bluuebunny/crossref_metadata_2025 huggingface dataset:
INDEPENDENTLY PREDICTIVE PROGNOSTIC VARIABLES AFTER RESECTION FOR COLORECTAL CARCINOMA
Authors: Payne John E. , Meyer Horst‐Joachim
Published: January 2008

Background:Clinical variables such as surgical morbidity, comorbidity and follow‐up have been claimed to influence ultimate survival in patients who have resection for colorectal cancer. It is unclear whether the effect of clinical covariates is confounding or independent. We have attempted to build a comprehensive model, which is capable of testing the dependence and importance of prognostic factors.

Methods: A consecutive series of patients admitted between 1970 and 1988 and followed until 1992 had data recorded about presentation, pathology, hospitalization, aftercare and long‐term outcome. The patients were also divided into two approximately equal groups that were cared for by one and seven surgeons, respectively. Clinical and pathological covariates were built into a Cox (multivariate) proportional hazard model of crude survival. This was achieved with the SPSSadvanced statistical package version 6.1. Comparison between groups was then performed of clinical and pathological factors and subsequent cancer management.Results: There were 207 patients whose average age was 75 years, median survival was 43 months and operative mortality was 4%. The Cox model was robust. Covariates that had independent survival effects were pathological stage (P= 0.0000), grade (P= 0.014), age (P= 0.018), heart disease (P= 0.001), and group (P= 0.0008). Some of the dependent variables were symptoms, type of surgery, complications and length of stay. The groups, however, were well matched for age, stage, substage and comorbidity. Furthermore there were no substantial differences in mortality, complications or follow‐up frequency. There was a significant survival difference (P =0.0003) between groups, which was restricted to patients who were in clinicopathological stages B and C. Within stages B and C there was a significant (P =0.008) survival difference between patients who were or were not treated for recurrent disease. Diagnosis of recurrence was pursued more aggressively (P< 0.01), and decisions to treat recurrent disease were made more frequently in group 1 (P= 0.0002).

Conclusions:Pathology, comorbidity and the management of recurrence all have a significant independent effect upon crude survival after colorectal carcinoma resection.
HE WHO CANNOT TAKE PART IN THE FRIENDLY MEAL IS HALF CUT OFF FROM THE SOCIETY OF MAN*
Authors: Myers N. A.
Published: January 2008

The history of oesophageal surgery is reviewed with particular reference to the early history of ingested foreign bodies, oesophagotomy and oesophageal stricture. Some emphasis is placed on those conditions, which are of particular significance in childhood. A brief mention is also made of the history of carcinoma of the oesophagus.
SHOULD PERI‐OPERATIVE INFRA‐INGUINAL GRAFT DUPLEX SCANS BE ROUTINELY PERFORMED?
Authors: Tong Yisha , Royle John
Published: January 2008

Background: The ability of duplex ultrasound graft surveillance to detect graft stenosis is well documented. However, the optimal time to commence duplex ultrasound graft surveillance is not clear.

Methods: An early duplex ultrasound study was performed on 90 infra‐inguinal bypass grafts within 2 weeks of surgery. Further duplex scans were performed at intervals after surgery of 1 month, 3 months, 6 months, 1 year and then annually. An ankle/brachial systolic pressure index (ABI) was performed before the infra‐inguinal bypass and then 24 h after the surgery. The ABI was also routinely measured at the time of each graft duplex examination.

Results: Six graft thromboses (6.7%) were demonstrated on the first graft duplex within 2 weeks of the surgery. The 24‐hour postoperative resting ABI were less than 0.5 in all six cases. Significant graft stenoses (> 50%) or native artery diseases were detected in six cases (6.7%) on the first graft scan (proximal anastomosis stenosis, 1; mid‐graft stenosis, 3; peroneal artery stenosis, 1; popliteal artery occlusion, 1). The resting ABI was less than 0.5 in one of these cases. Vein patch angioplasty was performed on graft stenosis in two cases following the first duplex scan. In 78 cases with either normal or minimal graft/native artery stenosis (< 50%), the resting ABI were less than 0.5 in only two cases (2.6%). The first graft duplex ultrasound examinations were technically difficult or gave a poor image in 21 cases (23.3%). During the subsequent graft duplex follow‐up, seven graft thromboses were demonstrated at an average of 5.9 months after surgery (1–12 months). Significant stenosis (> 50%) was demonstrated in 10 additional cases at an average of 8.5 months after surgery (1–12 months).

Conclusions: The data of the present study do not support routine peri‐operative graft duplex scanning in addition to a 1‐month graft duplex scan. Early postoperative resting ABI should be routinely performed. If the resting ABI is less than 0.5, an immediate duplex scan should be carried out to assess graft integrity. A long‐term non‐invasive graft surveillance programme is important in the detection of graft stenosis.
PERISTALSIS IN AN INTERPOSED COLONIC SEGMENT IMMEDIATELY FOLLOWING TOTAL OESOPHAGOGASTRECTOMY
Authors: Myers J. C. , Mathew G. , Watson D. I. , Jamieson G. G.
Published: January 2008

Background: The motility pattern of colon used for oesophageal replacement in an oesophagogastrectomy is thought to be altered following interposition. Whether this is the result of adaptation or the removal of motor control mechanisms is unknown. Motility patterns of the interposed colon during the immediate postoperative period have not been previously studied. Methods: A patient who had an oesophageal adenocarcinoma and an unhealed gastric ulcer, underwent total gastrectomy and oesophagectomy. A colonic segment oriented isoperistaltically was used for oesophageal replacement. During the surgery, a customized 10 channel motility catheter was introduced transnasally into the colonic segment, and 24 h after surgery measurement of motor activity was undertaken using a perfused manometric system.

