bluuebunny/crossref_metadata_2025 huggingface dataset:
HIGH DOSE LOPERAMIDE SUPPOSITORIES: A NOVEL APPROACH FOR IMPROVING CLINICAL FUNCTION AFTER RESTORATIVE PROCTOCOLECTOMY
Authors: Levitt M. D. , Jenner D. C. , Maher M. J.
Published: January 2008

The effect of loperamide suppositories on patients following restorative proctocolectomy was studied by means of a randomized, double‐blind, crossover trial comparing active suppositories (20 mg b. d. X 1 week) with placebo. Ten patients (8 male, 2 female; 7 J pouch, 3 W pouch; 8 ulcerative colitis, 2 familial adenomatous polyposis) were studied 3–60 months (median, 31.5) after ileostomy closure. Ages ranged from 24 to 63 years (median, 41.5). All patients kept a diary of their bowel habits and eight underwent a standardized test of pouch compliance. Urgency volume (UV) and maximum tolerable volumes (MTV) and the volume at onset of large isolated pouch contractions (LIC) were recorded. Statistical analysis was by the Wilcoxon test for paired data. Mean daily stool frequency during the placebo phase ranged from 3.7 to 7.8. It was reduced during the active phase in only seven patients (P > 0.1) but was reduced in all six patients whose placebo phase stool frequency was five or more. Urgency volume was increased by use of active suppositories in six of the eight patients tested (P > 0.1). There was no consistent effect on MTV. Large isolated pouch contractions were not seen in either test in one patient. In all of the remaining seven patients LIC were recorded after the placebo phase. After the active phase LIC first appeared at higher volumes in three but were not seen at all in four patients. High dose loperamide suppositories suppress pouch contractions and tend to lower stool frequency especially when high initially. They represent a novel therapeutic approach to high stool frequency in pouch patients.
DERMATOFIBROSARCOMA PROTUBERANS IN A RENALTRANSPLANT PATIENT
Authors: La Kar Neng , Lai Fernard Mac‐Moune , King Walter W. K. , Li Philip K. T. , Siu Diana , Leung Chi Bon , Lui Siu Fai
Published: January 2008

Dermnatofibrosarcoma protuberans is an unusual soft tissue tumour with a propensity for local recurrence and rarely metastatic spread. Given its indolent course it may be mistaken for atypical scarring or a keloid growth. Early diagnosis and prompt wide local resection of this entity are required in order to prevent a local recurrence. We report a patient who developed locally invasive dermatofibrosarcoma protuberans 4 years after a successful renal transplantation. Although other forms of sarcoma have been reported as a complication of organ transplantation and immunosuppression, this pathology has, so far, not been reported in a transplant recipient.
PREDICTING HEALING OF LOWER LIMB ULCERS
Authors: McMahon J. H. A. , Grigg M. J.
Published: January 2008

Management of ischaemic ulcers in patients with compromised peripheral arterial circulations relies on the physical examination and the simple, non‐invasive assessment of arterial supply. This study aims to determine if transcutaneous oxygen pressure (tcPo2) measurement can improve management decisions based on ankle or toe systolic blood pressure measurement. Twenty‐two consecutive patients with ischaemic ulcers had tcPo2, measured and the ankle/brachial (ABI) and toe/brachial (TBI) indices calculated. Two months after surgery 12 of 22 (55%) ulcers were healing and 10 (45%) were indolent. Postoperative tcPo2 values were predictive of wound outcome (P <0.001). A tcPo2> 31 mmHg was invariably associated with healing whilst a tcPo2, 28 mmHg was associated with indolence. Anklebrachial indices and TBI were unable to be calculated in all patients due to falsely elevated pressures and hallux amputations, respectively, and neither was predictive of outcome (ABI P= 0.152, TBI P = 0.069). The response to revascularization was less in diabetic patients with a mean tcPo2 increase of 18 mmHg compared to non‐diabetic patients with a mean tcPo2 increase of 37 mmHg. TcPo2 measurement appears to be a reliable technique that can influence ischaemic ulcer management.
RETROPERITONEAL SCHWANNOMA: A CASE SERIES AND REVIEW
Authors: Gubbay A. D. , Moschilla G. , Gray B. N. , Thompson I.
Published: January 2008

Schwannomas account for only a small percentage of retroperitoneal tumours. Presentation is typically varied and non‐specific and pre‐operative diagnosis is difficult. Herein are described five cases of retroperitoneal schwannoma. Presentation was varied, ranging from abdominal pain, abdominal mass, obstructed labour or an incidental finding. All patients had either an abdominal computed tomography scan and/or ultrasound performed. Pre‐operative biopsy either by fine needle aspiration (in one patient) or core biopsy in two patients was unhelpful. In four patients with smaller tumours, complete excision was possible with no apparent long‐term morbidity and no clinical evidence of recurrent tumour with follow up from 3.5 months to 11 years. For the largest tumour, complete surgical excision was not attempted as it would have entailed significant morbidity.
FRANTZ'S TUMOUR: PAPILLARY AND CYSTIC CARCINOMA OF THE PANCREAS
Authors: Tait N. , Greenberg M. L. , Richardson A. J. , Osborn R. A. , Little J. M.
Published: January 2008

