bluuebunny/crossref_metadata_2025 huggingface dataset:
TN06 BONE BANKING
Authors: Boyle R. A. , Stalley P. D. , Loxton D. , Windolf M.
Published: April 2007

This paper presents an audit of 22 years of bone banking at Royal Prince Alfred Hospital, along with a review of the current literature regarding the use of allograft bone.

Comparisons both locally and internationally are made, and we are confident that standards in Australia are equivalent to those internationally. The requirement for bone graft material in Australia is likely to rise, as more reconstructive and revision surgery is undertaken, along with increases in primary arthroplasty procedures.
TS12 COMBATING COAGULOPATHY
Authors: Gunn K. N.
Published: April 2007

The clinical trigger to consider the presence of a coagulopathy is the onset of non‐surgically controllable bleeding. While earlier consensus documents considered this event predictable by modelling blood loss, and factor level decline, we now recognize confounding variables such as shock, hypothermia, metabolic disturbances and fibrinolysis confuse the picture to such an extent traditional treatment algorithms are irrelevant. The monitoring of coagulopathy by traditional coagulation screens also lacks validation, and is usually so delayed in response time to become irrelevant to appropriate management.

Attaining euvolaemia is possible with large volume dedicated infusion systems but in a patient with massive mediator release and comorbidities may not achieve adequate tissue oxygen delivery. Evidence based transfusion triggers are still lacking. Management of coagulopathy is by component replacement early. Delays occur because of slow coagulation test turnaround times, and the place of newer point of care monitors and thrombelastography needs evaluation. Delay in delivery of blood components due to processing time may worsen the outcome. Factor VIIa probably has a unique place in the management of coagulopathy in these patients, but studies are needed to define dosage and time of dose (2). The management of acidosis and hyperlactaemia are fundamentally improved by better perfusion, but short term correction may be indicated to reinforce coagulation factor function.
TS13 HAEMOSTASIS IN THE AUSTRALIAN DEFENCE FORCE: THE TOURNIQUET CONTROVERSY
Authors: Neuhaus S. J.
Published: April 2007

In civilian trauma concerns about tourniquet‐related problems has rendered tourniquets virtually obselete. The use of tourniquets in a battlefield setting however remains surrounded by controversy. Whilst many accept that if properly used, tourniquets can be life saving devices, opinion is divided regarding its role. Some surgeons have recommended abolition of the tourniquet, whist others advocate that every combat solder should be issued with a tourniquet as part of their personal equipment. The recent introduction of the self applied C‐A‐T tourniquet into the Australian Defence Force has re‐ignited controversy as to the appropriate role of tourniquets in an operational setting.

During Vietnam, Desert Storm and Somalia haemorrhage from extremity wounds was a leading cause of preventable combat deaths. Improvements in body armour and increased exposure to blast injury has resulted in a relative increase in limb injuries in recent operations. Experience in Somalia, Iraq and Afghanistan particularly by Special Operations communities has led to a re‐assessment of the efficacy of battlefield tourniquet systems. The C‐A‐T tourniquet has been widely used in Iraq and Afghanistan. No iatrogenic injury has been reported, even with tourniquet times up to 8 hours.

This paper will discuss the history of tourniquet use in the military from its first introduction in 1674 to the most recent ADF doctrine (ADFP XXX). It will also present trial results from the UK and US and recommendations from the 2006 Advanced Technologies Applied to Combat Casualty Care Conference (ATACC).

This paper will address the basis of current doctrine and provide a case for and against the use of tourniquets in an operational setting.
TS15P UNCOMMON ABDOMINAL HEMORRHAGE DUE TO BLUNT TRAUMA: BLENDING FROM AN ASYMPTOMATIC ABDOMINAL TUMOR INJURY – A CASE REPORT
Authors: Collet e Silva F. S. , Bardella R. , Fontes B. , Poggetti R. S. , Birolini D.
Published: April 2007

Asymptomatic tumors are not uncommon, may be diagnosed during clinical examination or during surgical interventions for other purposes such as treatment of a hemorrhage due a blunt trauma.

Case report  6 year‐old boy had fallen, hitting his abdomen against a rock, and arrived at hospital ten hours later. Initial assessment he was complaining of diffuse abdominal pain; his physical examination showed: respiratory rate: 16 mov/min, blood pressure: 100 × 80 mmHg, heart rate: 100 bat/min, and Glasgow coma score: 15. His abdomen was distended, with guarding and rebound tenderness, and had a palpable mass. FAST ultrasound was positive; and Ct‐scan showed an abdominal mass with 15 × 12 × 7 cm dimension, and moderate amount of free blood in the abdominal cavity. Laboratory tests showed: hemoglobin 9.9 mg/dl, hematocritic 28.8%, white blood cells 6.900 cel/dl.

Midline laparotomy was performed, a large, injured and bleeding mesenteric mass was found encircling superior mesentery artery and several small bowel loops; 500 ml of free blood was found in the peritoneal cavity. Mesenteric mass was partially removed with a segment of the small bowel. Findings of anatomico‐pathologic examination revealed an intestinal Burkitt lymphoma, with mesenteric linfonodes. Patient had an uneventful postoperative course, and started with quimotherapy.

