bluuebunny/crossref_metadata_2025 huggingface dataset:
HP03 LONG‐TERM SURVIVAL AFTER LAPAROSCOPIC LIVER RESECTION FOR COLORECTAL LIVER METASTASES
Authors: Bryant R. D. , Hatzifotis M. , Martin I. , Fielding G. , Nathanson L. , O’rourke N.
Published: April 2009

Purpose:   Short term outcomes for laparoscopic liver resection (LLR) have been well reported in the literature, however there are few published data on long‐term survival after LLR for colorectal liver metastases (CLM) and no studies have determined that the prognosis after LLR for CLM is comparable to open liver resection (OLR). Direct retrospective comparison of survival between laparoscopic versus open series is difficult due to the selection bias of the laparoscopic group. Published predictive indices in OLR enable the prediction of survival based on the patient's clinical risk score. Our aim is to determine the long term survival after LLR for CLM and to compare this to these published indices based on the patients’ clinical risk factors.

Methodology:   Retrospective analysis of a prospectively maintained database.

Results:   44 patients underwent LLR for CLM, including 13 right hepatectomies, 2 left hepatectomies, 16 left lateral sectionectomies and 13 non‐anatomical resections. 36% had >1 tumour, 33% had a maximal tumour diameter of ≥5 cm, 61% a node positive primary and 43% a CEA >60. Median follow up was 30.8 months. 5 year survival was 46.1% (26.4–63.6%) and median survival was 46.7 months (36.3–88.6 months). Actuarial survival curves are compared to published survival curves.

Conclusions:   Long‐term survival after LLR for CLM is comparable to published results for OLR.
HP08 LONG TERM FOLLOW‐UP OF LAPAROSCOPIC HELLER MYOTOMY FOR ACHALASIA
Authors: Heggie K. M. , Pilgrim C. , Brown W. , Choi J. , Smith A. , Nottle P.
Published: April 2009

Purpose:   This study aimed to determine long‐term quality of eating and adverse symptoms following laparoscopic Heller's myotomy with fundoplication, particularly assessing if there was a difference with the type of fundoplication performed.

Methodology:   Patients (n = 67) who underwent laparoscopic Heller myotomy with partial fundoplication (anterior or posterior) from January 2000 to August 2008 were identified. Demographic data, presenting symptoms, investigations and operative details were retrospectively recorded. Patients were sent questionnaires assessing dysphagia, regurgitation, chest pain and weight loss before and after surgery, overall satisfaction with surgery and ability to tolerate a normal diet following surgery. Differences according to fundoplication technique were assessed.

Results:   Duration of symptoms prior to surgery was a median of 12 months (range 3–168); 24% had undergone previous intervention. 42 patients had an anterior Dor fundoplication, 24 patients underwent a posterior Toupet procedure and 1 patient had no fundoplication. Median length of stay was 4 days. 46 patients returned their questionnaire. Median follow‐up time was 3.3 years (range 4–98 months). Symptom scores were all significantly improved post‐operatively (p < 0.00). 74% reported being able to eat a normal diet, although 30% reported always having dysphagia to bread and 21.7% to meat. Satisfaction with surgery was 8.32/10. 96% would have the procedure again. There was no statistical difference between the two fundoplication groups.

Conclusion:   Patients’ symptoms are improved following surgery for achalasia and overall they are satisfied with their diet. There is no difference according to the type of fundoplication performed.
HP09 *META‐ANALYSIS OF D1 VERSUS D2 GASTRECTOMY FOR THE TREATMENT OF GASTRIC CARCINOMA
Authors: Siddaiah‐subramanya M. B. , Hossain M. B , Chakraborty J. , Khan S. , Memon B. , Memon M. A.
Published: April 2009

Purpose:   The therapeutic benefit of D2 gastrectomy for gastric carcinoma has not been clearly demonstrated in RCTs. The aim was to conduct a meta‐analysis of RCTs to investigate the merits of D1 versus D2 gastrectomy for the treatment of gastric cancer.

Methodology:   A search of Medline, Embase, Science Citation Index, Current Contents, PubMed and the Cochrane Database identified all RCTs comparing D1 versus D2 gastrectomy published in the English Language between 1980 and 2007. The six variables analysed included anastomotic leak, re‐operation rate, overall complications, mortality, hospital stay and 5 year survival.

Results:   Six trials totalling 1591 patients (D1 = 813, D2 = 778) were analysed. There was a significant reduction of 60% in the relative odds of anastomotic leaks for D1, a significant reduction of 61% in relative odds of postoperative complications for D1, a significant lesser risk of 66% in the odds ratio of re‐operation for D1 and a significant decrease of 7.15 days of duration of hospital stay for D1. The relative odds of mortality favoured D1 group (17% reduction of death) as well. Lastly the 5 year survival between the two groups was not different.

Conclusion:   Based on this meta‐analysis, D1 gastrectomy is associated with significant fewer anastomotic leaks, postoperative complications; re‐operation rate and decreased length of hospital stay. Furthermore the trend in mortality favoured D1 gastrectomy compared to D2 cohort. Lastly the five year survival in D1 gastrectomy patients was not compromised compared to D2 cohort.
ML02P ADULT SURGICAL PATIENTS: THE QUESTION OF COMPETENCY TO CONSENT
Authors: Pearce F. E.
Published: April 2009

Surgeons are well aware of the legal and ethical implications of failing to provide informed consent. However, consenting patients for surgical procedures becomes more challenging when there is a question regarding the patient's competency, especially when the patient is refusing life saving treatment.

