bluuebunny/crossref_metadata_2025 huggingface dataset:
Taxonomy, phylogeny, biogeography, and ecology of Sabulodinium undulatum (Dinophyceae), including an emended description of the species
Authors: Hoppenrath Mona , Horiguchi Takeo , Miyoshi Yukiko , Selina Marina , Taylor ‘Max’ F.J.R. , Leander Brian S.
Published: April 2007

Samples of Sabulodinium undulatum Saunders et Dodge, the type species of the monospecific genus, were collected and characterized from Germany, Russia, Japan and Canada. This species has a laterally flattened, oval cell with a truncated apex and a dorsally pointing small episome. The dorsal margin of the hyposome has an undulating shape. A dorsal spine and/or antapical spine are sometimes present. The specimens of this heterotrophic species are 27.5–42.5 μm long and 18.5–36.0 μm wide, and have a theca with the plate arrangement apical pore complex (APC) 5′ 1a 6″ 5c 4s 6′′′ 1′′′′. The shape of the dorsal theca is variable. The species distribution seems to be restricted to northern temperate regions. Sabulodinium undulatum occurred in all sandy eulittoral areas throughout the year and was also present in sandy sublittoral and supralittoral (beach) samples. The species can tolerate a broad range of temperatures and salinities. Sabulodinium occurred from −2.0 to +24.3°C and 4–35 salinity. It is likely that the observed variability in morphology and habitat reflect several varieties. We propose to establish three varieties within the species, namely S. undulatum var. undulatum, S. undulatum var. glabromarginatum, and S. undulatum var. monospinum. The systematic position of Sabulodinium is discussed in the context of comparative morphological and molecular phylogenetic data.
BS16P MULTIFOCAL BREAST CANCER: WHICH DIMENSIONS CORRELATE WITH NODAL SPREAD AND OUTCOME?
Authors: Phillips C. , Turkiewicz D. , Pyke C.
Published: April 2007

Purpose  In the presence of multifocal breast cancer, debate continues as to which dimension (the diameter of the largest lesion or combined total diameter of all synchronous lesions) correlates best with the likelihood of nodal spread, local and systemic recurrence and hence death. Pathological assessment and reporting on such tumours is a mandatory part of Breast Audit. What is the value of this?

Methodology  Data from all women with multifocal breast cancer (as defined by more than one focus of invasive cancer in an ipsilateral breast on pathological examination) presenting during the period between 1997 and March 2003 was reviewed. Lymph node status, local recurrence, systemic recurrence and death were correlated with the diameter of the largest focus and aggregate diameter of all lesions.

Results  63 patients with multifocal breast cancer (from 534 primary breast cancers treated) were reviewed. with a median follow‐up of 4.98 years. There were 10 cancer‐related deaths during this time. 34 tumours (54%) were upstaged using the aggregate diameter. “Aggregate diameter” correlated more strongly than the “largest diameter” with regards to survival however only nodal status and number of foci statistically significantly correlated with survival. “Aggregate diameter” and “largest diameter” were both similarly highly correlated with nodal status.

Conclusions  The results obtained from this study suggest assessment and inclusion of all foci appears to be an important part of pathological breast cancer assessment. Our current work involves comparison to similarly staged unifocal tumours to determine whether multifocality per se can be used as a surrogate prognostic factor independent of the diameter of the largest focus.
BS23 TARGETED THERAPY
Authors: Bundred N. J.
Published: April 2007

Breast cancer has led the way in developing drugs for targets (e.g. oestrogen receptor) since the initial excitement over the benefit of Tamoxifen and more latterly, Aromatase Inhibitors (AI’s) research has focussed on finding novel agents to other targets. The HER2 oncoprotein is targeted extracellularly by Herceptin with an appropriate 50% reduction in breast cancer recurrence in 4 major trials. Newer agents, such as the HER1/HER2 inhibitor, Lapatinib, are currently entering clinical trials.

Problems arise when the target (e.g. HER1) does not reflect the growth drive of a tumour. Thus, targeted therapy to the HER1 receptor has largely been unsuccessful in breast cancer.

Biological subtypes will help to improve trial development and identify which patients need which therapies. Importantly, it will allow rational development of combination therapies within subgroups. Newer agents becoming available include progesterone receptor antagonists and Src inhibitors which may only be effective in tumours expressing the receptor (i.e. luminal A or triple negative cancers respectively). Potential benefits of targeted therapy on breast cancer treatment will be discussed.
CT23 WHAT’S NEW IN ICU
Authors: Shaw G. M.
Published: April 2007

Intensive care medicine is at the intersection of medical, surgical and engineering sciences. While the lion’s share of attention in medical research focuses on magic bullets, these have largely failed to deliver in intensive care. Specifically, significant improvements have come from improving what might be regarded as the ‘bread and butter’ of clinical practice. Improvements the management of sedation, ventilation, glycaemic control, sepsis, shock and renal support have resulted in significant improvements in patient outcomes.

Simple measures such as switching off sedation on morning rounds can reduce duration of mechanical ventilation and length of intensive care stay by 32 to 35%1.

Reduction of tidal volumes in acute respiratory distress syndrome (ARDS) from 12 to 6 ml per kilogram has reduced mortality from 39.8% to 31% in a landmark study of 861 patients2. This is consistent with findings from smaller clinical trials and animal data linking shear forces in the lung, produced by mechanical ventilation, with biological injury.