Comments  This case report shows an unusual traumatic abdominal blending that could not be clearly diagnosed before laparotomy was performed. The emergency of this case was bleeding control, decision to remove mass was taken only for this purpose, and not to treat the tumor. As removal of the whole mass was impossible, a partial removal was performed.
TS16P TUBE THORACOSTOMY: THE IMPORTANCE OF SWING
Authors: Reddy C. , Hardman A. D. , Tharion J.
Published: April 2007

Intercostal catheter placement is common practice in the management of haemothorax and pneumothorax, with over 12,000 being inserted per year (1) in Australian hospitals. It is however an invasive procedure with the potential for significant iatrogenic injury. This is even more pertinent in the trauma setting where stress levels are high and time may be limited. Historically, complications that have been associated with intercostal catheter placement include: lung parenchymal laceration, bleeding from intercostal vessel injury, cardiac injury, ectopic tube placement, empyema, diaphragmatic and intra‐abdominal organ laceration. In an attempt to minimise and avoid these complications, there has been a shift in the teaching of the method of tube placement from that of a trocar technique to the blunt dissection (EMST) approach (2). While this will hopefully reduce the rate of procedural complications, it still may not guarantee clinical practice free of complications. Furthermore when these complications are suspected, there is a need for repeated clinical assessment (at times, independent of imaging) in order to allow the early identification any such iatrogenic injury. The presentation will provide a review of the literature and outline the various forms of iatrogenic injury associated with tube thoracostomy; highlight the importance of clinical reassessment following intercostal catheter placement, with particular reference to a case presentation; and discuss techniques to avoid and minimise potential complications.
TS17P MECHANISMS OF INJURY CAUSING LIMB FRACTURES WITHIN THE PAEDIATRIC POPULATION
Authors: Ngui N. K. , Tewari S. , Chan I. , Jovanovic A. , Hefner P. A.
Published: April 2007

Objective  Playground and sporting accidents account for a large percentage of paediatric injuries, yet they are largely preventable. The aim of this study is to investigate the risk factors and mechanisms associated with upper and lower limb fractures in children.

Method  145 children admitted to a regional Australian hospital (Coffs Harbour Base Hospital) totalling 207 upper and lower limb fractures over an 12 month period between January 1st 2004 to December 31st 2004 were identified from the hospital medical records database. Retrospective analysis was performed on demographic data, fracture type and mechanisms causing the fracture.

Results  Males accounted for 69.7% of all childhood limb fractures. 77.7% of all fractures were upper limb, while 22.3% were lower limb. The leading causes of lower limb fractures were football injuries, push bike accidents, and aquatic accidents, accounting for 51.8% of all lower limb fractures. Monkey bars, swings, trees, skateboard and scooter accidents were associated with a relatively high prevalence of upper limb injuries when compared to other injury mechanisms. Football, push bike and skateboard accidents alone accounted for 40.6% of fractures in our male patients. This figure was only 4.5% in our female patients, and in general, the causes of fractures in females are more evenly distributed.

Conclusion  Limb fractures in children have a diverse range of causes, but specific fractures occur more frequently in particular sexes and with certain activities. There is a role for further injury prevention targeting specific high risk groups and activities.
TS02 MANAGEMENT OF FLAIL CHEST IN TRAUMA: ANALYSIS OF RISK FACTORS AFFECTING OUTCOME
Authors: Ali B. A. , Sanfilippo F.
Published: April 2007

Background  Flail chest in thoracic trauma is associated with significant complications and carries high morbidity and mortality. At present there is no standardized management plan for flail chest. The aim of this study was to determine the risk factors affecting morbidity, mortality, and length of stay in the hospital.

Methods  We evaluated all patients admitted to our trauma centre between January 2002 and December 2004. Age, presence of pneumothorax, trauma severity score (ISS), length of stay, lung contusion and deaths were recorded.

Results  There were 100 patients with a mean age of 52 (SD 19.8, range 17–90). The median length of stay was 17 days, and the average ISS score was 30 (SD 13.2). 74% had flail chest and lung contusion, 2 patients had pneumothorax, and 7 (7%) patients died 3 (5.4%) patients with 1–4 fractured ribs died, compared with 4 (8.9%) patients with 5 or more fractured ribs (p = 0.70, Fisher’s exact test). The mean ISS score was 32.3 (SD 19.5) for those who died compared with 29.8 (SD 12.7) in those who did not die (p = 0.63, t‐test). There was a moderate positive correlation between ISS score and length of stay (r = 0.36, p = 0.0002, Pearson correlation coefficient).

Conclusion  ISS score was found to be a moderate potential predictor on outcome regarding length of stay in the hospital. There is an apparent increased risk of death with more fractured ribs and therefore a standadised surgical management plan for ribs fixation may reduce the risk of death in this patient group.
TS05 WHOLE‐BODY MULTISLICE CT‐SCANNING AS PRIMARY IMAGING TOOL IN THE EMERGENCY MANAGEMENT OF SEVERE TRAUMA
Authors: Nau T. N. , Dwyer D. D. , Glenn D. G.
Published: April 2007

Aim  Whole‐body multislice CT‐Scanning (MSCT) has become the primary imaging device in many European and North American trauma centres. We aim to present a new standardised protocol that has lead to a markedly improved diagnostic managment in an Australian metropolitan trauma centre.