In Australia, the Common Law presumes every adult is competent to consent to medical treatment until proven otherwise. There are three capacities one requires for competency in decision making and hence the ability to consent to treatment. Firstly a person requires the capacity for understanding and communication. Secondly, they need to be able to reason and deliberate and thirdly a person requires a set of values or the conception of good.

Guardianship legislation exists in all states involving consent to medical treatment of adults who lack capacity to consent on their own behalf. This legislation exists to protect the autonomy of the patient and promote their best interests. It provides for a substitute decision maker to act on behalf of the incompetent patient.

I will refer to a number of factors which may interfere with a patient's competency to give consent or refuse treatment, some of which are reversible. I will discuss the definition of competency of adults to consent or refuse treatment with reference to current laws in Australia, the issue of autonomy and the duty of care a surgeon must provide their patient in regards to informed consent in the context of the incompetent patient.
MS03 BRAIN INJURIES
Authors: Rosenfeld J. V.
Published: April 2009

Blast injuries to the head and neck comprise various combinations of primary blast injury to the brain with brain swelling and all types of intracranial haemorrhage; open wounds with multiple metal and bone fragments in the brain; head and neck, cervical and facial vascular injury; skull base fractures with CSF leak; pharyngo‐laryngeal injury, acute airway compromise; facial and scalp burns, scalp defects; orbit and eye injuries; profound shock and multiple other systemic injuries. The principles of management include early tracheostomy, vigorous replacement of blood loss and correction of coagulopathy, nasal and wound packing, neck exploration and repair of carotid artery injury, early generous craniectomy, haematoma evacuation, removal of accessible fragments and debridement of devitalized cerebral tissue, ventriculostomy, duroplasty, and use of broad spectrum antibiotics. Repair of ocular injury or eye removal is often deferred. CT is required for planning the extent of the neurosurgery and CT angiography is useful when cervical vascular injury is suspected. The timing and extent of the neurosurgery must be balanced against the relative priorities of the other injuries and the state of physiological compromise. The surgery for these injuries is generally more extensive compared with what is described in the literature for penetrating brain injury from previous wars. The management of these complex head and neck injuries should be conducted by a multidisciplinary team of head and neck (ENT) surgeon, neurosurgeon, ophthalmologist, oral and maxillo‐facial surgeon and plastic/burns surgeon.
PM01 PAIN MANAGEMENT OF PERIPHERAL NEUROMAS
Authors: Briscoe P. A.
Published: April 2009

The patient has ongoing pain following trauma or surgery, you wonder “Can it be a neuroma?”. What can be done?

Despite re‐operation and burying the neuroma, the pain continues.

Where now?

Perhaps the peripheral stimulus is no longer important. The patient has developed “sensitisation” both peripherally and centrally such that further surgery at the site of the lesion may actually exacerbate the problem.

A brief discussion of the concepts of peripheral and central sensitisation and possible management strategies will be delineated.
PM04 OSTEOPOROTIC VERTEBRAL CRUSH FRACTURES – PRESENTATION AND MEDICAL MANAGEMENT
Authors: Rowland C.
Published: April 2009

Vertebral crush fractures can be symptomatic in a quarter of patients. Both symptomatic and asymptomatic osteoporotic vertebral crush fractures increase the risk of future fractures, both vertebral and non‐vertebral fractures e.g. 1 vertebral fracture triples the risk of another vertebral fracture over one year and almost triples the risk of hip fracture in women over 65 years of age.

Medications such as bisphosphonates can reduce (approximately halve) the risk of subsequent fractures when combined with adequate calcium and vitamin D. This needs to be combined with strategies to reduce falls. The efficacy and side effects of the available medications will be reviewed.
PR12 ATYPICAL FIBROXANTHOMA AND MALIGNANT FIBROHISTIOCYTOMA – A TEN‐YEAR REVIEW
Authors: Withers A. H. , Brougham N. D. , Barber R. , Maitra R. N. , Tan S. T.
Published: April 2009

Purpose:   To review the clinical and histological differences between atypical fibroxanthoma (AFX) and malignant fibrohistiocytoma (MFH).

Methodology:   Cases of MFH and AFX were identified and histologically reviewed from our non‐melanoma skin cancer (NMSC) database 1996–2007 for the Central Region of New Zealand. Medline search and recent pathology textbooks were reviewed to determine current opinion and evidence for the diagnostic differentiation between AFX and MFH.

Results:   Of the 54,002 cases of NMSC, 103(0.2%) were histologically reported as AFX and 14(0.03%) MFH, with a mean age of 77 (range 51–93) and 74 (28–88) years respectively. The mean size of AFX was 16.3 (5–70) mm occurring on the head & neck (n = 97), limb (n = 3), trunk (n = 2). 15 (14.7%) lesions were incomplete excised. 12 (11.7%) cases developed local recurrence and 1 metastasis. The mean size of MFH was 20.9 (range 7–50) mm occurring on the head & neck (n = 10), trunk (n = 2), groin (n = 1) and limb (n = 1). 3 (21.4%) lesions were incompletely excised. 2(14.3%) patients developed local recurrence and 2 metastases. Local recurrence occurred in 12 (11.7%) cases of AFX and 2 (14.3%) cases of MFH. The literature states clinical and histological differences between AFX and MFH, but no immunohistochemical (IHC) stain reliably differentiates between them.

