median of 16% (131 studies). Biliary complications and infections were the most commonly reported donor morbidities. Nearly all donors had returned to normal function by 3 to 6 months (18 studies). In conclusion, there are small, but real, risks for living liver donors. Due to the short history of adult-to-adult living donor liver transplantation, the long-term risks for donors are unknown.

Adaptation, Psychological↗
PubMed2006

Laparoscopic radical prostatectomy for localized prostate cancer: a systematic review of comparative studies.

PURPOSE: We compared the safety and efficacy of laparoscopic and open radical prostatectomy through a systematic assessment of the literature. MATERIALS AND METHODS: Literature databases were searched from 1996 to December 2004 inclusive. Studies comparing transperitoneal laparoscopic radical prostatectomy, extraperitoneal endoscopic radical prostatectomy or robot assisted radical prostatectomy with open radical retropubic prostatectomy or radical perineal prostatectomy for localized prostate cancer were included. Comparisons between different laparoscopic approaches were also included. RESULTS: We identified 30 comparative studies, of which none were randomized controlled trials. There were 21 studies comparing laparoscopic with open prostatectomy with a total of 2,301 and 1,757 patients, respectively, and 9 comparing different laparoscopic approaches with a total of 1,148 patients. In terms of safety there did not appear to be any important differences in the complication rate between laparoscopic and open approaches. However, blood loss and transfusions were lower for laparoscopic approaches. In terms of efficacy operative time was longer for laparoscopic than for open prostatectomy but length of stay and duration of catheterization were shorter. Positive margin rates and recurrence-free survival were similar. Continence and potency were not well reported but they appeared similar for the 2 approaches. There were no important differences between laparoscopic approaches. CONCLUSIONS: Laparoscopic radical prostatectomy is emerging as an alternative to open radical prostatectomy but randomized, controlled trials considering patient relevant outcomes, such as survival, continence and potency, with sufficient followup are required to determine relative safety and efficacy.

Humans↗
PubMed2006

National breast cancer audit: overview of invasive breast cancer management.

BACKGROUND: The National Breast Cancer Audit is an initiative of the Breast Section of the Royal Australasian College of Surgeons collecting surgical information in early breast cancer. It is managed in conjunction with the Australian Safety and Efficacy Register of New Interventional Procedures - Surgical. An overview of results for invasive breast cancer from January 1999 until December 2004 is presented to provide preliminary data for participating surgeons. METHODS: Invasive breast cancer cases were retrieved from the National Breast Cancer Audit database for the 274 participating breast surgeons in Australia and New Zealand. Data for a variety of clinical parameters were analysed to provide an overview of the diagnostic, histological, surgical and adjuvant therapy management issues. RESULTS: There were 25,026 cases of invasive breast cancer. Annual percentages of mammographically detected cancers from 1999 to 2004 did not differ significantly. Breast-conserving surgery rates also remained stable at 60%. Margins were involved in 5% of patients; an additional 9% had final margins of less than 1 mm. Radiotherapy followed breast-conserving surgery in most cases (86%). Patients undergoing mastectomy with large tumours (>5 cm) underwent radiotherapy in 71% of cases. When at least four lymph nodes were positive, radiotherapy followed mastectomy in the majority (75%) of cases. The most frequently carried out axillary procedure was a level 2 dissection. Chemotherapy was received by 78% of oestrogen receptor negative, axillary node positive, postmenopausal patients. Tamoxifen was used in the majority (83%) of oestrogen receptor positive cases. CONCLUSION: Surgeons contributing their invasive breast cancer data show a high quality of treatment. Some further improvement may be possibly related to excision margins and tamoxifen prescription for oestrogen receptor negative cancers. Chemotherapy prescription might also warrant further investigation.

Aged↗
PubMed2005

How little is enough? The evidence for post-vasectomy testing.

PURPOSE: Post-vasectomy semen analysis (PVSA) is the traditional method of confirming sterility after vasectomy. However, PVSA protocols vary in the end points accepted, and the number and timing of tests. In this systematic review we make evidence based recommendations on the appropriate PVSA protocol. MATERIALS AND METHODS: Databases (MEDLINE, Current Contents, Cochrane Library and EMBASE) were searched up to and including March 2003. Studies were included if they dealt with post-vasectomy testing and contained data on at least 1 of the time or number of ejaculations to azoospermia, pregnancy, repeat vasectomy and histological analysis of vas specimens. RESULTS: A total of 56 studies were included in the review. Time to achieve azoospermia was variable, although the median incidence of patients with azoospermia was consistently more than 80% after 3 months and after 20 ejaculations. A small percent of patients (14,845 or 1.4%) demonstrated persistent nonmotile sperm, although some of them eventually achieved azoospermia. The reappearance of nonmotile sperm was reported in 7 studies, occurring up to 22 months after vasectomy. CONCLUSIONS: The evidence supports a PVSA protocol with 1 test showing azoospermia after 3 months and 20 ejaculations. If the sample is positive, periodic testing can continue until azoospermia is achieved. Patients with persistent nonmotile sperm in low numbers could be given cautious assurance of success. No evidence was located to support histological testing of the excised vas deferens.