A recent study of 1548 mainly cardiothoracic surgical patients found that intensive insulin therapy reduced intensive care mortality from 8.0% with conventional treatment to 4.6%, with the greatest reduction in death due to multiple‐organ failure with a proven septic focus3. Bloodstream infections, acute renal failure, red‐cell transfusions, and critical‐illness polyneuropathy were also all reduced by over 40%.

Early goal directed therapy reduced in‐hospital mortality from 46.5% to 30.5% in a cohort of 263 patients admitted to an emergency department in patients with severe sepsis or septic shock4. Significant benefits resulted from early resuscitation of shocked patients using predefined protocols.

Summary  Targeted protocolised therapies across a wide range of intensive care conditions have resulted in the greatest outcome benefits for critically ill patients.
CR11 PATIENT RECALL OF INFORMED CONSENT INFORMATION PRIOR TO COLONOSCOPY
Authors: Thomson I. G. , Schache D. , Miller B. , Gourlas P. , Cohen J.
Published: April 2007

Purpose  To determine if patients presenting for colonoscopy can remember information discussed in the informed consent process. Focusing on whether patients know of the possible risks.

Methodology  A prospective study of patients presenting for elective colonoscopy through the Colorectal Unit. Patients were consented in outpatient clinics prior to the procedure using the colonoscopy consent form supplied by Queensland Health. On the day of the procedure a 2 page questionnaire with 13 questions was completed by the patient prior to their colonoscopy. Indications for colonoscopy date of consent & procedure and seniority of consenting doctor were obtained from medical records.

Results  100 patients completed the questionnaire. 94% of patients could correctly identify colonoscopy as the procedure being undertaken. 45% of patients were able to identify that there were any risks involved with the procedure. Only 28% of patients could name perforation as a possible risk. h regard to other investigative options 83% could not identify any from a list of three. Despite this 92% felt they were given enough information and were happy to proceed.

Conclusion  This study highlights room for improvement in the current informed consent process. The current process falls short in educating patients of the possible serious risks involved. Patients do not recall other therapeutic options given. The consent process does convey basic information allowing the patient to identify the name of the investigation and anatomical area investigated. Despite these shortcomings most patients felt they were given enough information to proceed.
CR16P METHYLENE BLUE INJECTION REDUCES PAIN AFTER LATERAL ANAL SPHINCTERTOMY
Authors: Seow‐Choen F. , Tan K. Y.
Published: April 2007

Introduction  Intradermal methylene blue has been used successfully in pruritus ani. The mechanism is likely the destruction of dermal nerve endings. We report a new method in achieving postoperative pain relief using intradermal methylene blue injection to the perianal region after lateral anal sphincterotomy.

Methods  Consecutive patients undergoing lateral anal sphincterotomy between July 2004 and January 2006 were studied prospectively. All were performed under local anesthesia. Four ml 1% methylene blue and 16 ml 1% lignocaine was injected into the perianal skin and intersphincteric space. Patients were asked to fill in a pain chart with a visual analog scale of 0 to 10.

Results  There were 24 patients studied during this period. The median pain scores were under 2.5 for the first 4 days and were 0 from the 5th postoperative day. Nineteen out of 24 wound have healed by 2 weeks post sphincterotomy. There were no perianal complications.

Conclusion  Intradermal injection of methylene blue together with local anesthetic gives good post‐operative pain control with minimal complications.
CR08 ONE YEAR EXPERIENCE WITH FAST‐TRACK SURGERY FOR ELECTIVE COLONIC RESECTION
Authors: Zargar Shoshtari K. , Connolly A. B. , Israel L. H. , Clark M. A. , Hill A. G.
Published: April 2007

Purpose  Fast‐Track Surgery or Enhanced Recovery After Surgery (ERAS) programs are becoming increasingly common. However there are concerns regarding safety, readmission rates and the impact on overall morbidity. We aimed to compare the results from our ERAS program for elective colonic surgery with those from our institution prior to commencement of ERAS.

Method  We established an ERAS program for colonic resection at Manukau Surgical Centre (MSC) in Auckland. This included strategies such as epidural analgesia, early feeding and mobilisation. Patients were discharged once they were able to tolerate a full diet, had evidence of return of GI function and pain was managed with oral analgesia. They were followed up within a week.

Results  From Dec 2005 to Dec 2006, 35 consecutive patients undergoing elective colonic resection at MSC under our ERAS program were studied prospectively. The control group consisted of 35 consecutive patients undergoing colonic resection under conventional care at the same institution prior to Dec 2005. Groups were comparable with respect to physiological and operative CR‐POSSUM scores. Median day stay for the ERAS group was 4 (3–27) compared to 8 (4–30) days for the conventional group (p < 0.001). ERAS was associated with a trend towards an earlier return of gastrointestinal function, reduced rate of infective and pulmonary complications. There were no differences in the readmission rates.