Conclusion:   Differentiating AFX from MFH based on histology and IHC is difficult and our cases did not conform to the typical presentation indicated in the literature. AFX and MFH are likely to belong to a spectrum of soft tissue sarcomas with variable aggressiveness.
PR15 NEW TECHNIQUE IN PERINEAL AND POSTERIOR VAGINAL WALL RECONSTRUCTION: SUPERIOR AND INFERIOR GLUTEAL ARTERY PERFORATOR FLAPS
Authors: Rozen W. M. , Wagstaff M. J. D. , Whitaker I. S. , Enajat M. , Audolfsson T. , Acosta R.
Published: April 2009

Purpose:   Perineal and posterior vaginal wall reconstruction following abdominoperineal and local cancer resection requires replacement of dead space and restoration of function. Ideal reconstructive options include those which avoid muscle sacrifice, do not interfere with colostomy formation, and avoid the use of irradiated tissue.

Methodology:   We present our experience with a new technique for perineal and vaginal reconstruction: superior and inferior gluteal artery perforator (SGAP or IGAP) flaps. We describe the operative technique and outcome in 14 consecutive patients. Six cases were performed as primary reconstruction and 8 cases were delayed, with all receiving preoperative radiotherapy.

Results:   Immediate reconstructions underwent preoperative imaging with ultrasound only, while delayed reconstructions underwent preoperative CTA. Postoperatively, patients were ambulated immediately, with all bed rest and sitting performed on the contralateral buttock or side for 4 weeks. There were no flap failures or partial flap losses, and no postoperative hernias. Four patients developed early minor wound dehiscence that was resutured in three cases. Revisional surgery was performed for reduction of three bulky flaps. All female patients reported resumption of sexual intercourse following this procedure.

Conclusion:   Gluteal artery perforator flaps are good options for perineal reconstruction, avoiding the donor site morbidity associated with rectus abdominis or gluteus maximus muscle harvest.
PR17 *ABDOMINOPLASTY AND URINARY INCONTINENCE
Authors: Shakerian R. , Kode G. M.
Published: April 2009

There has been anecdotal evidence that patients undergoing abdominoplasty have had improvements in their voiding dysfunction postoperatively. To date, there have been three case reports in which correction of urinary incontinence (UI) following abdominoplasty has been described (Widgerow 1992, Mast 1999 & Guneren 1999). However no study has evaluated the influence of abdominoplasty on voiding dysfunction. This prospective study aimed to confirm the anecdotal reports, objectively substantiate the subjective improvements and attempt to explain why abdominoplasty may result in resolution of UI.

Methodology:   Twenty consecutive abdominoplasty patients were assessed by a standardised questionnaire pre and postoperatively. Pelvic floor measurements (resting tone & maximal strength) were also obtained. Procedures included either radical or sub‐umbilical abdominoplasty.

Results:   The study involved 20 patients aged between 25 and 62 years. 14 were found to have stress urinary incontinence. Postoperatively 10 patients described improvement in their symptoms, 3 had no change, whilst 1 patient had worsening of her symptoms. 16 patients were found to have improved pelvic floor strength, 2 remained unchanged and 2 had reduced pelvic floor strength.

Conclusion:   Improvement in UI following abdominoplasty was clearly demonstrated. We suggest that this may be attributable to a better bladder neck and urethral angle position, as well as increased pelvic floor tone secondary to reflex contraction of the pelvic floor muscles. Patients reporting UI should be carefully assessed preoperatively. Aim for the future is to predict who simply requires an abdominoplasty to solve the problem and who requires a combined procedure with a urologist.
PR02 *SPRING‐ASSISTED CRANIOPLASTY – RESULTS OF CHRONOLOGICAL CHANGES TO SKULL DIMENSIONS
Authors: Ou yang O. , Rahman M. , Gates R. , Gianoutsos M. , Hunt J. , Marucci D.
Published: April 2009

Purpose:   To demonstrate chronological changes of spring expansion in the treatment of scaphocephaly and brachycephaly. Spring‐assisted cranioplasty has become the first‐line treatment option for patients less than one year‐old with scaphocephaly and in some cases with brachycephaly. The speed of spring expansion and its in‐situ expansile behaviour has not been previously demonstrated in humans.

Methodology:   From January 2008 to December 2008, five patients underwent spring‐assisted Cranioplasty (4 scaphocephaly, 1 brachycephaly). The cephalic index, head circumference was measured chronologically until 3‐month postoperatively. Postoperative intracranial volume was calculated in one centre with post‐spring removal head CT. Prospective review of patient's operative time and blood loss, hospital time, changes in cephalic index (CI) and intracranial volume.

Results:   The average age of the patients were 5.2 months, operative time was averaged 70 minutes, operative blood loss was less than 50 ml, however three of five cases required blood transfusion day 1 postoperatively. Average hospital stay was 3 days, the preoperative CI was 70% for scaphocephalic patients and 83% for the brachycephalic patient. The 3‐month postoperative CI was 76% and 79%, respectively, the changes in intracranial volume was 356 ml.