Results: Peristaltic contractions were observed with a mean contraction amplitude of 39.6 mmHg in the proximal channel, 90.3 mmHg in the distal channel and a mean propagation velocity of 0.51 cm/s.

Conclusions: Peristaltic colonic contractions continue to occur in the early postoperative period in the colonic segment used to replace the oesophagus. In view of this, colon replacing the oesophagus should always be arranged in an isoperistaltic fashion.
LAPAROSCOPIC GASTROSTOMY: TOWARDS THE IDEAL TECHNIQUE
Authors: Luck Andrew , Hewett Peter
Published: January 2008

Background: Laparoscopic gastrostomy is the best option for long‐term gastric intubation when percutaneous endoscopic gastrostomy is not possible. The ideal technique is yet to be defined.

Methods: A technique of suturing the gastric wall to the posterior rectus sheath under direct vision has been developed. The method is simple and avoids the difficulties and potential complications described with other techniques.

Results: The technique has been used in three cases with excellent results and no complications.

Conclusion: The described technique is a further advance in defining the ‘ideal’ technique of laparoscopic gastrostomy.
LEECHES IN MEDICINE
Authors: Thearle M. John
Published: January 2008

Leeches have been used in medicine for blood‐letting since ancient times. Leeching has varied in popularity over the years. It reached its zenith during the early decades of the 19th century with a gradual decline by the end of the century. Since the 1980s leeches have been introduced to remove blood where its accumulation may interfere with healing, particularly after plastic tissue‐flap surgery. The history and current use of medicinal leeches in Australia is examined.
CONSERVATIVE AND SURGICAL TREATMENT OF TENNIS ELBOW: A STUDY OF OUTCOME
Authors: Thurston A. J.
Published: January 2008

Background: Tennis elbow is one of the most common lesions of the arm. The first description is attributed to Runge in 1873 but the name derives from ‘Lawn Tennis Arm’ described by Morris in 1882. The majority of cases are believed to be caused by musculo‐tendinous lesion of the common extensor origin at or near the attachment to the lateral epicondyle. While there are some comprehensive reports in the literature of patients treated by one technique or another, there are no comprehensive reports of groups of patients for whom various techniques were employed in logical sequence until resolution was reached.

Methods: This paper presents retrospective analysis of case notes and an analysis of questionnaires completed by the patients.

Results: In this study we found that 67% of patients who presented with tennis elbow received relief through steroid injections either alone or in combination with tennis elbow band or nonsteroidal anti‐inflammatory drugs. The use of either tennis elbow band or non‐steroidal anti‐inflammatory drugs or injected steroids made no statistical difference to the outcome.

Conclusions: We also found that the patients who did not respond adequately to conservative measures were relieved of their symptoms by surgery.
SAINTS IN SURGERY
Authors: Magee Reginald
Published: January 2008

There are nearly 300 saints whose names are associated with diseases or the cure of the sick and this relationship has come about either by some miracle attributed to them or by some aspect of their martyrdom. Some diseases have a number of saints as patrons and some saints have many different patronages. A selection has been made of some that have an association with surgical conditions.
PROGNOSTIC FACTORS IN ELECTIVE AORTIC RECONSTRUCTIVE SURGERY
Authors: Holland A. J. A. , Bell R. , Ibach E. G. , Parsons R. W. , Vu H. T. V. , House A. K.
Published: January 2008

Background: The present study was carried out to determine the risk factors associated with peri‐operative mortality and long‐term survival in patients undergoing abdominal aortic reconstructive surgery (ARS).

Methods: A retrospective review was performed of the case notes of all patients having ARS at a university teaching hospital during a 5.5‐year period, and their details entered onto a pro forma.

Results: A total of 252 patients underwent ARS between July 1989 and December 1994. The peri‐operative mortality was 7.5%. The most frequent adverse events were cardiac events, accounting for 8 (42%) of the peri‐operative deaths. The risk of a peri‐operative cerebrovascular accident was low (n = 3, 1.2%) as was the risk of peri‐operative renal failure requiring dialysis (n = 3, 1.2%). Factors independently linked to increased peri‐operative mortality included moderate‐to‐severe hypertension (P= 0.05, odds ratio = 3.54), those with renal impairment (P= 0.05, odds ratio = 2.69), and blood transfusion requirements (P< 0.001, odds ratio = 1.26). Long‐term survival was independently shortened by occlusive disease (P= 0.004, hazard ratio = 2.78) and ischaemic heart disease (P< 0.001, hazard ratio = 3.58).

Conclusions: The risks of ARS were significantly increased in patients with severe hypertension, those with renal impairment and those requiring blood transfusion. Long‐term survival was shortened for those patients with occlusive aortic disease and ischaemic heart disease. These risk factors should be carefully assessed in each patient before performing elective ARS.
THE MAJOR TRAUMA MANAGEMENT STUDY: AN ANALYSIS OF THE EFFICACY OF CURRENT TRAUMA CARE
Authors: Danne Peter , Brazenor Graeme , Cade Richard , Crossley Peter , Fitzgerald Mark , Gregory Peter , Kowal Diane , Lovell Lynette , Morley Peter , Smith Mark , Taylor Russell , Walker Stephen
Published: January 2008

Background: An audit of the management and outcome of major trauma patients was carried out to determine ways in which the system of care may be improved.

