Multiply transfused patients of severe aplastic anemia are at increased risk of graft rejection. Five such patients underwent peripheral blood stem cell transplantation from HLA-identical siblings with a fludarabine-based protocol. The conditioning consisted of fludarabine 30 mg/m 2 / day  6 days, cyclophosphamide 60 mg/kg/day  2 days and horse antithymocyte globulin (ATG)  4 days. Two different ATG preparations were used: ATGAM (dose 30 mg/kg/day  4 days) or Thymogam (dose 40 mg/kg/ day  4 days). Engraftment: median time to absolute neutrophil count (ANC) 40.5  10 9 /l was 11 days (range: 8-17) and median time to platelet count 420  10 9 /l was 11 days (range: 9-17). At a median follow-up of 171 days (range: 47-389), there has been no graft rejection and all patients are in complete remission. Acute GVHD (grade 1) occurred in one patient only. Chronic GVHD developed in two patients (extensive in one and limited in another). The transplants were performed in non-HEPA filter rooms. In only one patient, systemic antifungal therapy (voriconazole) was used. The use of Thymogam brand of ATG for conditioning is being reported for the first time. Our experience suggests that this fludarabine-based protocol allows rapid sustained engraftment in high-risk patients without significant immediate toxicity.

examining the impact of hospital-volume on surgical quality and longer-term survival.

Background Improved post‐operative mortality following gastrectomy for cancer in hospitals with higher resection volumes has not been reported in Australia. Using a population‐based study in Queensland, we aimed to compare post‐operative mortality following gastrectomy between high‐ and low‐volume hospitals stratified by their service capability. Methods All patients undergoing gastrectomy for adenocarcinoma in Queensland between 2001 and 2015 were obtained from the Queensland Oncology Repository. Hospital service capability was defined using the 2015 Australian Institute of Health and Welfare hospital peer groupings. Hospitals were grouped into ‘high‐volume (≥5 gastrectomies annually), high service capability’ (HVHS); ‘low‐volume (<5), high service capability’; and ‘low‐volume, low service capability’ (LVLS). Negative binomial regression models were used to compare 30‐ and 90‐day mortality rates between hospital groups adjusting for age, sex, socio‐economic status, Charlson and American Society of Anesthesiologists scores, treatment regimen, stage and time‐period. Potential mediation of mortality differences between hospital groups due to differences in the type of gastrectomy performed was also examined. Results LVLS hospitals have higher adjusted 30‐day (incidence rate ratio (IRR) 2.97, 95% confidence interval (CI) 1.65–5.35) and 90‐day (IRR 1.95, 95% CI 1.23–3.09) mortality rates compared with HVHS hospitals. There is no significant difference in adjusted 30‐day (IRR 1.16, 95% CI 0.48–2.79) and 90‐day (IRR 1.12, 95% CI 0.59–2.13) mortality rates comparing low‐volume, high service capability hospitals with HVHS hospitals. The type of gastrectomy performed did not significantly influence differences in mortality compared between hospital groups. Conclusion In the Australian environment, post‐operative mortality following gastric cancer surgery may be optimized by centralizing gastrectomy away from hospitals characterized by LVLS.

Background The impact of hospital characteristics on the quality of surgery and survival following oesophagogastric cancer surgery has not been well established in Australia. We assessed the interaction between hospital volume, service capability and surgical outcomes, with the hypothesis that both the quality of surgery and survival are better following treatment in high‐volume, high service capability hospitals. Methods All patients undergoing oesophagectomy and gastrectomy for cancer in Queensland, between 2001 and 2015, were included. Demographic, pathology and outcome data were collected. Hospitals were categorized into high (HV) (≥5 gastrectomies; ≥6 oesophagectomies) and low volume (LV). Hospital service capability was defined as high (HS) and low (LS), and then linked to hospital volume: HVHS, LVHS and LVLS. Higher quality surgery was defined using six perioperative parameters. Univariable comparisons of quality of surgery between hospital groups used chi‐squared tests. The 5‐year overall survival was compared using log‐rank tests and Cox proportional hazard models. Results For both gastrectomy and oesophagectomy, higher quality surgery occurred more frequently in HVHS hospitals (gastrectomy: HVHS = 44.2%, LVHS = 23.1%, LVLS = 29.1% (P < 0.01); oesophagectomy: HVHS = 34.5%, LVHS = 24.4%, LVLS = 21.7% (P = 0.01)). Following oesophagectomy, the 3‐ and 5‐year overall survival was better following treatment in HVHS (P < 0.01). There was no difference between the groups following gastrectomy. Conclusion In Queensland, the quality of surgery was higher in HVHS hospitals performing gastrectomy and oesophagectomy; however, the impact on cancer survival was only seen following oesophagectomy.

Background: International literature recommends centralising gastric cancer surgery, however, with volumes that define 'high-volume resection' being higher than those in most major centres in Australia and New Zealand. These reports rarely focus on the difference between total (TG) and partial gastrectomy (PG). We assessed the impact of resection volume and service capability on operative mortality, morbidity and surgical quality in patients who had a PG and TG. Methods: Patients who had gastrectomy for adenocarcinoma, between 2001 and 2015, were collected from the Queensland Oncology Repository. Hospitals were characterised by cases-per-annum (high-volume [HV] ≥ 5 and low-volume [LV] < 5) and hospital service capability as (high-service [HS] and low-service [LS]), giving three hospital groups: HVHS, LVHS and LVLS. Chi-squared tests were used to compare post-operative mortality, morbidity, failure to rescue (FTR) from complications and surgical quality between these three groups.Results: There were 426 patients who had a TG and 827 having PG. HVHS centres performed 59% of PG with high surgical quality rates of: HVHS = 53%, LVHS = 34% and LVLS = 46% (p < 0.01). Surgical complications were highest in LVLS (LVLS = 19%, LVHS = 11%, HVHS = 11%; p = 0.02). There was no difference in 30-day mortality nor in FTR. For TG, HVHS performed 67% of these procedures, with lower 30-day mortality (2%) and FTR rates (5%) compared with LVHS (7%, 22%) and LVLS (12%, 28%; p < 0.01). There was no difference in operative morbidity and surgical quality between hospital groups. Conclusion: Despite the 'high-volume' threshold for gastrectomy being the lowest described in the literature, we have shown that centralisation to HVHS centres was associated with lower operative mortality for TG and improved quality of surgery for PG.