Frantz's tumour (papillary and cystic tumour) of the pancreas is a rare neoplasm usually seen in young women. It is of low grade malignancy and deserves special note among pancreatic malignancies as it is frequently amenable to local resection and has a good long‐term survival rate after excision. Three such cases have been treated at Westmead Hospital, one young male and two females. In two the disease was confined to the pancreas. In one, local invasion outside the pancreas and trans‐coelomic spread to the ovaries was present at the time of diagnosis. Complete surgical removal of macroscopic disease was achieved in all three and all remain disease free between 2 and 4 years post‐surgery. All have good exocrine and endocrine pancreatic function. These cases are discussed in detail. The need to be aware of this uncommon variant of pancreatic cancer is stressed. Investigation and treatment options are reviewed. The role of cytology studies in diagnosis and the potential for long‐term surgical control of this tumour are highlighted on the basis of our limited experience and that presented in recent surgical literature.
RECONSTRUCTION OF TOTAL LOSS OF UPPER LIP WITH HAIR‐BEARING FLAPS
Authors: Jacob Ollapallil J.
Published: January 2008

Carcinoma of the lip is a relatively common problem in Papua New Guinea, accounting for some 12% of all malignant turnours in the oral cavity. The cancer is associated with chewing betelnut with slaked lime and smoking. Advanced squamous cell carcinoma of the upper lip is necessarily managed by primary surgery when radiotherapy facilities are not available. Adequate surgical treatment of these carcinomas usually requires full thickness excision of a portion or whole of the lip. The purpose of this paper is to demonstrate the role of hair‐bearing scalp flap for reconstruction of total loss of the upper lip in male patients.
DISTAL CLAVICULAR EXCISION: A DETAILED FUNCTIONAL ASSESSMENT
Authors: Petchell J. F. , Sonnabend D. H. , Hughes J. S.
Published: January 2008

Distal clavicular excision is commonly performed for a number of clinical conditions. The results of the procedure are not well described. Using the Constant, American Shoulder and Elbow Surgeons (ASES). University of California at Los Angeles (UCLA) and Neer scoring systems, the medium term results of distal clavicular excision were assessed. Over an 8 year period, 39 patients underwent distal clavicular excision for conditions other than acromioclavicular instability (subluxation or dislocation). A single technique was employed. A retrospective study was performed of all 18 patients who could be contacted. In those cases patient satisfaction was universal. Pre‐operative pain was severe in 16 patients (89%) and moderate in two (11%). Following surgery, five (28%) were free from pain, 10 (55%) had only mild or occasional pain, and three (17%) reported moderate pain. The difference between pre‐operative and postoperative levels of pain was highly significant (P < 0.001). However, continuing difficulties with work (59%). sleeping (55%) and activities of daily living (59%) were reported. Ten of 14 (71%) wishing to return to sporting activities were able to do so without restriction. Neither shoulder strength nor range of movement was fully restored following surgery, which relieved pain but did not restore normality. This series may facilitate subsequent assessment of arthroscopic distal clavicular excision.
ISSUES IN BIOMEDICAL STATISTICS: COMPARING MEANS UNDER NORMAL DISTRIBUTION THEORY
Authors: Ludbrook John
Published: January 2008

The test used most commonly in biomedical research to compare means when measurements have been made on a continuous scale is Student's t‐test, followed closely by various forms of analysis of variance. These tests require that defined populations have been randomly sampled, but there are other assumptions about populations and samples that must be satisfied. These include: (i) normality of the population distributions; (ii) equal variance in those normal populations; and (iii) statistical independence of the samples. This review offers advice to investigators on how to recognize breaches of the assumptions of normality and equality of variance, and how to deal with them by modifying the usual t‐test or by transforming the experimental data. The sample‐size also has an important bearing on statistical inferences: (i) if it is too small. the risk of Type II error is inflated; and (ii) inequality of sample size exaggerates the effects of inequality of variance. The assumption of independence is breached if repeated measurements are made serially rather than in random order, but adjustments to analysis of variance can be made to correct for the inflated risk of Type I error. The review also considers the problem of making multiple comparisons of means. and recommends solutions.
CHOLEDOCHOPLASTY FOR CHOLECYSTOCHOLEDOCHAL FISTULA (MIRIZZI SYNDROME TYPE II): A CASE REPORT AND LITERATURE REVIEW
Authors: Strugnell Neil A. , Sali Avni
Published: January 2008

The following is a case report of a cholecystocholedochal fistula (Mirizzi syndrome Type II) in a 61 year old woman. The use of a pedicled graft of gall‐bladder remnant in the treatment of this condition is presented. If the condition is recognized early, bile duct injury can be prevented and the need for more complex techniques of bile duct repair or bypass may be averted.
GIANT DOUBLE PARATHYROID ADENOMA PRESENTING AS A HYPERCALCAEMIC CRISIS
Authors: Fahey Thomas J. , Hibbert Emily , Brady Peter , Stiel John , Delbridge Leigh
Published: January 2008

The largest documented case of a double parathyroid adenoma is reported. The patient presented in hypercalcaemic crisis with a large intrathoracic mass. After removal of a massive cystic parathyroid adenoma from the right superior mediastinum. a second very large parathyroid adenoma was found on the contralateral side adjacent to the left thyroid lobe. This case illustrates the importance of the cervical approach, as well as routine bilateral neck exploration. for all cases of primary hyperparathyroidism.
SURGERY FOR GALLSTONES IN THE ELDERLY
Authors: Askew A. R.
Published: January 2008

In a consecutive series of 349 patients undergoing surgery for gallstones. 66 patients (19%) were aged over 65 years. Within this group of elderly patients. 51 underwent laparoscopic cholecystectoiny which was successful in 84% of cases. The most frequent cause for conversion to open surgery was the presence of dense pericystic adhesions. Fifteen patients (23%) underwent elective open surgery. The principal reason was co‐existent duct stones. There was no operative mortality and procedure related morbidity in the elderly following laparoscopic or open surgery was similar. Laparoscopic cholecystectoiny can be safely and effectively performed in the majority of elderly patients. offering thein the perceived advantages of this technique. However. the presence of duct stones in 18% of cases necessitates careful evaluation of these patients pre‐operatively.
PENETRATING INJURIES OF THE AXILLARY ARTERY
Authors: Degiannis Elias , Levy Richard D. , Potokar Thomas , Saadia Roger
Published: January 2008

