bluuebunny/crossref_metadata_2025 huggingface dataset:
CT30 PERCUTANEOUS VALVE ACCOMPLISHMENTS AND CHALLENGES
Authors: Campbell A.
Published: April 2007

At the end of the 20th century several inventors had suggested methods for catheter based implantation of cardiac valves. In September of 2000 Professor Philipp Bonhoeffer made transcatheter valve delivery a reality with the implantation of a stent mounted biological valve in the pulmonary position. Dr. Alain Cribier followed in 2002 with the first successful transcatheter implantation of a valve into the more challenging aortic position. Cardiac surgeons and industry seemed to show little interest in percutaneous valve delivery until January of 2004 when Edwards Life Science invested over $125 million in acquiring PVT, the company building the valves implanted by Dr. Cribier and Medtronic revealed the company’s support for Dr. Bonhoeffer’s efforts. A number of challenges have been identified and significant progress has been made in addressing some of these challenges. This presentation will describe the challenges associated with pulmonic and aortic transcatheter valve delivery. The progress that has been made in overcoming these challenges as well as the efforts being made to overcome the remaining challenges will be discussed.
CT31 HYPERBARIC OXYGEN IN POST‐CARDIAC SURGERY STROKE PATIENTS – THE CHRISTCHURCH EXPERIENCE
Authors: Gibson A. J.
Published: April 2007

Introduction  Post‐operative strokes occur in a small percentage of adult cardiac surgical patients and have devastating consequences for these patients. There is evidence to suggest that Cerebral Arterial Gas Embolism (CAGE) is an important aetiological factor in most of these cases.

Hyperbaric Oxygen therapy (HBOT) is the administration of 100% oxygen at greater than atmospheric pressure. It is accepted as the definitive treatment for CAGE related to SCUBA diving accidents. The similarities between this and the pathophysiology of post cardiac‐surgical strokes due to iatrogenic CAGE suggest that beneficial effects from HBOT may accrue to these patients.

Purpose  The purpose of this study is to review the experience of treating post cardiac‐surgical stroke patients in our local hyperbaric oxygen facility, including their presentation, delay before treatment and outcomes. The current evidence base is reviewed.

Method  A retrospective case series analysis was conducted.

Results  Over a 10 year period, patients with post cardiac‐surgical strokes and who presented within the first 48 hours were referred for HBOT, of whom 12 were treated. The neurological outcomes were excellent in all but one case who died.

A review of the literature provides a rational basis for the potential benefits of HBOT in this scenario, but at present there is only limited clinical data to support its use.

Conclusion  The postulated mechanisms for the development of post cardiac‐surgical strokes provide a sound theoretical basis for the suggestion that the use of HBOT is associated with improved outcomes. However there is no prospective data to support such a claim. Such a trial would be problematic and until more evidence is available, HBOT should be considered on a case by case basis.
CT06 AORTIC FAT PAD AND NEW ATRIAL FIBRILLATION POST CARDIAC SURGERY. CARDIAC LYMPHATICS REVISITED
Authors: Lupinski R. W.
Published: April 2007

Lymphatics of the heart have not generated any broad or sustained interests among clinicians. Few publications on cardiac lymphatics are available, anatomy not routinely known and the true role of cardiac lymphatics remains doubtful. One important anatomical concept needing clarification is that of the lymphatic nature of conduction tissue. Sino‐atrial node lymphatic collector is incorporated into Aortic Fat Pad and as such is the most frequently damaged lymphatic vessel during cardiac surgery. Thus, preservation of Aortic Fat Pad and its lymphatic collector should reduce the incidence of new atrial fibrillation in patients post cardiac surgery, an observation reported in the literature recently.
CT07 THE UNIVERSAL ANASTOMOTIC STENT – A NOVEL PROXIMAL CORONARY ARTERY BYPASS ANASTOMOTIC DEVICE
Authors: Harden M. P. , Sims A.
Published: April 2007

Purpose  Proximal anastomotic devices have been developed to produce predictable results that eliminate surgical technique as a variable with respect to the anastomosis, improve graft patency and lower the incidence of stroke. One criticism of current devices is foreign material contact at the anastomosis which is thought to stimulate intimal hyperplasia and thrombosis. In co‐operation with AllVascular Restorative Vascular Solutions, an anastomotic device for use in vein graft‐aortic anastomosis, the Universal Anastomotic Stent (UAS), was developed to eliminate foreign body contact with blood.

Methodology  The design concept for the UAS was based on the Venous Valve Transfer stent developed by AllVascular. This stent is designed to transfer a functional venous valve to a vein with valve incompetence as a treatment of venous valve insufficiency. The UAS prototype developed from this stent underwent pre‐clinical testing in sheep for design review.

Results  Animal trials established that an external nitinol expanding stent can be used to create an arterial anastomosis. Loading a vein graft onto the UAS proved difficult in the absence of a crimping tool. A design concept for a dedicated loading tool has been developed and an animal model for future testing was finalised.

Conclusions  The UAS, compared to existing anastomotic devices, has the advantage of maintaining intima‐intima contact at the anastomosis, which may reduce the inflammatory response. External stenting may limit compliance mismatch at the anastomosis and reduce intimal hyperplasia. Further animal testing is required to establish if this novel anastomotic device will be suitable for human use.
CT08 SURGICAL MANAGEMENT OF INFECTIVE ENDOCARDITIS: OUR EXPERIENCE
Authors: Das D. , Mohanraj A. , Hayward P. , Kuba P. K. , Seevanayagam S. , Buxton B.
Published: April 2007

Purpose  In the light of improvement in results of surgery for acute infective endocarditis(IE),we analysed our surgical outcomes and risk factors associated with mortality in patients operated for acute IE in the past decade.