Conclusion:   30% of its total expansion occurs during the operation. The remaining spring's expansion capacity takes place in the first postoperative month as the skull lengthening occurs. Spring‐assisted cranioplasty is useful in increasing intracranial volume in patients with craniocerebral disproportion and high risk of developing increased intracranial pressure.
PR29P COSMETIC MEDICAL TOURISM: ITS TRUE COST
Authors: Yang Y.‐T. , Al‐ANI S. , Bartlett G. , Moazzam A.
Published: April 2009

Cosmetic tourism has been enjoying unprecedented public attention of late. Enticing New Zealanders with the promise of low cost, overseas travel and the advertised exotic adventure, its popularity grows steadily amongst consumers.

We report four cases of complications that had arisen from cosmetic tourism presented to our unit within the last 18 months.

With each case presentation, we aim to identify the pitfalls of such practice and thus reasons that lead to these devastating and costly complications for the consumers and health system.

Finally, a literature review on the impacts and responses to cosmetic medical tourism from our region and other developed countries including the UK and the US will be presented.

In summary, outsourcing health care in our current climate subject our patients to uncertain quality of care, which could seriously threaten their wellbeing. If legislation is to be proposed to limit agents in the advertising and purveyance of medical tourism in New Zealand, it is imperative that accurate account of the adverse events and cost to the taxpayer are recorded. The cost and challenge this global phenomenon poses to our practice warrant prompt study of its extent and impact to the New Zealand plastic surgical community.
PR03 STEROID THERAPY FOR PROBLEMATIC PROLIFERATING HAEMANGIOMA
Authors: Tan B. H. , Tan S. , Leadbitter P. , Aburn N.
Published: April 2009

Aim:   To evaluate the effectiveness and safety of intralesional and systemic steroid therapy in treating problematic proliferating haemangioma.

Methods:   233 patients with haemangioma were culled from our vascular anomalies database. Indications for treatment, treatment regime, response, side effects and the need for other treatment were recorded. Intralesional Triamcinolone up to 4 mg/kg/injection was preferred for small, localised lesions and oral Prednisolone 2–2.5 mg/kg/day was used for larger lesions, especially around the periorbital region. The mean follow‐up was 29.7 months.

Results:   46(36%) of the 129 patients with proliferating haemangioma required active treatment with 24 receiving steroid therapy. 5 patients received intralesional steroid with 4 needing 2 injections and 2 requiring other treatment modality. All but 1 lesion underwent accelerated regression with no complications. 19 patients received Prednisolone at a mean age of 10 (range, 4–29) weeks. Dramatic response in 10 (53%), stabilisation in 5 (26%) and continued growth occurred in 4 (21%) patients, 3 of whom required debulking surgery. Rebound growth occurred in 9 patients during dose tapering, requiring reintroduction of high dose steroid in 6. Vision dysfunction resolved completely in all affected patients. 3 patients developed growth retardation during treatment but this normalised 3–10 months following cessation of steroid therapy. No other major complications were noted.

Conclusion:   Intralesional and systemic steroid are relatively safe and effective in treating problematic proliferating haemangioma. Systemic steroid therapy is associated with few short‐term side effects, hence a multidisciplinary management is essential.
PR31P ESCHAROTOMY BY FACSIMILE
Authors: Avery G. J.
Published: April 2009

Aim:   To determine what transmissible resources are available to Plastic Surgery Registrars to provide advice and direction to Surgeons outside of the four New Zealand Regional Burn units needing to perform escharotomies on burn patients. To produce a simple transmissible resource to provide assistance for surgeons performing escharotomies outside of a plastic surgery centre.

Methods:   Regional Burn unit's in New Zealand were contacted via the on call Plastic Surgery registrar and asked to provide advice supported by diagrams in order to safely perform extremity and trunk escharotomy. Review of the available Burn, Plastic Surgery, General Surgery and Emergency Medicine text‐books was also undertaken.

Results:   Readily transmissible guidelines are not currently in use and are not available in the majority of plastic surgery or burn text‐books.

Conclusions:   Escharotomies will usually be performed in a Burn or Plastic and Reconstructive Surgery Centre. At times however, these will need to be performed outside of these centres by Surgeons with little or no experience with the procedure, under the distant guidance of the receiving centre. This can safely be achieved, and with the use of appropriate instructions the comfort and effectiveness with which they are performed can be optimised. A concise single A4 sheet indicating locations, indications and precautions for escharotomy incisions is not currently in use. The adoption of this simple resource would be a valuable supplement to telephone consultation and guidance to safely perform this potentially life and limb saving procedure where delay in transfer necessitates its performance.
PR32P EVALUATING ANATOMICAL RESEARCH IN SURGERY: A PROSPECTIVE COMPARISON OF CADAVERIC AND LIVING ANATOMICAL STUDIES OF THE ABDOMINAL WALL
Authors: Rozen W. M. , Chubb D. , Stella D. L. , Taylor G. I. , Ashton M. W.
Published: April 2009

Background:   Cadaveric research has widely influenced our understanding of clinical anatomy. However, while many soft‐tissue structures remain quiescent after death, other tissues undergo structural and functional changes that may influence their use in predicting living anatomy. In particular, our understanding of vascular anatomy has been based upon cadaveric studies in which vascular tone and flow do not match the living situation.

Methods:   An angiographic analysis of the abdominal wall vasculature was performed using plain‐film and computed tomography (CT) angiography in 60 cadaveric and 140 living (70 patients) hemi‐abdominal walls The deep inferior epigastric artery (DIEA) and all of its perforating branches larger than 0.5 mm were analysed for number, calibre and location.

