Background: Conventional photon-based radiotherapy, such as with intensity-modulated radiation therapy and three-dimensional conformal radiation therapy, remains the standard treatment for oesophageal cancer where radiotherapy is required. However, they are associated with potential radiotoxicity to surrounding organs that confer significant morbidity and mortality. Proton beam therapy has emerged as a new technology with the potential to reduce organ at risk radiation through more precise tumour targeting. This updated systematic review and meta-analysis evaluates the efficacy and safety of proton beam therapy compared to conventional radiotherapy for oesophageal cancer. Methods: A comprehensive literature search was conducted across Medline, Embase and Cochrane Central databases. Articles which evaluated clinical outcomes and dosimetry data for proton beam therapy compared to conventional radiotherapy in patients with oesophageal cancer were included in this review. Results: Thirty-three studies, predominantly from the United States of America, were included. Pooled analysis demonstrates strong evidence to suggest proton beam therapy led to reduced grade 4 lymphopenia, reduced total pulmonary complications, improved odds in overall and progression free survival and reduced organ at risk radiation compared to conventional radiotherapy. These findings occur on the background of studies at low-moderate risk of bias but high clinical heterogeneity. Conclusion: There is preliminary evidence to suggest proton bream therapy reduces organ at risk radiation and radiotoxicity in oesophageal cancer. While these findings support the potential use of proton therapies, the limitations of the underlying evidence calls for further research to validate the long-term radiotoxicity and oncological outcomes before implementation of this therapy in policy and practice can occur.

Background: Prognostic Nutritional Index (PNI) and the Geriatric Nutritional Risk Index (GNRI) scores are commonly used nutritional indexes. These scores can provide objective assessment to both surgeon and patient of peri-operative risk as well as long term survival. Aim: To determine the use of nutritional scoring tools as predictors of short- and long-term outcomes in elderly patients undergoing surgery in Tasmania, Australia. Methods: The study was approved by the Human Research Ethics Committee of the Royal Hobart Hospital, Tasmania. Retrospective cohort study of elderly patients who underwent surgery from 2015-2020. Statistical analyses were performed using appropriate statistical software with significance set at α = 0.05. Patient demographics, comorbidities and nutritional indices were compared between survival groups using univariate and multivariate cox regression analysis. Kaplan-Meier survival curves were constructed for both, with survival differences assessed using log-rank tests. Results: One hundred and twenty-two patients aged >70 years underwent surgery. Short-term complications including MACE and 30-day mortality were associated with patients with low GNRI and PNI scores (p<0.05). Lower PNI scores and DLCO were independently associated with decreased overall survival with a mean follow-up of 4 years. Specifically, each unit increase in PNI was associated with a 6% reduction in the hazard of death (HR 0.94, p = 0.012), and each percentage point increase in DLCO was associated with a 3% reduction in the hazard (HR 0.97, p = 0.037). Multivariate analysis demonstrated GNRI score (<101) was significant as a predictor for re-admission and PNI score (<47) was significant as a predictor for rehab (p<0.05). Conclusion: Nutritional scoring tools can provide useful prognostic information and should be utilised routinely pre-operatively to risk stratify and allow for optimisation pre-operatively.

Purpose Aboriginal and Torres Strait Islander peoples experience major health inequities; however, emergent surgical outcomes are not well defined. We compared the short term outcomes following an emergent laparotomy of indigenous and non indigenous patients at a regional Australian hospital. Methodology We conducted a retrospective cohort study of adult emergency laparotomies at Cairns Hospital between 2020 and 2024. Indigenous status was obtained from hospital records. The outcomes measured were surgical site infection (SSI), return to theatre and length of stay (LOS). Multivariable logistic regression adjusted for age, body mass index (BMI), diabetes, smoking, immunosuppression, bowel resection, peritoneal contamination and operative time. A 1:1 nearest neighbour propensity score–matched analysis without replacement was used to compare indigenous and non-indigenous patients with similar baseline and operative characteristics. Results Of 527 patients, 96 (18.2%) were indigenous and 431 (81.8%) non indigenous. Indigenous patients were younger (mean 50 vs 62 years) but more likely to have diabetes (24% vs 11%) and to be current smokers (54% vs 25%), with similar BMI and operative time; bowel resection was less frequent (41% vs 56%). In adjusted models, indigenous status was not associated with SSI (adjusted odds ratio [aOR] 1.13, 95% CI 0.65–1.94) or return to theatre (aOR 0.85, 95% CI 0.48–1.53). In the matched cohort (94 indigenous, 94 non indigenous), SSI (31.9% vs 29.8%; p=0.87) and return to theatre (29.8% vs 30.9%; p=1.00) remained similar. Conclusion In this emergency laparotomy cohort, Aboriginal and Torres Strait Islander status was not independently associated with worse short term surgical outcomes once baseline and operative factors were accounted for.