Clinical Protocols↗
PubMed2005

A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals.

OBJECTIVE: To assess the effectiveness of different strategies for increasing the uptake of prophylaxis for venous thromboembolism (VTE) in hospitalized patients through a systematic review of the literature. METHODS: Literature databases and the Internet were searched from 1996 to May 2003. Studies of strategies to improve VTE prophylaxis practice were included. Studies where no policy or guideline was implemented or where the focus of the study was not VTE prevention were excluded. RESULTS: Thirty studies were included. The quality of the available evidence was average with the majority of studies being uncontrolled before and after design and thus limited by the historical nature of much of the available data. Adherence to guidelines and the provision of adequate prophylaxis were poor in studies which relied on passive dissemination of guidelines. In general, the use of multiple strategies was more effective than a single strategy used in isolation. The most effective strategies incorporated a system for reminding clinicians to assess patients for VTE risk, either electronic decision-support systems or paper-based reminders, and used audit and feedback to facilitate the iterative refinement of the intervention. There were no studies adequately powered to demonstrate a reduction in rates of VTE. Insufficient evidence was available to make useful comparisons of strategies in terms of costs and resource utilization. CONCLUSIONS: Passive dissemination of guidelines is unlikely to improve VTE prophylaxis practice. A number of active strategies used together, which incorporate some method for reminding clinicians to assess patients for DVT risk and assisting the selection of appropriate prophylaxis, are likely to result in the achievement of optimal outcomes.

Guideline Adherence↗
PubMed2005

Detecting curable disease following hepatectomy for colorectal metastases.

INTRODUCTION: Although resection may be curative for patients with hepatic colorectal metastases, recurrence occurs in the majority. Recurrence is occasionally amenable to repeated resection. The aim of the present study was to evaluate which modalities, at what intervals, detected potentially curable resection. METHODS: The records of patients undergoing hepatectomy for colorectal metastases over 10 years in one centre were retrospectively reviewed to determine when and how recurrence was diagnosed. Specific attention was paid to the detection of potentially curable disease. RESULTS: Of 41 recurrences, 22 occurred in the first year postoperatively, 21 of which were suitable for palliative treatment only. Ten of 19 recurrences occurring after 1 year underwent potentially curative intervention, 10 were diagnosed by computed tomography (CT). Carcinoembryonic antigen did not diagnose any curable recurrence. CONCLUSIONS: A follow-up protocol is proposed, based on annual CT.

Biomarkers, Tumor↗
PubMed2005

National Breast Cancer Audit: establishing a web-based data system.

BACKGROUND: An audit of surgical treatment of early breast cancer was introduced nationally in 1999. In August 2002, the Australian Safety and Efficacy Register of New Interventional Procedures - Surgical, under the auspices of the Royal Australasian College of Surgeons, assumed responsibility for managing this audit. This article provides an update of audit activities, now known formally as the National Breast Cancer Audit (NBCA), including a description of the new governance structure and the development of a secure online surgical audit system. METHODS: Major changes have taken place in the design and governance of the NBCA during the last two years. Two committees have been established to oversee the audit. A clinical advisory committee comprises experts from a number of fields including breast surgery, oncology, government, and from peak breast cancer and consumer bodies. A technical advisory committee oversees many of the technical issues that have arisen with the development of an online data entry system. The online system of data entry was developed and launched to surgeons in May 2004. RESULTS: There are now 28,000 cases of primary breast surgery in the audit. Around 250 surgeons are currently participating, an increase of over 50 surgeons since May 2004. Surgeons can review their data using the online system and compare their own results by generating reports which graph their own results against national aggregate data. CONCLUSIONS: There has been a significant increase in the volume of data received since the launch of the secure online system. The governing committees are working towards creating a clinical audit which will provide an improved data entry system and better reporting for all participating surgeons. The NBCA can also serve as a template on which to base other surgical audits.

Adolescent↗
PubMed2005

Vaccinations for waste-handling workers. A review of the literature.

