bluuebunny/crossref_metadata_2025 huggingface dataset:
ES18 *FOLLICULAR THYROID CANCER PRESENTING AS BONE METASTASES
Authors: Serpell J. W. , Andrabi S. A.
Published: April 2009

Purpose:   Follicular Thyroid cancer (FTC) is the second commonest thyroid malignancy. Between 5 and 20% of patients with FTC will have a distant metastasis at the time of presentation. The aim of the present study was to highlight: different modes of FTC presentation, especially bone metastases; the incidence of minimally invasive versus widely invasive cancer; patients presenting with distant metastasis with no evidence of FTC in the thyroid; and patients presenting with metastasis despite regular follow up for benign multi nodular goitre.

Methods:   A retrospective review of 26 cases of FTC identified from a database of 1670 prospectively collected thyroidectomies was undertaken.

Results:   There were 23 females and 3 males of median age 46 (range 25 to 92) years. In 17 (65%) patients, cytology showed a follicular lesion; necessitating a diagnostic hemithyroidectomy, and a 50% rate of two stage surgery. All patients were confirmed cases of FTC on histopathology. Six of twenty six patients had distant metastases in bone; two of these six did not have evidence of cancer in thyroid, one presented with metastasis despite regular follow up for benign multi nodular goitre and the remaining three with distant metastases in bone had evidence of cancer in thyroid. Nineteen of these were categorized as minimally invasive cancer compared to 5 who had widely invasive cancer.

Conclusion:   The present series highlights a rare subgroup of patients presenting with bone metastases without identifiable FTC in the thyroid gland.
ES02 PARATHYROID SURGERY. A TRUE MARRIAGE OF SKILL, TECHNOLOGY AND SCIENCE
Authors: Malycha P.
Published: April 2009

Parathyroid surgery has always been considered difficult as many surgeons do not feel confident that they can reliably find the parathyroid glands. To gain the required skill level detailed understanding of the developmental embryology, anatomy, and endocrinology as well as good understanding of calcium metabolism. A meticulous and skilled technique is required to perform the almost bloodless operation needed to find parathyroid glands. A failed primary operation leads to a very difficult second operation associated with a significant potential for complications and failure. The following significant changes in parathyroid surgery have occurred in the last decade: (1) Minimally invasive parathyroidectomy (MIP): MIP has become the operation of choice for primary hyperparathyroidism (1HPT) where a single gland has been identified by surgeon performed ultrasound (SPU) and/or sestamibi (SM). This occurs in around 80% of cases. However, as any one who teaches MIP knows it is the knowledge and experience that comes from bilateral neck exploration (BNE) in the remaining 20% that determines the success of MIP. Also, recurrent or persisting disease may be amenable to a minimally invasive approach with SPU, SM and physical localisation techniques similar to those used in breast cancer localization. (2) Surgeon performed ultrasound SPU: Henceforth, endocrine surgeons will use SPU pre‐operatively and per‐operatively. SPU alone will detect 79% of adenomas. (3) Sestamibi parathyroid scans SM: SM alone will detect 78% of adenomas. Both SM and SPU will be both positive in 68% of patients and MIP will be achieved in better than 96% of operations. However, only one need be positive to consider attempting MIP. (4) Recognition of an illness profile associated with primary hyperparathyroidism: Pre and post operative illness profiles reveal that 1HPT has many more and more significant symptoms than is often recognised. These symptoms are helped by surgery with more than 80% of patients undergoing surgery recording a significant improvement in wellness and quality of life at 12 months. (5) The need to longer term follow up of patients who have had surgery: Longer term follow up of patients undergoing either BNE or MIP showed that this benefit persists. However up to 10% of MIP and 5% of BNE had recurred by 4 and 6 years respectively.

Conclusion:   Parathyroid surgery is the jewel in the endocrine surgeon's crown. It requires a true marriage of skill, technology and science. As endocrinologists become more informed about the value of high quality surgery they become more willing to refer patients. In the future it will be a combined multidisciplinary service that will concentrate and determine the referral base. Endocrine surgeons in an era of sub‐specialisation will have to have an academic, clinical and research based training to fulfil their role.
ES05 ADRENAL INCIDENTALOMA: HISTOPATHOLOGICAL CORRELATION AND RISK OF MALIGNANCY
Authors: O'neill C. J. , Spence A. , Logan B. , Suliburk J. , Sidhu S. , Sywak M.
Published: April 2009

Purpose:   The incidence of adrenal incidentalomas is rising due to the widespread use of abdominal imaging. Although the majority of adrenal incidentalomas can be observed, larger suspicious lesions will require adrenalectomy. Adrenal fossa lesions are not always adrenal in origin and a variety of non‐adrenal pathologies may mimic incidentalomas. The aim of this study is to review the histopathology and clinical outcomes of patients undergoing surgery for adrenal incidentaloma.

Methods:   A retrospective study of consecutive patients undergoing adrenalectomy for incidentaloma was performed. Data were retrieved from a prospectively maintained adrenal tumour database and medical records.

Results:   In the study period 2003 to 2008, 131 patients underwent adrenalectomy. Thirty‐seven (28 %) where characterized pre‐operatively as incidentalomas. Two (5%) of these incidentalomas were adrenal carcinomas (ACC) and both patients remain alive and disease free 2 years post surgery. The incidence of ACC in the non‐incidentaloma group was 9 from 94 (9.4%). The relative risk reduction of death from ACC for patients undergoing surgery for incidentaloma was 0.051 compared to those presenting with clinically apparent tumours. The number needed to treat for adrenal incidentaloma to avoid one death from adrenal cancer was 20. In 5 (14%) patients with a pre‐operative diagnosis of an adrenal incidentaloma, histopathology revealed tissue of non‐adrenal origin. The pathology of these included; bronchogenic cyst, leiomyosarcoma, pseudocyst, haematoma and GIST.