This is a retrospective study of 32 patients with penetrating injury of the axillary artery. There was an overall mortality of 6% entirely accounted for by associated injuries. Pre‐operative angiography was used in 12 of these patients either to confirm the presence of an injury or to define its location. Twelve patients underwent lateral arteriorrhaphy or an end‐to‐end anastomosis and 19 patients had an interposition graft. No immediate problems were experienced with polytetrafluoroethylene grafts compared with autogenous vein grafts. There were 14 patients with a concomitant venous injury; 13 were repaired and only transient arm oedema was experienced. Eleven patients had a brachial plexus injury and, of these, nine underwent a secondary nerve repair with a poor outcome. Axillary artery injury has a good prognosis with a morbidity related mainly to associated nerve injury and a mortality accounted for by injuries to other body systems.
HEPARIN‐REBOUND IN THE EARLY POSTOPERATIVE PHASE FOLLOWING CARDIOPULMONARY BYPASS
Authors: Subramaniam P. , Skillington P. , Tatoulis J.
Published: January 2008

The incidence of the ‘heparin‐rebound’ phenomenon after protamine neutralization of systemic heparinization required for cardiopulmonary bypass (CPB) was investigated. Heparin‐effect was detected in 43% of patients studied at 2h, 31% at 4h, and 37% at 8h after reversal of circuit heparin on CPB. Heparin‐rebound was shown to be associated with a small but significant increase in postoperative bleeding which was not of clinical importance.
RENAL TRANSPLANTATION IN VERY YOUNG CHILDREN
Authors: Supabphol Athikom , Francis David M. A. , Millar Robert J. , Hutson John , Kelly Justin , Walker Rowan G. , Powell Harley , Jones Colin L.
Published: January 2008

Results of renal transplantation in very young children with end‐stage chronic renal failure have been poor compared with those in older children and adults. Consequently small children either may not be treated or may be placed on chronic dialysis programmes. Between 1988 and 1992, six children under the age of 5 years received seven renal transplants at the Royal Children's Hospital, Parkville, Victoria, Australia; five from live donors and two from cadaver donors. All children were treated with peritoneal dialysis before transplantation, and immunosuppressed with a standardized regimen of cyclosporine, azathioprine and prednisolone. An extraperitoneal incision was used, and the donor renal vessels were anastomosed to the lower abdominal aorta and inferior vena cava or the common iliac vein. All children received intensive monitoring and fluid replacement during the peri‐operative period. Patient survival was 100%. One cadaver graft failed 1 week after transplantation because of irreversible acute rejection. This child subsequently received a successful second transplant. Two children developed postoperative urinary fistulae which were treated successfully by further operation. Current renal function in all children is excellent. The success of this programme has led us to review our attitude towards renal transplantation in this age group and to advocate live donor renal transplantation as the treatment of choice in very young children with end‐stage chronic renal failure whenever possible.
BRAIN ABSCESSES: REVIEW OF 30 CASES TREATED WITH SURGERY
Authors: Ng Puay Yong , Seow Wan Tew , Ong Peck Leong
Published: January 2008

Thirty patients with brain abscesses who were treated at the Department of Neurosurgery, Tan Tock Seng Hospital, Singapore, during the period July 1989 to July 1993, were reviewed. There were seven females and 23 males with mean follow up duration of 19 months. The predisposing factors identified were otogenic infections in 10 cases (33%), paranasal sinus infection in 2 cases (7%) and congenital heart disease in 6 cases (20%). All cases underwent aspiration or excision of the abscess. Repeat operations were carried out if the abscess reaccumulated. A total of 49 aspirations and 16 excisions were performed. Twenty‐five patients (84%) made a good recovery, three patients (10%) were moderately disabled, one patient (3%) was severely disabled and one patient (3%) died. There was no postoperative haemorrhage or wound infections. Two patients (7%) developed hydrocephalus and three (10%) had seizures postoperatively.
A DOUBLE LUMEN SUPRAPUBIC URODYNAMIC CATHETER
Authors: Dewan P. A.
Published: January 2008

A 7.5 FG double lumen suprapubic urodynamic catheter has been developed to avoid the effects of urethral catheterization and provide reliable continuous pressure monitoring. The device is an adapted central venous catheter which is easily introduced through a peel‐away sheath, after the insertion of a guide wire.
LATE FOLLOW UP OF AUTOAUGMENTATION OMENTOCYSTOPLASTY IN A SHEEP MODEL
Authors: Dewan P. A. , Owen A. J. , Stefanek W. , Lorenz C. , Byard R. W.
Published: January 2008

Four male sheep were studied 12 months after an autoaugmentation omentocystoplasty (AAOC). The omentuni was lined with urothelium, but continued inflammation and/or fibrosis were seen within the subepithelial tissues associated with a failure to achieve enlargement of the bladder when compared with a control group of six animals. The median compliance value was 59 mL/cm H 2O for the AAOC animals and 9.8 mL/cm H2O for the control group, indicating that no improvement in bladder dynamic function had been achieved with the AAOC in sheep, and no significant improvement had occurred with time when the results were compared with those seen 6 months earlier.
MICROSURGICAL VASOVASOSTOMY IN MILITARY PERSONNEL
Authors: Wright Gavin M. , Cato Alex , Webb David R.
Published: January 2008