Methodology  A retrospective study of 85 consecutive patients (54 males, 31 females, Mean age 50.4 ± 18.9 years) who underwent surgery for IE between January 1997 to December 2006 was performed. The preoperative profiles,intraoperative findings and the postoperative outcomes were analysed.

Results  Native valve endocarditis (NVE) was present in 78/85 patients and prosthetic valve endocarditis(PVE) in 7/85 patients. The aortic, mitral, tricuspid and multiple valves were involved in 30, 28, 15 and 9 pateints respectively. Seven out of 12 intravenous drug abusers had tricuspid valve involvement.The commonest organism was Staphylococcus aureus. The indications for surgery were heart failure (75.2%), failure of medical management (15.2%), abcess (9.4%) and embolism (8.2%). 65 patients underwent valve replacements (55 prosthetic valves, 6 homografts and 2 Ross procedures). 20 patients underwent valve repairs/vegetectomies, of which 5 were mitral repairs. There were 16 in‐hospital deaths (18.8% overall). The mortality was 16.6% in NVE compared to 42.8% in PVE (p < 0.05). PVE, ventilation greater than 24 hours, acute renal failure and severe left ventricular dysfunction were associated with increased mortality (p < 0.05). 4 patients required reoperation for recurrent endocarditis during 1 year follow‐up.

Conclusion  Operation for active IE carries acceptable mortality rate for this aggressive disease. Prolonged ventilation, renal failure and severe LV dysfunction are associated with increased risk of mortality.
CT09 ACUTE ISCHAEMIC VENTRICULAR SEPTAL RUPTURE – A FORMIDABLE SURGICAL CHALLENGE
Authors: Sibal A. K. , Prasad S. , Milsom P. F. , Raudkivi P. J. , Alison P. M. , Haydock D. A.
Published: April 2007

Purpose  To evaluate our surgical results for ischaemic Ventricular Septal Rupture and suggest practice guidelines.

Methodology  A retrospective review of data from patient records from 1992 to 2006 for presentation, surgical approaches, recurrence and mortality and analyzed for future management guidelines.

Results  We had 36 patients with a mean age of 70.44(+/− 6.34). 14 patients (38.9%) had an inferior/ posterior defect, 28 were in shock (22 on IABP). Severe LV and RV dysfunction were present in 18 and 20 patients respectively. Repair involved patches after infarctectomy (17) or infarct exclusion (18), using either continuous or interrupted suture. Concomitant CABG was performed in 15. 11 patients had residual shunts, 2 requiring device closure and one surgery. Prolonged ICU and hospital stay was the norm. Early mortality was 52.78% (inferior defects – 85.71%, anterior defects – 31.82%). On Univariate analysis Inferior VSD (OR 7.7; 95% CI 1.7, 33.3), Moderate to severe RV impairment (OR 5.0; 95% CI 0.92, 33.3), Pre op shock (OR 6.7; 95% CI 1.6, 33.3), Early presentation post MI and infarctectomy during repair (3.8; 95% CI 0.9, 15.4), predicted mortality. For subgroup of anterior VSD, only pre‐op shock (OR11.1; 95% CI 1.0, 100) predicted a poor outcome. On multivariate analysis, Inferior defects and shock at presentation were the dominant predictors for early death. Repair without cardioplegia (OR5.2; 95% CI 0.48, 56.09) was the only risk factor for recurrence.

Conclusions  Acute ischaemic VSD is a grim surgical disease with high mortality. Inferior defects should be offered surgery only in exceptional circumstances due to uniformly poor outcome.
CR10 LAPAROSCOPIC RIGHT HEMICOLECTOMY PERFORMED DURING THE ‘LEARNING CURVE PHASE’ DOES NOT IMPACT ON ONCOLOGICAL RESECTION
Authors: Mignanelli E. , Torey E. , Skinner S.
Published: April 2007

Purpose  Laparoscopic colectomy for the management of colonic neoplasia is technically feasible and increasingly popular. It is expected that the laparoscopic operation deliver similar oncological clearance to open operation. The ‘learning curve’ for laparoscopic right hemicolectomy has been estimated to be 20 cases and is now set as a guideline by ASCRS. This study was performed to compare histopathology specimens following laparoscopic right hemicolectomy (LRH) performed during the ‘learning curve’ phase with those following open right hemicolectomy (ORH) to evaluate oncological clearance of colonic neoplasms.

Methods  125 patients were identified as having undergone right hemicolectomy by two surgeons for colonic neoplasia from January 2001. Data regarding patient details and tumour pathology were obtained by retrospective case note review. Thirty‐five patients underwent LRH compared to 90 who had ORH during the same period. Histopathology from the two groups were compared for length of specimen resected, proximal and distal resection margins, size of tumour resected or number of lymph nodes harvested. Analysis was performed using Student’s T‐test.

Results  The two groups were matched with respect to age, sex and tumour characteristics. There was no significant difference between the groups in terms of length of specimen resected (p = 0.37), proximal (p = 0.29) and distal (p = 0.40) resection margins, size of tumour resected (p = 0.37) or number of lymph nodes harvested (p = 0.58).

Conclusions  ‘Learning curve’ laparoscopic right hemicolectomy allows similar lymphovascular clearance to traditional open surgery.
CR12 ENTEROCUTANEOUS FISTULAE – ARE WE GETTING IT RIGHT?
Authors: Gyorki D. E. , Brooks C. , Gett R. , Heriot A. G.
Published: April 2007

Purpose  Enterocutaneous fistulae (ECF) present a difficult management problem and can cause significant morbidity. The aim of the study was to assess the outcome of these patients.

Methodology  A retrospective chart review of all patients with ECF managed at a tertiary centre between 1996 and 2006. Demographic, management and outcome data was recorded. Factors influencing ECF closure and outcome were assessed with Cox regression analysis.