A review of the literature relating to the need for vaccination against infectious disease in the solid waste industry was conducted, focusing on hepatitis A, hepatitis B and tetanus. Databases (Medline, PreMedline, EMBASE, CINAHL, Current Contents, Cochrane Database, HTA Database, DARE, OSHROM) were searched up to and including August 2003. Articles were included in the review if they reported the prevalence of immunity to hepatitis A, hepatitis B or tetanus in solid waste workers or the incidence of clinical infection with any of these diseases. Papers about hazardous or medical waste, incineration or other infectious diseases were excluded. Forty-four papers constituted the evidence database. Only one paper studied the prevalence of antibodies to hepatitis A and hepatitis B in solid waste workers compared with sewage plant workers and office workers, and no difference was found between these groups of workers. There was some evidence to support a theoretical risk of infection with hepatitis A, B and tetanus; however, no studies could be found of the risk of these diseases in solid waste workers. No single cases of these diseases being acquired occupationally in solid waste management were identified in the literature. Workers in the solid waste industry may theoretically be at increased risk of acquiring infectious diseases occupationally. However, at present no studies could be found which have documented this risk.

Hazardous Waste↗
PubMed2004

Resection of the angle of Treitz and distal diverticulization of the duodenum in penetrating abdominal injuries.

BACKGROUND: Access to the 4th part of the duodenum in the region of the ligament of Treitz can be very difficult. Primary repair or traditional duodenal diverticulization is often technically challenging for managing trauma at this location. Due to the frequent concomitant injuries and hemorrhage, a quick, simple and safe repair technique is highly desirable. METHODS: 3 patients with penetrating injuries to the 4th part of the duodenum were managed by a technique affording good exposure, and involving linear stapling across the bowel proximal and distal to the site of injury, with a jejuno-duodenal anastomosis to the 2nd part of the duodenum, the proximal jejunum having been delivered through a window fashioned in the transverse mesocolon. RESULTS: All patients survived and suffered no complications of their duodenal repair. CONCLUSIONS: The technique described offers a relatively simple, apparently safe and effective approach to a difficult problem in trauma surgery.

Abdominal Injuries↗
PubMed2004

A systematic review of intraoperative radiotherapy in early breast cancer.

A systematic review was undertaken to assess the safety and efficacy of intraoperative radiotherapy (IORT) in early breast cancer compared with breast conserving surgery with postoperative radiotherapy. Literature databases were searched up to March 2002 inclusive. IORT studies of any design and breast conserving therapy randomised controlled trials with sample sizes greater than 500 patients (with at least one arm of breast conserving therapy (BCT)) and systematic reviews on BCT published since 1992, were included for comparison. Seven unique IORT studies were located; one randomised controlled trial, one study with a concurrent control group and five case series. Minor postoperative complications were reported following IORT. Short-term results were similar for both treatment modalities in terms of local recurrence, disease-free and overall survival. However, the current evidence base is poor, making definitive assessment on IORT very difficult. Further research is required to clarify several issues such as identification of the most appropriate subgroups of patients for IORT, a comparison of the currently available mobile IORT technologies, establishing whether IORT is most appropriate as a boost replacement dose or replacement for all postoperative radiotherapy, the examination of how biological repair processes may differ between the two treatment modalities and determining precisely where local recurrences originate with respect to the original tumour site.

Breast Neoplasms↗
PubMed2004

The Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S) assesses new surgeries.

The Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S) is a programme of the Royal Australasian College of Surgeons (RACS). We provide assessments of new and emerging surgical techniques, establish and facilitate clinical and research audits or trials, and produce clinical practice guidelines. We use horizon scanning to identify new techniques. ASERNIP-S conducts systematic literature reviews and accelerated systematic literature reviews on the safety and effectiveness of new surgical techniques before they are widely accepted into the health care system. The RACS recently endorsed two new ASERNIP-S systematic reviews and three accelerated systematic reviews.

Australia↗
PubMed2004

A systematic review of holmium laser prostatectomy for benign prostatic hyperplasia.

PURPOSE: We undertook a systematic review to assess the safety and efficacy of holmium laser prostatectomy compared to transurethral resection of the prostate. MATERIALS AND METHODS: We searched literature databases through August 2002. Holmium laser studies, including holmium laser resection of the prostate (HoLRP) and holmium laser enucleation of the prostate (HoLEP), of any design, and the transurethral prostatectomy (TURP) arms of randomized controlled trials (RCTs) with sample sizes greater than 50 patients, date restricted to 1995 onward, were included for comparison. RESULTS: Three RCTs comparing HoLRP and TURP, and 2 RCTs comparing HoLEP and TURP were identified. For each of the holmium procedures there was also 1 nonrandomized comparative study and a number of case series (HoLRP 13, HoLEP 10). With the exception of 1 randomized trial the quality of the available evidence was poor, with the other RCTs lacking information regarding methods of randomization, allocation concealment and blinding. The majority of studies were characterized by relatively short followup periods and significant losses to followup. In terms of safety the data suggest that the holmium laser procedures are superior to TURP with regard to a number of key indicators of blood loss (transfusion rates, postoperative bladder irrigation, duration of catheterization and length of hospital stay), although amount of blood loss was rarely reported. In terms of efficacy the holmium laser procedures appear to be similarly effective to TURP in relieving the symptoms of benign prostatic hyperplasia. CONCLUSIONS: Holmium laser prostatectomy is at least as effective as TURP for managing the symptoms of benign prostatic hyperplasia. However, at the present time the long-term durability of the holmium procedures with respect to TURP cannot be determined due to a lack of published studies with sufficient followup.

