bluuebunny/crossref_metadata_2025 huggingface dataset:
MORBIDITY AND MORTALITY AFTER SINGLE‐ AND DOUBLE‐STAPLED COLORECTAL ANASTOMOSES IN PATIENTS WITH CARCINOMA OF THE RECTUM
Authors: Moore J. W. E. , Chapuis P. H. , Bokey E. L.
Published: January 2008

Background: The optimal method of restoring intestinal continuity after rectal resection has been controversial. This study aims to compare the morbidity, mortality and survival of patients having either single‐stapled (SS) or double‐stapled (DS) colorectal anastomoses following resection of the rectum for cancer.

Methods: Peri‐operative and long‐term follow‐up data were prospectively documented in all patients undergoing rectal resection for carcinoma with a stapled anastomosis at our institution over a 14‐year period. Patients were stratified by anastomotic technique (SS or DS). Peri‐operative mortality, complications potentially related to anastomotic technique and cancer‐related outcome were compared.

Results: Two hundred and thirty‐five patients had SS and 65 patients had DS anastomoses. The groups were well matched for age, sex, and tumour stage. Double‐stapled anastomoses were used more frequently in the distal third of the rectum (P < 0.001). The distal margin of resection was not influenced by anastomotic technique. Major anastomotic leakage in 2.9% of SS cases was not significantly different from 6.1% of DS cases, and leakage was not influenced by anastomotic technique at any given level of the rectum. Two‐year local recurrence rates were not significantly different between groups (SS 3.5%: DS 5.9%).

Conclusions: These results suggest that the double‐stapling technique is as safe as the single‐stapling technique for constructing an anastomosis after excision of the rectum for cancer, in terms of the risk of leakage, the development of an anastomotic stricture. or local recurrence.
VESICO‐URETERIC REFLUX AND SURGICALLY TREATED PELVI‐URETERIC JUNCTION OBSTRUCTION IN INFANTS UNDER THE AGE OF 12 MONTHS
Authors: Woo Henry H. , Farnsworth Robert H.
Published: January 2008

Background: Pelvi‐ureteric junction obstruction has been increasingly diagnosed in infants, mostly as a consequence of antenatal ultrasound examinations.

Methods: Of 55 infants below the age of 12 months who underwent dismembered pyeloplasty over a 7‐year period, we aimed to determine the patterns and outcome of associated vesico‐ureteric reflux that was present in 15 (28%) of the 53 infants in whom follow‐up was available.

Results: A total of eight infants had resolution of their reflux with conservative management and the median time to resolution was 15 months. Five infants proceeded to ureteroneocystotomy.

Conclusions: Given the association of vesico‐ureteric reflux and pelvi‐ureteric junction obstruction, routine cystography is recommended when the diagnosis of pelvi‐ureteric junction obstruction is made.
JOHN WILKINS, SURGEON, 1826–1905: EXPERIENCES IN WILLIAMSTOWN (MELBOURNE) AND NEW ZEALAND
Authors: Lowe Ronald F.
Published: January 2008

John Wilkins was a prominent colonial surgeon for 15 years in Williamstown, Victoria. During the early gold rushes he prospered from investments in property. In Melbourne he aimed to become a recognized authority in diseases of the eye and throat, but he did not achieve his aims, and caused bitterness in the medical community by advertising. After 10 years he moved to Dunedin where he produced the first publication on anaesthesia in New Zealand. He moved to Christchurch, but found contentment in Auckland where he practised general medicine with special consultations in general surgery and diseases of the eye, ear, nose and throat, and where he lived for the remainder of his life.
FIRST AID IN THE AIR
Authors: Donaldson Eric , Pearnt John
Published: January 2008

Background: First aid is commonly required during commercial aircraft flights, especially during international flights. An intimidating and sometimes threatening array of in‐flight medical emergencies challenge the doctor, flight attendants and other passengers in such medical emergencies. Cramped conditions, difficulties of access to the victim, lack of privacy, cultural and language differences and noise and vibration all compound to increase the difficulties of the normal first aid drills which are required in the management of in‐cabin emergencies. Doctors who fly as passengers are liable to be called upon to render first aid in the air. We provide an analysis of the types of medical emergencies encountered during commercial air travel.

Methods: We have reviewed all consecutive in‐flight medical incident reports for QANTAS international flights for 1993. All incidents requiring the attention of a doctor were included.

Results: A total of 454 significant medical incidents occurred. These included, in rank order, syncope (35%), angina and cardiac emergencies (23%), gastrointestinal conditions (13%), respiratory tract infections and asthma (9%) and anxiety and panic reactions warranting medical intervention (5%).

Conclusions: Syncope, the management of gastrointestinal symptoms and problems of angina comprise over half (58%) of the presenting symptoms which confront a fellow traveller who may coincidentally be a medical practitioner. Problems of anxiety, sleeplessness, airport bustle, immobility, barotrauma, alcohol abuse and mild hypoxia are discussed in the context of precipitating factors which may trigger an in‐flight emergency. Psychological problems are very common and challenge the first aider, whether or not he or she is medically trained. We emphasize the necessity for doctors and nurses to be trained in first aid, as a distinct profession in its own right and a series of drills and skills which are distinctive from those of surgery‐based health care. The 5% annual increase in air‐passenger traffic, predicted for the next two decades, highlights the importance of special training for ‘first aid in the air’.
PAEDIATRIC RENAL TRAUMA: CAUTION WITH CONSERVATIVE MANAGEMENT OF MAJOR INJURIES
Authors: Thompson‐Fawcett Mark , Kolbe Anne
Published: January 2008

Background: The kidney is the most frequently injured abdominal organ in children and controversy surrounds some aspects of management. This study looks at the experience of our institution and reviews the literature towards developing an optimal strategy for managing this common childhood injury.