Results  Thirty‐three patients (17 male) were identified with ECF (median age 63, range 27–84). The primary aetiology was Crohn’s (30%), anastomotic leak (24%), iatrogenic (18%), mesh (6%), neoplasia (6%) and other (16%). Definitive surgery was undertaken in 21 (64%) at a median of 6.4 months (0.4–72 range) following presentation. Twenty percent of patients required emergency surgical intervention and 5 patients required preoperative total parenteral nutrition (TPN). Surgical management was formal resection and reanastomosis in all patients, with a mean operative time of 4.75 hours (SD = 1.8). The median hospital stay for the operative group was 19 days (7–85). Four patients required post‐operative TPN. Fistula closure rate was 97% (operative group 21/21, non‐operative group 11/12). Mean follow up was 37.3 months (0.5–217). Six operative patients (19%) developed fistula recurrence. There were 2 deaths at 2 and 5 months (fistula aetiology malignant colonic fistula and radiation enteritis respectively). No factor was predictive of fistula recurrence.

Conclusion  Patients with enterocutaneous fistula can be treated with low morbidity and low recurrence rate in a multidisciplinary setting. Patients with ECF should be referred to specialist units for management.
CR13 UTILITY OF 18‐FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY (FDG‐PET) IN THE STAGING AND MANAGEMENT OF ANAL CANCER
Authors: Tasevski R. , De Winton E. , Ngan S. , Mackay J. , Hicks R. , Heriot A. G.
Published: April 2007

Purpose  Accurate nodal staging in anal cancer is important for prognosis and planning of chemo‐radiation fields. Mounting evidence exists for FDG‐PET in the staging and management of cancer, with superior sensitivity and specificity compared to conventional imaging (CI) shown for several tumour sites, although little published data for anal cancer. The aim of the study was to determine the impact of FDG‐PET on the nodal staging and management of patients with primary anal cancer.

Methods  Sixty‐two consecutive patients with anal cancer referred to a tertiary centre between August 1997 and November 2005 were staged with CI and FDG‐PET. The stage determined by CI and the proposed management plan was prospectively recorded prior to FDG‐PET. The impact of FDG‐PET on stage and management was assessed and the accuracy of changes confirmed by subsequent clinical follow‐up.

Results  The stage was changed in 23% (14/62) as a result of FDG‐PET (15% up‐staged, 8% down‐staged). The staging FDG‐PET scan had high impact (altering management intent) in 3% (2/62), and medium impact (altering radiotherapy fields) in 13% (8/62). Fourteen percent of T1 patients (3/22), 42% of T2 patients (10/24) and 38% of T3‐4 patients (6/16), assessed using CI, had a change in their N or M stage following FDG‐PET. Sensitivity for nodal disease for CI and FDG‐PET was 72% and 92% and specificity was 99.5% and 100% respectively.

Conclusion  FDG‐PET shows increased sensitivity over CI for staging nodal disease in anal cancer and changes management in a significant proportion of patients.
CR15 LOCAL RECURRENCE AFTER CURATIVE RESECTION FOR RECTAL CANCER IS ASSOCIATED WITH ANTERIOR POSITION OF THE TUMOUR
Authors: Rickard M. J. F. X. , Chan C. L , Bokey E. L. , Chapuis P. H. , Renwick A. A. , Dent O. F.
Published: April 2007

Background  Mobilization of rectal cancer can be difficult if the tumour is located anteriorly and may result in a higher incidence of local recurrence. The aim of this study was to determine whether local recurrence and survival following curative resection of rectal cancer were associated with the position of the tumour.

Methods  Data were drawn from a comprehensive, prospective hospital registry of all resections for rectal cancer from January 1990 to December 1998, with follow‐up to December 2003.

Results  The 5‐year local recurrence rate was 15.9 (95 per cent confidence interval (c.i.) 11.0 to 22.8) per cent in 176 patients with tumours that had an anterior component compared with 5.8 (95 per cent c.i. 2.8 to 11.9) per cent in 132 patients with tumours without an anterior component (P = 0.009). This association persisted after adjustment for other factors linked to local recurrence (hazard ratio (HR) 2.4 (95 per cent c.i. 1.1 to 5.4)). Similarly, anterior position had a significant negative independent association with survival (HR 1.4 (95 per cent c.i. 1.0 to 2.00)).

Conclusion  Anterior position is an independent negative prognostic factor for both local recurrence and survival after curative resection of rectal cancer.
CR18P LAPAROSCOPIC VS OPEN TOTAL MESORECTAL EXCISION FOR RECTAL CANCER: AN EVALUATION OF THE MESORECTUM’S MACROSCOPIC QUALITY
Authors: Breukink S. O. , Grond A. J. , Pierie J. P. E. N. , Hoff C. , Wiggers T. , Meijerink W. J. H. J.
Published: April 2007

Purpose  Next to surgical margins, yield of lymph nodes, and length of bowel resected, macroscopic completeness of mesorectal excision may serve as another quality control of total mesorectal excision (TME). In this study, the macroscopic completeness of laparoscopic TME was evaluated.

Methodology  A series of 25 patients with rectal cancer were managed laparoscopically (LTME) and included in this study. The pathologic specimens of the LTME group were prospectively examined and matched with a historical group of resection specimens from patients who had undergone open TME (OTME). The two groups were matched for gender and type of resection (low anterior or abdominoperineal resection). Special care was given to the macroscopic judgment concerning the completeness of the mesorectum.

Results  A three‐grade scoring system showed no differences between the LTME and OTME groups.