Methods  Based on growing evidence in the literature the MSCT is used as the primary imaging tool in severely injured patients and is routinely performed after completion of primary and secondary survey. The routine protocol consists of a non‐contrast head and cervical spine CT, followed by a contrast chest, abdomen and pelvic CT. Apart from an initial chest X‐Ray, routine X‐ray trauma series are not performed anymore. The criteria for this whole‐body MSCT are strictly limited to patients that required trauma team activation and can be sufficiently stabilised in the emergency room.

Results  This adapted diagnostic algorithm has shown to be very fast and efficient. The average duration of initial management can be reduced significantly, in addition the number of initially missed injuries is markedly reduced.

Conclusions  Primary whole‐body MSCT has become a valuable diagnostic tool in the emergency management of severe trauma. A strictly followed protocol has been shown to be crucial to avoid overuse, in terms of radiation as well as exposing the unstable patient to an unnecessary high risk.
TS06 NEUROTRAUMA IN THE RURAL AND REMOTE SETTING
Authors: Vonau M.
Published: April 2007

This paper reviews the management of head injuries arising in the rural and remote areas of Queensland.

Methodology  Data was obtained from the Queensland Trauma Registry from January 2003 to December 2004, a total of 3,088 patients, 1667 classified as major injury.

Queensland is the second largest state in Australia with most of the 4 million population living along the eastern seaboard, mainly in the southeast corner and a widely dispersed rural population in small towns. There are neurosurgical services in Brisbane, the Gold Coast and Townsville.

Results  Forty percent of patients are referred from another hospital for definitive care with transfer times of up to 10 hours between the referring and definitive care hospital. Of those requiring craniotomy 60% of patients are referred from a another hospital again with lengthy transfer times well beyond the 2 hour transfer time for the deteriorating head injury with intracranial haemorrhage as recommended in the NSA/RACS set of guidelines for the “Management of Acute Neurotrauma in Rural and Remote Locations”.

This paper reviews the problems which include deficient retrieval resources, a reluctance by non‐neurosurgeons to perform emergency neurosurgery, a lack of training amongst younger surgeons, and perceived medicolegal issues.

The paper also compares the situation in other states and territories.

Conclusions  Recommendations are made to improve the delivery of neurotrama care.
TS07 OUTCOME OF TRAUMATIC RUPTURE OF THE DIAPHRAGM (TRD)
Authors: Goonewardene K. , Warwick A. M. , Burton P. R. , Brown W. A.
Published: April 2007

Purpose  TRD is an uncommon but serious consequence of blunt trauma. It is often associated with other life threatening injuries and its diagnosis is challenging. Limited information exists on outcomes following rupture, although there are increasing reports of late recurrent herniation. Our aim was to document the outcome of TRD initially and at intermediate term follow up (up to five years).

Methodology  A review of all patients suffering TRD, over the past five years, at The Alfred Hospital was performed. Injury severity score (ISS), associated injuries, diagnosis‐ early versus late and imaging modality used, and surgical repair technique were recorded. All patients were followed up with a questionnaire, regarding symptoms of recurrence and chest X‐ray (CXR).

Results  33 patients (18 female, 15 male; mean age 36 yrs, mean ISS 42) were included. All injury mechanisms were high energy (motor vehicle occupants 27, pedestrians 5, horse rider 1); 25 sustained other intra‐abdominal injuries. There were nine early and no late deaths.

CXR was diagnostic in 14 cases, with 23 recognised early (pre‐operatively). 6 were diagnosed intra‐operatively (5 for instability, 1 following unremarkable imaging). 3 late diagnoses (>24 hours after presentation) occurred, with 1 at 6 months post injury. Emergent primary repair was undertaken using non‐absorbable sutures, although in three cases absorbable sutures were used.

Conclusions  TRD is associated with high energy blunt force and severe multi‐system injury. We advocate emergent primary repair with non‐absorbable suture and advise a minimum five year follow‐up.
TS08 PROSPECTIVE VALIDATION OF THE INDEPENDENT PREDICTORS FOR POSTINJURY INTRA‐ABDOMINAL HYPERTENSION
Authors: Vans Wessem K. J. P. , Mackay P. J. , Balogh Z.
Published: April 2007

Purpose  Prospective validation of recently established independent predictors for postinjury abdominal compartment syndrome (ACS) was performed.

Methodology  All trauma patients who met inclusion criteria (ICU admission, ISS > 15, Base Deficit (BD) > 5, or resuscitation with >5 L crystalloids) were prospectively monitored. Patients with isolated head injuries were excluded. Demographics, ISS, resuscitation fluids, physiological parameters, intra‐abdominal pressure (IAP) and the independent predictors in two time windows “ED discharge”[SBP, crystalloids, Time‐to OR, transfusions] and “ICU admission”[crystalloids, urine output (UO), Hb, Temperature, BD] were collected. Data are presented as mean  ±  SEM, p < 0.05 considered significant.

Results  Twenty‐two blunt trauma patients were monitored (Age 39 ± 5 years, 77% males, ISS 32 ± 2, SBP 107 ± 5 mmHg, BD 7 ± 1). No patients developed ACS. Seven patients developed IAH (IAP > 20 mmHg). IAH and non‐IAH patients had the same age (41 ± 7 vs 37 ± 5 yrs) and admission BD (7.5 ± 1.3 vs 6.3 ± 1.2). IAH patients had higher ISS than non‐IAH patients (39 ± 3 vs 30 ± 2). Outcomes (IAH vs non‐IAH): ICU LOS (39 ± 3 vs 30 ± 2), Mortality (0% vs 7%), MOF (29% vs 0%).