Methods: The Major Trauma Management Study (MTMS) collected data prospectively on all consecutively admitted major trauma patients at eight major hospitals during a 12‐month period. Outcome was studied using trauma and injury severity score (TRISS) and a severity characterization of trauma (ASCOT) analyses, as well as a preventable outcome analysis, which looked at survivors with complications or with a Glasgow Coma Score < 15 on discharge from hospital, as well as studying deaths.

Results: The group of 859 patients was more severely injured than most described previously, with a mortality of 14.8% and a mean injury severity score of 19.8. Formal ASCOT analysis indicated 2.25% fewer survivors than would be predicted by Major Trauma Outcome Study norms. Extrapolating the TRISS and ASCOT process to include those patients with missing data, and then comparing groups of matched severity with the norms, gave no statistically different outcome in the MTMS group of patients. Preventable outcome analysis revealed rates of preventable and potentially preventable (P/PP) outcomes of 32% among deaths and 8% among survivors. The types of management deficiencies responsible for P/PP outcomes are identified.

Conclusions: The points of deficiency in a system of care have been identified, and the development of an integrated trauma system in Victoria, based upon these facts, is recommended. Children, the elderly, patients with head injuries and patients being transferred between hospitals would benefit from improvements to the system of care. The calculation of efficacy rate (0.95 for the MTMS patients) is recommended to accurately assess the system of care. Preventable Outcome Analysis is more relevant to auditing a system of trauma care in detail, than is ASCOT or TRISS. The MTMS has refined and defined the process so that it is reproducible in further comparative studies.
EVALUATION OF 250 FREE‐FLAP RECONSTRUCTIONS AFTER RESECTION OF TUMOURS OF THE HEAD AND NECK
Authors: O'Brien Christopher J. , Lee Kenneth K. , Stern Harvey S. , Traynor Sean J. , Bron L. , Tew Poh‐Jin , Haghighi Koroush S.
Published: January 2008

Background: Microvascular free‐tissue transfer is now the primary method of reconstruction in many centres. The aim of this study was to evaluate the applications, complications and limitations of free‐flap reconstruction in a series of patients with tumours of the head and neck.

Methods: This study reviewed prospectively accessioned computerized records in a dedicated head and neck database. Patients treated between 1987 and 1995 with a minimum of a 1‐year follow‐up were reviewed. There were 242 patients with a mean age of 58 years (172 men and 70 women). The most common tumour sites were oral cavity (42%), oropharynx (32%) and hypopharynx (11%). Mucosal squamous carcinoma accounted for 87% of primary cancers.

Results: Among the 250 free flaps, the radial forearm flap (205) and free jejunum (25) predominated. There were 21 episodes of vascular occlusion (8%), failure of 10 flaps (4%) and two patients died perioperatively (0.8%). A second free flap was used in five of 10 cases of flap failure. The fistula rate was 4.4% among 203 patients at risk for this complication, which comprised four of 178 forearm flaps and five of 25 free jejunal grafts. Four of 16 jaw reconstructions failed.

Conclusions: A 96% success rate was achieved using free‐tissue transfer for head and neck reconstruction. The overall complication rate was low but jaw reconstruction and free jejunal grafts posed the greatest problems because of failure of radial bone and fistulas, respectively. The radial forearm septocutaneous flap was very reliable and remains our mainstay for oral reconstruction.
PATTERNS OF SERUM CEA FALL AFTER HEPATIC ARTERIAL CHEMOTHERAPY AS SOLE THERAPY AND COMBINED WITH CRYOTHERAPY FOR COLORECTAL METASTASES
Authors: Hocking R. A. , Morris D. L.
Published: January 2008

Background: Hepatic artery chemotherapy (HAC) and cryoablation are treatments for unresectable liver metastases from colorectal carcinomas. Our centre has previously published data that describe survival statistics of patients after each of these treatments. It has also been established that serial serum carcinoembryonic antigen (CEA) concentrations may be used to monitor disease progress, and that the magnitude of fall is prognostic for both treatments. The pattern of fall of CEA following cryotherapy and regional chemotherapy has not previously been compared.

Methods: In this study, we examined 26 HAC patients and 24 cryotherapy patients.

Results: The mean percentage of the pre‐treatment CEA concentration for the HAC group was 60.5% at 50 days and 29.4% at 150 days, and for the cryotherapy group 24.9% at 50 days and 24.3% at 150 days. Calculating the difference between means revealed a significantly different mean fall in the cryotherapy group at 50 days (P < 0.001) and a difference in mean fall at 150 days (P > 0.1) which was not significant. In patients who responded to hepatic artery chemotherapy, the eventual CEA fall was very similar in magnitude. Conclusions: The pattern of fall of CEA differs in these two treatments.
OUTPATIENT LAPAROSCOPIC SURGERY
Authors: Willsher P. C. , Urbach G. , Cole D. , Schumacher S. , Litwin D. E. M.
Published: January 2008

Background: Outpatient laparoscopic surgery has been adopted by number of centres but an assessment of the patients' view of postoperative symptoms and satisfaction has not been reported. This study was undertaken to prospectively assess protocol for outpatient laparoscopic surgery established with the aims of minimizing postoperative symptoms and optimizing same–day discharge.