Conclusion  ERAS is a practical and safe method of managing patients undergoing major colonic surgery and such structured care plans not only reduce hospital stay but may also be associated with reduced immediate post‐operative morbidity.
AL01 PACIFIC ISLANDS PROJECT – PAST PRESENT AND FUTURE
Authors: Watters D. A. K.
Published: April 2007

The Pacific Islands Project began in 1995 and in its early years had a focus on providing specialist services that were not available in the 10 island nations visited. In 2002 Nauru was added and PIP Phase III will end its 9 month bridging/extension phase in September 2007. During the last 12 years Fiji School of Medicine has commenced a postgraduate medical training program in surgery similar to that has been in existence in PNG since 1975. There are now a growing number of Pacific‐trained surgeons who can select suitable cases, do some of the surgery, and supervise the postoperative care. Increasingly visiting teams have focused on transferring skills and building local capabilities (capacity building). The RACS, the Project Director and the speciality coordinators have managed the first three phases of the project in Australia. Phase III had on‐going evaluation by an internal RACS committee under the chairmanship of Professor Hamish Ewing. AusAid also externally reviewed the project late in 2006. That review was generally complimentary as to what has been achieved but also points to some new goals for the future. At the time of writing this abstract the future direction of PIP is yet to be decided and designed. This will be done mid 2007. However, it is to be hoped there will be a new program, focused on capacity building, that is managed in the Pacific and employs the skills of Pacific Island Specialists wherever possible. RACS is likely to continue to play an important role in sourcing visiting specialists, organising training positions, arranging courses. We have much expertise to offer but there is no longer any need for us to set the agendas.
ES15P ATYPICAL FOLLICULAR’ FNAC – RELATIONSHIP WITH FINAL HISTOPATHOLOGY
Authors: Pang T. , Sidhu S. , Sywak M. , Reeve T. , Delbridge L. , Ihre‐Lundgren C.
Published: April 2007

Background  Fine needle aspiration cytology (FNAC) is a useful technique for the investigation of thyroid lesions. However, about 15% of FNAC results are classified as ‘atypical follicular’– a dilemma for the surgeon.

Purpose  To investigate the relationship between ‘atypical follicular’ FNAC results and final histolopathological diagnosis.

Methodology  Retrospective review of patients who underwent thyroid FNAC at the University of Sydney endocrine surgical unit.

Results  Study period – 1985 to 2005; Study population – 424 patients with an atypical FNAC and a malignancy on final histopathology. This accounted for 21% of all atypical FNAC results (n = 1956). Demographics – 342 females, 82 males with a mean age of 47.2 (SD 16.7). The most common presentation in this group was a single thyroid nodule n = 252, followed by multinodular goiter n = 155. Overall, 269 (63.4%) had papillary/mixed (papillary and follicular) carcinoma, 106 (25%) had follicular carcinoma and 49 (11.6%) other malignant pathology. Of the subjects with papillary cancers, 34% had papillary microcarcinoma. Demographics were not predictors of pathology. Over the study period of 20 years, no changes in the pattern of histopathology findings were noted.

Conclusion  Although the ‘atypical follicular’ FNAC has traditionally been considered to be either follicular adenoma or carcinoma, a great proportion of subjects actually have a papillary carcinoma demonstrated on histopathology. A significant proportion of this was accounted for by the presence of incidental papillary microcarcinoma.
ES18P ROLE OF EXTERNAL RADIOTHERAPY IN PARATHYROID CARCINOMA
Authors: Nair A. , Abraham D. T. , Paul M. J. , Seshadri M. S. , Nihal T. , Selvan C. K.
Published: April 2007

Introduction  Parathyroid carcinoma is a challenging problem to a surgeon and adjuvant radiotherapy is important to reduce the recurrence.

Methods  A retrospective review was conducted of all cases of parathyroid carcinoma from 1990–2006. 6 patients were identified.

Results  There was a male preponderance. Mean age of presentation was 49 years. The clinical presentation was similar to benign primary hyperparathyroidism except for the presence of palpable nodule in 80% of patients with carcinoma compared to 11% among patients with benign primary hyperparathyroidism. One patient had chronic pancreatits propably secondary to hyperparathyroidism. All patients had hypercalcaemia with elevated serum PTH levels and no significant difference compared to benign hyperparathyroidism. Surgery was done in all. Local metastasis to the cervical lymph nodes was seen in 33% off patients. The tumors showed a high predilection to the inferior parathyroid glands.. All subjects underwent radiotherapy with cobalt at mean dose of 50 cGy. The mean duration of recurrence was about 2 years. 50% had local recurrence, 2 had recurrent tumor excision including one from vocal cord. Bony metastasis was found in one as evidenced by hot spots in sestamibi scan. 2 of the 6 died, both of them had unrelated disease as cause of death. 1 lost to follow up.

Conclusion  Parathyroid carcinoma constitutes around 2–3% of patients. In the presence of a palpable nodule, chance of being malignant should be kept in mind. Recurrence rate can be reduced by post operative external radiotherapy.
ES09 THE UNIVERSITY OF SYDNEY ENDOCRINE SURGERY DATABASE: 50 YEARS OF CONTINUOUS DATA ACCRUAL
Authors: Reeve T. S. , Lundgren C. , Poole A. G. , Bambach C. , Barraclough B. , Delbridge L.
Published: April 2007

Databases have recently become de rigeur. Our Unit database has for 50 years comprehensively documented all 17 401 endocrine surgeries by its active surgeons, commencing when surgical records were hand recorded and now evolved to a PC based program. Since 1957 the database has been integral to writing 136 research publications in referred journals relating to endocrine surgery. The most common form of database related research publication has been the development and evaluation of new endocrine techniques, to which this unit has made extensive contributions. Notable examples are introducing total thyroidectomy for benign multimodular goitre, one of the first publications ever worldwide on the topic coming from the unit in 1987. Data acquisition has also allowed documentation of the safety and efficacy of new minimally invasive endocrine procedures. The next most common form of original research relates to patterns of either thyroid or parathyroid disease in the community. For example this Unit was one of the first to report, over a decade ago, increasing incidence of differentiated thyroid cancer. The database has provided clinical information to support laboratory or molecular genetics research. It has also proven useful comparing outcomes in groups of patients separated in time. Surgical databases such as this have proved a powerful tool in improving societal heath care. Prospective acquisition of clinical data, without necessarily having a research objective defined prior to commencement of data accrual provides an unequalled resource to answer questions that may not have been thought of when the data was commenced.
GS13P OUTCOME OF TRANS‐ANAL EXCISION FOR RECTAL CANCER
Authors: Banerjee S. , Levitt M. D.
Published: April 2007

Aims  The aim of this study is to assess the outcome of trans‐anal excision of rectal cancer in a single Surgeon’s practice and determine possible selection criteria for this procedure.