“ED‐discharge predictors”: The IAH and non‐IAH patients had similar admission SBP, ED crystalloid volume, transfusions and ED time.

“ICU‐admission predictors”: IAH and non‐IAH patients had similar UO, crystalloid infusions, BD, temperature but the IAH group had lower Hb (99 ± 5 vs 111 ± 3 g/dl) than the non‐IAH patients.

Conclusions  The incidence of ACS decreased from 14% to 0% in a comparable population. The predictors for ACS did not predict IAH. After the elimination of the lethal ACS, the clinical importance of postinjury IAH has to be defined.
VS01 PREDICTIVE MODEL OF SUCCESS FOR EVAR
Authors: Anderson J. L. , Fitridge R. , Boult M. , Barnes M. , Maddern G.
Published: April 2007

Purpose  To provide an overview of a predictive model of success that has been developed using the five‐year results from the audit of endovascular aneurysm repair (EVAR).

Methodology  Preoperative and operative EVAR information was collected from surgeons for procedures performed between November 1999 and May 2001. Annual follow‐up has continued with a view to examining mid to long‐term safety and effectiveness. Data was linked through the National Death Index to obtain accurate mortality information.

A statistician applied generalised linear models (logistic regressions) on the data to predict measures of success. Stepwise forward logistic regressions were used to select which of the preoperative patient variables were included in each success measure model. Using this analysis, an interactive Microsoft Excel program was designed to help surgeons to evaluate the predicted likelihood of success of the procedure.

Results  Eight predictor variables were used to assess relationships with various measure of success. Measures included technical success, likelihood of re‐interventions, graft complications, migration, conversion to open, rupture, endoleak, mortality and survival. Copies of the model (Excel spreadsheet) were circulated to members of the audit reference group and other specialist vascular surgeons for comment. Clinical feedback was used to further refine the model and improve its utility.

Conclusions  The predictive model is available to vascular surgeons through the RACS website. It was developed as an aid for surgeons and patients to decide treatment options. Surgeons and patients can discuss patient’s likely outcomes (e.g. complications and survival likelihood) to better inform the EVAR decision.
VS10 CAROTID ENDARTERECTOMY WITH EARLY ICA CONTROL: AN MRI STUDY
Authors: Bourke B. M. , Lannan M. , Khoury S.
Published: April 2007

Introduction  Diffusion‐weighted magnetic resonance imaging (DWI) is a powerful tool to detect early cerebral ischaemia and can detect new post‐operative but clinically silent lesions before CT and conventional MR. Studies to date have used 1.5 T magnets and concerned CEA patients under general anaesthesia. This study concerns CEA patients under local anaesthesia using a 3T scanner.

Patients and Methods  Between 23/6/06 and 11/1/07, 40 consecutive CEAs were performed. All procedures were performed in awake patients with selective early control of the ICA beyond the plaque. All patients received Dextran 40 and all received a vein patch. DWI was performed 1–2 days pre‐operatively and within 1 week post‐operatively.

Results  Three required a shunt. There were no deaths, no strokes, no TIAs and no cranial nerve dysfunction. Thirty‐five of forty were discharged after 1 post‐operative night. Four remained longer for non‐related reasons and 1 for swallowing difficulty resolving after 36 hours. In 8 patients MR was contra‐indicated or not possible, and a further 2 refused the post‐operative study because of claustrophobia. One patient was found to have a cerebral tumour. In 5 patients new silent lesions were detected. Lesions were singular in 4 and double in 1 patient. Four of the 6 lesions were ipsilateral and 2 contralateral.

Conclusions  This is the first reported such study using 3 T and CEA patients under local anaesthesia. The significance of the findings will be discussed. Because it is rapid and non‐invasive, DWI should be the new gold standard of quality control for carotid interventions, particularly in trials comparing modes of management.
VS12P USE OF THE SUPERFICIAL FEMORAL POPLITEAL VEIN AS A CONDUIT IN SELECTED VASCULAR SCENARIOS
Authors: Gillespie C. , Jauffret B.
Published: April 2007

In 1986 Schulman et al first reported the use of the superficial femoral popliteal vein (SFPV) as a conduit for femoral‐popliteal arterial bypass. Since then it has been well reported as an alternative conduit in various scenarios, predominantly in the reconstruction of a neoaortoiliac system for infected prosthetic aortic grafts.

It is a large calibre vessel, 8–12 mm in diameter, with good handling properties, a high graft patency rate, and a thick wall rendering it resistant to infection. Aneurysmal change occurs rarely after long‐term follow‐up. Anatomic studies show that on average lengths of 40–50 cm in men and 30–40 cm in women can be harvested on each side with minimal symptomatic venous consequences. Less than one third of patients after SFPV harvest develop oedema despite significant venous outflow obstruction on plethysmography. These characteristics make it an excellent conduit for both venous and arterial bypass in selected vascular cases.

We present a series of 3 patients in whom the SFPV was used as a conduit. The first was an iliofemoral bypass for an isolated traumatic iliac artery dissection in a 35 year old man. The second was a complex 4th redo for a failed femoral‐popliteal bypass operation. The third was a portal vein reconstruction during a pancreaticoduodenectomy for a pancreatic tumour encasing the portal and superior mesenteric veins. In all 3 cases the grafts have remained patent during follow‐up, with only one patient developing symptomatic oedema.

