25, 50 and 75 years ago

The aim of this study is to establish a model to evaluate surgical outcomes and, where indicated, recommend changes to improve the quality of surgical care in Western Australia (WA). Open resection for aneurysm of the abdominal aorta was the ﬁ rst procedure evaluated and the results are reported in an accompanying paper. The Quality of Surgical Care Project (QSCP) is conducted under the aegis of the Royal Australasian College of Surgeons (RACS) in WA, and brings together a multidisciplinary team of surgeons, public health researchers and health service administrators. The Western Australia Health Services Research Linked Database (the WA Linked Database) is used to provide linked chains of patients ’ records residing in the state health department from the following sources: hospital morbidity data system, birth and death records, mental health services data, can-cer registrations and midwives ’ noti ﬁ cations. This links 16 years of population-based patient records from 1980, including all public and private hospital admissions and re-admissions. The Quality of Surgical Care Project was established to use and to correlate the data from the WA Linked Database. The result is a powerful database for a contained population that is available for scienti ﬁ c analysis by a multidisciplinary team of clinical epi-demiologists, surgeons and health service managers. Users will have the ability to establish benchmark standards for the outcomes of surgical procedures in WA for use in quality improvement programmes run by the College and will facilitate self- directed performance auditing activities as a commitment to greater community accountability. The Quality of Surgical Care Project provides a potential model of bene ﬁ ts to be realized by both the medical profession and the community through multidisciplinary collaboration supported by adequate information. Although migration from WA is relatively low, future linkage to the state electoral roll will allow correction for any population change.

The aim of this study is to establish a model to evaluate surgical outcomes and, where indicated, recommend changes to improve the quality of surgical care in Western Australia (WA). Open resection for aneurysm of the abdominal aorta was the first procedure evaluated and the results are reported in an accompanying paper. The Quality of Surgical Care Project (QSCP) is conducted under the aegis of the Royal Australasian College of Surgeons (RACS) in WA, and brings together a multidisciplinary team of surgeons, public health researchers and health service administrators. The Western Australia Health Services Research Linked Database (the WA Linked Database) is used to provide linked chains of patients' records residing in the state health department from the following sources: hospital morbidity data system, birth and death records, mental health services data, cancer registrations and midwives' notifications. This links 16 years of population-based patient records from 1980, including all public and private hospital admissions and re-admissions. The Quality of Surgical Care Project was established to use and to correlate the data from the WA Linked Database. The result is a powerful database for a contained population that is available for scientific analysis by a multidisciplinary team of clinical epidemiologists, surgeons and health service managers. Users will have the ability to establish benchmark standards for the outcomes of surgical procedures in WA for use in quality improvement programmes run by the College and will facilitate self-directed performance auditing activities as a commitment to greater community accountability. The Quality of Surgical Care Project provides a potential model of benefits to be realized by both the medical profession and the community through multidisciplinary collaboration supported by adequate information. Although migration from WA is relatively low, future linkage to the state electoral roll will allow correction for any population change.
Ansari MZ, Costello AJ, Jolley DJ, Ackland MJ, Carson N, McDonald IG. Adverse events after prostatectomy in Victorian public hospitals. ANZ J Surg 1998;68:830-836 A retrospective analysis of data from the Victorian Inpatient Minimum Database (VIMD) was conducted to analyse trends in prostatectomy rates in Victorian public acute-care hospitals from 1989/90 to 1994/95. The study also sought to identify predictors of adverse events (AE) after prostatectomy, and to compare in-hospital complications between open prostatectomy and transurethral resection of prostate (TURP). All patients who had undergone any prostatectomy were identified according to the relevant ICD-9-CM procedure codes (60.2-60.4) documented in the VIMD. The main outcome measures, AE, were identified using the ICD-9-CM supplementary classification of external cause of injury (E850-858, E870-876, E878-879 and E930-949). The variables used as predictors were year of prostatectomy, type of admission (planned, emergency), location of the hospital (rural, metropolitan), type of procedure (TURP, open), and teaching status of the hospital. Crude and adjusted odds ratios (OR) were based on univariate and multivariate logistic regression. Results: The rates of prostatectomies have significantly increased over the 6-year study period (P for trend <0.0001). The percentage of AE after prostatectomy increased simultaneously from 6.1% to 12.9% (P < 0.0001). During the same period, the in-hospital mortality rate after prostatectomy decreased from 1.2% to 0.5%, and length of stay decreased from 10.3 to 6.1 days (Kruskal-Wallis P < 0.0001). The significant predictors of outcome were year of prostatectomy (P for trend <0.0001), emergency admissions (OR = 1.57; P < 0.0001), metropolitan hospitals (OR = 0.81; P = 0.0003, non-teaching hospitals (OR = 0.78; P < 000 L), and open prostatectomy (OR = 1.52; P = 0.04). More in-hospital complications were associated with open prostatectomy than with TURP. The rise in AE rate after prostatectomy is unlikely to reflect poor quality of care because in the same period there was a significant decrease in in-hospital mortality after prostatectomy. A more likely explanation is heightened awareness of AE with a lower threshold for reporting such events. Important factors other than variations in quality of care can result in an increase in AE. Hence the reported increase should be interpreted with caution before attempting to conclude that changes in clinical practice could have a direct impact on these rates.