Conclusion  The current study supports the hypothesis that oncologic resection using laparoscopic TME is feasible and adequate.
CR19P THE VALUE OF BEDSIDE COLONOSCOPY FOR THE CRITICALLY ILL PATIENT IN INTENSIVE CARE UNIT
Authors: Kao K. T. , Church J. , Moreira A.
Published: April 2007

Purpose  Bedside colonoscopy for the critically ill patient in Intensive Care Units (ICU) confronts the endoscopist with a new set of challenges and aims. This study examines the value and benefits that colonoscopy offers to critically ill patients with acute lower gastrointestinal disease.

Methodology  ICU patients who received bedside colonoscopy were identified from the colonoscopy database and the indications, co morbidities, depth of intubation, progression to surgery and death were recorded.

Results  39 patients underwent one or more bedside ICU colonoscopies to investigate ischemic colitis (11, confirmed in 8, 3 operated), colonic distension (10, all decompressed, 2 operated), lower gastrointestinal hemorrhage (13, cause found in 3, 2 operated), and diarrhea (4 patients). 14 patients died. Overall, 18 patients were diagnosed with ischemic colitis; 7 were operated and 6 died.

Colonoscopy reached the cecum in 16 patients, the hepatic flexure in 25 and the splenic flexure in 36. Prep was poor in 15 patients and stool prevented completion in 13. In 30% of patients colonoscopy was not pursued to the cecum because decompression was achieved without it, or because ischemic colitis was already diagnosed Colonoscopic techniques specific to ICU included prevention of a loop outside the patient and “slide‐through” with copious irrigation.

Conclusion  Bedside ICU colonoscopies are able to make an accurate diagnosis. Reaching the cecum is often not the aim of the study, nor is the diagnosis of small adenomas. In many cases a serious colorectal disease can be diagnosed or excluded, helping in the management of these severely ill patients.
CR02 RECTAL ENDOMETRIOSIS: THE RESULTS OF RADICAL EXCISION
Authors: Brouwer R. , Woods R.
Published: April 2007

Background  The aim of this paper is to review the results of radical surgical excision of rectal endometriosis.

Methods  All cases of endometriosis involving the rectum treated by a single colorectal surgeon were identified from a prospective database and the results reviewed.

Results  Between 1995 and 2005, 213 rectal procedures were performed on 203 patients together with an endo‐gynaecologist. 18 cases involved dissection of endometriosis off the rectal wall, 58 involved full‐thickness excision of the anterior rectal wall and 137 segmental excisions of the rectum were performed. The mean follow‐up was 68 months (range 7–158 months). A loop ileostomy was required in 7 (5 percent) of the segmental resections. 75 percent of cases were laparoscopic. Infertility was significantly more common in the group requiring a segmental resection (P = .026) and a history of rectal pain during defecation more common in patients having dissection of endometriosis off the rectal wall (P = .031). There were no other significant differences in symptoms between the different types of rectal surgery. The morbidity for all rectal procedures was 7 percent and there was no significant difference in complication rate between the different groups. The overall rectal recurrence rate was 5 percent and was significantly more common in the group who had dissection of the endometriosis off the rectal wall (P = .004).

Conclusions  Endometriosis of the rectum can be successfully treated with low morbidity and low recurrence rates by excising the disease as completely as possible using full‐thickness excision of the anterior rectal wall or segmental resection of the rectum.
CR20P NEED FOR STOMA DETERMINES LENGTH OF STAY AFTER LAPAROSCOPIC RECTAL SURGERY AND NOT CONVERSION TO OPEN SURGERY
Authors: Jones O. M. , Moran B. J. , Cecil T. D.
Published: April 2007

Purpose  Published evidence suggests a shorter length of stay (LOS) following laparoscopic colorectal resection. Increased LOS may result from conversion to open surgery and post‐operative complications but these factors are generally unpredictable. By contrast, the need for a permanent or temporary stoma is often predictable and may alter the LOS.

Methodology  This was a retrospective analysis of a prospectively collected database of all laparoscopic rectal procedures performed under the care of one surgeon since June 2003. Conversion was defined as an incision made in order to progress the intra‐abdominal dissection, either by a midline, Pfannenstiel or targeted incision.

Results  105 patients were included in the study (90 anterior resections, 10 abdomino‐perineal resections (APER), 3 Hartmann’s resections and 2 completion proctectomies). Conversion was performed in 27 patients (26%). Median LOS was 6 (range 3–83) days for the laparoscopic group and 7 (range 4–24) days for the converted group (p = ns). A stoma was performed in 27 patients (26%). Following anterior resection without stoma, median LOS was 6 (3–83) days. By contrast, after anterior resection with covering stoma, median LOS was 9 (3–30) days, whilst in those patients undergoing APER, Hartmann’s or completion proctectomy, the corresponding figure was 13 (5–35) days (p < 0.0001).

Conclusions  Conversion to open operation during laparoscopic rectal surgery did not increase mean LOS in this study. However, patients receiving a stoma have significantly longer hospital stays. Intensive pre‐ and post‐operative stoma education should be considered in these patients if overall in‐patient stay after laparoscopic surgery is to be reduced further.
CR21P MALE SEXUAL DYSFUNCTION AFTER LAPAROSCOPIC PELVIC SURGERY IS UNCOMMON WHEN PERFORMED BY SURGEONS BEYOND THEIR “LEARNING CURVE”
Authors: Jones O. M. , Stevenson A. , Stitz R. W. , Lumley J. W.
Published: April 2007

Purpose  The CLASICC trial reported higher levels of sexual dysfunction in men after laparoscopic pelvic surgery as compared to patients undergoing open surgery. This finding has since been replicated in a smaller study from Singapore. This has led some surgeons to question the role of the laparoscopic approach to pelvic surgery. This issue has been addressed further in this study.