Methods: One hundred and forty‐two cases of paediatric renal trauma are reported from a catchment population of approximately 240 000 children < 14 years of age over a 12 year period. Injuries were classified into four groups: groups 1 and 2 were regarded as minor injuries (85%) and group 3 and 4 injuries were those with extravasation of urine or pedicle injury (15%). Results: The male:female ratio was 2:I with an average age of 8.5 years. Major renal injuries frequently required large amounts of resuscitation fluid. Associated injuries were present in 41% of all cases with an average of two injuries each. With one exception in each case, the development of complications and the need for early surgery were confined to major injuries. There were no long‐term complications. The renal loss rate was 2.1%.

Conclusions: Renal injuries can be usefully classified into major or minor by determining whether extravasation of urine or pedicle injury is present. Minor injuries should be managed conservatively. Major injuries causing ongoing haemorrhage require urgent surgery. Other major injuries should be imaged regularly and patients with more severe urinomas benefit from early elective surgery at 2–5 days. In cases where extravasation of urine has not shown clear evidence of settling by 5 days' elective surgery probably results in less morbidity and fewer complications than protracted conservative treatment.
BONE REPLACEMENT IN HEAD AND NECK SURGERY: A BIOCOMPATIBLE ALTERNATIVE
Authors: Cole Ian , Dan Noel , Anker Anthony
Published: January 2008

Background: Defects in the skull have presented difficult reconstructive problems. Recently glass‐ionomer cement and preformed implants have been used to repair bony defects in the skull base and in cranio‐facial surgery. Three patients are reported to illustrate possible applications for this new material.

Methods: Ionocap cement and Ionoroc‐skull standardized implants have been used. The cement is available as a two component blister pack. When mixed and blended a gel is produced which can be worked for approximately 5 min before hardening. It can then be contoured and drilled to the required shape. The resultant material is biocompatible and biostable, is non‐toxic and permanently bonds to bone with no increase in temperature or shrinkage.

Results: The material has been used to fill the temporal defect left by transplantation of the temporalis muscle for oral reconstruction, the anterior and lateral walls of the maxilla and following craniofacial resection, the posterior wall of the frontal sinus and anterior skull base.

Conclusions: Three patients with different reconstructive problems have been presented to illustrate the use of an alloplastic material that has a tensile strength similar to bone* and firmly adheres to it. The material was found to be safe and easy to use. All three patients have now been followed for 12 months with no adverse affects.
VIDEO ASSISTED THORACOSCOPIC STAPLE RESECTION OF A GIANT BULLA
Authors: Yim Anthony P. C. , Ho Jonathan K.
Published: January 2008

Video assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax has been well described. However, there are few reports on the use of this technique on giant bullae. We report a 49 year old man with a symptomatic giant bulla who underwent a successful thoracoscopic staple resection. His chest drains were removed on the second postoperative day and he was discharged on the third postoperative day with virtually no discomfort. We conclude that thoracoscopic staple resection of a giant bulla is feasible technically and is an attractive alternative to the conventional open technique.
ACUTE AORTIC DISSECTION AS A COMPLICATION OF CORONARY ARTERY SURGERY
Authors: Subramaniam Peter , Skillington Peter
Published: January 2008

Acute dissection of the ascending aorta is a rare, potentially fatal complication of cardiac surgery. During surgery patients with long‐standing hypertension and atheromatous arterial disease require careful handling and cannulation of the aorta and aggressive intra‐operative and postoperative management of aortic pressure. We present the successful treatment of a patient with acute aortic dissection following elective coronary artery surgery.
PRECLINICAL TRIAL OF A BlOARTlFlClAL LIVER SUPPORT SYSTEM IN A PORCINE FULMINANT HEPATIC FAILURE MODEL
Authors: Sheil A. G. R. , Sun J. , Mears D. C. , Warin M. , Woodman K. , Johnston B. , Horvat M. , Watson K. J. , Koutalistras N. , Wang L‐S.
Published: January 2008

Background: This study describes the pre‐clinical trials of an extracorporeal bioartificial liver support system (BALSS). It includes the biochemical changes which occur in the plasma and blood of pigs with devascularized livers when the plasma is treated in a BALSS, and the testing of the system for presence or absence of infective agents, pyrogens and for toxicity.

Methods: Hepatic cells were prepared from littermate juvenile white landrace pigs with a double‐step collagenase digest technique. The cell preparations were incubated with collagen‐coated dextran microspheres (CDM) for 3 h and the medium was tested to determine cellular metabolic activity. Incubation continued for a further 20 h during which the hepatic cells attach to the CDM. The CDM‐attached cells were inoculated into a hollow fibre bioreactor which was part of an extracorporeal liver support system.

Results: Hepatic cell content of the bioreactor was 6 × 109± 3 × 1018 cells, equivalent to those present in half a pig's liver. The system was tested in a controlled trial with the plasma of pigs with fulminant hepatic failure (FHF) due to devascularized livers. When plasma from FHF pigs was circulated through the device there was significantly less of an increase in the accumulation of ammonia, lactate and most amino acids when hepatic cells were included in the circuit compared with those in control experiments when they were excluded. Similar changes occurred in porcine blood. There were few infections diagnosed and an absence of pyrogens, endotoxins and toxicity in the bioreactor contents or in the terminating reservoir or animal blood samples.