Methods  Retrospective review of hospital records, specimen histopathology and imaging of consecutive patients with rectal cancer undergoing trans‐anal excision as the primary treatment.

Results  25 patients had trans‐anal excision of rectal cancer including 3 cases of carcinoid tumour and 1 case of gastro‐intestinal stromal tumour (GIST). 5/25 proceeded to radical rectal resection because of the presence of adverse features including lympho‐vascular and peri‐neural invasion and poorly differentiated cell type; residual tumour was present in 4/5 cases, nodal metastases in 3/5 patients each of whom received pre‐operative chemotherapy and radiotherapy. 2/25 patients developed recurrence at 12 and 48 months from excision. One of these patients had distant recurrence at 12 months having proceeded to radical rectal resection and the other patient (aged 99), managed with trans‐anal excision alone, recurred locally at 48 months. Both cases of recurrence were T3 tumours. Overall, 19/20 cases managed with trans‐anal excision alone had no recurrence with a follow‐up period of 12–48 months. 16 of these patients had T1 malignancy.

Conclusion  T1 tumours may be treated with trans‐excision alone in the absence of adverse pathological features. It is unclear from our study whether T2 should be managed in this way due to their small number in this study and T3 tumours are clearly at high risk of recurrence with this treatment alone.
GS14P ROUTINE USE OF MEDICAL EMERGENCY TEAMS IN MANAGING SURGICAL EMERGENCIES
Authors: Kim H. K. , Wong K.
Published: April 2007

Introduction  Trauma teams and cardiac arrest teams provide an urgent and expert multi‐disciplinary response to time critical emergencies. The present study documents the contribution of a medical emergency team (MET) to managing non‐trauma surgical emergencies.

Materials and Methods  Data was prospectively collected over a two year period concerning the contribution of medical emergency teams to the resuscitation of all patients with non‐trauma surgical emergencies and altered vital signs in hospital wards.

Results  Over the study period, the details of 19 patients with surgical emergencies were recorded. 63% of emergencies occurred outside of normal working hours. In 53% of cases, the surgical registrar was off‐site or physically unavailable to attend the emergency immediately. In 11% of cases, the medical emergency team was activated prior to the arrival of the surgical registrar. In 26% of cases, the patient was left unattended whilst awaiting arrival of the surgical registrar. The medical emergency team provided resuscitation procedures and arranged urgent investigations in all patients, physically transported the patient to the operating theatre in 16% of patients and prepared for general anaesthetic in the operating theatre in 11% of cases. The surgical registrar complemented the medical emergency team response by liaising with consultant surgeons, anaesthetists and operating theatre staff in all cases. All patients received definitive treatment within 30 minutes of MET response.

Conclusion  Routine use of medical emergency teams in the initial resuscitation of patients with surgical emergencies expedites definitive management.
GS16P BEST PRACTICE FOR ASSESSMENT OF VARICOSE VEINS
Authors: Horrocks E. , Roake J. A. , Lewis D. R.
Published: April 2007

Purpose  Varicose veins are a significant health problem which attract much medico‐legal attention. Recent publications have suggested “best practice” regarding assessment of patients with varicose veins. A retrospective audit was performed comparing clinical practice in a New Zealand teaching hospital with suggested standards.

Methods  Clinic letters from 80 patients awaiting varicose vein surgery were reviewed. Data were collated regarding presenting problem, relevant medical history, clinical findings on examination, further investigations and outcome.

Results  Presenting complaint was noted for 99% of patients but actual symptoms were only recorded for 41%. The degree of disability caused by varicose veins was documented for 33% and patient concerns in 4%. Half of the patients presented with leg ulcers but ABPIs were only recorded in 26% of clinic letters. Duplex scanning was recommended prior to surgery for 69% of patients and hand held Doppler assessment of venous disease was recorded in 61% cases. Clinic letters did not specify the nature and extent of disease in 6% of cases, and although every patient was recommended for surgery the exact procedure was specified in only 24%. Details of surgical risks and complications were only present in 20% of letters, and only 21% of patients received a printed information sheet.

Conclusions  The quality of the data recorded in the clinic letters of fell below suggested standards for assessment of patients with varicose veins. Improving the documentation of patient assessment will allow better communication between providers of healthcare and make clinical errors less likely.
GS22P PROTOCOLS FOR MANAGEMENT OF BOWEL OBSTRUCTION MAY NOT IMPROVE PATIENT OUTCOMES
Authors: Mignanelli E. , Skinner S.
Published: April 2007

Purpose  Bowel obstruction is a common surgical presentation, but has no defined management protocol. Our aim was to devise a series of protocols for small bowel obstruction (SBO) and large bowel obstruction (LBO) and determine if protocol implementation affects patient outcomes.