Methods: Patients were considered appropriate for an outpatient laparoscopic procedure if they met the following criteria: if they were less than 70 years of age; if they were ASA category I or II; if they lived within 30 min of healthcare facility; and if they had an appropriate escort to accompany them on discharge and who would stay with the patient on the night after surgery. Clinical data were prospectively recorded. A telephone interview was carried out on the day after surgery to assess postoperative symptoms and patient satisfaction.

Results: One hundred patients were planned for outpatient laparoscopic surgery (60 laparoscopic cholecystectomy, 36 laparoscopic groin hernia repair, and four miscellaneous); 95 of them were discharged on the day of surgery. The five patients remained in hospital because of surgical indications rather than complications of the anaesthetic. There were no readmissions on subsequent days. The telephone interview showed that pain was adequately controlled for 84% of patients, and that nausea (9%) and vomiting (4%) were uncommon. One hundred per cent of patients considered the anaesthetic and nursing care to be good or excellent, and 95% indicated they would have outpatient surgery for future similar procedure. Twenty‐nine per cent felt well enough to return to work on the second postoperative day.

Conclusions: The success of this programme relates to patient selection and education, appropriate anaesthesia and defined anaesthetic and surgical protocol.
SURGEON, DON'HEAL THYSELF: A STUDY OF THE HEALTH OF AUSTRALASIAN UROLOGISTS
Authors: Wines Andrew P. , Khadra Mohamed H. , Wines Robert D.
Published: January 2008

Background: Modern surgical practice is stressful and anxiety–producing. We investigated urologists health and their attitude to their own health care.

Methods: Two hundred and seventy–five Australasian urologists were surveyed to ascertain their attitudes to their physical and psychological health; 205 responses were received.

Results: Ten per cent reported serious physical illnesses. Fewer than half had their own general practitioner (GP), and fewer than one–third had seen doctor in the previous 12 months. A majority had, at some time, prescribed themselves medication, including antibiotics, narcotic and non‐narcotic analgesia and benzodiazepams. Nearly all reported that aspects of their urological practice caused them anxiety. More felt that this anxiety was the result of pressures experienced outside the operating theatre than problems directly related to performing surgery. A small number of psychological problems were reported, and fewer than 10 per cent had ever visited psychiatrist. It was evident that most Australasian urologists were unwilling to discuss any psychological problems that they may have. Even when specific problem had been identified, few sought the appropriate care.

Conclusions: It would be advantageous for Australasian urologists and doctors in general to see their GP more regularly, and be more willing to discuss any psychological difficulties that they may experience.
AN AUDIT OF PANCREATIC PSEUDOCYST MANAGEMENT AND THE ROLE OF ENDOSCOPIC PANCREATOGRAPHY
Authors: Ng Bradley , Murray Brendon , Hingston Guy , Windsor John A.
Published: January 2008

Background: A rational algorithm for the management of symptomatic pancreatic pseudocysts is necessary with the increasing availability of radiological, surgical and endoscopic methods of treatment.

Methods: A retrospective audit of the management and outcome of all patients who presented with symptomatic pancreatic pseudocysts to the Auckland Hospital over a 9‐year period (1988–96) was made.

Results: There were 44 patients (28 men, 16 women; median age 50; range 18–81) in this series. Initial management was not based on pseudocyst size, duration, location, wall thickness, the patients' symptoms and comorbidity, or the aetiology of pancreatitis. Of the 27 patients who had initial conservative management, 15 pseudocysts (56%) completely resolved. Of the 17 patients who were initially or subsequently treated with percutaneous catheter drainage (PCD), 10 pseudocysts (59%) completely resolved without additional treatment. Of the 13 patients initially or subsequently treated by surgery, all but one completely resolved after the first procedure. Two patients were successfully treated with endoscopic pancreatic stent placement. Complications arose in eight patients treated with PCD (47%) and four patients treated with surgery (31%). There was no mortality. The decision for active treatment was not preceded by delineation of the pancreatic duct by ERCP (endoscopic retrograde cholangiopancreatography) in 60% of patients.

Conclusions: More than one‐third of all patients with symptomatic pancreatic pseudocysts can be managed conservatively. Surgery yields excellent results but PCD has a high failure rate in patients with an underlying pancreatic duct stricture. A rational management algorithm is presented, based on pre‐intervention ERCP, which should improve patient selection and outcome.
PANCREATITIS AND PRIMARY HYPERPARATHYROIDISM: FORTY CASES
Authors: Carnaille B. , Oudar C. , Pattou F. , Combemale F. , Rocha J. , Proye C.
Published: January 2008

Background: Pancreatitis is associated with primary hyperparathyroidism (PHPT) in 1.5–7% of cases. The relationship of cause and effect between the two diseases has been debated.

Methods: To evaluate this relationship, the clinical, biochemical and pathological data on 1435 patients operated on for hyperparathyroidism (HPT) over the past 30 years were retrospectively reviewed. A total of 1224 of these patients had biologically proven and cured PHPT and 211 patients had renal HPT (RHPT). The diagnosis of pancreatitis (PTS) was based on a high serum amylase level and/or abnormalities on ultrasound or computed tomography (CT) scan explorations. Only patients without biliary stones were included in the PTS group associated with HPT.