Conclusions: We believe that the results, demonstrating function of the porcine hepatic cells in the circuit, together with low risks, justify a clinical trial of use of the BALSS in Australia.
AVULSION OF THE ISCHIAL APOPHYSIS
Authors: Gill David R. J. , Clark W. B.
Published: January 2008

Avulsion of the ischial apophysis is a rare injury. We report the successful treatment of an avulsion of the ischial apophysis by open reduction and internal fixation.
STEREOTACTIC 14 GAUGE CORE‐BIOPSY OF THE BREAST: RESULTS FROM 101 PATIENTS
Authors: Frayne J. , Sterrett G. F. , Harvey J. , Goodwin P. , Townsend J. , Ingram D. , Parsons R. W.
Published: January 2008

Background: Along with fine needle aspiration (FNA) cytology, core‐biopsy has become an integral part of the assessment of mammographically detected breast lesions.

Methods: A series of stereotactic large‐core‐biopsies of mammographically detected breast lesions was studied to assess the accuracy and limitations of the technique in diagnosing malignancy and in giving specific benign diagnoses, and its use in determining surgical management.

Results: Eighty per cent of carcinomas were diagnosed as malignant (absolute sensitivity). In 88.8% of the cancers, the core‐biopsy was classified as malignant, suspicious or atypical/indeterminate (complete sensitivity), and in 72% of the invasive carcinomas, invasive tumour was present in the core. The technique was more successful for invasive carcinomas than for ductal carcinoma in situ (DCIS) (absolute sensitivity 86.1 and 55.5, respectively; P= 0.28) and for malignant mass lesions than for a mass with associated microcalcifications or for pure microcalcifications (absolute sensitivity 91, 71 and 66.6%, respectively; P= 0.19). In five of the 45 cancers (11.1%), no tumour tissue was present in the core, but all were excised after mammographic review and no delays in diagnosis have been experienced to date. The benign to malignant ratio for excised lesions was 0.11:1. Of the benign lesions, a specific diagnosis was given in 49% (calcifications in the core in a background of fibrocystic change, or postoperative scarring, or fibro‐adenoma); the remainder showed non‐specific benign findings. All patients where invasive carcinoma was diagnosed in the core underwent axillary clearance and wide local excision or mastectomy at their first operation.

Conclusions: This technique can markedly reduce the number of benign lesions needing open biopsy, and provide information allowing definitive management of most carcinomas at the first operation. The accuracy of core‐biopsy was lower in DCIS/ microcalcification lesions; extra core samples or a combination of FNA and core‐biopsy may be of value in these cases.
THE MANAGEMENT OF LEFT‐SIDED LARGE BOWEL OBSTRUCTION: AN AUDIT
Authors: Isbister W. H. , Prasad J.
Published: January 2008

Background: The outcomes of patients admitted acutely to hospital with left‐sided large bowel obstruction (LBO) were examined.

Methods: All patients admitted to the colorectal service (University Department of Surgery, Wellington School of Medicine) with LBO between 1975 and 1990 were reviewed. Sixty‐four patients with left‐sided LBO were identified.

Results: The most commonly found obstructing lesion was cancer. Two patients were not managed surgically. In 17.7% of patients there was development of postoperative respiratory complications and 16% developed wound problems following primary surgery. Fifty‐nine patients survived their primary surgery and 45 had stomas. The stoma closure rate was 71.1% (32 of 45). The overall mortality rate for patients managed surgically was 6.5% (four of 62). The mortality rate for stoma formation was 4.3% (two of 47). The mortality rate for resection and then stoma closure was 3.2% (one of 32).

Conclusions: This study has shown that a staged approach to the management of unselected patients with left‐sided LBO is safe. Restoration of bowel continuity was achieved in 70% of patients.
LYMPHOVASCULAR CLEARANCE IN LAPAROSCOPICALLY ASSISTED RIGHT HEMICOLECTOMY IS SIMILAR TO OPEN SURGERY
Authors: Moore J. W. E. , Bokey E. L. , Newland R. C. , Chapuis P. H.
Published: January 2008

Background: The application of laparoscopic techniques to malignant colorectal disease has led to concerns regarding the adequacy of excision achieved. This study was performed to compare specimen histopathology following laparoscopically assisted right hemicolectomy (LARHC) with that following open right hemicolectomy (ORHC).

Methods: Data regarding patient details and tumour pathology were obtained by case‐note review and from the Concord Hospital Colorectal Cancer Database. Thirty‐two patients had LARHC for neoplastic lesions and 34 had ORHC for similar lesions over the same period. The two groups were well matched with respect to age, sex, weight and tumour characteristics. Early stage disease was more common in the LARHC group.

Results: There was no clinically significant difference between the groups in terms of margins of clearance or number of lymph nodes harvested.

Conclusions: LARHC allows lymphovascular clearance indistinguishable from that afforded by open surgery. Long‐term outcome and survival data are required to confirm its role in the treatment of malignant colorectal disease.
INTERNAL PANCREATIC FISTULAE WITH SEROUS EFFUSIONS IN CHRONIC PANCREATITIS
Authors: Dhar Puneet , Tomey Sudhir , Jain Pradeep , Azfar Mohammed , Sachdev Ajay , Chaudhary Adarsh
Published: January 2008

Background: Serous effusions in chronic pancreatitis are infrequent but persistent. These occur usually as a consequence of internal pancreatic fistulae and commonly involve the pleural cavity or peritoneum.