Methodology  This study represents a retrospective analysis of a prospectively collected database for a single unit, comprising 2,000 patients undergoing laparoscopic colorectal surgery. Data collected prospectively at post‐operative clinic visit on impotence and retrograde ejaculation were evaluated.

Results  150 males undergoing pelvic surgery were identified. The incidence of impotence and retrograde ejaculation were less than 5% for men undergoing laparoscopic pelvic surgery. This does not differ significantly from rates seen in patients undergoing open pelvic surgery in this unit.

Conclusions  In this unit, laparoscopic pelvic surgery has been performed only since 2001, by which time there had been experience of over 1,000 laparoscopic abdominal procedures. Previous studies reporting poorer functional outcomes have probably included a significant number of patients on the surgeons’“learning curve”. By contrast, the low rates of sexual dysfunction in this unit may be attributable to pelvic dissection only being undertaken by experienced laparoscopic surgeons.
CR22P PERINEAL FLAP RECONSTRUCTION FOLLOWING EXTENDED RESECTION FOR PELVIC MALIGNANCY
Authors: Yeo A. W. , Heriot A. G. , McCombe D. B. , Morrison W. , Mackay J.
Published: April 2007

Purpose  Extended resection for colorectal pelvic malignancy has shown good outcome but may involve extensive perineal resection necessitating plastic surgical reconstruction. The aim was to assess the indications, techniques, morbidity, and outcome of perineal flap reconstruction for extended pelvic resection.

Methods  Patients requiring perineal flap reconstruction following colorectal resection at a tertiary centre from 1994 to 2006 were identified from a prospective colorectal database. Details of the indication, procedure, morbidity, and outcome were obtained from the database and retrospective chart review.

Results  21 patients (11 male, 10 female), median age 59 years (range 26–80) underwent perineal flap reconstruction. Indications for resection were advanced primary colorectal cancer (7), recurrent rectal carcinoma (8), recurrent anal carcinoma (3), and other pelvic malignancy (3). 18/21 patients had neoadjuvant radiotherapy. Reconstruction was by pedicled flap in 14 patients (5 gracilis flap, 7 vertical rectus abdominal muscle flap; 1 gluteal rotation flap) and latissimus dorsi free flap with microvascular anastomosis in 7 patients. Eighteen patients had immediate reconstruction and three were delayed. Five patients underwent vaginal reconstruction following posterior vaginectomy. There were four major flap complications (19%) requiring five unplanned reoperations. There were 2 minor complications (10%) requiring 1 unplanned reoperation. There were no donor site or longterm flap complications.

Conclusion  Perineal flap reconstruction by both pedicled and free flaps may be achieved with low morbidity following extended pelvic resection.
CR04 SIX YEAR, PROSPECTIVE ANALYSIS OF RECTAL BLEEDING CLINICS AT THE QUEEN ELIZABETH HOSPITAL, ADELAIDE, SOUTH AUSTRALIA
Authors: Lee J. S. J. , Rieger N. , Stephens J. , Rodda D. , Hewett P. , Lawrence M.
Published: April 2007

Background  One stop rectal bleeding clinics are designed to diagnose and treat colorectal diseases which present with rectal bleeding. The Queen Elizabeth Hospital rectal bleeding clinic is an open access clinic and is unique in South Australia. It offers flexible sigmoidoscopy and facilities for treating common anorectal conditions.

Methods  All patients presenting to the rectal bleeding clinic were prospectively recorded into a database. Data is collected on the presentation, past medical history, diagnosis, treatment and intended follow‐up.

Results  A total of 1539 cases were seen in the clinic between March 2000 and February 2006. Flexible sigmoidoscopy was performed in 1145 cases (75.03%). Banding or injection of haemorrhoids was performed in 383 cases. A total of 590 patients were referred for colonoscopy and of these 27 were diagnosed with colorectal adenocarcinoma or squamous cell cancer of the anus. The majority of these patients were over 50 years old (26 of 27; 96.30%) and had associated symptoms, such as weight loss or altered bowel habit, with their rectal bleeding (23 of 27; 85.19%).

Conclusions  Rectal bleeding clinics can facilitate early diagnosis of colorectal malignancy and can also provide a ‘one stop shop’ for treating benign anorectal conditions.
CR06 DEFICIENCIES IN PATHOLOGICAL REPORTING OF COLORECTAL CANCER IN VICTORIA
Authors: Robinson D. R. , Winn R. D. , Bell S. W.
Published: April 2007

Background  Colorectal cancer (CRC) pathological reporting deficiencies have been shown to be common with deviations from the minimum data set. Both information from the surgeon and pathologist is necessary for a complete report. These deficiencies have been shown to be correctable with the use of proformas. We performed an audit on a random sample of CRC pathological reports from the first six months of 2004, in Victoria Australia.

Methods  A random sample of pathological reports for CRC were obtained from the Victorian cancer council. 120 of these reports were reviewed by a team of surgical and pathological trainees. Presence or absence of the NHMRC minimum data set for CRC reporting was recorded.

Results  There were large deviations from the minimal dataset. Most notable was the absence of the information on the apical node, the presence of metastasis and vascular and perineural invasion.

Conclusions  The opportunity existed for considerable improvement in the pathological reporting of CRC in Victoria in 2004.
CR07 CONTINUOUS WOUND INFUSION OF LOCAL ANAESTHETIC IN THE CONTROL OF PAIN FOLLOWING ELECTIVE ABDOMINAL COLORECTAL SURGERY
Authors: Polglase A. L. , McMurrick P. J. , Simpson P. J. B. , Chee J. , Ooi C. W. , Kingsland S. R.
Published: April 2007

Purpose  Local anaesthetic wound infusions have been investigated in recent years as a potential alternative to standard analgesic regimens following major surgery. This study investigates the efficacy of a continuous wound infusion of ropivacaine in conjunction with best practice postoperative analgesia following midline laparotomy for colorectal surgery.