Results:   Both large, named vessels and small calibre vessels show marked differences between living anatomy and cadaveric specimens. The DIEA was of larger diameter (4.2 mm vs. 3.1 mm, p < 0.01) and had more detectable branches in the cadaveric specimens. Perforators were of greater calibre (diameter 1.5 mm vs. 0.8 mm, p < 0.01) and were more plentiful (16 vs. 6, p < 0.01) in cadaveric specimens. However, the location of individual vessels was similar.

Conclusions:   Cadaveric anatomy displays marked differences to in‐vivo anatomy, with the absence of living vascular dynamics affecting vessel diameters in cadaveric specimens. Blood vessels are of greater measurable calibre in cadaveric specimens than in the living. Consequently, cadaveric anatomy should be interpreted with consideration of post‐mortem changes, while living anatomical studies, particularly with the use of imaging technologies, should be embraced in anatomical research.
PR38P PEDICLED ABDOMINAL FLAPS FOR LOWER TRUNK DEFECTS
Authors: Mahadik P. J. , Deva A. , Yadav P. S. , Quazi G. A.
Published: April 2009

Introduction:   Large defects of the lower trunk after cancer resections pose a challenge for a reconstructive surgeon. Pedicled flaps based on the deep inferior epigastric artery provide a very simple but an effective way to cover them.

Methodology:   9 patients from 24–58 yrs of age were studied at 2 hospitals over a period of 2 yr (2007&2008). Soft tissue defects after resections of SCCs, melanomas etc ranged from 6 × 10 cm to 15 × 28 cm. All were reconstructed with an inferiorly based Rectus abdominus flap.

Results:   Almost all the patients had excellent results with no total flap loss. The average operative time was 2.5 hrs. Had a partial flap loss in one case and the average hospital stay being 7 days.

Conclusion:   The rectus flap with skin is quite reliable and a simple option for such complex defects. It provides enough bulk and skin pliability needed in these areas and are pretty fast to learn and do.
PR46P THE ARTERIAL ANATOMY OF THE ACHILLES TENDON: ANATOMICAL STUDY AND CLINICAL IMPLICATIONS
Authors: Chen T. M. , Rozen W. M. , Pan W.‐R. , Ashton M. W. , Richardson M. D. , Taylor G. I.
Published: April 2009

Background:   The Achilles tendon is the most frequently ruptured tendon in the lower limb and accounts for almost 20% of all large tendon injuries. Despite numerous published studies describing its blood supply, there has been no uniformity in describing its topography. The current study comprises a detailed anatomical study of both the intrinsic and extrinsic arterial supply of the Achilles tendon, providing the detail sought from studies calling for improved planning of surgical procedures where damage to the vascularity of the Achilles tendon is likely.

Methods:   A dissection, microdissection, histological and angiographic study was undertaken on 20 cadaveric lower limbs from 16 fresh and 4 embalmed cadavers.

Results:   The Achilles tendon is supplied by two arteries, the posterior tibial and peroneal arteries. Three vascular territories were identified, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. The mid‐section of the Achilles tendon was markedly more hypovascular that the rest of the tendon.

Conclusion:   The Achilles tendon is at highest risk of rupture and surgical complications at its midsection. Individuals with particularly poor supply of the mid‐section may be at increased risk of tendon rupture, and approaches to the tendon operatively should consider the route of supply by the peroneal artery to this susceptible part of the tendon.
PR48P THE GIRL WHO WANTED TO LOOK “NORMAL”: EXTREME FACIAL CONTOURING SURGERY IN SEVERE MCCUNE‐ALBRIGHT SYNDROME
Authors: Neary F. A. , Moaveni Z.
Published: April 2009

McCune‐Albright Syndrome was first described in 1937. It is a rare condition with an estimated prevalence of between 1 in 100,000 and 1 in 1,000,000 and occurs sporadically in all races. It is defined by at least two features of: fibrous dysplasia, café au lait pigmentation and autonomous endocrine hyperfunction.

This case presentation is of a young woman with McCune‐Albright Syndrome with severe cranio‐facial involvement. We discuss our management of this difficult problem thus far with staged surgical procedures to obtain both functional and cosmetic benefits.
PR53P TREATMENT OF PROBLEMATIC PROLIFERATING HAEMANGIOMA WITH PROPRANOLOL
Authors: Ngan N. C. , Tan S. T. , Leadbitter P.
Published: April 2009

Aims:   The mainstay treatment for problematic proliferating haemangioma is pharmacologic with high dose steroid being the first line treatment. A dramatic response occurs in 30% of cases, equivocal in 40% and continued growth is observed in the remainder cases. Steroid therapy is associated with significant side effects. We report our experience in treating proliferating haemangioma with Propranolol, discovered serendipitously by Léauté‐Labràze et al recently.

Methodology:   A 9‐week old boy was referred with a steroid‐resistant proliferating haemangioma involving the upper lip and nose causing feeding and breathing difficulties. The patient was commenced on Propranolol at 0.5 mg/kg twice daily for 24 hours increasing to 1 mg/kg twice daily. The treatment was administered as an inpatient with 4‐hourly heart rate and blood pressure and postprandial (30 minutes) blood glucose level monitoring, for the first 48 hours. The second patient was a 3‐month old boy with a similar rapidly proliferating lesion on the upper lip and nose. He was commenced on similar Propranolol regimen. Both patients were maintained on the original total daily dose of Propranolol.

Results:   In both cases rapid reduction of the size and softening of the lesion was noted within 48 hours of treatment with on going accelerated regression observed during the follow‐up period of 4 and 2 months respectively. No cardiovascular or metabolic side effects were observed in both patients.