Results: A total of 3.2% (n= 40) of patients with PHPT had PTS, which was acute in 18 cases, subacute in 8 cases and chronic in 14 cases. This rate of PTS is higher than in a random hospital population. Surgical cure of HPT was followed by the spontaneous healing of 17/18 acute PTS, whereas six of the 22 patients with subacute or chronic PTS developed complications due to the evolution of their disease (diabetes, pancreatic duct stenosis treated by surgery). A single diseased gland was found in 27 patients with PTS, which is in favour of primary parathyroid disease, being responsible for, and not a consequence of, PTS. Only the serum calcium (13.0 vs 12.1 g/dL) level was significantly increased in PHPT patients with PTS, when compared to those without PTS. The calcium level is probably of major importance in the development of PTS, which was never encountered in 211 patients with RHPT, who had low calcium and high PTH levels.

Conclusions: The data suggest that (i) the PTS‐PHPT association is not incidental; (ii) PTS is the consequence and not the cause of PHPT; (iii) hypercalcaemia seems to be a major factor in the development of PTS in PHPT patients; and (iv) cure of PHPT leads to the healing of acute PTS, whereas it does not affect the evolution of subacute and chronic PTS.
EARLY FEEDING AFTER ELECTIVE OPEN COLORECTAL RESECTIONS: A PROSPECTIVE RANDOMIZED TRIAL
Authors: Stewart B. T. , Woods R. J. , Collopy B. T. , Fink R. J. , Mackay J. R. , Keck J. O.
Published: January 2008

Background: A period of starvation after colorectal resections to allow for resolution of the clinical evidence of ileus has been an unchallenged surgical doctrine until recent times. A prospective randomized trial comparing early feeding to traditional management in patients undergoing open elective colorectal resections is reported.

Methods: Patients undergoing elective intraperitoneal colorectal resections without stoma formation were randomized to either an early feeding or control group. The early feeding group were allowed free fluids from 4 h postoperatively progressing to a solid diet from the first postoperative day as they tolerated it. The control group remained nil orally until passage of flatus or bowel motion and were then commenced on fluids progressing to solids over 24–48 h.

Results: There were 40 patients in each group well matched for age, sex, type and duration of operation, method of analgesia and mobilization. Thirty‐two patients (80%) in the early feeding group tolerated a diet within 48 h. There was no significant difference in the rate of vomiting, nasogastric reinsertion or complications. The early feeding group tolerated a diet, passed flatus, used their bowels, and were discharged from hospital significantly earlier than the control group.

Conclusion: Early feeding after elective open colorectal resections is successfully tolerated by the majority of patients, leading to earlier resolution of ileus and hospital discharge.
UNPLANNED RETURN TO THE OPERATING ROOM
Authors: Isbister William H.
Published: January 2008

Background: Unplanned return to the operating room (OR) has been suggested as one of the indicators that could be used to assess the quality of surgery in a hospital setting. The present study was undertaken in order to try to identify those factors that were important in determining the need for the return to the OR in patients undergoing a series of colorectal surgical procedures.

Methods: All patients who returned to the OR following an index colorectal procedure during a 15‐year period on a colorectal service, were identified from the unit's database. The site of original disease, presentation, type of surgery performed, reason for re‐operation and post‐surgical morbidity and mortality were examined.

Results: Overall there were 2011 colorectal surgical admissions, and of these 19 males (61.2 years) and 18 females (67.4 years) underwent an unplanned return to the OR. In 34 patients the index operation was performed by a consultant surgeon. A total of 46% of index operations were performed in an emergency setting. The majority of patients had colorectal cancer. Most lesions were situated in the sigmoid colon or rectum. Postoperative adhesive obstruction was the commonest reason for return to the OR. No patient re‐obstructed following re‐operation. Overall eight wounds dehisced and five patients suffered anastomotic leakage. Intra‐abdominal sepsis was found in 12 patients. Twenty‐one patients developed urinary tract infections. Twenty‐eight patients were discharged well, two patients were discharged dying with advanced malignancy and there were seven postoperative deaths (18.9%).

Conclusions: Unplanned return to the OR is a function of both the patient's presenting problem and the surgical skill and judgement of the surgeon. It is thus in part determined by the patient casemix in a unit, service or institution.
ASSOCIATION OF OBESITY, GENDER, AGE AND OCCUPATION WITH CARPAL TUNNEL SYNDROME
Authors: Lam Nicholas , Thurston Alan
Published: January 2008

Background: The present study determines the association of obesity, gender, age and occupation in patients with carpal tunnel syndrome (CTS) in a New Zealand population.

Methods: Analysis of questionnaires and clinical review of patients who had undergone surgical decompression of the median nerve in the carpal tunnel.

Results: The age and gender distribution of 655 hands (512 patients) that had undergone carpal tunnel release (CTR) were compared with the age and gender distribution of the New Zealand population. The results indicate that the 3‐year‐period prevalence of CTS in females is more than double that in males. Proportionally there were more patients over age 55 than in the general population. The findings also indicate that, proportionally, six times the number of females who worked in moderate manual work underwent CTR compared with the general female population and proportionally twice the number of males who worked in heavy office/clerical work underwent CTR compared with the general male population. It was also found that CTR patients are twice as likely to be overweight (body mass index [BMI] > 25) than the general population and female patients are twice as likely to be obese (BMI > 30) than the general population.