Methodology  310 patients presenting for major colorectal surgery were included in this prospective, randomised, double‐blind, placebo controlled trial. Patients were allocated to receive either ropivacaine 0.54% or normal saline via a dual catheter Painbuster Soaker(tm) continuous infusion device for 72 hours postoperatively.

Results  The continuous wound infusion of ropivacaine following abdominal colorectal surgery conveys minimal benefit when compared with saline wound infusion. No statistically significant difference could be shown for, pain at rest, morphine usage, length of stay, mobility, nausea or return of bowel function.

Conclusion  Management of pain following elective abdominal colorectal surgery is best achieved through adopting a multimodal approach to analgesia. Delivery of ropivacaine to midline laparotomy wounds via a Painbuster Soakerä device is safe but has no clinical application following major abdominal colorectal surgery.
AL02 CUMULATIVE SUM (CUSUM) TECHNIQUES TO MONITOR PERFORMANCE AND PROVIDE FEEDBACK
Authors: Watters D. A. K.
Published: April 2007

CUSUM was first used in 1954 as a quality control measure in industrial processes. It was first applied to surgery in 1994 and has been adopted by cardiothoracic surgeons spurred on to some extent by the Bristol Inquiry. CUSUM can be applied to any procedure (or process) where a binary outcome can be obtained; for example, did an anastomotic leak occur? Yes or No. If yes the operation is a failure and if no it is a success. Having determined what outcome is being assessed the next challenge is to decide (in advance) what is acceptable and what is unacceptable performance. This might be determined by consensus of a group of surgeons or derived from the literature. However, the literature is subject to publication bias of good results and might not be reflective of a true “whole practice” audit. Most operations have obvious outcome endpoints that can be assessed though some form of risk stratification and subdivision of outcomes needs to be applied. For example emergency colorectal surgery has a higher mortality rate compared with elective surgery. The workshop will show how CUSUM plots are derived and used in practice. The technique requires no more than an add‐in option in Microsoft excel to calculate the graphs. There are two types of graph: 1 a cumulative failure graph identifies changes in performance early as the plot crosses predetermined performance lines. 2 a CUSUM graph gives an immediate visual impression of performance as the plot crosses action lines. This means that a previously competent surgeon whose outcomes start to change (perhaps for health reasons) would be noticed soon after the change.
AL03 RECONCILIATION
Authors: Beasley A. W.
Published: April 2007

This paper traces the career and achievements of Sir Edward ‘Weary’ Dunlop, not least that he forgave his Japanese captors. It examines the problem of forgiveness and the reconciliation that forgiveness permits, and considers the application of these considerations to three problems faced by surgeons: the problem of litigious patients; the problem of managerial overgrowth; and the problem of political ignorance.
AL04 INTRODUCTION: THE CONCERNS OF THE FOUNDERS
Authors: Beasley A. W.
Published: April 2007

When the Founders met in Dunedin in 1927, they had been working for seven years towards what became the College. During that period they had identified four areas of concern in their search for surgical quality in the two countries: surgical standards; hospital standards; anaesthetic standards (somewhat obliquely identified) and research for the public good. Subsequent speakers will examine the College’s activities in these four areas of concern over the past 80 years.
AL05 OF STRINGS AND SPLINTS AND WARS AND WOUNDS
Authors: Jeffery A. K.
Published: April 2007

Robert Hamilton Russell (1860–1933), a Melbourne surgeon of international repute, played a pivotal role in the formation of the College. In 1925 a letter signed by G.A.Syme H.B.Devine and Russell was sent to senior surgeons in Australia and NewZealand suggesting the establishment of a body to improve surgical standards, a proposal first put by Louis Barnett in 1920.

Born in Kent with medical training at King’s College, Hamilton Russell was House Surgeon to Lister and profoundly influenced by Lister’s mentoring. Russell emigrated to Melbourne in 1890 and with appointments at the (Royal) Children’s Hospital and the Alfred, developed wide surgical interests including fracture management.

At the start of World War I, Hamilton Russell was in England and joined the Australian Voluntary Hospital in France. On returning to Melbourne in 1915 he presented a paper on the treatment of war wounds and in 1916 a paper on fractures included his new method of continuous traction for femoral shaft fracture. At this time the proper management of war wounds and fractures was being vigorously debated.

It was not until the Spanish Civil War, three years after Hamilton Russell’s death, that significant advances were made in the management of war injuries. In Barcelona, Joseph Trueta successfully combined the principles of triage, blood transfusion, early surgery, wound excision and plaster immobilisation. In 1939 Trueta escaped to Britain and with the aid of influential colleagues his techniques with some modification were adopted during the 1939–45 conflict and form the basis of war wound management today.
ES01 THE IMPACT OF SYNOPTIC CYTOLOGY REPORTING ON THYROIDECTOMY RATE IN A SINGLE INSTITUITION
Authors: Tsan C. J. L. , Serpell J. W.
Published: April 2007

Background  Fine needle aspiration cytology (FNAC) is integral to diagnosis and management of patients with thyroid nodules. We introduced synoptic cytology reporting for thyroid nodules in 2004. The aim of the study was to examine the impact of synoptic cytology reporting.

Methods  A comparative study of two 2‐year periods (1/8/2002–1/8/2004 and 2/8/2004–2/8/2006) prior and post introduction of synoptic reporting was conducted from a prospectively collected database of patients presented with thyroid nodules. All data were analysed using Microsoft excel and statistics calculated with likehood ratio and chi square tests.