This case series illustrates the wide spectrum of applications for this safe and effective conduit. Used until now mostly as a rescue conduit after the failure of synthetic grafts, should SFPV be considered as the first choice for younger patients?
VS13P THE IMPACT OF THE ESCHAR TRIAL ON CLINICAL PRACTICE
Authors: Warwick A. M. , Thomas C. , Dodd P. D.
Published: April 2007

The ESCHAR trial, published June 2004, showed that patients with venous ulceration who had superficial or mixed superficial and segmental deep venous reflux had a decreased likelihood of recurrent ulceration if they were treated with superficial venous surgery. This prompted us, firstly, to review our service to see if we were following this level one evidence; secondly to estimate how many of our patients could benefit from adopting this practice.

Method  Retrospective audit of all patients attending a nurse‐led ulcer clinic for a 6 month period between June and December 2004.

Results  163 patients attended during the audit period. Data were retrieved for 146. Of these only 54 (37%) had purely venous ulceration on clinical assessment, of whom 31 had a venous duplex scan. 21 patients had superficial only, or mixed superficial and deep reflux; 8 had no reflux; 2 had deep reflux only. Of these 21 patients who could potentially be suitable for superficial venous surgery, 1 had deep venous occlusion, 4 patients refused surgery, 4 were considered unsuitable for surgery on medical grounds, 7 were not assessed for surgery, only 3 patients were awaiting superficial venous surgery.

Conclusion  Despite the publication of evidence supporting superficial venous surgery in selected patients only 3/146 (2%) patients attending our clinic were listed for venous surgery. However 7/21 (33%) were not assessed for treatment. This study demonstrates the inertia in adopting “best evidence” into clinical practice. Even so the numbers of leg‐ulcer patients likely to benefit from surgery appears surprisingly small.
VS15P THERAPEUTIC EMBOLISATION IN THE TREATMENT OF RECURRENT HAEMARTHROSIS FOLLOWING KNEE ARTHROPLASTY
Authors: Law M. T. , McClure D. N.
Published: April 2007

Recurrent spontaneous haemarthrosis after knee arthroplasty occurs in less than 1% of cases, commonly thought to be result of impingement of hypertrophic vascular synovium or fat pads, exacerbated by anticoagulation or antiplatelet agents. Traditional managements include conservative management with rest and ice initially, followed by open or arthroscopic washout and synovectomy if bleeding recurs or fail to settle. We present 3 cases of recurrent haemarthrosis following knee arthroplasties which were successfully treated with angiography and coil embolisation. Injuries to one of the genicular arteries were identified as the cause in all three cases with one manifesting in formation of a traumatic arteriovenous malformation. All cases were associated with resolution of symptoms with no recurrence (follow‐up period 6 months – 5 years, median of 2 years). We discuss the possibility that direct injury to genicular arteries and the development of subsequent complications including arteriovenous malformation and false aneurysm as more likely aetiology of recurrent bleeding.
VS02 AORTIC CALCIFICATION: STUDIES IN PATIENTS WITH PERIPHERAL ARTERY DISEASE AND A MOUSE MODEL
Authors: Golledge J. , Pal S. , Jayalath R. , Van Campenhout A. , Clancy P. , Rush C.
Published: April 2007

Purpose  Aortic calcification is associated with subsequent cardiovascular events however relatively little is understood about its pathogenesis. This presentation describes on‐going work to improve measurement, diagnosis and understanding of aortic calcification.

Methodology  Studies have been carried out in a cohort of patients with peripheral artery disease and within an animal model.

Results  We have developed and validated a technique to accurately assess the severity of infrarenal abdominal aortic calcification using CT angiography within patients. Utilising this technique we have investigated a number of potential blood tests to assess their value in determining aortic calcification severity. Within a mouse model of aortic calcification we are investigating the role of bone marrow derived cells in calcification development.

Conclusions  Further understanding of the mechanisms underlying aortic calcification may identify targets to treat calcification which are independent of those for atherosclerosis.
VS05 LAPAROSCOPIC ENDOVASCULAR AORTOBIFEMORAL BYPASS
Authors: Jansen S. J. , Lawrence‐Brown M. M. D. , Hartley D. E. , Ducke W. , Resch T. , Semmens J. B.
Published: April 2007

Purpose  Patients with iliac stenosis or occlusion may currently be denied endovascular solutions to aneurysmal or occlusive disease. We have previously described a method for laparoscopic delivery of a transperitoneal endovascular conduit avoiding the need for a muscle‐cutting incision1. We now describe a laparoscopic technique for endovascular placement of a partially stented aortbifemoral (ABF) bypass which may be used for proximal endovascular manipulation e.g. in the thoracic aorta, and thereafter retained as a bypass.

Methodology  Ethical approval was obtained to use a fresh frozen cadaver. The left common iliac artery, distal aorta and proximal right common iliac artery were dissected laparoscopically. Wire access of the distal aorta was obtained using a hollow needle. A partially stented graft was then deployed under fluoroscopy into the distal aorta. One limb was clamped intra‐corporeally while the other was delivered through a port to enable endovascular access and manipulation. The limbs were then tunneled retroperitoneally and anastomosed to the femoral arteries in the conventional manner retaining the stent graft as a permanent bypass.

Results  Introduction and deployment were successful.