Methods: To assess strategies in operative management, the records of 12 patients who underwent surgery for internal pancreatic fistula with underlying chronic pancreatitis were reviewed retrospectively. Seven patients had pancreatic ductal calculi. Three cases underwent external drainage. Three cases with leaking pseudocysts underwent cystojejunostomy‐en‐Y. Three cases with ductal dilatation or calculi underwent lateral pancreaticojejunostomy and three patients had caudal pancreatectomy for distal disease.

Results: Eight patients were completely controlled of all symptoms, with no sequelae. One case each had recurrent pancreatitis and ascites but did not require re‐operation. There were two deaths: one with massive haematemesis and one with pre‐existent multi‐organ failure and sepsis.

Conclusions: Pancreatic duct stones may be causally associated with internal pancreatic fistulae. Delineation of ductal anatomy and pathological aberrations of the pancreas, including determination of the leak site, was of paramount importance in planning surgery. Peroperative ductography proved the most useful in this regard.
THE PORTRAYAL OF THE DOCTOR IN NON‐MEDICAL LITERATURE 15. THE SURGEON
Authors: Posen Solomon
Published: January 2008

Fictional surgeons are perceived as confident and competent individuals. They may not have a profound knowledge of basic physiology or statistical methods and their social behavior may lack refinement, but they are great technologists and most of their patients get better. Inside the operating room, surgeons are absolute autocrats, with a few abusing their position and turning into petty tyrants.

The prominent status of fictional surgeons within the medical profession is reflected in their arrogant and patronizing attitudes towards patients, primary care doctors and non‐surgical specialists.

Fictional surgeons are impatient, irascible and aggressive. These traits make them poor communicators and teachers. A few are suspected of harbouring sadistic tendencies. On the other hand, when the surgeon turns his aggression towards the disease process rather than his colleagues or his trainees, it enables him to achieve some spectacular therapeutic successes.
FALSE ANEURYSM OF THE POPLITEAL ARTERY COMPLICATING ACUPUNCTURE
Authors: Lord Reginald V. N. , Schwartz Peter
Published: January 2008

This is the first reported case in which acupuncture needle injury of the popliteal artery caused the development of a false aneurysm. The patient presented with rupture of the aneurysm and was successfully managed by arterial repair.
‘IDIOPATHIC’ CHRONIC GASTRIC VOLVULUS
Authors: Willsher Peter C. , White Rohan C. , Dumbrell Paul
Published: January 2008

Gastric volvulus usually occurs secondary to another condition such as hiatal hernia. We report a case of so‐called ‘idiopathic’ gastric volvulus where the only abnormality was laxity of the gastric attachments. Upper gastrointestinal endoscopy was unhelpful in making the diagnosis, but a barium meal clearly demonstrated the abnormality. The patient underwent a Polya gastrectomy with a retrocolic gastroenterostomy, which was thought to be the best method of ensuring gastric fixation.
HYPERPARATHYROIDISM PRESENTING AS PANCREATITIS OR COMPLICATED BY POSTOPERATIVE PANCREATITIS
Authors: Shepherd J. J.
Published: January 2008

Background: The association of hyperparathyroidism with acute pancreatitis either pre‐operatively or postoperatively has been questioned in recent overseas literature.

Methods: A review of medical records and histology reports in the Royal Hobart Hospital from 1971 to 1993 was carried out to identify all cases of acute pancreatitis associated with primary hyperparathyroidism.

Results: Seven cases are presented, six with histological confirmation, of hyperparathyroidism associated with pancreatitis in a period when 137 confirmed cases of primary hyperparathyroidism were treated. None of these patients had gallstones. In two, alcohol abuse may have been the aetiological factor. Five patients had successful neck exploration and none of them have experienced any further attacks including a 25 year old who had four hospitalizations and one laparotomy for pancreatitis in the year before parathyroidectomy 12 years ago. Two patients died from acute pancreatitis, one without exploration and the other with a mediastinal parathyroid adenoma that was not located at surgery.

Conclusions: Most parathyroid surgeons would proceed to mediastinotomy, if necessary, at initial exploration in a patient with previous hypercalcaemic crisis. This should also be considered in patients with a history of acute pancreatitis.
CHANGES IN FIBRINOGEN LEVELS IN PATIENTS UNDERGOING OPEN AND LAPAROSCOPIC NISSEN FUNDOPLICATION
Authors: Pike Gregory K. , Bessell Justin R. , Mathew George , Watson David I. , Mitchell Phillip C. , Jamieson Glyn G.
Published: January 2008

Background: Venous thromboembolic complications may be more common after laparoscopic surgical techniques, possibly due to changes in venous flow and blood coagulability.

Methods: This study assessed fibrinogen, cross‐linked fibrin degradation products (D‐dimer), prothrombin international normalized ratio (INR), activated partial thromboplastin time (APTT) and platelets, during and after both open and laparoscopic Nissen fundoplication to determine whether coagulability is increased by the laparoscopic approach.

Results: Seven patients underwent open and thirteen underwent laparoscopic Nissen fundoplication. Fibrinogen levels following open fundoplication fell from 2.8 ± 0.3 g/L pre‐operatively to 2.0 ± 0.3 g/L following skin incision, and then increased to 4.1 ± 0.4 g/L on the first postoperative day. Similar changes in fibrinogen occurred following laparoscopic fundoplication (2.7 ± 0.2, 2.5 ± 0.2 and 3.8 ± 0.4 g/L, respectively). No significant changes in the other coagulation indices were observed.