Results  There were a total of 660 patients. Of these 376 were operated and 284 non‐operated. The female to male ratio was 1 : 7. Comparing the 2 periods, the overall FNAC sensitivities were 60% vs 79.1%, specificities were 83.7% vs 79.4%, accuracy 76% vs 79.3%, false positive 16.3% vs 20.6% and false negative of 40% vs 20.9%. The non diagnostic rates were 7.4% vs 3.15%. FNAC prompted surgery in 66.7% vs 100% in carcinoma and 56.4% vs 73.6% in adenoma. A benign FNAC prompted surgery in 15% VS 19.8% of cases. The total rate of surgery has decreased by 2.7%.

Conclusions  Synoptic cytology reporting has resulted in an overall improvement in all measures of the tests. The rate of surgery has decreased by 2.7%. Synoptic cytology reporting is therefore recommended for all endocrine surgical units.
ES11 INCREASING INCIDENCE OF THYROID CANCER IN RETROSTERNAL GOITRE
Authors: Grodski S. , Brown T. , Gill A. , Sywak M. , Sidhu S. , Delbridge L.
Published: April 2007

There has been a documented worldwide increase in the incidence of thyroid cancer attributed to increased surveillance. The aim of this study is to determine wether thyroid cancer incidence is also increasing in the group of patients with retrosternal goitre, who are not typically the subject of ultrasound surveillance.

This is a retrospective clinical review of all patients undergoing thyroidectomy for retrosternal goitre over a 40 year period. Histology of all recorded thyroid cancers were reviewed by a single pathologist and reclassified according to current WHO criteria. Statistical analysis was performed using the chi‐square test.

Between 1966 and 2005, 2026 patients were operated on for retrosternal goitre on a background of 13,793 thyroid procedures. While absolute numbers of retrosternal procedures remained stable, the rate as a percentage of all thyroid surgery dropped from 21% to 12% (p < 0.05). At the same time the percentage of retrosternal goitres with carcinoma increased from 3.6% to 8% (p < 0.05). However, if microcarcinomas (<10 mm) are excluded then the increase is only 2.9% to 4.3% (p = NS).

Routine ultrasound surveillance is not relevant for patients with retrosternal goitre and hence the changes in thyroid cancer incidence in this study can not be attributed to this change in practice. This study has once again demonstrated an increasing incidence of thyroid cancer, however, there is no increase in the incidence of clinically significant cancers.

This study removes surveillance as a confounding factor and has shown that the increasing incidence of thyroid cancer is due to increased reporting of microcarcinomas and that there is no increase in clinically significant cancers.
ES12 CAN GIANT PARATHYROID ADENOMAS BE SAFELY REMOVED BY MINIMALLY INVASIVE PARATHYROIDECTOMY?
Authors: Meyer‐Rochow G. Y. , Sidhu S. B. , Delbridge L. W. , Grodski S. , Sywak M. S.
Published: April 2007

Purpose  Minimally invasive parathyroidectomy (MIP) has become the procedure of choice for the surgical management of a parathyroid adenoma (PA) which localizes on preoperative imaging. The removal of giant PA (weighing greater than two grams) by the minimally invasive technique has not previously been described. Our aim was to determine the safety and efficacy of the removal of giant parathyroid adenomas at MIP.

Methodology  This is a retrospective case control study. The study group comprise all patients undergoing MIP where the gland weight was >2.0 gm in the period 1998 to 2006. The control group comprised all other patients undergoing MIP (gland weight <2.0 gm over the same period.) MIP was performed using the lateral mini‐incision technique.

Results  There were 52 giant PA (M : F – 16 : 36, mean age 61.9) comprising 3% of all cases, and 785 control patients (M : F – 160 : 625, mean age 58.9). The mean weight of the giant PA was 3.64 gm (range 2.0 to 10.8 gm). The giant PA were successfully removed in 49/52 cases with 3 conversions (5.7%), whereas there were 40/785 conversions (5.0%) in the control group (p = 0.83). There was 1/52 (1.9%) permanent recurrent laryngeal nerve injury in the study group and 2/785 (0.3%) nerve palsies in the control group (p = 0.51). One patient (1.9%) in the giant PA group had persistent hyperparathyroidism, whereas there were 21 (2.7%) patients in the small adenoma group requiring re‐exploration for persistent hyperparathyroidism. There were 2/52 (3.8%) carcinomas in the giant PA group compared to 2/785 (0.25%) in the control group.

Conclusion  Excision of giant PA using a minimally invasive technique can be performed with the same safety, efficacy and outcomes as for smaller adenomas.
ES13 PHEOCHROMOCYTOMA – AN ANALYSIS OF 123 PATIENTS
Authors: Selvan C. K. , Nair A. , Paul M. J. , Abraham D. T. , Thomas N. , Seshadri M. S.
Published: April 2007

Background  Pheochromocytomas are diagnosed in <1% of patient evaluated for hypertension.

Methodology  A retrospective analysis of case records of those patients with histopathologically confirmed pheochromocytoma in our hospital from 1976–2006 [30 YEARS] was conducted.

Result  A total of 123 patients were diagnosed during this period. The median age at presentation was 31 years (range 9–71) with a male to female sex distribution of 75% and 36%. 80% were hypertensive at the time of diagnosis. Headache(84%), palpitations(64%) and sweating(60%) are the most common presenting complaints.Tachycardia [>100 per minute]were seen in 31%. Hypertensive changes in eyes were seen in 87%. In ECG, QTc prolongation in 26%, left ventricular hypertrophy in 30%. Diabetes mellitus/IGT was seen in 35%. Elevated urinary VMA (24 hrs) was seen in 93% when done on 3 consecutive days.