Conclusions: Carpal tunnel syndrome is more than twice as common in females as it is in males, and patients aged more than 55 years are more likely to suffer from CTS. Females with CTS are more likely to work in moderate manual work and males with CTS are more likely to work in heavy office/clerical work. Obesity and CTS are related statistically.
THE MITROFANOFF PROCEDURE IN PAEDIATRIC URINARY TRACT RECONSTRUCTION
Authors: Ahmed Saeed , Sen Sudipta
Published: January 2008

Methods: Between 1991 and 1996, 23 children underwent urinary tract reconstruction of varying complexity together with a continent diversion according to the Mitrofanoff principle. The appendix was used in 14 patients and the ureter in seven. Two patients had previously had an appendicectomy and the ureters were not suitable. One had a catheterizable channel made from an isolated segment of colon and the other had a detrusor tube constructed.

Background: Urinary tract reconstruction is required in many congenital and some acquired urological conditions in childhood. The majority are managed by clean intermittent catheterization (CIC), for which purpose the appendix or other tubular structure may be used to provide a continent catheterizable abdominal stoma.

Results: Twelve patients with an appendix conduit, six with a ureteric conduit, and one with a colonic tube are continent, although the latter has had some problems with stomal stenosis. All manage CIC with comfort, the older children doing the procedure themselves. One appendix conduit has stomal incontinence and another was inadvertently divided during renal transplantation. The detrusor tube strictured and was removed.

Conclusions: A continent abdominal stoma using the Mitrofanoff principle gives reliable results in children and is well tolerated. It should be considered in the management of children undergoing urinary tract reconstruction when CIC is necessary. The appendix is eminently suitable for this purpose but the ureter provides a satisfactory alternative in selected cases. When neither is available, alternative techniques for constructing a catheterizable continent channel may be considered.
STAGING OF OESOPHAGEAL CARCINOMA BY ENDOSCOPIC ULTRASOUND: PRELIMINARY EXPERIENCE
Authors: Pham T. , Roach E. , Falk G. L. , Chu J. , Ngu M. C. , Jones D. B.
Published: January 2008

Background: Endoscopic ultrasound (EUS) is a relatively recent imaging modality that is capable of visualizing oesophageal tissue layers and para‐oesophageal structures. Current pre‐operative staging of oesophageal cancer is less than satisfactory, and a modality which may improve pre‐operative staging, thus allowing a more rational approach to choice of treatment, may be a welcome addition to current techniques. The purpose of the present study was to evaluate the accuracy of EUS in the staging of oesophageal carcinoma in a consecutive cohort of patients.

Methods: Forty‐three patients with oesophageal cancer were prospectively staged with EUS using the radial scanning Olympus EUM–3 echo‐endoscope. In the 28 patients who underwent surgery EUS staging was correlated with operative and histological findings to evaluate the EUS accuracy rate of assessing tumour depth (T stage), and the presence of nodal involvement (N stage) using internationally accepted TNM staging criteria.

Results: Endoscopic ultrasound accuracy rates for overall T‐staging was 61% whereas that of N‐staging was 75%. The overall TNM pathological staging was 75% accurate by EUS.

Conclusions: Compared to published literature figures for oesophageal staging by computed tomography scanning (39–54%) these results demonstrate that EUS has a reasonable accuracy rate for staging. Endoscopic ultrasound may prove to be a useful additional modality in the management of oesophageal cancer.
PAEDIATRIC SURGICAL TRAINING: A SYSTEM THAT WORKS
Authors: Merriman T. , Maoate K. , Clarnette T. , Hutson J. M.
Published: January 2008

Background: Paediatric surgical trainees going through the system at the Royal Children's Hospital (RCH), Melbourne, have been impressed with the amount of time dedicated to postgraduate training compared with other institutions. They generally felt well prepared to sit for Fellowship examinations. We decided to look at the programme offered at the RCH and objectively assess the results.

Method: A review was undertaken of the training system at the RCH. Opinions were sought from recent and current trainees and compared with trainees in other disciplines. Figures were obtained from the RACS Examinations Office with respect to pass rates at Fellowship examinations.

Results: The training programme is outlined in some detail. A total of 79% of candidates passed their FRACS in paediatric surgery while at the RCH since 1985, compared with 52% from all other institutions.

Conclusions: A successful training programme requires a commitment to educate one's junior colleagues. Busy consultants can contribute actively by offering to teach and by encouraging their trainees to attend rounds and tutorials. The rewards are better‐educated and well‐rounded surgeons as well as, hopefully, a higher pass‐rate at the Part 2 examination.
DIAGNOSTIC FAILURE IN COLONOSCOPIES FOR MALIGNANT DISEASE
Authors: Miller Brian J. , Cohen Jon R. , Theile David E. , Schache David J. , Ku Jack K.
Published: January 2008

Background:

While colonoscopy has become established as more accurate than double contrast barium enema for detecting colonic polyps and cancers, as well as offering the opportunity for therapy, there are occasional instances where colonoscopy is misleading. The present study is to determine what problems occur, with a view to finding a solution.

Methods:

The records of the Colorectal Project at the Princess Alexandra Hospital indicate retrospectively that 346 patients have been correctly diagnosed with cancer of the colon and rectum by colonoscopy in the 5 years up to October 1996. During the same time eight patients (2.3%) were recorded at the same hospital as being misdiagnosed by colonoscopy, the lesion being either missed completely or misplaced.

Results:

In five of these patients there was failure to recognize that the whole colon had not been examined endoscopically, thereby missing a more proximal lesion. In two patients the lesion was missed although the entire colon was examined. In one patient the lesion was discovered but inaccurately sited. Six of these mistakes would have been obviated by the routine use of fluoroscopy to confirm the totality of the colonoscopy and to site any lesions found. The other two cases occurred because of failure to remember that colonic examination during withdrawal should be performed meticulously back as far as the anal canal. Failure to diagnose a colon cancer on the initial colonoscopy led to an average delay of 6 months for definitive care.