This paper details the operative techniques, results and reasons for reversals of vasectomy in military personnel. Fifty‐two reversals were performed by two surgeons (AC & DW) over a 7 year period. Data collection was by (i) retrospective analysis of service documents, surgical registers and laboratory records and (ii) response to a questionnaire. The interval between original vasectomy and reversal vaned from 5 months to 16 years. Change of sexual partner was the most common reason for requesting the procedure. There were two recorded postoperative infections and no postoperative mortality. Post‐reversal semen analysis proved anastomotic success in 49 out of 51 cases (96%). Semen analysis was not returned for the remaining case. Of the couples who had been trying for at least 18 months, 28 out of 42 (67%) had conceived, including one miscarriage. A further seven cases had been trying for less than 18 months, or had no opportunity due to physical separation. Two of these seven patients ended their relationship soon after operation. Pregnancy outcome was unknown in three cases.
CHANGING TRENDS IN UROLOGY PRACTICE: INCREASING OUTPATIENT SURGERY
Authors: Kaye Keith W.
Published: January 2008

This study was performed to assess the changes occurring in the field of urology with developments in outpatient surgery during a 5 year period. Using ICD‐9‐CM code, data for all urology procedures performed in the main operating rooms, day surgery and laser centre operating rooms of a large, general hospital were collected for the years 1987–92. A substitution index (SI) was determined as the ratio of the number of outpatients to the total number of procedures and expressed as a percentage. Changes in the SI reflects the degree to which emphasis has shifted from conventional inpatient to outpatient surgery. It was found that 26% of urology procedures were being performed as outpatients in 1987, and this increased to 42% by 1992. When broken down according to organ, the greatest increase in SI from 1987 to 1992 was for the kidney (57%) and the least, the penis (2%). with ureter, urethra, testes and scrotum all revealing intermediate, but significant, increases (27, 28 and 24% respectively). This paper thus demonstrates that, as in other fields, urology has experienced a marked increase in outpatient surgery. With developments in surgical and anaesthetic techniques, financial pressures, changing physician and patient attitudes and technological advances, further increases in urology outpatient care can be expected.
COLONOSCOPY: HOW FAR IS ENOUGH?
Authors: Isbister William H.
Published: January 2008

Total colonoscopy is arguably the best method available for examination of the colon and rectum. Colonoscopy costs are high and rising and it may be that in the future practitioners will be unable to afford to colonoscope all of the patients presently being examined. This retrospective study was undertaken in an attempt to examine the cost, in terms of lesions missed, of a limited endoscopy programme. During a 15 year period, 1426 colonoscopies were performed at Wellington Hospital, New Zealand. Total colonoscopy was possible in 79% of all patients. Three perforations occurred. Nine patients bled and two required blood transfusion after biopsy or ‘snaring’ of polyps. After exclusion of patients with continuous inflammatory bowel disease (IBD) 75% of all lesions were found in or distal to the descending colon. More cancers were found in patients colonoscoped because of bleeding. Thirty‐two of 93 cancers diagnosed were proximal to the descending colon but 18 presented with bleeding. A further seven had a radiological abnormality. Only 7.5% of colorectal cancers would be missed by flexible sigmoidoscopy (65 cm) and 758 of the costs of total colonoscopy would be avoided if only patients presenting with bleeding and IBD were offered total colonoscopy and patients with radiological abnormalities were treated according to the abnormality. This compromise, based on the data presented, may represent a rational way to reduce colonoscopy costs.
PRIMARY FIBROSARCOMA OF THE HEART
Authors: Coskun Hasan , Bozkurt A. Kürsad , ÖZbay GülŞen , Demirkesen Cuyan , Kaynak Kamil , Vural Fikret Sami
Published: January 2008

A case of primary fibrosarcoma of the heart, which was diagnosed in a 17 year old man, is presented. Extensive tumour resection and postoperative radiation therapy was carried out. The patient is alive after 18 months after the operation. Although these tumours are associated with very poor survival. early diagnosis and combined therapy may prolong life expectancy.
A COMPARATIVE STUDY OF TWO TYPES OF LATEX SURGICAL GLOVES IN ELECTIVE ORTHOPAEDIC SURGERY
Authors: Liew S. M. , Stoney J. D. , Falkenberg M. P. , Leitl S. M.
Published: January 2008

Glove perforation during surgery represents a potential risk of infection for the surgeon. The authors postulated that thicker latex gloves may offer greater protection. The perforation rates for the Ansell Gammex™ glove and the thicker Baxter Triflex™ gloves were compared in single‐ and double‐glove usage and no difference was found between the two brands, in either usage. The authors recommend double‐gloving for all orthopaedic operations with regular glove changes during major procedures.
MORBIDITY AND MORTALITY AFTER ABDOMINAL AORTIC SURGERY IN A POPULATION OF PATIENTS WITH HIGH CARDIOVASCULAR RISK
Authors: Henderson A. , Effeney D.
Published: January 2008