MIBG was positive in 85%. Malignant pheochromocytoma was diagnosed by tumour invasion/metastasis seen 10.44%. Extra adrenal pheochromocytoma 18%, followed by bilateral pheochromocytoma in 11%. Hereditary pheochromocytoma in 13% which include 5 with Von Hippel Lindau and 6 with MEN.

A median follow‐up was 12 months (range 1–204) in which persistent hypertension was seen in 16%. Cholelithiasis in 7%.

Conclusion  In our case series the mean age (31 yrs) of presentation seems to be younger compared to other case series. 16% of our patients were asymptomatic at the time of presentation. Urinary VMA was elevated in 93% of patients when done in 3 consecutive samples. Extra adrenal pheo was common in our patients (18%). MIBG was false negative in 15% of those patients with pheochromocytoma.
ES14P THYROID CANCERS IN CHILDHOOD – A PROSPECTIVE REVIEW OF THE MALAYSIAN POPULATION
Authors: Harjit K. , Hisham A. N.
Published: April 2007

Objective  The aim of this study was to review the incidence and pattern of childhood thyroid cancers at our center. We also evaluate the possible risk factors and the outcome of treatment.

Methodology  Prospective review of all childhood thyroid cancers operated at Putrajaya Hospital from Jan 2002 to Dec 2006. All data was prospectively reviewed and analyzed.

Results  A total number of 20 patients (58.8% of the total number of paediatric goiters) were accrued in this study. The Male : Female ratio was 1 : 4. The mean age was 16.1 (ranged 6–21 years). All patients were euthyroid on presentation. 13 presented with a solitary nodule, 6 with a multinodular disease, 1 thyroglossal cyst and 6 with associated palpable lymph nodes. All were differentiated thyroid cancers; 18 were papillary thyroid cancer (14.1% of total adult population, 18/127) and 2 were follicular (10.5%, 2/17).Total thyroidectomy was done in 12 patients, completion surgery in 8. 9 patients required additional modified radical neck dissection. There was no history of previous irradiation to neck. All patients received radioiodine ablation (RAI) postoperatively. Average weight of gland was 3.2 g and the average size was 3.5 cm. 2(10%) patients developed nodal recurrence. There was no morbidity or mortality in this series. 1 patient had recurrent laryngeal nerve paresis preoperatively. All 20 patients are still alive on a mean follow up of 22 months.

Conclusions  Our study showed that the incidence of malignancy in childhood goiters is significantly high and best option of treatment is total thyroidectomy with or without neck dissection.
ES16P HYPOTHYROIDISM FOLLOWING HEMITHYROIDECTOMY
Authors: Su S. Y. , Serpell J.
Published: April 2007

Background  The incidence and risk factors for hypothyroidism in patients undergoing partial thyroid surgery remain unclear. Hypothyroidism is an under‐appreciated sequel of hemithyroidectomy. The early recognition of post‐operative hypothyroidism will alleviate symptoms and may prevent recurrent thyroid disease.

Aim  To investigate the incidence, time to onset and risk factors for the development of hypothyroidism following hemithyroidectomy.

Methods  Patients undergoing hemithyroidectomy from August 1992 to June 2006 by a single surgeon were identified from an existing, prospectively collected thyroid database. Records were reviewed retrospectively. Patients were analysed for age, sex, family history of thyroid disease, thyroid antibody levels, pre and post‐operative TSH, histological diagnosis, the presence of concurrent thyroiditis, and the lag time to diagnosis of hypothyroidism. Chi‐squared or Fisher’s exact test were performed.

Results  Hypothyroidism was diagnosed in 36 (12%) of 300 patients. The mean time to diagnosis was 7.54 months. The mean thyroxine dose was 77.38. Patients with post‐operative hypothyroidism had a higher incidence of elevated pre‐operative TSH levels (8.3% versus 0; P < 0.01), thyroiditis on histology (50% versus 12.2%; P < 0.01) and elevated thyroid antibodies levels (48.1% versus 11.3%; P < 0.01). Age, gender, family history of thyroid disease, and thyroid pathology were not significant risk factors for hypothyroidism.

Conclusion  Given an incidence of 12%, all patients should have post‐operative thyroid function assessment. Elevated preoperative TSH and thyroid antibody levels, and the presence of thyroiditis on histology are indications for close monitoring.
ES03 THE DELPHIC LYMPH NODE AND THYROID CANCER
Authors: Isaacs J. D. , Ihre‐Lundgren C. , Sidhu S. , Sywak M. , Edhouse P. , Delbridge L.
Published: April 2007

Background  Named after the oracle of Delphi, the Delphic (or prelaryngeal) lymph node has long been regarded as a predictor of malignancy in thyroid cancer. It also has a notorious reputation for being a marker of advanced nodal disease. There is no current medical literature to support or refute these claims. The aim of this study was to determine the true significance of Delphic lymph node involvement in thyroid cancer.

Methods  1,000 consecutive patients undergoing total thyroidectomy formed the study population. All information was obtained from a prospectively maintained database as well as from review of the histopathology records.

Results  227 of 1,000 (22.7%) had a final diagnosis of thyroid cancer. In 63 of 227 (27.8%), the final diagnosis of cancer was unsuspected. The Delphic lymph node was removed in 112 of 227 patients, with 22 of 112 cancerous. Thus, 19.6% of patients had involvement of the Delphic lymph node when it was removed. Delphic node involvement was associated with significantly greater nodal disease (10.1 vs 1.4 nodes; p < 0.05). No patient in either group had Delphic node involvement diagnosed on clinical grounds preoperatively.

Conclusion  Despite its reputation, the Delphic lymph node is not itself an independent predictor of the presence of thyroid cancer. It is however a useful marker of extensive local nodal disease. Identifying intra‐operatively whether the Delphic node is involved may assist in planning the extent of neck dissection during total thyroidectomy.