Background 10-15% of patients with gallstone related pathology have choledocholithiasis, with endoscopic retrograde cholangiopancreatography (ERCP) being a treatment option. Spontaneous passage of common bile duct (CBD) stones not infrequently result in negative ERCPs with unnecessary procedural risks and resource utilisation. To reduce this, we aim to derive predictors for spontaneous stone passage. Methods We performed a single centre, retrospective cohort study at St John of God Midland Hospital in Western Australia, Perth on 78 patients who underwent ERCP following imaging confirmed choledocholithiasis from June 2022 – Sep 2024. Multivariable logistic regression models were used to analyse predictors for spontaneous stone passage. Receiver Operating Characteristics (ROC) curve and Youden Index were used to investigate if the drop in liver function test (LFT) indices from initial diagnosis of choledocholithiasis to just prior to ERCP can predict spontaneous stone passage. Results 21.5% of patients with imaging proven choledocholithiasis had no evidence of stones on ERCP, suggestive of interval spontaneous passage. Size of CBD stone was independently associated with spontaneous stone passage. For each 1mm increase in stone size, the odds of spontaneous passage decreased by 54% (adjusted OR 0.46, 95% CI 0.27–0.77; p=0.003). Among the 5 biochemical predictors evaluated (bilirubin, AST, ALT, ALP, GGT), the drop in ALT from initial choledocholithiasis diagnosis to just prior to ERCP demonstrated a fair diagnostic performance with an area under curve (AUC) of 0.708 (95% CI: 0.548-0.868). At the optimal ALT cutoff of 210.5 U/L, the test achieved moderate sensitivity (70.6%) and moderate specificity (74.2%) in predicting spontaneously passed stones, resulting in a Youden Index of 0.448. Conclusion 1 in 5 CBD stones will likely pass spontaneously. For patients with a small CBD stone and ALT drop of 210.5 U/L, repeat imaging could be considered prior to ERCP for reassessment.

Background: Poor quality ward rounds contribute to a large proportion of patient complications, delayed discharge, and increased hospital cost. This systematic review investigated all interventions aiming to improve patient and process-based outcomes in ward rounds. Methods: This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD42023394325). MEDLINE, Embase, Emcare, and PsycInfo were searched for studies with interventions aiming to improve ward round processes or patient outcomes in hospital settings. Studies were excluded if there was no baseline comparator or they were not in the ward round setting. Interventions were coded as checklist interventions (that is electronic or paper-based pro formas, templates, and checklists), structure interventions (that is defined rules or protocol to guide or standardize conduct), or other interventions. Outcomes were assessed via meta-analyses using the I2 statistic, Cochran’s Q P value, and random-effects models. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for RCTs and the Newcastle–Ottawa scale for non-randomized studies. Results: This review included 84 studies, from 18 countries, in 23 specialties, involving 43 570 patients. Checklist interventions significantly reduced ICU length of stay, improved overall documentation, and did not increase ward round duration. Structure interventions did not increase the time spent per patient or impact 30-day readmission rates or patient length of stay. Conclusion: This is the first systematic review with meta-analyses synthesizing the evidence of all ward round interventions targeted at improving patient and process outcomes. Results from this review should be used to inform guidelines for the ‘ideal ward round’.

Purpose Frailty is common among patients undergoing emergency laparotomy and is associated with adverse postoperative outcomes, yet routine frailty assessment remains inconsistently implemented despite international guideline recommendations. This study evaluates the prevalence of frailty using three rapid assessment tools and examines their associations with postoperative outcomes following emergency laparotomy. Methods We conducted a single-centre retrospective cohort study of adults undergoing open emergency laparotomy over a 12-month period. Frailty was assessed retrospectively using the Clinical Frailty Scale (CFS ≥5), Emergency Surgery Frailty Index (EmSFI ≥7), and five-item Modified Frailty Index (mFI-5 ≥2). Primary outcomes were 30- and 90-day mortality. Secondary outcomes included postoperative complications, ICU admission, hospital length of stay, and discharge destination. Unadjusted analyses were descriptive. Multivariable logistic regression models were constructed with frailty measures specified as the primary exposures and adjusted for age, sex, operative indication, and anaesthetist-assigned ASA grade. Results Among 102 patients (median age 67 years, IQR 54–79; 53% female), frailty prevalence was 26% by CFS, 24% by EmSFI, and 27% by mFI-5, with 37% meeting at least one frailty threshold. In unadjusted analyses, patients living with frailty experienced higher rates of postoperative complications, ICU admission, longer hospital stay, and reduced likelihood of independent discharge home. After adjustment, frailty thresholds were not independently associated with 30- or 90-day mortality, while mFI-5–defined frailty was independently associated with ICU admission. Conclusion Frailty assessment in emergency laparotomy identifies patients at increased risk of postoperative morbidity, ICU utilisation, and discharge dependence but does not independently predict short-term mortality after adjustment for key clinical factors.