Background High hospital‐volume and service capability are associated with improved mortality following complex cancer surgery. Using a population‐based study in Queensland, we assessed differences in mortality following oesophagectomy and pancreaticoduodenectomy, comparing high‐ and low‐volume hospitals stratified by service capability. Methods Data on all patients undergoing oesophagectomy and pancreaticoduodenectomy for cancer in Queensland between 2001 and 2015 were obtained from the Queensland Oncology Repository. Hospital service capability was defined using the 2015 Australian Institute of Health and Welfare hospital peer groupings. Hospitals were grouped into ‘high‐volume (≥6 oesophagectomies or pancreaticoduodenectomies annually) with high service capability'; ‘low‐volume (<6) with high service capability' and ‘low‐volume with low service capability'. Multivariate Poisson models were used to estimate differences in 30‐ and 90‐day mortality between hospital groups adjusting for age, sex, socioeconomic status, Charlson and American Society of Anesthesiologists scores, chemotherapy, radiotherapy, stage and time‐period. Results For oesophagectomy, adjusted 90‐day mortality was higher in low‐volume compared with high‐volume hospitals, regardless of service capability (low‐volume, high service: incident rate ratio (IRR) 3.86, 95% confidence interval (CI) 1.74–8.57; low‐volume, low service: IRR 3.40, 95% CI 1.16–10.00). For pancreaticoduodenectomy, mortality was higher in low‐volume compared with high‐volume centres regardless of service capability: 30‐day mortality (low‐volume, high service: IRR 2.32, 95% CI 1.07–5.03; low‐volume, low service: IRR 3.92, 95% CI 1.45–10.61); 90‐day mortality (low‐volume, high service: IRR 2.36, 95% CI 1.29–4.30; low‐volume, low service: IRR 3.32, 95% CI 1.64–6.71). Conclusion High hospital resection volumes are associated with lower post‐operative mortality following oesophagectomy and pancreaticoduodenectomy regardless of hospital service capability. This data supports centralization of these procedures to high‐volume centres.

Introduction: Better outcomes following surgery for oesophageal, gastric and pancreatic cancers in highvolume centres compared with low-volume centres have been reported in population-level studies based in the United States of America (USA) and Europe. In some regions, this has led to the centralisation of the surgery for these cancers to high-volume centres which has been reported to be associated with improvements in post-operative outcomes. In Australia, centralisation of surgery for these cancers is controversial due to a lack of robust data in favour of a volume-outcome relationship within Australian centres and concerns regarding access to care for regional and rural populations. This is of particularly relevance as rural and regional populations are reported to have a higher risk of developing many cancers, compared with their urban counterparts. We aimed to compare surgical outcomes between hospitals grouped by volume and service-capability and compared the incidence and survival following the diagnosis and treatment of upper gastrointestinal cancers between areas grouped by access to high-volume care. Methods: Data on all patients diagnosed with oesophageal, gastric and pancreatic cancers in Queensland, between 2001 and 2015, were obtained from the Queensland Oncology Repository. Hospitals were grouped by: resection volume (High = six or more oesophagectomies or pancreaticoduodenectomies or five or more gastrectomies annually; Low = less than six; less than five); and service-capability (High= Principle Referral hospitals or Private Group A hospitals; Low = All other hospitals). Patients were grouped according to their access to a high-volume treatment centre, calculated as road distance from the patient's residential location to the closest high-volume centre (<100 km,100-199 km, 200-399 km and 400 or more km). Multivariable Poisson regression models were used to compare adjusted cancer incidence between access groups and to compare post-operative mortality between hospital groups. Multivariable logistic regression models were used to compare quality of surgery between hospital groups, and flexible parametric survival models and Cox-proportional hazard models were used to compare cancer-specific and overall survival between access groups and hospital groups respectively.

Aim. Single-access laparoscopic surgery (SALS) can be effective for benign and malignant diseases of the ileum in both the elective and urgent setting. Methods. Ten consecutive, nonselected patients with ileal disease requiring surgery over a twelve month period were included. All had a preoperative abdominopelvic computerized tomogram. Peritoneal access was achieved via a single transumbilical incision and a “surgical glove port” utilized as our preferred access device. With the pneumoperitoneum established, the relevant ileal loop was located using standard rigid instruments. For ileal resection, anastomosis, or enterotomy, the site of pathology was delivered and addressed extracorporeally. Result. The median (range) age of the patients was 42.5 (22–78) years, and the median body mass index was 22 (20.2–28) kg/m2. Procedures included tru-cut biopsy of an ileal mesenteric mass, loop ileostomy and ileotomy for impacted gallstone extraction as well as ileal (n = 3) and ileocaecal resection (n = 4). Mean (range) incision length was 2.5 (2–5) cm. All convalescences were uncomplicated. Conclusions. These preliminary results show that SALS is an efficient and safe modality for the surgical management of ileal disease with all the advantages of minimal access surgery and without requiring a significant increase in theatre resource or cost or incurring extra patient morbidity.