Conclusions: These results demonstrate hypercoagulability on the first postoperative day, irrespective of the operative technique. No differences between the results following laparoscopic and open fundoplication were demonstrated.
A PROPOSED MODEL FOR THE MOVEMENT OF CELLS WITHIN THE |ABDOMINAL CAVITY DURING CO2 INSUFFLATION AND LAPAROSCOPY
Authors: Thomas W. M. , Eaton M. C. , Hewett P. J.
Published: January 2008

Background: The application of laparoscopic‐assisted surgery to gastrointestinal malignancy has lead to the recurrence of malignancy in wounds created during these procedures by laparoscopic ports.

Methods: Possible mechanisms of this complication have been studied in an in vitro model. Using filter systems, we have examined the expelled carbon dioxide used during laparoscopy and the laparoscopic ports and instruments for the presence of malignant cells.

Results: No malignant cells were identified in the exhaust CO2 examined, whereas all instruments and laparoscopic ports were contaminated by malignant cells.

Conclusions: These findings suggest that direct contamination by the instruments and ports and not dispersion of malignant cells by CO2 is the route by which port seeding of tumour cells occurs.
PARAFFINOMAS OF THE BREAST: AN ORIENTAL CURIOSITY
Authors: Alagaratnam Thevakaruna T. , Ng Wing F.
Published: January 2008

Background: The injection of liquid paraffin wax was a form of breast augmentation practised in Hong Kong 30–40 years ago. Patients may present many years later with complications of this treatment.

Methods: The records of 43 patients diagnosed with paraffinomas of the breast at a teaching hospital in Hong Kong were reviewed. These patients had received paraffin injections 3–41 years (median 17) previously.

Results: Patients presented with hard masses in the breast 4–18 cm (median 17) diameter. Ulceration or infection occurred in 10 patients. Mammography revealed a honeycomb appearance in the affected breast. Treatment included biopsy only (7), excision of masses (3) and total mastectomy (30, bilateral in 27). Histology demonstrated hyalinized and densely sclerotic fibrous tissue with cystic spaces of various sizes.

Conclusions: Awareness of this condition facilitates the differentiation from tuberculosis and carcinoma of the breast which often present late in this population of patients. Adequate treatment usually requires total mastectomy.
THE PREVALENCE OF MEN‐I IN TASMANIA
Authors: Wilkinson S. , Young M. , Shepherd J. J.
Published: January 2008

Background: An extensive programme was undertaken to trace and screen four known families in Tasmania with multiple endocrine neoplasia type 1 (MEN‐I).

Methods: Written and personal contact was made with family members over the age of 20 years recommending a review by family practitioners for the purpose of recording their medical history and collecting a blood sample. Those suspected of MEN‐1 were referred to our Department for further investigation.

Results: In January 1993, the total number of individuals alive and known to be affected by MEN‐I was 107, giving a prevalence of MEN‐I disease in Tasmania of 23/100 000. The estimated prevalence of the MEN‐I trait in Tasmania (including affected cases and those considered at 50% risk of possessing the trait) is 45/100 000.

Conclusion: The prevalence of MEN‐I has never previously been determined accurately. The prevalence of MEN‐I in Tasmania is at the upper end of the possible range and would justify the allocation of resources for screening programmes equal to those available for the detection of several less prevalent genetic diseases.
OPTIMIZING THE HOSPITAL MANAGEMENT OF LEG ULCERS
Authors: Gruen Russell L. , Chang Stanley , MacLellan Donald G.
Published: January 2008

Background: Leg ulcers are common and are often the cause of a long hospital admission. However, little information is available on the efficacy and efficiency of inpatient leg ulcer management. The inpatient management of leg ulceration was examined and areas for improvement were sought.

Methods: The management of patients admitted to a teaching hospital with a primary diagnosis of leg ulceration was examined, the costs estimated and areas for improvement identified. A retrospective analysis of 174 admissions to Heidelberg Repatriation Hospital between I January 1991 and 31 December 1992 was performed.

Results: Of 119 patients, 61 had ulcers due to arterial disease and 34 due to venous disease. Over 2 years, leg ulcers accounted for 5259 inpatient bed days, a mean of 44.2 days per patient. The estimated cost exceeded $2 750 000, averaging over $12 000 per admission. Thirty‐three percent of patients had no recorded investigations into the cause of their ulcer and fewer than 50% had documented improvement at discharge.

Conclusions: Leg ulcers are costly due to their extended treatment on an inpatient basis. Unfortunately, hospital admission does not guarantee optimal wound healing rates. A leg ulcer protocol is proposed to minimize inpatient stay and improve investigation and management in an outpatient or community setting.
BIOMECHANICAL EXPLANATION OF A SIMULTANEOUS CLOSED RUPTURE OF BOTH FLEXOR TENDONS IN THE SAME DIGIT
Authors: Lanzetta Marco , Conolly W. Bruce
Published: January 2008

Closed ruptures of both normal flexor tendons in the same finger are extremely rare, only nine cases having been reported in the literature. The authors describe the case of a patient who sustained a closed rupture of both flexor digitorum profundus and flexor digitorum superficialis of the ring finger, following a forced hyperextension injury. The present paper highlights the importance of the mechanism of injury and explains its biomechanical basis. The patient was treated by a two‐stage reconstruction of the flexor digitorum profundus and regained full flexion and extension of the finger.
TREATMENT PRINCIPLES IN ADVANCED COLORECTAL CANCER
Authors: Zalcberg J. R. , Friedlander M. L. , Collopy B. T. , Barton M. , Gray B.
Published: January 2008

Background: Colorectal cancer is an important disease in the Australian community. Whilst there has been much discussion about the appropriate management of local disease, particularly with respect to the issue of adjuvant therapy, there has been relatively little local discussion of treatment options in metastatic colorectal cancer.