Laparoscopic cholecystectomy (LC) is one of the most commonly performed general surgical procedures and represents a major source of perioperative antimicrobial exposure. Although infectious complication rates are low, variability in antibiotic prescribing persists, particularly in elective low-risk cases. This narrative review synthesises contemporary evidence regarding perioperative antimicrobial prophylaxis in low and high-risk LC, with a focus on SSI outcomes, guideline recommendations and antimicrobial stewardship implications. A structured literature search of MEDLINE, Embase and the Cochrane Library was performed, including randomised controlled trials, observational studies, systematic reviews, meta-analyses and international guidelines published between 2010 and 2025. The evidence consistently demonstrates no clinically meaningful reduction in SSI rates with routine prophylactic antibiotics in low-risk elective LC. Despite this, antibiotic use remains widespread. In high-risk LC, particularly acute cholecystitis, baseline SSI risk is increased; however, current evidence does not reliably demonstrate benefit from broad-spectrum agents, extended prophylaxis or postoperative antibiotics. Several meta-analyses report no reduction in infectious complications and identify increased hospital length of stay associated with antibiotic use. International guidelines uniformly discourage prophylaxis in low-risk LC but vary in their recommendations for high-risk patients, reflecting ongoing uncertainty and limited high-quality data. From a stewardship perspective, LC represents a high-impact opportunity to reduce unnecessary antimicrobial exposure through risk stratification, standardised single-dose prophylaxis where indicated and avoidance of postoperative continuation in the absence of established infection. In conclusion, omission of prophylactic antibiotics in low-risk LC is strongly supported by current evidence. Antibiotic use in high-risk LC should be individualised and evidence-informed, with further high-quality trials required to define optimal practice.

Background: Choledocholithiasis is a common presentation of gallstone disease. Previous studies have demonstrated that both one-stage laparoscopic cholecystectomy + common duct exploration (LC+LCBDE) or two-stage laparoscopic cholecystectomy + Endoscopic Retrograde Cholangiopancreatography (LC + ERCP) are safe management strategies. This study aims to compare and contrast the treatment approaches used for choledocholithiasis, including LC+ERCP, LC+LCBDE, or LC+LCBDE + ERCP. Methods: A retrospective observational study was conducted of patients undergoing laparoscopic cholecystectomy at the Sunshine Coast University Hospital and Health Services from 1 January 2022 to 1 January 2025. Patients were categorised into three groups: LC + ERCP, LC + LCBDE, and LC+LCBDE+ERCP. Demographic, pre- and post-operative biochemical markers, imaging, and surgical outcomes were collected and compared between groups. Results: A total of 1760 laparoscopic cholecystectomies were performed. Of these, 227 patients (12.9%) required management for choledocholithiasis, with 101 patients undergoing bile duct exploration as emergency cases under ASU (Acute Surgical Unit). This ASU model is staffed on a rotational basis by General surgeons of all sub-specialities. 125 (55%) patients underwent a single-stage LC+ LCBDE, whereas 87 (38.3%) patients underwent LC+ERCP, and only 14 (6.2%) required both LTCBDE + ERCP. Stone clearance was achieved in 100% of patients managed with LC+ERCP and in 91.3% of patients in the single-stage LC+LCBDE group. There were no significant differences in surgical outcomes or post-operative complications between groups. Conclusion: These findings support the use of single-stage LC+ LCBDE as a safe and effective approach for choledocholithiasis and that these results can be achieved by general surgeons of all sub-specialities.