Conclusion:   Accelerated regression is observed in 2 infants with problematic haemangioma following Propranolol therapy with no observed side effect. The possible mechanism of action of beta‐blocker on cell proliferation is discussed.
PR54P WHAT IS BIOFILM AND WHAT DOES IT HAVE TO DO WITH SURGERY?
Authors: Hadi R. , Vickery K. , Deva A. K. , Charlton T. S.
Published: April 2009

Purpose:   To present a review of biofilms and their significance in surgical practice.

Aim:   To better understand the role biofilms play in in‐vivo infection, implantable medical device infection and transmission of infections by patient‐ready instruments.

Methodology:   A review was of the biofilm literature was conducted using UNSW, USYD and RACS search engines. Studies were examined for a definition of biofilm and approaches to detection and removal. Subjects of particular relevance to surgical practice were considered to be the role of instrument cleaning in biofilm control and biofilm as a risk factor in viral and prion transmission and infection of implantable medical device. The standardisation of hospital cleaning protocols for medical devices is considered for biofilm control.

Results:   From a medical perspective, biofilms may form on living tissues such as wounds, sinuses, native heart valves. Biofilms may also infect implantable and surface medical devices such as indwelling catheters, breast implants, prosthetic joints, as well as central lines and cannulas. Biofilms may also cause inter‐patient transmission of infections through inadequate cleaning regimes of endoscopes, nasoscopes, and surgical instruments particularly cannulated and hinged. Currently there are Australian Standards for disinfection and sterilisation, but no Australian Standard for removal of biofilm.

Conclusions:   There needs to be an increased recognition of the role biofilms play in infections. Methods for assessment of biofilm removal need to be developed and adequate cleaning regimes implemented in the health care setting.
PR07 VOLUME DISPLACEMENT TECHNIQUES FOR BREAST CONSERVING SURGERY
Authors: Littlejohn D. R.
Published: April 2009

Breast conserving surgery (BCS) is no longer limited to simple wide local excision. Simple and advanced volume displacement techniques and volume replacement techniques are now becoming more commonplace. These techniques extend the role of BCS and improve the cosmetic and functional outcome. Volume displacement is becoming the preferred technique for extending BCS. We aim to discuss the indications, surgical technique, outcomes and patient attitudes towards this surgery.

In my audit 37 patients were treated with “therapeutic mammaplasty” 2000–2009 (8% of all patients having BCS). Mean tumour size was 24 mm, 50% LN +ve, mean specimen weight 346 g, margins of 14 mm and 1 contralateral cancer found. 4.4% of breast cancers have contralateral pathology. This is compared to other series. In our survey on attitudes to breast reduction surgery 76% of lay people felt breast reduction was appropriate for symptomatic women, 13% felt it appropriate for cosmetic reasons only and 91% felt it appropriate as part of their cancer treatment.

In conclusion volume displacement techniques are here to stay, are safe, have functional and cosmetic advantages, oncological advantages, allow extensive histological assessment of the contralateral breast and can aid in the delivery of radiotherapy.
PR09 DYNAMIC SMILE RECONSTRUCTION USING THE MASSETER NERVE TRANSFER IN THE ELDERLY
Authors: Grinsell D. G.
Published: April 2009

Purpose:   The nerve to masseter has long been used as a recipient to innervate free muscle flaps for facial nerve reconstruction in adults and children alike. This presentation demonstrates the effectiveness and utility of the masseter nerve to directly re‐innervate the native muscles forming a natural smile in an elderly population.

Methodology:   Twelve patients aged 40 to 92 years underwent facial nerve resection for malignant disease. There were 11 immediate and one delayed reconstructions utilising the masseter nerve for reconstruction of the smile. The nerve to masseter was dissected and transposed to achieve a direct neurorrhaphy to the nerve to zygomaticus major without the necessity of a nerve graft.

Results:   The earliest movement of the commissure of the mouth was detected at 10 weeks postoperatively. All patients reviewed at 6 months showed dynamic movement and were graded cosmetically as either good or excellent.

Conclusion:   This is a fast, simple and reliable technique which achieves good cosmetic outcomes for facial reanimation in an elderly population and dispels the myth that dynamic reanimation of the smile is not achievable in patients over 50 years old.
AL03 ADVERSE EVENTS: OUR RESPONSIBILITY FOR REPORTING, REVIEWING AND RESPONDING
Authors: Collins J.
Published: April 2009

The sustained production of competent surgeons in sufficient numbers to meet the increasing needs of society commences with recruitment and selection of the most able medical graduates. As the process begins through self‐selection, accurate information must be readily available to enable these graduates make an informed judgement on their career choice.

Each surgical discipline aspires to use best practice selection in order to identify those who have the potential to acquire the necessary standard of technical and non technical skills and attributes required to practice as a surgeon.

A selection system must rank applicants effectively and be reliable, valid, fair, defensible, cost effective and feasible. Best practice selection commences with an analysis of the relevant knowledge, skills, abilities and attitudes associated with successful performance in the particular target job. This information is used to construct a person specification in order to identify selection criteria at a level appropriate for entry to training. Selection methods are then chosen which will best elicit measurable applicant behaviour related to these selection criteria.