Methods: The critical principles underlying treatment in this setting are briefly outlined in the present article, indicating wherever possible what options could be considered standard, and based on the available literature, which approaches must still be considered experimental at this time.

Results: Overall, the results of treatment in this group of patients remain poor.

Conclusion: Further clinical trials are required to address the issues affecting patients with metastatic colorectal cancer.
PANCREATIC STENTS IN THE MANAGEMENT OF CHRONIC PANCREATITIS
Authors: Treacy P. J. , Worthley C. S.
Published: January 2008

Background: Elevated pancreatic duct pressure is a potential source of pain in patients with chronic pancreatitis. Endoscopic pancreatic duct stenting is a minimally invasive way of reducing this pressure and may be a useful adjunct to surgery in these patients.

Methods: We prospectively reviewed a series of nine symptomatic patients with obstructive chronic pancreatitis and relative contraindications to open surgery, who were managed by attempted endoscopic placement of a pancreatic stent.

Results: Stents were successfully inserted endoscopically into the main or accessory duct in six patients and into a pseudocyst, transduodenally, in one patient. Of the two unsuccessful insertions, one proceeded to longitudinal pancreato‐jejunostomy and in the other a stent was inserted at distal pancreatic cyst‐jejunostomy. Median follow up was 21 months (range 14–43). In all eight cases with stent insertion there was rapid pain resolution, pain scores falling from 9/10 (8–10) to 2 (1–5) after 2 days (1–7). Associated symptoms of weight loss, nausea and vomiting settled in all eight cases. In one patient with a persistent pancreatic fistula, the fistula resolved. In the three with pseudocysts, the cysts resolved on computed tomography (CT) (one recurred). Five patients subsequently proceeded to stent removal after 6 months (5–23). In three of these, the stent was removed endoscopically, and replaced endoscopically in two cases, with pain resolution. Two patients underwent transduodenal pancreatic duct septectomy (one had stent change prior) and one proceeded to pseudocyst‐gastrostomy, with pain resolution. The remaining three patients with stents in situ remain symptom‐free. No patient suffered acute pancreatitis.

Conclusions: In selected patients with obstructive chronic pancreatitis, insertion of a pancreatic stent is a safe procedure, which can lead to rapid symptomatic control over the intermediate period. A significant proportion will need further intervention.
GASTRIN RECEPTOR ANTAGONIST Cl‐988 INHIBITS GROWTH OF HUMAN COLON CANCER IN VIVO AND IN VITRO
Authors: Romani Rossana , Howes Lawrence G. , Morris David L.
Published: January 2008

Background: Whilst gastrin has been found to be trophic for some colorectal cancer cell lines, and gastrin receptor antagonists are able to block this phenomenon, their potency has been modest.

Methods: The effect of a new, potent and selective CCK B receptor antagonist, CI‐988 on the growth of LoVo, a human colon cancer cell line both in virro and in vivo was investigated.

Results: Basal growth of LoVo in vitro was inhibited by up to 58.93 ± 7.30% with concentrations of CI‐988 as low as 1 × 10‐‐11 mol/L whereas the addition of gastrin (G17) at 0.5 nmol/L had no effect. LoVo was also grown in vivo for 10 days in nude mice subsequently treated with CI‐988 at 10 mg/kg per day orally for 20 days. CI‐988 inhibited the growth of xenografts by 53%.

Conclusion: This was the first study in cancer with this potent gastrin receptor antagonist, (21–988. The results suggest that CI‐988 may be of use in inhibiting the growth of colorectal cancer.
SURGEON‐SUPERINTENDENTS ON CONVICT SHIPS
Authors: Pearn John
Published: January 2008

Surgeon‐superintendents on the convict ships transporting convicted men, women and youths to Australia played a key role in the evolution of medical standards in Australia. The British Transportation Acts of 1717 and 1825 added the punishment of exile and banishment to the prevailing penology of the era, that of retribution and deterrence. The surgeon‐superintendents formed a bulwark during the sea voyages (between 88 and 258 days), protecting the convicts against the potential abuses of the time. Between 1787 and 1868, some 160 000 convicts were transported to the open air gaols at Sydney, Norfolk Island, Van Diemen's Land (Hobart, Macquarie Harbour, Maria Island and Port Arthur), Moreton Bay, Melville Island and Fremantle. Seventeen convict ships left England for Australia in 1823 alone. The surgeon‐superintendent's role on the high seas evolved over this time from one of amateur casualness with a primary responsibility to the system rather than to individual convicts, to that of a highly efficient, courageous professionalism. It became a new specialty discipline in its own right. Mortality on the convict transportation voyages fell from one in three convicts embarked in 1790 to zero mortality in the convicts transported on the Sultana in 1859. The key role of the surgeon‐superintendent, in the context of preventive medicine, is developed in the present paper. Historical nodes in the evolution of the new discipline of prison doctor were the 1814 Report of Redfern (himself a former convict), and the evolution from the 1820s of doctors who became the pioneers of the specialty discipline of the Prison Medical Service in Australia. The experiences and influences of surgeon‐superintendents on convict transportation vessels formed the catalyst for the Passenger Act (UK) of 1855 which, for the remaining decades of the 19th century, regulated the lives of millions of immigrants to Australia and New Zealand.
INITIAL PARATHYROID EXPLORATION: CURRENT TRENDS IN AUSTRALIA
Authors: Sinha Sankar N. , Subramaniam Peter
Published: January 2008

Background: An Australia‐wide multicentre prospective study was undertaken to audit cases of initial parathyroid exploration between 1 January and 31 December 1992. One hundred and sixty‐two cases were audited. The audit was designed to study pre‐operative biochemical assessment, localization techniques and the technique of exploration.