Postoperative myocardial infarction is a major risk factor in patients undergoing abdominal aortic surgery. Correction of cardiac ischaemia prior to abdominal aortic surgery improves outcome. The morbidity and mortality of 639 consecutive patients were reviewed from an area with poor access to cardiac surgery, operated upon in a single tertiary referral hospital for aortic aneurysm or aortobifemoral grafting. A total of 101 patients with ruptured aortic aneurysm who survived to reach the intensive care unit experienced a hospital mortality of 29%. Multiorgan failure was the cause of death in 48% and postoperative myocardial infarction in 31%. Of the 253 patients with intact aortic aneurysm, which included elective and urgent resection, the mortality was 9%. There was a high incidence of uncorrected pre‐operative ischaemic heart disease and myocardial infarction was the major cause of death (62%). Pre‐operative myocardial infarction was predictive of postoperative cardiac morbidity and mortality. Of the 285 patients undergoing aortobifemoral grafting the mortality was 3% despite a high incidence of pre‐operative ischaemic heart disease. Further reductions in postoperative death from ruptured aortic aneurysm must await improved screening to diagnose and treat the aneurysm before rupture. In patients operated upon electively, improved pre‐operative cardiac screening and coronary bypass grafting where appropriate, especially for patients with aortic aneurysm and previous myocardial infarction, may further reduce pen‐operative mortality.
CAROTID SURGERY IN NORTHERN TASMANIA: A RETROSPECTIVE REVIEW
Authors: Subramaniam P. , Stary D. , Scott A.
Published: January 2008

A retrospective survey of 138 carotid endarterectomies performed in Northern Tasmania over a 6 year period was conducted to identify risk factors for postoperative neurological complications. A total of 80% of patients were operated on for transient ischaemic attacks (TIA) referable to stenosis of the ipsilateral internal carotid artery (ICA). A total of 77% of patients who were operated on had angiographic evidence of severe (over 80%) stenosis of the affected ICA. A combined postoperative permanent neurological deticit and mortality rate of 5.8% was achieved. Severe stenosis of the contralateral internal carotid artery and pre‐operative symptomatic instability were associated with the development of postoperative neurological complications.
THE COSTS OF TREATING BREAST CANCER IN AUSTRALIA AND THE IMPLICATIONS FOR BREAST CANCER SCREENING
Authors: Butler J. R. G. , Furnival C. M. , Hart R. F. G.
Published: January 2008

The aim of the study was to determine if there is a relationship between the stage of breast cancer at the time of detection and the costs of treatment and to assess whether any such relationship would have an influence on the cost of a mammographic screening programme.

A retrospective analysis of the stage at presentation for primary breast cancer and the treatment costs over the duration of treatment was made. Multiple regression analysis was employed, with treatment cost as the dependent variable and categorical variables to represent stage at detection. A total of 301 women whose treatment for breast cancer commenced at the Royal Brisbane Hospital participated in the study.

A statistically signficiant relationship was found between the stage of disease at the time of detection and subsequent treatment costs; more advanced stages of disease incurred higher treatment costs. This relationship was robust even after taking into account the age of patients, their discharge status, and differences between patients in the duration of treatment. When the effect of earlier detection on treatment cost was assessed in relation to a breast screening programme, cost savings were estimated to be in the range of 8–36% of total screening costs.

There are treatment cost savings to be gained from breast cancer screening as a result of the detection of earlier stages of disease. These treatment cost savings should be offset against the cost of a mammographic screening programme.
ENDOSCOPIC KNOT TYING MADE EASIER
Authors: Murphy Donald L.
Published: January 2008

A new laparoscopic instrument has been developed to facilitate intracorporeal suturing and knot tying. The instrument combines both needle‐holding jaws and a loop‐forming member. The handle is ergonomically designed and contains a locking mechanism. This simple technique of knot tying extends the role of instrument rotation and contrasts out all other known methods of knot tying.
FISTULA‐IN‐ANO: AN UNUSUAL PRESENTATION OF CHRONIC SCHISTOSOMIASIS
Authors: Georghiou Paul R. , Tilse Martyn H. , McCormack Joseph G. , Neely Mervyn G.
Published: January 2008

A 30 year old Ethiopian man presented with recurrent perianal abscess and fistula‐in‐ano. Ova of Schistosoma mansoni were found on faecal microscopy. and were suhsequcntly ientified in fibrous tissue excised from the fistula tract Chronic schislosoinincis should be recognized as a rare cause of fistula‐in‐ano. Treatment of schistosoniiasis with praziquantel may prevent further complications of this condition.
OBSTRUCTED DEFECATION: CURRENT STATUS OF PATHOPHYSIOLOGY AND MANAGEMENT
Authors: Lubowski D. Z. , King D. W.
Published: January 2008

Obstructed defecation poses a challenging clinical problem and in many patients presenting with this syndrome the underlying pathophysiology cannot be determined. Up to now, attempts to diagnose and treat obstructed defecation (anismus) have focused on the function of the somatic pelvic floor musculature surrounding the anorectum, and concepts such as ‘puborectalis paradox’ and ‘spastic pelvic floor’ have gained widespread acceptance despite there being no objective data to support such concepts. New evidence showing that defecation is an integrated process of colonic and rectal emptying suggests that anismus may be much more complex than a simple disorder of the pelvic floor muscles. In a small number of patients obstructed defecation is caused by a more simple mechanism, such as internal sphincter hypertonia or a large rectocele, which is easily corrected surgically. Careful selection of patients for treatment, based on identifying the underlying pathophysiological disorder, is emphasized.
SOLITARY RECTAL ULCER SYNDROME: THE CLINICAL ENTITY AND ANORECTAL PHYSIOLOGICAL FINDINGS IN SINGAPORE
Authors: Ho Y. H. , Ho J. M. S. , Parry B. R. , Goh H. S.
Published: January 2008