Methods  This prospective single‐blinded study involved an initial Medline literature review to develop “ideal management protocols” for both SBO and LBO. Patients with bowel obstruction were identified at admission and assigned to a treatment protocol. Treating clinicians were blinded to the protocols and managed patients as they normally would. Patients were followed prospectively with investigations and management compared to “ideal management protocol”. Results were evaluated using Students’ T‐Test and T test.

Results  Sixty consecutive patients were identified. The use of nasogastric tubes (65%) was lower than expected from the “ideal protocol”, but their use did not significantly impact on time to first bowel action (p = 0.48), length of stay (p = 0.19), time to surgery (p = 0.16). Urinary catheters were used in 70% of patients, but had no significant impact on renal function (p = 0.27). In adhesive SBO, Gastrograffin follow – through was used in 61.5% of cases, but did not impact on time to first bowel action (p = 0.13), length of stay (p = 0.08), time to surgery (p = 0.48). In LBO contrast enema was performed in only 30.1% of cases, but there was no significant delay in surgery (p = 0.98).

Conclusion  Current management of SBO and LBO varied widely from the “ideal management protocol”, yet patients managed outside the protocols showed no significant differences in overall outcomes.
GS30P YOUNGER PATIENTS ARE MORE LIKELY TO SUFFER POST‐CHOLECYSTECTOMY DIARRHOEA
Authors: Fisher M. , Tong L. K. , Spilias D. C.
Published: April 2007

Purpose  Fatty food intolerance and diarrhoea (PCD) are increasingly being recognised as distressing postoperative sequels in a proportion of patients undergoing laparoscopic cholecystectomy. Understanding of PCD, its predisposing factors and associated symptoms is important for both consent and postoperative management.

Methodology  100 consecutive patients underwent chart review and telephone contact. A standardised questionnaire was used to collect data on age; sex; weight/BMI; pre‐ and post‐operative bowel habits, bloating, pain, dietary intolerance, dietary modification and patient satisfaction. Patients were divided into two categories, those with and those without PCD. Groups were compared using t‐test and univariate analysis to determine significance at p‐value of 0.05.

Results  Two patients were excluded due to preoperative diarrhoea (2%). PCD, defined by changes in consistency and frequency of bowel actions (p = 0.0004), was observed in 17 of 98 patients (17%). PCD was associated with younger age (p = 0.014), higher weight (p = 0.041), less bloating preoperatively (p = 0.045) and higher likelihood of bloating postoperatively (p = 0.048). There was no statistically significant correlation with dietary intolerance, dietary modification or patient satisfaction. 7 patients (7%) reported postoperative constipation or resolution of pre‐existing diarrhoea.

Conclusions  Subjective PCD and dyspeptic symptoms correlate with measurable differences in bowel habits. Younger patients are significantly more likely to develop PCD and should specifically be warned of this possibility.
HS02 BOTULINUM TOXIN A IN OBSTETRIC BRACHIAL PLEXUS PALSY
Authors: Johnstone B. R. , McCombe D. , Coombs C. , Britt K.
Published: April 2007

Purpose  To evaluate children with obstetric brachial plexus palsy treated with botulinum toxin A (Botox)injections to assist with the management of contracted muscles and joints as well as co‐contraction.

Methods  Since September 2004, 20 children have been treated. The median age at treatment was 2.1 years (range 7 months to 11 years). As experience was gained, the total dose of Botox increased from 4 to 10 units per kg.

Results  12 patients were treated primarily for restriction of passive external rotation at the shoulder at an average age of 24 months (range 7 to 42 months). This group had the most impressive gains which became apparent within a week of injection. There was a high level of parental satisfaction with an improvement in passive range and increased ease of physiotherapy. Six had excellent and 4 had good results. The two patients who had little improvement had clear indications for surgery. Seven (58%) of these 12 patients went on to have a repeat injection , in 2 cases with a higher dose, aiming to achieve further gains. Five patients were treated for co‐contraction of the latissimus dorsi and/or teres major were aged 8 months and from 8 to 11 years. They reported minor gains.All five patients who had triceps injections had improved elbow flexion.

One patient had an over active biceps injected with minor benefit.

Conclusion  It is hoped that persistent physiotherapy assisted by botulinum toxin A injections targeting internal rotators can reduce gleno‐humoral joint dysplasia, posterior subluxation and the need for open procedures. Shoulder subluxation identified by ultrasound should be further imaged with CT or MRI and be considered for an open procedure.
HS05 CRPS – CURRENT IDEAS ON MANAGEMENT
Authors: Shipton E. A.
Published: April 2007

Complex regional pain syndrome (CRPS) is characterised by extreme pain and dysfunction of the sympathetic nervous system in one region of the body, usually an extremity.(1) It involves the somatosensory, sympathetic and the somato‐motor systems. It consists of local neurogenic inflammation out of proportion to injury; severe pain in the skin, subcutaneous tissues and joints; and central hyperexcitability that is often compounded with a sympathetic component. It is multifaceted manifesting both central and peripheral neurologic pathophysiology, including a prominent psychosocial component.