A number of selection methods are used which include structured references, curriculum vitae and interviews. Other methods available although rarely used include tests of mental ability, aptitude tests and personality inventories. More recently selection or assessment centres (a selection method, not a place) involving a combination of selection techniques such as written exercises, interviews and work simulations have been shown to be highly effective. Eligibility criteria for application (long listing), shortlising for interview, scoring of items within each selection method and overall % weighting for each method are important variables in the selection process.
RS12P THE FIRST AUSTRALASIAN SCHOOL OF RURAL MEDICINE – HOW RURAL FELLOWS ADDRESSED THE “ANATOMY PROBLEM”
Authors: Stewart F.
Published: April 2009

The first Australasian School of Rural Medicine opened in Armidale, in 2008. The curriculum is the University of Newcastle's problem‐based course. “Basic Sciences” relevant to the week's problem are taught by “overview”. Anatomy is taught by “problem‐relevant system overview”. Simultaneous curriculum‐delivery occurs at both universities.

College Fellows among the School's “founding fathers”, concerned about anatomy “deficiency” in ‘new curricula’ courses, believing anatomy to be critical to rural medical practice, wanted their School's students taught regional anatomy by dissection, applied to physical examination, diagnostic image‐interpretation, rural surgery and pathology. Such teaching is not a part of the “joint curriculum”.

Solution – establish a voluntary‐attendance, after‐hours course, ‘Evening Anatomy Club’. Launched, in March, “Club” teaching involved weekly preparatory study, completion of an assignment (marked and returned at the next class), a lecture, followed by surgeon‐facilitated practical sessions utilizing bones, images, prosections, surface anatomy and dissection.

Three, surgeon‐facilitated, “Dissection Long‐weekends” followed – students were introduced to physical examination, anatomical “variation”, identifying pathology via documentation of features, findings, for the cadaver. Table groups proposed, and revised, contributory cause of death for their patient. Finally, their diagnosis of cause, by post‐mortem examination, was contrasted with the formal Death Certificate's cause.

“Club” meetings concluded with a voluntary examination. A survey related to the course, its content, teaching, and student‐perceived relevance, was conducted.
RS13P TRANSURETHRAL RESECTION OF PROSTATE (MONOPOLAR VS BIPOLAR): A REGIONAL EXPERIENCE
Authors: Ponti B. T. , Teng H. S.
Published: April 2009

Purpose:   Transurethral Resection of the Prostate (TURP) is widely considered to be the gold‐standard treatment for Benign Prostatic Hyperplasia (BPH). More recently, bipolar diathermy TURP has been used in preference to monopolar diathermy due to various technical benefits. This retrospective audit has been conducted to determine whether this technique has had any discernable effects on regional centres.

Methodology:   All monopolar and bipolar TURP charts within a six month period were reviewed and consecutive cases of each were analysed to obtain the objective data presented. All TURPs were performed by the same consultant surgeon in the same hospital. The parameters to be defined were: Patient age, operation duration, duration of catheterisation post‐operatively, length of stay, weight of prostatic resection + histology and complications.

Results:   21 consecutive monopolar TURP cases and 22 consecutive bipolar TURP cases were reviewed and the data collated. It was observed that bipolar TURP had advantages including a reduced length of stay (1.3 days vs. 2.4 days) and a reduced post operative catheterisation period (1.3 days vs. 2.1 days).

Other parameters remained comparable and no difference was noted in complication rates.

Conclusion:   Within the limitations of a retrospective audit, the above data can be said to demonstrate significant benefits for bipolar diathermy in TURP procedures in a rural setting. Long term cost benefits could be inferred, given reduced lengths of stay for individual patients.

The authors would recommend regional hospitals conducting TURPs to consider a transition to the bipolar TURP system if possible, given that complication rates were unchanged.
RS03 DOES HPV PLAY A ROLE IN THE OUTCOME OF HEAD AND NECK CANCER AMONG INDIGENOUS PATIENTS
Authors: Janakiraman R. , Thomas M. E.
Published: April 2009

Background/Objectives:   Race, ethnicity and social background can significantly affect outcomes in head and neck cancer. Part of the disparity is that the Indigenous patients tend to be younger and present with more advanced disease. These dramatic disparities cannot be completely explained by demographics, clinical characteristics, substance abuse or treatment modality. Increasing incidence rates are noted world‐wide for HPV‐ related cancers such as oro‐pharyngeal tumours and is significantly associated in non‐smokers/non‐drinkers. The burden of HPV incidence in Aboriginal Australians remains unstudied. This study evaluates the incidence and the role of HPV in the treatment outcome and survival in head and neck cancer patients in indigenous patients at Australia.

Methods:   All indigenous patients treated for squamous cell carcinoma of the upper aero‐digestive tract from 2000–2008 at Royal Darwin Hospital, Darwin, NT, Australia, were included in the analysis. Formalin fixed, Paraffin embedded blocks were retrieved and HPV status was checked detected by L1 consensus polymerase chain reaction (PCR), followed by restriction fragment length polymorphism (RFLP) analysis. Demographic data, treatment details and survival statistics were included to complete the analysis.

Results:   The incidence of HPV is very variable from other population studies. Interestingly, a very high prevalence of tobacco and alcohol abuse was also documented.

Conclusion:   Results suggest that there may be interactions between positive serology and drinking and smoking along with ethnicity, suggesting that the pathogenesis of this subset of patients is different and the treatment has to be individualised.
RS07P DE GARENGEOT HERNIA‐ AN UNUSUAL FINDING IN A RIGHT GROIN MASS
Authors: Sharp D. A. , To P.
Published: April 2009

The appendix in a femoral hernia is a rare and usually incidental finding at surgery, occurring in 0.5 to 3 per cent of femoral hernia cases [1]. Rarer still is the finding of an acute appendicitis in a femoral hernia, known as a de Garengeot hernia.