Method: A pro forma audit form was circulated to all Australian surgeons known to perform parathyroid surgery. Eleven responded.

Results: Free serum ionized calcium (iCa) was measured in 30% of cases, with the majority of pre‐operative calcium assays being performed using total serum calcium (tCa). In 40 cases (29%) pre‐operative localization techniques were used. These proved inaccurate in 10 cases. The intra‐operative technique of localization with methylene blue infusion was used in 11% of cases. All four glands were biopsied in 11 % of cases. No deaths were reported and a postoperative morbidity rate of 3.1 % was noted. Eighty‐eight per cent of patients were discharged within 5 days of surgery with a third going home within 48 h of neck exploration surgery. Only one patient (0.6%) required re‐exploration for persistent hypercalcaemia due to a second adenoma.

Conclusions: The surgical treatment of hyperparathyroidism can be regarded as safe, with minimum morbidity in experienced hands. Pre‐operative localization studies in initial parathyroid exploration are not indicated.
GENITOPERINEAL GANGRENE: EXPERIENCE IN SINGAPORE
Authors: Ong Hock Soo , Ho Yik Hong
Published: January 2008

Background: The experience with genitoperineal gangrene at the Department of Colorectal Surgery, Singapore General Hospital is documented.

Methods: The results of 12 patients treated during the 5 year period between 1 January 1990 and 31 January 1995 were studied. There were 10 men and two women. The mean age of the patients was 55.2 (range 37–83) years.

Results: Perianal pain and swelling were the commonest presentation. However, three patients were admitted in a toxic state with mental confusion. The gangrene progressed from anorectal sepsis in six patients. Five of these patients had diabetes mellitus. Escherichia coli was the commonest organism cultured. Early diagnosis, immediate resuscitation, antibiotics and early aggressive surgery was our management policy. Applying these principles, all except two patients survived (mortality 17%). One had advanced malignacy and the other had extensive hum injuries.

Conclusions: A high index of suspicion should he maintained in patients with diabetes and with anorectal sepsis. Should genitoperineal gangrene develop, aggressive surgery is often successful.
SURGERY IN THE CONFLICT REGION OF SRI LANKA
Authors: Dewan P. A. , Hakewill P.
Published: January 2008

Background: Médecins Sans Frontières provides medical support to Batticaloa, a town on the east coast, which is in the conflict region of Sri Lanka.

Methods: Information on the range of pathology, the services provided and the diseases treated was collected from a 25 day assignment in mid‐1995.

Results: Services and facilities are limited and the amount of work is extensive, as indicated by the 248 patients who had one or more operations and 814 surgical cases who were admitted. Ten per cent of the work was with conflict‐injured patients and the remainder covered a wide range of specialties. Complications were surprisingly few.

Conclusions: The surgical support supplied through MCdecins Sans Frontitres gives the people of Batticaloa much needed medical care and allows surgeons the opportunity to have an enormously satisfying experience.
SMOOTH MUSCLE CELL MIGRATION AND PROLIFERATION IS ENHANCED IN ABDOMINAL AORTIC ANEURYSMS
Authors: Patel M. I. , Ghosh P. , Melrose J. , Appleberg M.
Published: January 2008

Background: The aetiology of abdominal aortic aneurysms (AAA) is as yet undetermined. Smooth muscle cells (SMC) have been implicated in the pathogenesis of AAA as a result of their ability to produce elastin degrading proteases. The present study was undertaken to examine AAA SMC and aortic occlusive disease (AOD) SMC in terms of their respective migration and proliferation in vitro, in order to identify intrinsic differences between these cells.

Methods: Five AAA specimens, four AOD and five inferior mesenteric artery (IMA) specimens were established in culture. The cultures were examined for the extent and the rate of SMC outgrowth and proliferation. Cells were counted following trypsinization using a haemocytometer.

Results: For the AAA explants, the cellular outgrowths were first seen at 6.7 days, after culture initiation, while the corresponding outgrowth in the AOD group required 8.8 days (P<0.05) and the IMA group 11.4 days (P<0.05). AAA cells reached confluency at a mean of 22.4 days while AOD SMC required 28.6 days (P < 0.05) and IMA 31 days (P < 0.05). In the first passage, the time for AAA SMC doubling was 5.3 days compared to 6.2 days for AOD (P < 0.05) and 8.1 days for the IMA group (P < 0.05). Greater than 98% of the cells, in both groups, stained positive to SMC α‐actin.

Conclusion: From these data it is clear that there are intrinsic differences in cellular kinetics between SMC from the two disease states, supporting the hypothesis that AAA are not the result of atherosclerosis.
COLORECTAL INJURY: WHERE DO WE STAND WITH REPAIR?
Authors: Miller Brian J. , Schache David J.
Published: January 2008

Background: The chief danger of colonic injury is sepsis resulting from faecal spill. Primary repair is now well established in the USA, particularly for penetrating injuries, in up to 81% of patients. However, in Australia, highly destructive blunt trauma forms a larger proportion of injuries, and the purpose of this study was to determine if there are any contrasts in the management of these patients.