Mechanisms include trauma related cytokine release, exaggerated neurogenic inflammation, sympathetic afferent coupling, adrenoreceptor pathology, glial cell activation and cortical reorganisation.(2)

Diagnostic criteria and tests used will be discussed. Biomedical interventions include the use of primary and secondary analgesics, neural blockade, sympatholysis, ketamine, bisphosphonates, and spinal cord/peripheral nerve stimulation. Psychological and behavioural factors can exacerbate the pain and dysfunction associated with CRPS.(3) Mirror visual feedback was introduced recently for rehabilitation but needs to be evaluated in randomized controlled trials.(4)
HN04 GENETICS OF HEAD AND NECK PARAGANGLIOMA
Authors: Hunt P. J.
Published: April 2007

Paragangliomas (PGL) of the head and neck are rare tumours derived from neural crest origin that occur in both sporadic and hereditary forms. Genetic predisposition to paraganglioma affects up to 50% of all patients with head and neck paraganglioma. Patients with familial paraganglioma tend to present at a younger age and with multiple tumours. In the past, familial cases were attributed phenotypically to particular groupings, such as PGL type 1. Recent advances have identified mutations in genes encoding the three SDH subunits (SDHB, SDHC, SDHD) as responsible for the majority of familial head and neck paraganglioma. Succinate dehydrogenase is a mitochondrial enzyme complex with an important role in both the Kreb’s cycle and the mitochondrial electron transport chain. These mutations lead to the overexpression of several hypoxia‐inducible genes resulting in cellular proliferation and the development of paragangliomas. Understanding the relationship between mutations of SDHB, SHDC and SDHD and clinical manifestations of familial paraganglioma is important in the management, genetic testing and appropriate genetic counselling of individuals.
HP01 METALS IN GALLBLADDER CARCINOGENESIS
Authors:   Puneet, Singh M. , Singh S. P. , Shukla V. K.
Published: April 2007

Carcinoma gallbladder is the commonest malignancy in the Northern part of India. The heavy metals are known carcinogens while trace metals have protective effect.

Aim  The aim of the study is to estimate the heavy and trace metal (Lead, Zinc, Copper, Cadmium, Chromium, Manganese and Selenium) concentration in serum, bile, tissue and gallstone in patients with gallbladder diseases.

Method  This is a pilot study conducted in 45 cases (Group – I: 15 cases of carcinoma gallbladder, Group II: 15 patients of cholecystitis with cholelithiasis and Group – III: 15 patients of healthy control), to detect the relationship between the heavy and trace metal concentration and gall bladder carcinoma. Analysis of metal was done using Perkins‐Elmer model 2380 atomic absorption spectrophotometer.

Results  The serum concentration of copper and nickel was significantly high in carcinoma gallbladder patients as compared to patients with cholecystitis while zinc and selenium is low in carcinoma gallbladder patients. Bile concentration of zinc, selenium and manganese was significantly low in carcinoma gallbladder patients (p < 0.05) as compared to patients of cholelithiasis while cadmium and nickel was high. Tissue concentration of manganese was significantly low in carcinoma gallbladder patients as compared to patients of cholelithiasis while chromium was high. Gallstone concentration of copper, manganese and lead was significantly low in carcinoma gallbladder patients as compared to patients of cholelithiasis.

Conclusion  The heavy metals are in higher concentration in carcinoma gallbladder while trace metals are in lower concentration indicating possible role of heavy metal in gallbladder carcinogenesis.
HP14 DETERMINING THE MANOMETRIC AND ANATOMIC FEATURES WHICH INFLUENCE DISTAL OESOPHAGEAL RAMP PRESSURE
Authors: Myers J. C. , Jamieson G. G.
Published: April 2007

Purpose  Distal oesophageal ramp pressure upon swallowing results from resistance from the oesophago‐gastric junction below and pressure from above (peristaltic wave) with pressure build‐up in the distal oesophagus. Ramps are observed during manometry, but the factors which influence the magnitude of ramp pressure have not been elucidated. This study aims to establish the normal range for ramp pressures and ascertain manometric and anatomic features which affect ramp pressure, in order to study ramp pressures and dysphagia following antireflux surgery.

Methodology  A standard 8 channel motility catheter with a sleeve was used with a water perfused manometry system, to record the ramps at 3 cm above the lower oesophageal sphincter (LOS) associated with ten 5 mL water swallows.

Results  614 water swallows (5 mL) have been analysed in 68 subjects: 20 controls, 25 reflux patients and 23 patients after a partial (12) or total (11) fundoplication. Control patients had LOS of 17 ± 0.4 mmHg, relaxation pressure of 1.4 ± 0.2 mmHg and a ramp of 8 ± 0.3 mmHg (mean ± std error). Reflux patients had significantly lower pressures than controls for all parameters studied. As expected after anti‐reflux surgery, all pressures were significantly higher with total fundoplication producing the highest pressures. The ramp pressure after total fundoplication was 22 ± 0.6 mmHg and after partial fundoplication was 15 ± 0.5 mmHg.

Conclusions  Ramp pressure integrates the distal peristaltic amplitude with lower oesophageal resistance to outflow. It is possible that lower rates of dysphagia after partial fundoplication are associated with lower ramp pressures. However the relationship between ramp pressure and dysphagia remains to be elucidated.
HP02 A MULTICENTRE CONTROLLED STUDY OF INLINE RADIO‐FREQUENCY ABLATION DEVICE FOR LIVER TRANSECTION
Authors: Yao P. , Chu F. , Schilling M. , Zuckerman R. , Marchi J. , Morris D. L.
Published: April 2007

Purpose  Intraoperative blood loss during liver resection remains a major concern due to association with higher postoperative complications. The InLine RFA device (ILRFA) (Resect Medical Inc® Fremont CA) has achieved promising results in liver surgery with minimal blood loss and no increase of postoperative complications. In this multicentre controlled study, 108 patients undergoing liver resection were investigated.