Title: Impact of Single-Day Training on Surgical Management of Choledocholithiasis in Peripheral Hospitals Introduction: Choledocholithiasis occurs in up to 20% of patients undergoing cholecystectomy. While ERCP remains the dominant treatment modality, it requires access to specialised services and is associated with additional procedures, morbidity, and hospital transfers. Laparoscopic transcystic common bile duct exploration (TCBDE) offers a single-stage alternative but is underutilised by general surgeons. This study assessed whether a single-day TCBDE training course altered management practices and outcomes in hospitals without on-site ERCP capability. Methods: A retrospective audit was conducted across two peripheral hospitals within Eastern Health, Melbourne. All patients diagnosed with choledocholithiasis between April 2024 and April 2025 were included, comparing management in the six months before and after TCBDE training of seven experienced general surgeons. Outcomes assessed included initial management strategy, length of stay, complications, stone clearance, need for transfer, and 30-day readmission. Patients with malignant obstruction, ascending cholangitis, prior cholecystectomy, or unfitness for general anaesthesia were excluded. Results: Fifty-nine patients were included (28 pre-course, 31 post-course). Pre-course, 100% underwent ERCP. Post-course, 54.8% underwent TCBDE as first-line management, with ERCP reserved for 45.2%. Mean length of stay decreased from 5.9 days in ERCP patients to 4.6 days following TCBDE. Stone clearance rates were 96.4% (pre-course ERCP), 100% (post-course ERCP), and 82.5% for TCBDE. Most patients experienced no postoperative complications. Conclusion: A single-day TCBDE training course resulted in a meaningful shift toward single-stage surgical management of choledocholithiasis in peripheral hospitals, reducing reliance on ERCP and inter-hospital transfer. These findings support broader TCBDE training for general surgeons.

Background: There is debate regarding the optimal management of small-bowel neuroendocrine tumours (SBNETs), particularly concerning upfront resection in various clinical presentations. While symptom phenotypes are known to influence survival, their impact on technical surgical quality—especially in the emergency setting—remains poorly defined. This study evaluates whether symptom phenotype compromises the delivery of guideline-concordant surgical care. Methods: A retrospective analysis of 108 consecutive SBNET resections (2000–2023) at a specialized tertiary centre was performed. Patients were stratified into four phenotypes: obstructive/perforation (n = 54), carcinoid syndrome (22), asymptomatic/incidental (22), and other symptoms (9). Operative metrics, including lymph-node harvest (LNY) and margin status (R0/R1), were compared alongside overall survival (OS). Results: Symptom phenotype was a predictor of operative urgency and approach. Obstructive cases required emergency surgery in 50% of instances compared to ≤11% in all other groups (p < 0.001). Synchronous liver metastases were most prevalent in the carcinoid syndrome phenotype (50%) and lowest in the asymptomatic group (5%) (p = 0.002). Despite these disparities in presentation and urgency, technical quality markers were uniform across all groups : median LNY ranged from 10 to 13 p = 0.426), R1/R2 margin rates were statistically similar ($p = 0.290$), and median length of stay was 8 days for all cohorts (p = 0.311). Multivariable analysis identified the asymptomatic phenotype as independently protective for OS (HR 0.42, p = 0.032), while liver metastasis was the strongest adverse prognostic factor (HR 3.25, $p < 0.001$) Conclusions: Symptom phenotype dictates operative urgency and reflects disease burden but does not compromise the technical standards of surgery in a specialized unit. These findings suggest that high-quality, guideline-concordant lymphadenectomy is achievable even in emergency obstructive presentations, and correspondingly, access to specialized surgical oncology expertise may be sought even in obstructed patients to ensure technical quality is maintained.

Purpose: To validate a rapid 12-minute magnetic resonance imaging (MRI) protocol for diagnosing acute appendicitis in adults, addressing the need for accurate, ionising-radiation free MRI in patients presenting with acute abdominal pain. Methodology: Five-year retrospective cross-sectional study of 2,249 adult patients undergoing standardized 12-minute MRI for acute abdominal pain at Blacktown and Mt Druitt hospitals emergency departments (ED) from 2020 to 2024. Patient demographics, MRI reports and clinical documentation were extracted. The prevalence of appendicitis was 16% (354/2,249). MRI findings were compared against histopathology (n=328) as well as clinical follow-up (n=1921). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy with 95% confidence intervals were calculated. Results: The cohort was comprised of adult patients ranging from 18 to 93 years old (mean=27). MRI demonstrated 98.0% sensitivity (95% CI: 96.0-99.2), 99.8% specificity (99.5-99.9), 98.9% PPV (97.1-99.7), 99.6% NPV (99.2-99.9), and 99.5% overall accuracy (99.1-99.8). Of 342 appendicectomies performed, the negative appendicectomy rate was 4.7% (16/342). Alternate diagnoses were suggested in 61% (1365/2249) of patients. Conclusion: Rapid 12-minute MRI protocol achieves diagnostic accuracy comparable to CT while eliminating radiation exposure. MRI safely excludes appendicitis and identifies alternative pathology. This supports rapid MRI as a viable first-line imaging for suspected appendicitis in the emergency department.