Method: A retrospective survey was undertaken over the past 20 years of all of the patients with full‐thickness colorectal injuries presenting at the three major hospitals which receive multi‐trauma patients in Brisbane.

Results: Of 112 patients 114 sustained full‐thickness colorectal injuries. Forty patients had penetrating injuries, 41 had blunt injuries and 33 had iatrogenic injuries. Primary repair or resection and anastomosis was performed in 39% of patients with colonic injuries and the leak rate was 8%. Exteriorized repairs had a 67% leak rate. A colostomy was used in 58% of patients. The mortality for penetrating injuries was zero. The mortality for blunt colonic injuries was 17% and for iatrogenic injuries was 7% but for blunt rectal injuries was 50%. The overall mortality was 10%. Colostomy closure had a 20% morbidity but no mortality.

Conclusions: In the absence of shock, associated injuries, or gross faecal soiling primary repair or resection with anastomosis may be considered. For blunt injury, colostomy is still usually indicated, often with resection. For iatrogenic injury, when seen early, primary repair can be performed. We do not recommend exteriorized repair. Extraperitoneal rectal injuries require proximal colostomy and distal washout, with drainage where appropriate. Blunt devitalizing injury is relatively more common in Australia than in the USA and therefore there is less indication here for primary repair. Colostomy remains an important consideration in operative management.
THE ORTHOPAEDIC LEVER: A SIMPLE METHOD TO REDUCE UNSTABLE POSTERIORLY DISPLACED OR ANGULATED PROXIMAL FEMORAL FRACTURES
Authors: Donnan Leo T.
Published: January 2008

The satisfactory management of unstable posteriorly displaced or angulated proximal femoral fractures is an orthopaedic challenge. In these fractures, significant displacement of bony fragments is often associated with comminution and soft‐tissue stripping. Unsatisfactory fixation may lead to serious complications such as refracture with failure of the fixation device. Accurate reduction, reconstruction and fixation of these fractures are demanding in both strength and technique of the surgeon. The orthopaedic lever providing means for pre‐operative reduction that will maintain the reduced position while fixation is achieved is described.
CHOLEDOCHOLITHIASIS IN ANOMALOUS BILIARY SYSTEM
Authors: Leung L. C. , Wong C. Y. , Wong C. M. , Cheung K. K.
Published: January 2008

Although congenital biliary abnormalities are common, preduodenal portal vein is very rare, not to mention preduodenal common bile duct (CBD) which has not been described before in the literature. A case with both anomalies complicated by biliary tract stones is reported. A brief review of embryonic development is also presented to explain the unusual biliary anatomy of this patient.
IMMATURE MEDIASTINAL TERATOMA IN A 2 1/2 YEAR OLD CHINESE GIRL
Authors: Yim A. P. , Ho J. K. , Li C. K.
Published: January 2008

Teratoma is a rare tumour in children accounting for about 3% of all childhood malignancy. A case of immature mediastinal teratoma in a young Chinese girl is reported.
NEWER APPROACHES TO REGIONAL CANCER THERAPY THROUGH TUMOUR IMMUNOLOGY: IS THERE A ‘BREAKTHROUGH’?
Authors: Stephens Frederick O.
Published: January 2008

Eagerly awaited ‘breakthroughs’ in immunological treatment have in the past been disappointingly unsuccessful in changing the outlook for most patients with otherwise incurable cancers. Many hopeful agents have been studied in therapeutic trials but each in turn has proven to be largely disappointing. One of the latest products of immunological research, tumour necrosis factor (TNF) was found to be too toxic for systemic use but has been found to be highly effective in improving the results of treatment of melanoma when used in a closed‐circuit perfusion system in combination with another chemotherapeutic agent. In the past the use of closed‐circuit perfusion has been confined to limbs, but techniques have recently been developed to apply closed‐circuit perfusion to liver, pelvic organs, and some abdominal regions including pancreas. The potential for studies of TNF in combination with chemotherapy in closed‐circuit perfusion treatment of otherwise resistant cancers in these organs and tissue regions has been greatly expanded. In many cancer treatment centres in the past there has been a reluctance to use and to acknowledge the benefits of regional delivery of anti‐cancer chemotherapy. The need for these techniques in the safe and effective use of TNF has further confirmed the importance of these methods in comprehensive cancer treatment centres, and the need for further studies and better understanding of the use of regional and closed‐circuit perfusion methods.
37 kBq 14C‐UREA BREATH TEST AND GASTRIC BIOPSY ANALYSES OF H. PYLORI INFECTION
Authors: Allardyce Randall A. , Chapman Bruce A. , Tie Andrew B. M. , Burt Michael J. , Yeo K. James , Keenan Jacqui I. , Bagshaw Philip F.
Published: January 2008

Background: The treatment of H. pylori‐associated gastroduodenal disease is increasingly aimed at bacterial eradication which requires follow‐up assessment of therapeutic effectiveness and re‐infection. A simplified 37 kBq 14C‐urea breath test for H. pylori infection has been developed.

Methods: The 37 kBq 14C‐urea breath test was compared with biopsy urease (CLO) and histological analyses of gastric biopsies obtained from 63 patients undergoing endoscopy.

Results: The 30‐min breath test correlated closely with biopsy findings, had a sensitivity of 100%, a specificity of 95% and a positive predictive value of 92%.

Conclusions: The simplified, low‐dose, 14C‐urea breath test is a convenient, low‐cost, transportable means of facilitating the management of H. pylori‐associated diseases.