The clinical pattern and physiological abnormalities in solitary rectal ulcer syndrome (SRUS) occurring in Singapore, were investigated. Since April 1989. 25 patients have presented with histologically proven SRUS. There were 13 males and 12 females (20 Chinese, 4 Malay and 1 Indian) with a mean age of 47.5 (± 3.1) years. Ninety‐six per cent presented with rectal bleeding, 92% strained at stools, 40% had mucus discharge, 40% felt incomplete defecation and 32% digitated to defecate. Four had previous haemorrhoidectomies that did not cure their symptoms. The lesions were at a mean 6.8 (± 0.5) cm above the anal verge, usually anteriorly (64%) but one was circumferential. Anorectal physiology performed on 14 patients was compared with 13 age and gender matched normal controls. The measured mean resting perineum level in SRUS (1.4 ± 0.3 cm) was significantly lower than in normals (P < 0.01). The mean anal electrosensory threshold (2.5 ± 0.52 mV) was also significantly higher than in the controls (P < 0.05). Fifteen patients were successfully treated with a high fibre diet and avoidance of straining. Three patients required surgery and the most recent seven patients have responded well to biofeedback treatment. Awareness of this uncommon anorectal condition is necessary for early diagnosis and appropriate management. The physiological findings support a pelvic straining pathophysiology resulting in perineal descent, with less sensitive rectal mucosa prolapsing into, and raising, the anal canal electrosensory threshold. Treatment strategies aimed at correcting the straining have usually been successful.
FISSURE IN ANO
Authors: Isbister W. H. , Prasad J.
Published: January 2008

The present study documents a 15 year experience with anal dilatation in patients with fissure in ano. Patients who were unable to tolerate rectal examination were admitted urgently for anal dilatation. Patients in whom rectal examination and proctoscopy was possible were offered an anal dilator and were reviewed after 4 weeks. Patients who preferred not to use an anal dilator or who had not become asymptomatic were admitted for elective anal dilatation. Four finger anal dilatation was performed under general anaesthesia. Between 1975 and 1990 104 patients underwent 111 procedures. The male to female ratio was 1.3:1. Five patients were re‐operated because of failure of resolution of symptoms. Three patients with anal fissures and Crohn's disease were successfully managed by anal dilatation. Nine patients had excision of a ‘sentinel pile’ in addition to anal dilatation. Ten patients were admitted acutely. One patient developed a perineal haematoma. Seventy‐four procedures were performed as day cases. There was no mortality associated with the procedure. At the time of discharge from the clinic no patient complained of problems with continence. These results support our policy of gentle anal dilatation as first management choice in the treatment of anal fissure.
CHEST WALL ACTINOMYCOSIS IN ASSOCIATION WITH THE USE OF AN INTRA‐UTERINE DEVICE
Authors: McBride William J. H. , Hill David R. , Gordon David L.
Published: January 2008

A 31 year old woman presented with a chest wall abscess due to Actinomyces israellii and Porphyromonas asaccharolytica (previously Bacteroides asacchurolyticus). She was a long‐term user of an intra‐uterine device (IUD) and, although asymptomatic, had radiological evidence of pelvic infection. Actinomyces‐like organisms were seen on cervico‐vaginal smears. The abscess was surgically drained, the IUD removed, and a prolonged course of amoxycillin/clavulanic acid given.
ANAL PATHOLOGY IN PATIENTS WITH CROHN'S DISEASE
Authors: Platell Cameron , Mackay John , Collopy Brian , Fink Roy , Ryan Peter , Woods Rodney
Published: January 2008

Background: A distinctive feature of patients suffering from Crohn's disease is a predisposition to develop a variety of anal complications. The aetiology of such conditions is unclear, and the reported incidence of anal involvement in Crohn's disease varies party due to the various criteria used for classification. This study aims to review the management of patients with symptomatic anal pathology associated with Crohn's disease at St Vincent's Hospital, Melbourne.

Methods: A database of 306 patients with Crohn's disease referred to the department between January 1978 and October 1994 was reviewed to identify those patients with symptomatic anal disease. The anal pathology was recorded and classified. Demographic data and the clinical and surgical history of the patient were recorded.

Results: Of the 306 patients with Crohn's disease, 129 (42.4%) were identified as having symptomatic anal pathology. Patients were likely to present with anal symptoms after they had been diagnosed as having intestinal Crohn's disease (46.1%). The commonest presentations were perianal abscess (29.5%), anal fissure (27.6%), and low anal fistula (26.7%). A minority of patients presented with highkomplex anal fistulae (3.8%), or recto‐vaginal fistulae (5.2%). Five per cent of patients had Crohn's disease localized to the anal area. The pattern of intestinal disease in the remaining patients was small bowel 21.1%. small bowel and colon 31.9%, and colon 43.0%. A total of 244 local anal surgical procedures were performed on these patients; the commonest of these were drainage of an abscess (38.5%), examination under anaesthetic (29.1%). and laying open of a low anal fistula (22.5%). Following surgical treatment, the recurrence rate for perianal abscesses was 13%, and for low anal fistulae 6%.

Conclusions: The majority of patients with Crohn's disease who develop anal pathology have an excellent prognosis. A minority of patients develop complex anal fistulae and these remain a therapeutic challenge.
THE RISK OF AN UNPLANNED RETURN TO THE OPERATING ROOM IN AUSTRALIAN HOSPITALS
Authors: Ansari Mohammad Z. , Collopy Brian T.
Published: January 2008

Background: The unplanned return of the patient to the operating room (OR) after a previous procedure has implications concerning the quality of surgery, but little has been written on this subject.

Methods: The relationship of bed‐size and hospital type (private or public) was studied using data on this clinical indicator submitted to the Australian Council on Healthcare Standards Care Evaluation Program (ACHS CEP) by hospitals presenting voluntarily for accreditation in 1993.