Conclusion  This novel hybrid approach combines laparoscopic and endovascular techniques to place an ABF bypass without the need for abdominal incision and is therefore a minimally invasive solution to pelvic occlusive disease. It is worthy of consideration as many vascular surgeons will have the requisite skills.
VS06 THE OTAGO VARICOSE VEINS CONDITION‐SPECIFIC QUESTIONNAIRE FOR ASSESSMENT OF QUALITY OF LIFE FOLLOWING SURGERY OR SCLEROTHERAPY
Authors: Chen T. Y. T. , Macfarlane J. , Landmann M. G. , Van Rij A. M.
Published: April 2007

Purpose  The Otago Varicose Veins Condition‐Specific Questionnaire (OCSQ) is a validated quality of life (QOL) tool for use in the pre‐treatment setting. This follow‐on study investigates how the OCSQ reflects changes in QOL following treatment, and how these changes relate to clinical and vascular laboratory outcomes.

Methodology  Patients with varicose veins undergoing pre‐treatment assessment at the Otago Vascular Laboratory were recruited. The OCSQ was administered at the time of assessment and at 1, 3, 6, and 12 months post‐treatment. A follow‐up laboratory assessment was performed at 12 months. Pre and post‐treatment QOL at each time point were compared. The relationships between QOL, patient demographics and laboratory measures were examined.

Results  Of the 218 patients, the average pre‐treatment QOL score was 26.3% ± 17.3 (a higher score indicates a poorer QOL), and following treatment the scores improved at all time points (p < 0.05). The effect sizes were moderate to large, and the greatest QOL was seen at 3 months (11.3% ± 12.5). There was an association between longer prior disease duration and poorer QOL at 3 months (r = 0.31, p < 0.01), and between older age and poorer QOL at 12 months (r = 0.31, p < 0.01). Patients having treatment for recurrent disease showed lower levels of QOL than those with primary disease. Apart from the Venous Clinical Severity Score, no laboratory measure correlated with QOL.

Conclusions  The OCSQ is a useful tool in evaluating QOL following treatment for varicose veins. Changes in QOL are not well reflected in laboratory measures. Age, prior disease duration, and recurrent disease seem to limit the improvement in QOL following treatment.
VS09 MEDICAL MANAGEMENT OF EXTRACRANIAL VASCULAR DISEASE
Authors: Fink J. N.
Published: April 2007

Medical treatment is indicated for all patients with symptomatic or high‐risk asymptomatic extracranial vascular disease, whether or not a vascular intervention is planned or has been performed. Recent evidence mandates an aggressive approach to management of traditional vascular risk factors, frequently involving use of several medications concurrently such as angiotensin converting enzyme inhibitors, diuretics and statins. These treatments should be considered for all patients, including those with blood‐pressure and/or cholesterol measurements within what might be considered the “normal” range. However, treatment decisions should be tailored to individual patient circumstances. Vascular anatomical considerations must be taken into account, particularly the presence of severe bilateral internal carotid artery stenoses or occlusion. Combination antiplatelet therapy with aspirin plus dipyridamole is generally indicated for secondary prevention of cerebrovascular disease, whilst clopidogrel is used following stent placement. Advances in medical management of extracranial vascular disease which reduce the overall risk of cerebrovascular events have been introduced subsequent to some of the pivotal carotid surgery trials. Possible implications for surgical treatment decision‐making will be addressed.
Factors affecting settlement rate of the hemlock woolly adelgid,Adelges tsugae, on eastern hemlock,Tsuga canadensis
Authors: Butin Elizabeth , Preisser Evan , Elkinton Joseph
Published: April 2007

1 We assessed the importance of several factors potentially affecting the settlement rate of the invasive hemlock woolly adelgidAdelges tsugae(Hemiptera: Adelgidae) on uninfested foliage of the eastern hemlock,Tsuga canadensis. We conducted our experiments in Massachusetts (U.S.A.) with overwintering sistens adelgids, and applied standard densities of infested foliage to uninfested branches in a planned multiple‐comparison design.

2 Settlement rates of progrediens crawlers produced by the overwintering sistens were highest when adelgid‐infested foliage was loosely attached to uninfested foliage and both branches were then enclosed in a mesh sleeve.

3 Early‐emerging crawlers settled at a higher rate than did late‐emerging crawlers.

4 Increasing the density of infested branches did not affect settlement rates.

5 We also tested whether less severe winter conditions improved settlement, and found that overwintering infested foliage in a refrigerator decreased settlement rate relative to foliage overwintered outdoors.

6 Our results suggest a protocol for adelgid inoculations that could substantially increase the success rate of experimental manipulations and encourage additional research on the population dynamics of this pest.
Robotically assisted laparoscopic pyeloplasty: a transatlantic comparison of techniques and outcomes
Authors: Chammas Mario F. , Hubert Jacques , Patel Vipul R.
Published: April 2007

OBJECTIVE

To report a comparison of two techniques of robotically assisted laparoscopic dismembered pyeloplasty (RALDP), and their associated outcomes, for treating pelvi‐ureteric junction obstruction (PUJO), evaluating the potential differences in the initial 50 cases of two centres in North America and Europe.