Methodology  108 liver resections were performed in 4 medical centres, consisting of 54 ILRFA and 54 ultrasonic Surgical Aspirator (USA) transection as the control group. Pringle manoeuvre was applied only when required. Blood loss was measured from sponge weights and suction bottle contents.

Results  The type of liver resection was very similar in both groups. Median number of RFA deployments was 3 (1–12) with a median coagulation time of 9 (3–36) minutes. Median operation blood loss was 165 ± 20 ml (5–675 ml) in the ILRFA and 654 +/−83 ml (80–3600 ml) in the control, a 74.8% reduction (P < 0.001). The median transection blood loss per unit resection area was 3.29 ± 0.40 (0.14–12.33) ml/cm2 in the ILRFA patients compared with 6.41 ± 0.71 (0.92–36) ml/cm2 in controls, the reduction was 48.7% (P < 0.001). The transection time in ILRFA was slightly faster than that in controls, but not significantly different.

Conclusion  ILRFA precoagulation is a safe, effective technique for liver resections which significantly reduces blood loss.
HP28P METANALYSIS OF RECURRENCE AFTER LAPAROSCOPIC REPAIR OF PARAESOPHAGEAL HERNIA
Authors: Rathore M. A. , Najfi S. M. , Mc Muray A. H.
Published: April 2007

Introduction  Recurrence & reflux are two most important remote complications of lap‐PEH repair (concluded by us at a previous USG meeting UK). However the extent of recurrence remains unknown.

Aim  To determine the true incidence of recurrence of recurrence after lap‐PEH repair.

Material & methods  A metanalysis was performed. PubMed, Embase, hand search and personal communication were used to access and appraise studies. Inclusion criteria were full‐text papers from 1991 to date describing lap‐PEH repair on >25 pts, at least 6 m follow up and addressing recurrence. ‘Wrap migration’ papers were excluded. Papers were appraised and data was isolated on summary sheets. MS Office Excel 2005 was used to plot results and represented in graphs. Statistics involved calculating odds, 95 ci and alternative scenario.

Results  15 studies were eligible (all retrospective). A total of 1132 pts with 100 recurrences were noted. Overall rec rate (in all pts) was 8.8% and was 10.4% if only followed‐up patients (n = 748/1132) were considered. When patients with objective evidence (follow‐up Ba esophagogram) were used (301/1132), ‘true’ rec rate was 25.5% (i.e. 1 in 4 repairs recurred). Learning curve did not appear to be an issue. The studies revealed broad 95 ci and touching the line‐of‐no‐effect thereby increasing the ‘chance factor’. When alternative model was applied, esophageal lengthening (by Collis‐Nissen gastroplasty) revealed a significant protective influence.

Conclusion  The true incidence of lap‐PEH recurrence is 25.5%. Mandatory (protocol) follow‐up esophagograms at 1 y are essential. Subconsciously, two emphasis points in the repair have emerged – hiatoplasty and (superadded) esophageal lengthening.
HP34P EXTRANODAL MARGINAL ZONE B‐CELL LYMPHOMA OF MUCOSA ASSOCIATED LYMPHOID TISSUE (MALT) TYPE OF THE GALLBLADDER
Authors: Ng S. K. , Epair K. , Parsons S. , Wei A. , Banting S. W.
Published: April 2007

Purpose  Extranodal marginal zone B‐cell lymphoma of mucosa associated lymphoid tissue (MALT) type of the gallbladder is rare. We described a case of MALT lymphoma of the gallbladder with splenic and pulmonary dissemination, followed by a review of similar cases reported in English literature.

Background  A 60 year old woman presented to our surgical unit with abnormal liver function tests and gallbladder thickening on ultrasonography. Cholecystectomy revealed a chronically inflamed gallbladder with multiple gallstones. Histology showed abnormal sheets of small B lymphoid cells which were CD 20 positive, consistent with a diagnosis of MALT lymphoma. Staging CT showed bilateral pulmonary nodules and mild splenomegaly. PET scan demonstrated increase uptake in lung fields and normal uptake in spleen, bone marrow and lymph node. Bone marrow examination was negative. Final diagnosis is Stage 4 extranodal MALT. She remained in remission on three‐month review. No additional chemotherapy or radiotherapy was administered.

Discussion  Extranodal MALT lymphoma of the gallbladder has similar epidemiological features with other extranodal MALT lymphomas. Most patients present with symptoms consistent with cholecystitis. As the gallbladder does not normally contain lymphocytes, persistent lymphoid proliferation due to chronic inflammation may represent a critical step in the development and progression of MALT lymphoma (1). Cholecystectomy without adjuvant therapy is appropriate first line treatment if there is no other symptomatic disease (2). Long term surveillance for relapse and second lymphoma should be considered.
PS10 PHAEOCHROMOCYTOMA IN CHILDREN
Authors: Glengarry J. M. , Hamill J
Published: April 2007

Purpose  Phaeochromocytomas are rare tumours of the sympathoadrenal neuroendocrine system. It is known that these tumours are associated with Von Hippel Lindau (VHL) disease, multiple endocrine neoplasia type II and neurofibromatosis type I. Recently an association with succinate dehydrogenase type B and D gene mutations has been described. Discovery of a SDHB mutation in a girl at our hospital prompted us to review our experience with phaeochromocytoma in children.