Results: The mean rate of an unplanned return to OR was 0.6% (95% confidence interval 0.5–0.7). After adjusting for potential confounders in a logistic model, the risk of unplanned return to OR did not significantly differ by type of hospital (private, public), and location (rural, metropolitan). The risk of an unplanned return to OR was higher in large compared with small hospitals.

Conclusions: The finding of the risk of the event being greater in large compared with small hospitals is likely to be a reflection of casemix. An internal review of results (for any facility) is obviously necessary. With some operations a higher incidence of return to the OR may indicate vigilance in peri‐operative management.
OPERATIVE CHOLANGIOGRAPHY IN THE LAPAROSCOPIC ERA: A RETROSPECTIVE REVIEW OF THE QUALITY AND INTERPRETATION OF THIS INVESTIGATION
Authors: Draganic Brian , Perry Richard , Gani Jon
Published: January 2008

Background: Operative cholangiograms during the year of introduction of laparoscopic cholecystectomy were reviewed to examine their quality and interpretation.

Methods: 149 operative cholangiogram films (34 open and 115 laparoscopic) were reviewed retrospectively by a panel and scored for their ability to demonstrate biliary anatomy and detect bile duct stones.

Results: Cholangiography performed by the cystic duct was of similar quality, whether performed laparoscopically or open. Cholangiography via the cystic duct (conventional films) produces superior results for both anatomical delineation and detection of choledocholithiasis (80% adequate) than cholangiography performed by direct gallbladder puncture (29–35% adequate).

Conclusion: There is no clear evidence to suggest that an intra‐operative specialist radiological review of cholangiograms performed by the cystic duct would improve the detection of bile duct stones.
NODULAR FASCIITIS AND RELATED PSEUDOSARCOMATOUS LESIONS OF SOFT TISSUES
Authors: Samaratunga H. , Searle J. , O'Loughlin B.
Published: January 2008

Background: Nodular fasciitis is characterized by a proliferation of spindle cells which may be misdiagnosed as sarcomas due to the rich cellularity, mitotic activity and variant morphologic patterns.

Methods: This report includes 42 cases of nodular fasciitis and related conditions of skin and soft tissue from the pathology files of the Royal Brisbane Hospital, Queensland, Australia. There were 33 cases of nodular fasciitis, three cases of ossifying fasciitis, three cases of proliferative fasciitis, two cases of proliferative myositis and one case of intravascular fasciitis. Two‐thirds of cases were referred from outside Royal Brisbane Hospital.

Results: Nodular fasciitis and ossifying fasciitis occurred most commonly in young adults with 16 patients (44%) between the ages of 20 and 29. However, the other variants of nodular fasciitis including proliferative fasciitis, proliferative myositis and intravascular fasciitis occurred in older people (six patients being older than 49 years) and more commonly occurring in men (n= 5). A painless, rapidly growing mass was most common. The lesions of nodular fasciitis were most often located in the upper extremity with the forearm most commonly affected.

Conclusions: Nodular fasciitis and related conditions are benign. All patients are alive and well 3 months to 13 years (mean 7.2 years) after simple local resection.
IS THE MID‐INGUINAL POINT AN ACCURATE LANDMARK FOR THE COMMON FEMORAL ARTERY IN VASCULAR PATIENTS?
Authors: Hunt Jeremy A. , Harris John P.
Published: January 2008

Background: An accurate guide to the common femoral artery (CFA) is important in vascular patients as the CFA pulse may not be palpable. At least four different descriptions of the surface anatomy of the CFA are given in standard anatomic texts. This study was undertaken to determine the accuracy of the mid‐inguinal point as a guide to the CFA in patients undergoing femoral arteriography.

Methods: The surface anatomy of the CFA was determined using true anteroposterior arteriograms of 30 patients [20 men, 10 women, age (mean ± s. d.) 67 ± 6.8 years, range 56–82].

Results: The distance between the anterior superior iliac spine (ASIS) and the symphysis pubis was measured with callipers and defined as the inguinal distance [(mean ± s. d.) 16.03 ± 1.06 cm, range 14.00–18.50]. The midpoint of this line defined the mid‐inguinal point. Similarly, the distance was measured from the symphysis pubis to the midpoint of the CFA where it crossed the inguinal line on the arteriogram, and was defined as the femoral distance [(mean ± s.d.) 7.99 ± 0.51 cm, range 6.80–9.00]. The location of the CFA coincided with the mid‐inguinal point in only six (10%) of the 60 measurements. The difference between the CFA and mid‐inguinal point varied from 1.25 to 1.50 cm either side of the mid‐inguinal point, and in six (10%), the difference was 1 cm or more, and therefore of clinical significance.

Conclusions: On the basis of these findings we conclude that the relationship between the mid‐inguinal point and the CFA is not exact in vascular patients undergoing arteriography. The mid‐inguinal point, found using bony landmarks, is an appropriate guide to the CFA as it can be expected to lie within 1.5 cm either side of the mid‐inguinal point. The natural variability observed could account for the different anatomical descriptions of the surface anatomy of the CFA. No exact definition may be possible.
INTERNET AND SURGERY
Authors: Leow C. K.
Published: January 2008

In medicine, the Internet is already playing a significant role in the delivery of information on medical conditions, medical and academic institutions and non‐profit‐making support groups for patients. This article explores some of the available information on the Internet relevant to surgery and discusses its role in surgical training.
RE‐OPERATION FOR FAILED ANTI‐REFLUX SURGERY
Authors: Lim J. K. , Moisidis E. , Munro W. S. , Falk G. L.
Published: January 2008

Background: Between 1993 and 1995, 315 anti‐reflux procedures were undertaken on our service. A previous antireflux procedure had been performed in 31 patients referred (10%). Previous surgery was, in the main (80%), a Nissen fundoplication.