We present the case of a 47 year old male who presented with a four day history of a painful right groin lump with surrounding erythema of the skin. Ultrasound scan suggested the presence of an incarcerated inguinal hernia, but at operation it was discovered that the appendix was incarcerated in the femoral canal with the tip of the appendix ischaemic. Histology confirmed the presence of an acute appendicitis.

External compression of the appendix at the neck of the hernia is thought to be the cause of acute appendicitis within femoral hernias. The narrowness and rigidity of the femoral canal predisposes it to incarceration, but subsequently intraperitoneal spread of infection is limited. Thus the patient presents with local signs such as erythema and groin tenderness – usually excluding typical symptoms of peritonitis.

While extremely rare, this case highlights the importance of considering a De Garengeot hernia in the differential diagnosis for a right groin lump. Diagnosis is often only made at the time of surgery.
RS09P FLEXIBLE CYSTOSCOPY: A MODEL FOR THE UTILIZATION OF A RURAL DISTRICT HOSPITAL WITH STATE GOVERNMENT FUNDING
Authors: Smith I. A. , Awad N. , Rashid P.
Published: April 2009

Background:   Flexible cystoscopy (FC) is a well established lower urinary tract investigative tool. We describe the utilization of a rural district hospital to establish a FC service. Prior to this service, all FCs were performed at a regional base hospital proving inefficient. Establishing this service, via a NSW Government grant allowed for a more efficient use of operating theatre resources in a regional environment and permitted increased patient access to care.

Aim:   To highlight the efficiency and cost effectiveness in utilizing a peripheral hospital to provide a FC bladder cancer screening service. To outline a model for establishing such a service, and to describe the implications for improved patient care.

Method:   Funding for a day surgery FC service was not available via the state area health service. A grant application via the rural surgical enhancement programme was applied for and achieved. Equipment was purchased and the service commenced without difficulty.

Results:   The transition to FC at a district hospital proved relatively straight forward and efficiency has increased. Since initiation 171 FCs have been performed. 155 FCs were performed to screen for TCC. 15% went on to have a rigid cystoscopy and biopsy. Patient and staff satisfaction have been achieved. There has been a significant cost benefit to the district hospital and a better utilization of resources at the regional base hospital. The additional throughput has aided teaching of urological trainees.

Conclusion:   Via State Government grant funding, a rural district hospital has been utilized to create a model for FC. It has shown to be an efficient and effective model that can be utilized by other district hospitals.
SE10 THE EDUCATIONAL FRAMEWORK: IN PRACTICE
Authors: Heineman E. , Hamming J. F. , Borelrinkes I. H.
Published: April 2009

Competency‐based education in the field of medical specialties is attracting a lot of attention.

The CanMeds model has been adopted by many colleges in many countries.

In the Netherlands the 27 medical specialty colleges have been encouraged to redesign their curricula on the basis of the CanMeds model.

A proper framework was lacking and had to be developed. The result is a ‘house’ with a solid foundation ('support by peers’) and 10 different rooms: ‘legislation’, ‘profile of the health worker’, ‘competencies of the health worker’,’ themes’, ‘operalionalised competencies’, ‘assessment’, ‘educational method’, ‘educational activities’, ‘educational material’, ‘and ‘quality control’(educational process, check on legislation, professionalizing trainers and trainees, research of education).

This educational framework has been put into practice. It has shown to be a very useful instrument to encourage otherwise not educationally trained medical specialists to embark on the trail of competency‐based curriculum development.

The model as employed in the field of surgery will be presented and discussed.
SE17 SURGICAL EDUCATION AND TRAINING: A QUEST FOR EXCELLENCE IN A CHANGING SOCIETY
Authors: Collins J.
Published: April 2009

In 2008 a leading UK medical correspondent wrote: “the royal colleges must up their game – or die” because of their lack of influence in the debacle over medical training. Surgical education is at a crossroads and the sustained production of surgeons including surgical scientists faces many challenges. It might well be asked how the Royal Australasian College of Surgeons and its partner surgical specialties are responding to the winds of influence blowing their way.

The seeds of surgical education must be planted and nurtured in medical school, watered and fertilized after graduation by the Postgraduate Medical Councils and helped to prosper and bloom by the surgical colleges for those who choose surgery as a career. Meaningful and collaborative partnerships are therefore essential for the development of an integrated approach across the continuum of learning.

The College has responded to the many factors now influencing training by developing and implementing a new integrated surgical education and training program (SET), new processes and criteria for accreditation for hospital posts for training, more valid and reliable selection and new competency‐based curricula and assessment including workplace‐based assessment. A new and comprehensive foundation surgical skills course has been introduced and new courses implemented to help supervisors.

A major challenge surrounds sustaining the delivery of surgical programs and courses. Surgeons are faced with the conflicting priorities of clinical practice, education, research and administration. Research and patient care have become the dominant source of resources and prestige with a decline in the recognition and value of surgical education and teachers. An Academy of Surgical Educators is being developed by the College and its partner specialists to renew and reinvigorate surgical education, equip and support teachers and educational researchers all of which are vital to sustain the future of surgical education and continuing professional development.