Holmium↗
PubMed2003

Cognitive performance in patients after carotid endarterectomy.

OBJECTIVE: Research investigating the benefits of carotid endarterectomy (CEA) on cognitive functioning remains inconclusive. This study sought to determine what patient characteristics affect cognitive functioning and whether changes in cognitive functioning occur following surgery after controlling for these characteristics. METHODS: In a prospective longitudinal study, 39 patients scheduled for CEA surgery underwent neuropsychological testing in the week prior to their surgery. Two patients had a stroke following surgery, leaving 37 patients who were tested again at 7 days and 3 months following surgery. The surgery was performed under a locoregional anesthetic. RESULTS: Patient characteristics associated with cognitive functioning were age, education, and IQ. In addition, differences in cognitive performance on a number of tests were related to presenting symptoms. Stroke patients (n = 6) differed significantly from symptom-free patients (n = 18) and patients with symptoms (n = 13) on measures of verbal fluency, visual search and mental flexibility, and verbal learning. When differences in patient characteristics were controlled for, no significant changes in cognitive functioning were found that could be attributed to the effects of surgery. CONCLUSIONS: No changes in cognitive functioning were associated with CEA. Differences in cognitive functioning, however, were associated with patient characteristics, including differences in presenting symptoms.

Age Factors↗
PubMed2002

Treatment of non-resectable hepatocellular carcinoma with autologous tumor-pulsed dendritic cells.

BACKGROUND: The response of hepatocellular carcinoma (HCC) to therapy is often disappointing and new modalities of treatment are clearly needed. Active immunotherapy based on the injection of autologous dendritic cells (DC) co-cultured ex vivo with tumor antigens has been used in pilot studies in various malignancies such as melanoma and lymphoma with encouraging results. METHODS: In the present paper, the preparation and exposure of patient DC to autologous HCC antigens and re-injection in an attempt to elicit antitumor immune responses are described. RESULTS: Therapy was given to two patients, one with hepatitis C and one with hepatitis B, who had large, multiple HCC and for whom no other therapy was available. No significant side-effects were observed. The clinical course was unchanged in one patient, who died a few months later. The other patient, whose initial prognosis was considered poor, is still alive and well more than 3 years later with evidence of slowing of tumor growth based on organ imaging. CONCLUSIONS: It is concluded that HCC may be a malignancy worthy of DC trials and sufficient details in the present paper are given for the protocol to be copied or modified.

Adult↗
PubMed2002

Australian audit for the endoluminal repair of abdominal aortic aneurysm: the first 12 months.

BACKGROUND: The Australian Safety and Efficacy Register for New Interventional Procedures - Surgical (ASERNIP-S) was contracted by the Commonwealth Department of Health and Aged Care to audit the procedure of endoluminal repair of abdominal aortic aneurysm. The purpose of the audit was to examine the safety and efficacy of the endoluminal graft (ELG) and, where possible, compare it to the open procedure. The first 12 months of data collection has now been completed. An overview of these results and some of the problems associated with the establishment of this audit are given. METHODS: The administrative infrastructure to support the audit is based at the ASERNIP-S office in Adelaide. To achieve high compliance rates, regular contact was maintained with surgeons. A reference group of senior vascular surgeons was established to provide expert support to the audit. RESULTS: By December 2000, ASERNIP-S had collected data on approximately 85% of privately performed ELG procedures during the first year of the audit. The early mortality rate was 1.3% in the endoluminal group compared to 2.6% in the open group. The rate of procedural complications was 15% in both groups, but the percentage of systemic complications was higher following the open repair. Aneurysm size and the number of pre-existing conditions had a statistically significant relationship to the variation in the number of complications for ELG patients. CONCLUSIONS: Good compliance has been obtained from vascular surgeons for submission of the operative data sets. ASERNIP-S aims to follow this group of patients closely to assess the medium to long-term durability of this procedure.

Aged↗