Methods: Re‐operative investigations in all patients were manometry, 24 h pH monitoring, oesophagoscopy and barium radiology. On this basis the causes of failure of the previous surgery were established as hiatal failure in 20 (65%), unrecognized oesophageal dysmotility in three (10%) and fundoplication failure (slipped and disrupted) in eight (25%). Contrary to standard recommendations for re‐operation most re‐operative surgery was performed transabdominally (94%). Complications occurred in 16%.

Results: Review was undertaken at a mean of 21 months following surgery, and 91% of patients reported a good to excellent symptomatic outcome.

Conclusions: Transabdominal re‐operative anti‐reflux surgery has an acceptable complication rate and a surprisingly good symptomatic outcome in the medium term.
POSITIVE PROXIMAL RESECTION MARGINS AFTER RESECTION FOR CARCINOMA OF THE OESOPHAGUS AND STOMACH: EFFECT ON SURVIVAL AND SYMPTOM RECURRENCE
Authors: Gall C. A. , Rieger N. A. , Wattchow D. A.
Published: January 2008

Background: Our aim was to determine the frequency, survival and symptomatic local recurrence rate of patients with a positive proximal resection margin in a series of patients having a resection for carcinoma of the oesophagus or stomach.

Methods: A retrospective study of pathology reports and case notes. Survival and data on local recurrence were obtained from the patient or general practitioner.

Results: Ten (11.5%) of 87 patients having a gastric or oesophageal resection for carcinoma had a positive proximal resection margin. All 10 patients underwent a palliative resection for late‐stage disease. Nine were dead at an average 8.3 months (range 2–20 months) post‐resection and one patient remains alive at 9 months. Only one of these 10 patients had evidence of a local recurrence with recurrent dysphagia prior to death at 11 months.

Conclusion: A high incidence of a positive proximal resection margin was found. This occurred in patients who underwent a palliative resection for late‐stage disease, most of whom died before local recurrence became a problem. For patients recognized as having late‐stage disease, surgery for symptom palliation need not be aggressive (such as to include a thoracotomy) because achieving microscopic clearance is unlikely to affect the long‐term outcome.
AUSTRALIAN MULTICENTRE EVALUATION OF A NEW POLYURETHANE VASCULAR ACCESS GRAFT
Authors: Allen R. D. M. , Yuill E. , Nankivell B. J. , Francis D. M. A.
Published: January 2008

Background: A new three‐layered cast polyurethane vascular access graft (Thoratec® VAG) is the most recent addition to the list of materials used in the search for the perfect prosthetic graft material for haemodialysis vascular access. Despite its use in 23 countries, a clinical assessment has not been published.

Methods: An independent retrospective evaluation by questionnaire was obtained for 145 implantation procedures performed by 30 surgeons.

Results: Ninety‐two per cent of procedures were performed for an acute need for vascular access and 73% had prior failed vascular access surgery. Patients were hospitalized for a median of 4 days and the graft was initially used at a median of 3 days. Median follow‐up was 306 days. Thoratec® VAG had a problem‐free (primary) patency of 44.9% and a functional (secondary) patency 64.5% at 1 year. Major causes of graft loss were thrombosis (17%) and infection (11%). Intra‐operative thrombosis was the only significant risk factor for subsequent thrombosis (P =0.013). Infection was less in patients with antibiotic prophylaxis that included vancomycin (P =0.02).

Conclusion: The ability to use the graft soon after surgery is a major advance for patients who urgently need reliable medium to long‐term haemodialysis access.
BACTERIOLOGY OF NECROTIZING INFECTIONS OF SOFT TISSUES
Authors: Singh Gurpreet , Ray Pallab , Sinha Sunil K. , Adhikary Shailesh , Khanna Satish K.
Published: January 2008

Background: Necrotizing infections of soft tissues (NIST) are being attributed to a large variety of organisms, besides the originally described β‐haemolytic Streptococcus. A detailed bacteriological study of these infections was thought worthwhile.

Methods: A prospective study of 55 patients with NIST was carried out. Analysis of surface swabs and debrided tissue for aerobic and anaerobic bacteria and fungal infection was performed. A detailed bacteriological profile was obtained in 50 patients.

Results: A total of 257 isolates (167 aerobic, 90 anaerobic) was obtained. One to nine strains of bacteria were isolated from each patient. Aerobic bacteria alone were isolated in 26 patients while the remaining patients grew both aerobic and anaerobic bacteria. Forty‐two patients had at least one Gram‐positive bacterium while 40 had at least one Gram‐negative bacterium. Staphylococcus aureus was the organism isolated most frequently (52%). followed by Bacteroides fragilis (40%) and anaerobic cocci (38%). Group A β‐haemolytic streptococci were isolated in 16%. Blood cultures were positive in only eight patients. Fungal cultures were positive in six patients. Aspergillus fumigatus was the commonest pathogen.

Conclusions: Necrotizing infections of soft tissues are polymicrobial and no single bacterium is associated with a specific clinical entity. Importance should be placed on early recognition and treatment of the disease rather than on isolation of bacteria.
MODIFICATIONS TO THE HASSON TECHNIQUE
Authors: Poole G. H. , Frizelle F. A.
Published: January 2008

Blind peritoneal penetration with a Veress needle is an unnecessary risk. This risk is reduced by the use of the ‘Hasson technique’. We suggest two modifications to the Hasson technique which make it easier to undertake, and reduce the problem of peri‐port air leak.