Conclusions:

It is recommended that fluoroscopy be used routinely during colonoscopy to site accurately any lesions found, and to confirm the completeness of insertion if reliable landmarks, including terminal ileum, are not clearly identified.
RANDOMIZED CONTROLLED TRIAL COMPARING SAME‐DAY DISCHARGE WITH HOSPITAL STAY FOLLOWING HAEMORRHOIDECTOMY
Authors: Ho Y‐H. , Lee J. , Salleh I. , Leong A. , Eu K. W. , Seow‐Choen F.
Published: January 2008

Background:

A randomized controlled trial was conducted to compare traditional hospital stay haemorrhoidectomy (STAY) with same‐day discharge haemorrhoidectomy (DAY) with regard to costs, clinical outcome and patient satisfaction.

Methods:

A total of 54 consecutive patients were randomized to either STAY or DAY groups. A standardized excision of three piles was performed and the wounds were left open. The DAY patients went home on the same day but the STAY patients remained in hospital until their bowels had opened. A linear analogue pain score and patient satisfaction questionnaire were administered. During a mean follow‐up of 60.5 (standard error of mean =1.2) weeks, the complications and the total medical costs were recorded.

Results:

There were no differences in the age and sex distributions in both groups (STAY: 11 men, 16 women; mean age 40.6 (± 1.8) years; DAY: 10 men, 17 women; mean age 40.6 (± 1.9) years). Despite accounting for any readmissions, the DAY patients accumulated shorter total hospitalization stays (P < 0.001) and incurred less total medical costs (P= 0.04). The pain scores, analgesia requirements, postoperative complications, patient satisfaction and time taken off work were not different between the two groups. However, more patients in both groups preferred to stay after surgery if they should need another haemorrhoidectomy.

Conclusions:

Haemorrhoidectomy (with excision of three piles) can be safely performed as a day procedure, with reduced hospitalization and medical costs.
APPENDICITIS IN HIV‐POSITIVE PATIENTS
Authors: Bova R. , Meagher A.
Published: January 2008

Background:

The aim of the present study was to review the experience of appendicitis in human immunodeficiency virus (HIV)‐positive patients.

Methods:

A retrospective analysis of all HIV‐positive patients operated on for suspected acute appendicitis during a 10‐year period at St Vincent'Hospital was performed. These patients were compared to a group of 60 age‐ and sex‐matched patients with no HIV risk factors who were operated on during the same time period.

Results:

On presentation the clinical findings were similar in both groups, with two notable exceptions. No HIV‐positive patient had an elevated white cell count. The present study demonstrated a significant delay in presentation of the HIV‐positive group to the Emergency Department, possibly explaining the higher appendiceal perforation rate in this group. There were no cases of HIV‐related diseases mimicking acute appendicitis. There was no mortality, and morbidity was higher in the seropositive group.

Conclusions:

HIV‐positive patients with a history suggestive of acute appendicitis should not be treated differently from the normal population. Morbidity and mortality can be minimized by prompt surgical treatment.
EXTRACRANIAL REPAIR OF CEREBROSPINAL FLUID RHINORRHOEA
Authors: Bartley J.
Published: January 2008

Background:

Extracranial techniques, which have none of the inherent morbidity associated with intracranial techniques, can successfully repair rhinological cerebrospinal fluid (CSF) fistulas.

Methods:

A series of five consecutive adult patients with persistent rhinological CSF fistulas were reviewed retrospectively.

Results:

The success rate for initial closure was 60%. On the second operation both failures were successfully repaired.

Conclusions:

The external approach is safe, successful, alternative approach for the surgical repair of rhinological CSF fistulas.
TUMOUR CELL WOUND DISTRIBUTION AFTER COLECTOMY IN A PORCINE MODEL
Authors: Allardyce Randall A. , Morreau Philip N. , Frizelle Francis A. , Bagshaw Philip F.
Published: January 2008

Background:

Concerns over tumour implants have impeded the adoption of laparoscopic surgery for cancer. Explanations assume an increased number of malignant cells present in trocar wound sites. The following are tested in the present paper: (i) that the magnitude of wound contamination following surgery is related to the location of the tumour cells; and (ii) the surgical approach. Methods: We have used porcine sigmoid colectomy model to compare the number of tumour cells on laparoscopic wounds after resections in the presence of intraluminal, intramural and intraperitoneal 51Cr‐labelled, fixed HeLa tracer cells. Open colectomies were also performed in the presence of intraperitioneal tracer cells and their numbers on laparotomy wound surfaces were determined by gamma counting.

Results:

With intraperitoneal cells, laparotomies had 1087 (± 106) tracer cells per mm (n= 4) while trocar wounds had 103 (± 54) cells per mm (n= 10) (P > 0.05). Resection of intramural tumours resulted in lower trocar wound contamination (0.9 ± 0.6 cells/mm, n= 3). Resection of colon including intraluminal tracer cells resulted in 2.9 ± 2.1 cells/mm on trocar wounds (n= 3).