PATIENTS AND METHODS

Between November 2001 and August 2005, 100 patients had transperitoneal RALDP for PUJO in one centre in the USA (group 1) and one in France (group 2). Group 1 consisted of 50 patients (30 males and 20 females, mean age 31 years, range 16–62) and group 2 of 50 patients (17 males and 32 females, one bilateral PUJO; mean age 39 years, range 17–81). The right side was affected in 30 (60%) patients in group 1 and 32 (64%) in group 2. Differences in preoperative evaluation, surgical technique and follow‐up were evaluated.

RESULTS

In group 1 all procedures were completed laparoscopically. One conversion was necessary in group 2 due to technical difficulties. The mean operative duration was 122 min (group 1) and 127 min (group 2); the estimated blood loss was negligible (<100 mL) in both groups. Surgical findings included 15 patients with crossing vessels in group 1 and 28 in group 2. There were no peri‐operative complications in either group. The mean hospital stay was 1.1 days in group 1 and 5.8 days in group 2, reflecting differences in practice patterns. All patients were asymptomatic at stent removal and in subsequent clinical evaluations in both groups.

CONCLUSION

The combination of results form both series provide information suggesting that the robotically assisted approach is a viable treatment option. The results reflect some differences in techniques, follow‐up and practice patterns, but the outcomes were equally effective on both continents. Further follow‐up will allow us to determine the long‐term efficacy.
Post‐stroke urinary incontinence with impaired awareness of the need to void: clinical and urodynamic features
Authors: Pettersen Renate , Stien Ragnar , Wyller Torgeir B.
Published: April 2007

Authors from Oslo report the difficult problem of urinary incontinence after a stroke, with impaired awareness of the need to void. In this interesting paper they compared it to urge urinary incontinence, and felt that it probably reflects greater brain damage. They also found that there were various urodynamic patterns associated with the condition.

OBJECTIVE

To describe a clinical subtype of urinary incontinence (UI) after a stroke, i.e. with impaired awareness of the need to void (IA‐UI), and to compare it to urge UI after a stroke for the risk factors and medium‐term outcome.

PATIENTS AND METHODS

In a consecutive sample of 315 hospitalized stroke patients who were clinically stable and able to communicate, 65 with UI were identified (27 urge UI, 38 IA‐UI). All had a comprehensive clinical assessment and cerebral computed tomography (CT). Cysto‐urethrometry was performed in seven patients with IA‐UI.

RESULTS

Of the 38 patients with IA‐UI, 16 were partially aware of leakage, but not of bladder fullness; the remaining 22 denied leakage. Patients with IA‐UI were more functionally impaired (P = 0.001), had more visible new CT lesions (24 of 38 vs 10 of 27, P = 0.04) and less frontal lobe involvement (seven of 24 vs seven of 10, P = 0.05) than those with urge UI. Ten of 12 patients with parietal lobe involvement denied leakage; no particular lesion pattern was found in those with partial awareness. Two patients had normal cysto‐urethrometry, four showed terminal detrusor overactivity, and one had an incompetent urethral closure mechanism. In all, bladder sensation was reduced or absent. Only two of the surviving patients had regained continence after 1 year, whereas half of those with urge UI had become continent.

CONCLUSION

IA‐UI after a stroke differs from urge UI in clinical and prognostic respects, and probably reflects greater brain damage. It might explain the prognostic importance of stroke‐related UI. There are various urodynamic patterns. Patients with better preserved insight might benefit from early awareness training and even from additional medical treatment if bladder overactivity is present; this needs further investigation.
Prognostic accuracy of an artificial neural network in patients undergoing radical cystectomy for bladder cancer: a comparison with logistic regression analysis
Authors: Bassi PierFrancesco , Sacco Emilio , De Marco Vincenzo , Aragona Maurizio , Volpe Andrea
Published: April 2007

OBJECTIVE

To compare the prognostic performance of an artificial neural network (ANN) with that of standard logistic regression (LR), in patients undergoing radical cystectomy for bladder cancer.

PATIENTS AND METHODS

From February 1982 to February 1994, 369 evaluable patients with non‐metastatic bladder cancer had pelvic lymph node dissection and radical cystectomy for either stage Ta‐T1 (any grade) tumour not responding to intravesical therapy, with or with no carcinoma in situ, or stage T2–T4 tumour. LR analysis based on 12 variables was used to identify predictors of overall 5‐year survival, and the ANN model was developed to predict the same outcome. The LR analysis, based on statistically significant predictors, and the ANN model were the compared for their accuracy in predicting survival.

RESULTS

The median age of the patients was 63 years, and overall 201 of them died. The tumour stage and nodal involvement (both P < 0.001) were the only statistically independent predictors of overall 5‐year survival on LR analysis. Based on these variables, LR had a sensitivity and specificity for predicting survival of 68.4% and 82.8%, respectively; corresponding values for the ANN were 62.7% and 86.1%. For LR and ANN, the positive predictive values were 78.6% and 76.2%, and the negative predictive values were 73.9% and 76.5%, respectively. The index of diagnostic accuracy was 75.9% for LR and 76.4% for ANN.

CONCLUSIONS

The ANN accurately predicted the survival of patients undergoing radical cystectomy for bladder cancer and had a prognostic performance comparable with that of LR. As ANNs are based on easy‐to‐use software that can identify nonlinear interactions between variables, they might become the preferred tool for predicting outcome.
Robotic radical prostatectomy: outcomes of 500 cases
Authors: Patel Vipul R. , Thaly Rahul , Shah Ketul
Published: April 2007

OBJECTIVE

To report the outcomes of 500 robotically assisted laparoscopic radical prostatectomies (RALPs), a minimally invasive alternative for treating prostate cancer.