Methodology  Retrospective review of case notes of all children treated for phaeochromocytoma over the period 1997–2006 at Starship Children’s Hospital, NZ.

Results  Seven patients with 8 tumours were identified with average age of 10 years and average systolic BP of 161. The tumours were adrenal in location in 37.5% and 62.5% extra‐adrenal. Our malignancy rate was 12.5%. Familial disease was noted in two patients with one girl having VHL disease and the other found to carry a mutation in the SDHB gene. All children received preop antihypertensives and were treated operatively with seven open resections and one laparoscopic converted to open resection. One child received adjuvant radiotherapy. There were no recurrences or deaths.

Conclusions  Phaeochromocytoma in children varies from the adult form. It is more likely to be extra‐adrenal and have a greater chance of a familial genetic syndrome. The discovery of SDH mutations has altered the diagnosis of familial disease and carries implications for family screening, prognosis and surveillance. We emphasize the importance of taking a good family history and suggest screening for SDH mutations in all patients with phaeochromocytoma.
PS14 FACTORS INFLUENCING THE TIMING OF THE EXIT PROCEDURE FOR OBSTRUCTING FETAL NECK MASSES
Authors: Jefferies H. M. , Beasley S. W. , Blakelock R. T. , Kyle B. V. , Dixon A. P.
Published: April 2007

The EXIT procedure (ex‐utero intra‐partum treatment) has become the standard modality for dealing with a fetus when it is anticipated that there will be major problems establishing an airway at the time of birth. Rapid growth and expansion of cervical masses (most commonly cervical teratoma or lymphangioma) may deviate and compress the trachea and oesophagus, and obstruct fetal swallowing. This may cause severe maternal polyhydramnios and places the fetus at risk of death. Cervical masses first diagnosed between 20–24 weeks gestation may be observed to grow rapidly on serial ultrasonography, and require repeated amnio‐reduction and drainage of the cyst. The risks of multiple interventions to prolong the pregnancy, the rate of expansion of the solid component of the tumour, and of uterine death have to be balanced against the risks associated with extreme prematurity and delivery by the EXIT procedure to establish an airway.
PR15 THE BRANCHING PATTERN OF THE DIEA FOR PERFORATOR FLAPS: THE IMPORTANCE OF PREOPERATIVE CT ANGIOGRAPHY
Authors: Rozen W. M. , Phillips T. J. , Ashton M. W. , Stella D. L. , Taylor G. I.
Published: April 2007

Purpose  Abdominal donor site flaps are the standard in autologous breast reconstruction. With significant variation in the vascular anatomy of the abdominal wall, preoperative imaging is essential. Computerised Tomography Angiography (CTA) has been recently described for this purpose. Uniquely, the branching pattern of the Deep Inferior Epigastric Artery (DIEA) is demonstrated clearly on CTA. We sought to correlate the branching pattern of the DIEA to the location and course of perforators, as a tool for preoperative planning.

Methodology  45 hemi‐abdominal walls from both fresh and embalmed cadavers were used for isolated injection of the DIEA with contrast and radiographic imaging, allowing analysis of the location and intramuscular course of the perforators. The branching pattern on radiography was thus correlated to individual perforators.

Results  DIEA branching pattern correlated closely with the intramuscular course of perforators. A bifurcating branching pattern demonstrated a reduced intramuscular transverse distance traversed by each perforator. A trifurcating (Type 3) branching pattern demonstrated perforators that traversed significantly greater transverse distances. The vessel type, however, displayed no correlation with the number of perforators.

Conclusions  Intramuscular courses of perforators are significantly greater with a trifurcating branching pattern of the DIEA, and reduced with a bifurcating pattern. This correlates with less rectus abdominis muscle sacrificed during a DIEA perforator flap. As CTA is the optimal modality for demonstrating this pattern preoperatively, we suggest the use of CTA for preoperative assessment in TRAM and DIEA perforator flaps.
PR18 WHAT TYPE OF BIOPSY IS MOST USEFUL IN THE EVALUATION OF GIANT CUTANEOUS LIPOMAS? REVIEW OF THE LITERATURE AND REPORT OF FOUR CASES
Authors: Sathasivam S. , Perkins D.
Published: April 2007

Lipomas are benign tumours of the mesenchyme that are composed of mature lipocytes. They are the most common benign mesenchymal tumours with a prevalence rate of 2.1 per 1000 people. The malignant transformation of lipomas to liposarcoma is uncommon. A few reports suggested that large tumours (>10 cm), are more likely to contain sarcomas. Hence, the preoperative biopsy is an essential component of the workup in giant lipomas since it provides key information in determining the treatment protocol. Biopsy can be performed by fine‐needle aspiration, core‐needle biopsy, incisional biopsy or excisional biopsy.

We present four cases where preoperative minimally invasive biopsy techniques were utilised. In these cases, significant differences were noted between preoperative biopsies and the actual histology of the surgically resected specimen.

Open biopsies have a relatively higher risk of complication but a smaller chance of misdiagnosis, while needle biopsies are less likely to present with problems but are also frequently less accurate. Given the histological heterogeneity of these tumours, a large sample from a viable area of pathology is recommended for definitive preoperative diagnosis.

An open biopsy should be performed through a small incision, designed with consideration of the subsequent definitive operative procedure. A typical incisional biopsy will yield a 1–2 cm3 piece of fresh tissue for the pathologist to reliably exclude the presence of sarcoma in the lesion.