Conclusions:

More tumour cells were deposited on open than laparoscopic trocar wound surfaces. Also, the risk of wound implantation is less with intraluminal or intramural tumours than with intraperitoneal cells (P > 0.05).
ROUTINE CHOLECYSTOCHOLANGIOGRAPHY: A VIABLE ALTERNATIVE DURING LAPAROSCOPIC CHOLECYSTECTOMY
Authors: Young Christopher , Moont Michael
Published: January 2008

Background:

The advantages of cholangiography during laparoscopic cholecystectomy (LC), including identification of biliary anatomy and biliary calculi, are well known. The usefulness of cholecystocholangiography (CCC), by direct injection through the gallbladder, compared to the more popular cystic duct cholangiography (CDC), however, is not so well known.

Methods:

Two hundred consecutive patients who underwent LC were included in a prospective study of routine CCC. Between 5 and 60 mL of contrast is injected through the gall‐bladder fundus, using image intensifier control.

Results:

Cholecystocholangiography was attempted in 194 cases and was successful in 157 (80.9%). Twenty‐one of the 37 cases with a failed CCC proceeded to have a successful CDC, giving an overall cholangiography success rate of 91.8%. The presence of acute inflammation decreased the success rate. Eleven (6%) true positive cases of common bile duct (CBD) calculi were demonstrated (nine on CCC and two on CDC after failed CCC). There was one case of false positive CBD calculus and no false negatives.

Conclusions:

We have found that the routine use of CCC during LC is safe, successful, quick to perform, and does not prevent conversion to attempted CDC in the cases where it fails. Cholecystocholangiography may have advantages over CDC and be an alternative as the preferred imaging technique.
THE SIGNIFICANCE OF DONOR LEG DISTAL RUNOFF IN FEMOROFEMORAL BYPASS GRAFTING
Authors: Thompson‐Fawcett Mark , Moon Marc , Hands Linda , Collin Jack
Published: January 2008

Background:

The aim of this study is to determine if femorofemoral bypass grafting is an effective operation for unilateral iliac occlusive disease, and to assess for factors that may predict a poorer outcome. A retrospective review was conducted of cases identified from a prospective audit database.

Methods:

Information was obtained from the clinical notes of 97 patients who had 100 femorofemoral bypass graft operations. All living patients were invited for assessment which included colour duplex sonography of the graft and measurement of the ankle brachial index.

Results:

Using life‐table analysis, the five‐year graft secondary patency for claudicants was 79% and for those with critical ischaemia 78%. Five‐year survival for claudicants was 65% and for those with critical ischaemia, 38%. Poor distal runoff in the infrapopliteal arteries of the donor limb adversely affected graft patency. Graft survival was not affected by the indication for operation, by donor or recipient superficial femoral artery patency, or by the need for endarterectomy, pre‐operative angioplasty or the graft material.

Conclusions:

Femorofemoral bypass grafting is the procedure of choice for all patients who require surgical intervention for unilateral iliac occlusion and donor limb distal runoff may be an important determinant of graft patency.
LAPAROSCOPIC INGUINAL HERNIOPLASTY: A COMPARISON BETWEEN TRANSPERITONEAL AND EXTRAPERITONEAL TECHNIQUES
Authors: Cocks John R.
Published: January 2008

Background:

This study sequentially compares the results of 148 transperitoneal inguinal hernioplasties in 129 patients with 313 totally extraperitoneal hernioplasties in 254 patients.

Methods:

Patients were entered into the study prospectively and reviewed postoperatively at 1 day, 1 week, 5 weeks and 1 year.

Results:

There was no difference in length of hospital stay, postoperative analgesia requirements or the rate of early or late operative complications. The operating time was shorter and the return to normal activities was earlier for the totally extraperitoneal group. There were no intraperitoneal complications following the totally extraperitoneal operation.

Conclusions:

The extraperitoneal technique is favoured over the transperitoneal technique for laparoscopic inguinal hernioplasty.
CAN SINCALIDE CHOLESCINTIGRAPHY FULFIL THE ROLE OF A GALL‐BLADDER STRESS TEST FOR PATIENTS WITH GALL‐BLADDER STONES?
Authors: Gani J. S.
Published: January 2008

Background:

Patients referred to general surgeons for the treatment of gall‐bladder stones were studied to evaluate the role of sincalide cholescintigraphy as a gall‐bladder stress test in an effort to identify a group of patients whose pain was non‐biliary in origin and who would not be improved by cholecystectomy.

Methods:

Ten asymptomatic controls and 57 patients with gallstones and abdominal symptoms were studied. All patients were interviewed by an independent assessor who identified a group of patients in whom the role of gallstones in their presentation was uncertain (clinically possibly biliary group). All patients and controls underwent sincalide cholescintigraphy. The surgeons remained blinded to the study results throughout the study period. All patients were re‐evaluated 6–12 months later to establish the ultimate diagnosis based on their therapeutic response.

Results:

Several parameters of gall‐bladder function were studied from analysis of the sincalide cholescintigram. Lag time, ejection period, ejection rate and ejection fraction did not differ significantly among controls, patients proven to have non‐biliary disease and patients proven to have biliary disease. There were significant differences in mean gall‐bladder filling fraction between proven biliary and proven non‐biliary groups. However, the group of patients with clinically possibly biliary symptoms could not accurately be separated into those who benefited from cholecystectomy and those who improved without surgery on the basis of this parameter.

Conclusions:

Significant differences in gall‐bladder filling fraction between symptomatic and asymptomatic gallstone patients were identified suggesting reduced gall‐bladder compliance in symptomatic patients. However, the sincalide cholescintigram failed to emerge as a useful gall‐bladder stress test. Even in the 1990s, assessment by an experienced surgeon appears to be the most appropriate way to select patients for cholecystectomy.