PATIENTS AND METHODS

In all, 500 patients had RALP over a 30‐month period. A transperitoneal six‐port approach was used in each case, with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Prospective data collection included quality‐of‐life questionnaires, basic demographics (height, weight and body mass index), prostate specific antigen (PSA) levels, clinical stage and Gleason grade. Variables assessed during RALP were operative duration, estimated blood loss (EBL) and complications, and after RALP were hospital stay, catheter time, pathology, PSA level, return of continence and potency.

RESULTS

The mean (range) duration of RALP was 130 (51–330) min; all procedures were successful, with no intraoperative transfusions or deaths. The mean EBL was 10–300 mL; 97% of patients were discharged home on the first day after RALP with a mean haematocrit of 36%. The mean duration of catheterization was 6.9 (5–21) days. The positive margin rate was 9.4% for all patients; i.e. 2.5% for T2 tumours, 23% for T3a and 53% for T4. The overall biochemical recurrence free (PSA level <0.1 ng/mL) survival was 95% at mean follow‐up of 9.7 months. There was complete continence at 3 and 6 months in 89% and 95% of patients, respectively. At 1 year 78% of patients were potent (with or without the use of oral medications), 15% were not yet able to sustain erections capable of intercourse, and another 7% still required injection therapy.

CONCLUSION

RALP is a safe, feasible and minimally invasive alternative for treating prostate cancer. Our initial experience with the procedure shows promising short‐term outcomes.
Reliability of preoperative diagnostics and location of lymph node metastases in presumed unilateral prostate cancer
Authors: Weckermann Dorothea , Holl Gabriele , Dorn Robert , Wagner Theodor , Harzmann Rolf
Published: April 2007

OBJECTIVE

To investigate the reliability of preoperative diagnostics in predicting the true histopathological stage and grade of prostate cancer, and to examine whether lymph node (LN) metastases in unilateral prostate cancer are located unilaterally and therefore whether it is justified to dissect only the ipsilateral LNs in presumed unilateral disease.

PATIENTS AND METHODS

LN metastases in clinically localized prostate cancer are often located near the internal iliac vessels. They will be detected by extended or sentinel pelvic LN dissection (PLND). Both techniques might be time‐consuming and require extensive surgical experience. In all, 564 men with impalpable or unilateral palpable prostate cancer and positive biopsy cores only in one prostate lobe had a radical prostatectomy (RP) combined with radio‐guided PLND and in some cases an extended PLND.

RESULTS

A median of six sentinel LNs (mean, seven) and six non‐sentinel LNs (mean, seven) were dissected per patient; 52 of 564 men (9.2%) had positive LNs. Most men with unilateral disease had LN metastases on the same side of the pelvis. Comparing the clinical stage and grade with the tumour stage and grade of the RP specimen, there was a high percentage of upstaging and upgrading even in men with only one positive biopsy core.

CONCLUSION

Unilateral prostate cancer preferentially metastasizes to the ipsilateral pelvic LNs. Because there are a few cases of bilateral LN metastases even in unilateral disease, and as it is not possible to reliably predict unilateral disease on the basis of biopsy features, PLND only on the tumour‐bearing side has a high risk of understaging, and would possibly leave LN metastases behind.
Upper urinary tract tumour after radical cystectomy for transitional cell carcinoma of the bladder: an update on the risk factors, surveillance regimens and treatments
Authors: Sanderson Kristin M. , Rouprêt Morgan
Published: April 2007

The mini reviews this month cover two somewhat unusual topics, but I feel certain that they will be of interest to the readership. Metachronous TCC in the upper urinary tract after radical cystectomy has been an important topic in relation to the follow‐up, and this paper throws considerable light on the subject. The second paper is an excellent review of the literature on emphysematous cystitis.

Urothelial carcinoma is characterized by multiple, multifocal recurrences throughout the genitourinary tract; ≈ 3% of patients treated by radical cystectomy (RC) for invasive transitional cell carcinoma (TCC) of the bladder will subsequently develop a subsequent TCC in the upper urinary tract (UUT) urothelium. Metachronous upper UUT tumours (mUUT‐TCC) typically occur as a late oncological event (>3 years after RC). The vast majority of mUUT‐TCCs are detected only after the progression to tumour‐related symptoms, e.g. haematuria, flank pain or pyelonephritis, despite strict adherence to surveillance protocols. Failure of imaging and cytology to detect most asymptomatic tumours has led to questions about the need for routine UUT surveillance. Some authors have advocated a more tailored approach to surveillance after RC, targeting high‐risk patients and with limiting imaging in those patients at lowest risk of developing a subsequent UUT‐TCC. mUUT‐TCCs are most common in patients with TCC in the ureter or urethra, and with organ‐confined bladder cancer. Although the prognosis is generally poor, long‐term survival can be achieved in a subset of patients after radical nephroureterectomy (NU). Minimally invasive techniques, e.g. ureteroscopic and percutaneous resection, have been proposed as renal‐sparing alternatives to radical surgery for patients with low‐stage and ‐grade de novo UUT‐TCC. However, oncological control of renal‐sparing therapies in those with high‐risk mUUT‐TCC remains largely unconfirmed. Until oncological outcomes equivalent to the standard, radical NU, are reported in patients after RC, conservative treatment strategies should be avoided.