years ago
Bruce PT. Colocystoplasty: bladder replacement after total cystectomy. ANZ J Surg 1973;43:270-273 The formation of an artificial bladder has exercised the minds of surgeons for nearly a century. A segment of ileum or colon, the caecum, the rectum, the vagina and part of the stomach have all been used with varying success. An alternative to the present-day accepted method of urinary diversion (ileal conduit or ureterosigmoidostomy) is presented in a series of 10 cases, operated on over a five-year period. The clinical details, complications and results of colocystoplasty (Fig. 1) are analysed. This feasibility study gives the impression that the operation is worthwhile and that it probably represents the most physiological replacement of the bladder to date.
Wines RD, Lane V, O'Flynn JD. Postprostatectomy bleeding: active management by early endoscopic haemostasis and packing in a series of 3219 prostatectomies. ANZ J Surg 1973;43:274-278 This article reviews the results of active management of postprostatectomy bleeding in a series of 3219 patients with an overall mortality of 1.6%. One hundred and thirty-six patients with heavy bleeding or clot retention after prostatectomy were returned to the operating theatre for 162 procedures. Early clot evacuation and haemostasis with the use of a resectoscope produced satisfactory control in 124 of the 136 patients so treated. Packing of the prostatic fossa, either at the time of prostatectomy or after failed early endoscopic haemostasis, was performed 26 times with good control of bleeding but introduced an appreciable measure of morbidity associated with the suprapubic wound.

years ago
Sunderland S, Kelly M. The painful sequelae of injuries to peripheral nerves. ANZ J Surg 1948;18:75-118 In summary: (1) The paper reports the results of an investigation of the painful sequelae of injuries to peripheral nerves. Observations were based on cases in which severe pain in the hand or foot had persisted for at least 5 weeks after the receipt of an injury to a nerve trunk and in which the pain was not related to damage or to involvement of non-neural tissues. The term causalgia has been applied to this pain.
(2) Causalgia is primarily the sequel of gunshot lesions in which stretch of the nerve appears to play an important part. (3) In the great majority of cases it follows damage to the main sensory pathways from the palm or the sole. (4) The higher in this pathway the level of the lesion, the more likely is causalgia to ensue. (5) Its incidence bears no relation either to neuroma formation or to the degree of visible (damage to nerves or other tissues. (6) Though sympathectomy has proved a valuable therapeutic measure there is no other evidence to suggest that the sympathetic system is especially involved. (7) The clinical evidence suggests that the painful sequels of nerve injuries are the effect of the spread of damage to the central nervous system by retrograde and transneuronal changes. A centre of abnormal spontaneous activity is thereby set up in the cord, which acts as a focal point for the dissemination of spreading disturbances involving wider and wider areas of the cord. These produce effects on the peripheral tissues via adjacent posterior roots (hyperalgesia), while a succession of abnormal impulses reaches the cerebrum, producing effects on the sensorium (spontaneous pain). Anatomical and physiological evidence is produced which lends support to this interpretation. (8) The results of the surgical treatment of pain have been reviewed in relation to the anatomy and physiology of pain pathways and to the postulated focus of disturbance in the cord following peripheral nerve injury. (9) Most cases of causalgia undergo spontaneous cure and surgery should therefore be reserved for the severe and stubborn cases. The paths by which pain impulses travel are tortuous; and they may become more so when a dynamic disorder of sensory neurons has commenced. Thus, even the most skilfully planned operation to interrupt the pathways may fail to cure the pain. At the moment, the evidence suggests that, of the extraspinal procedures, preganglionic sympathectomy is more likely to bring relief than any other measure.