Conclusions:   Surgery for adrenal incidentaloma likely reduces the risk of death from ACC. Surgeons should be aware of the variety of non adrenal pathologies which may mimic adrenal tumours.
ES09 PATHOPHYSIOLOGY AND MANAGEMENT OF CALCIPHYLAXIS
Authors: Serpell J. W.
Published: April 2009

Calciphylaxis is a rare syndrome of unknown aetiology consisting of vascular and subcutaneous calcification causing ischaemic necrosis of skin, occurring in 4% of those with secondary hyperparathyroidism and chronic renal failure, with a mortality of up to 80% due to septic, necrotic, non‐healing lesions. Other common associations are obesity and diabetes mellitus.

The usual clinical presentation is a sudden onset of rapidly progressive, painful, erythematous, purpuric, stellate, necrotic skin lesions, typically occurring in the lower extremity, with normal pulses. Visceral involvement is common. The differential diagnosis includes pyoderma gangrenosum, vasculitis and erythema nodosum.

Phosphate, calcium and the calcium phosphate product are elevated.

Histology on punch biopsy demonstrates calcification, inflammation, panniculitis, necrosis and vascular micro‐thrombi. Soft tissue x‐rays show calcification of small vessels.

Treatment involves lowering the calcium phosphate product with phosphate binders orally, and calcimimetics such as Cinacalcet. Cinacalcet acts by lowering parathormone by increasing the sensitivity of the calcium receptor. This lowers serum calcium and the serum calcium phosphate product. Dialysis will also help with a low calcium containing dialysate.

Necrotic wounds require debridement and excision, antibiotics, and skin grafting.

Subtotal parathyroidectomy or total parathyroidectomy with autotransplantation will reverse the abnormal calcium phosphate balance and reduce pain and help ulcers to heal, but has not been shown to improve survival. Patients who do not die of sepsis or organ failure frequently undergo amputation of the involved limb.
GS12 HARTMANN'S VS. STENT AND WASHOUT, A REVIEW OF 112 CASES
Authors: White S. I. , Braun W. V. , Frenkiel B. , Martin P. J.
Published: April 2009

Background:   The aim is to compare the outcomes of surgical management of large bowel emergencies. The traditional treatment of Hartmann's resection was compared to the new modalities of Colonic stenting for malignant obstruction and laparoscopic washout for perforated sigmoid diverticulitis.

Methods:   This paper is a retrospective review of 112 consecutive large bowel emergencies presenting to The Tweed Hospital and John Flynn Private Hospital warranting surgical intervention during the 8 year period 2000–2008. Patients with obstruction from cancer and perforation from diverticulitis were included. Patients with volvulus, pseudo‐obstruction, bleeding, stercoral ulceration and prolapse were excluded. Patients with non urgent colonic stenting were also excluded.

Results:   The patient groups were comparable for age, ASA and pathology after exclusions. 57 patients underwent a Hartmann's (obstruction 23, perforation 34) vs. 55 patients undergoing stent for obstruction 21, or washout for perforation 34. Significant differences were observed in the mortality rates, Hartmann's 11/57 (19%) vs. stent and washout 2/55 (37%). Also length of stay: Hartmann's 15 days vs. stent and washout 6 days. Hartmann's was required to salvage 2 failed stents and 6 failed washouts. In 16 of 26 washouts and 11 of 17 stents patients underwent delayed elective resection.

Conclusion:   Patient selection, technical expertise and long learning curve were all aspects that influenced the early results of stenting and washout. Hartmann's is no longer the preferred treatment option for left sided colonic emergencies.
GS15 *NECROTISING FASCIITIS‐ ANALYSIS OF MORTALITY IN VICTORIA, AUSTRALIA
Authors: Lai C. C. , Widjaja A.
Published: April 2009

Background:   Necrotising fasciitis is a soft tissue infection with progressive tissue necrosis, affecting the deep fascial layers. It is a rare life‐threatening disease with mortality rates from 6.1–43%. Many factors have been associated with increased mortality. The aim of this study is to re‐evaluate these factors by analysing data from a larger patient series than any presented in the published literature to date.

Methods:   The medical records of 151 sequential patients with necrotising fasciitis treated in the Alfred Hospital from 1997–2004 were reviewed to identify the factors associated with increased mortality. The data was then analysed with multivariate analysis to identify the statistically significant factors.

Results:   Mortality rate of this study was 11.3%. The statistically significant factors were CRP > 200 on admission (p = 0.018), mechanical ventilation on admission (p = 0.002), older age (p = 0.0231), male (p = 0.013), delayed hyperbaric therapy from first symptoms (p = 0.045), spontaneous precipitant (p = 0.015), and complications of multi organ failure (p = 0.006), acute renal failure (0.011), acidosis (p = 0.001) or atrial fibrillation (p = 0.001), sepsis (p = 0.045).

Conclusions:   The knowledge of these factors will assist in the management of necrotising fasciitis by prioritising these patients, allocating more appropriate resources to prevent delay in hyperbaric treatment and by promptly treat the disease, especially in ICU setting to prevent complications and improve survival.
GS19 *THE ANTIOXIDANT STATUS OF AN INFLAMMATORY DISEASE AS MEASURED BY CYCLIC VOLTAMMETRY
Authors: Windsor J. A. , Mittal A. , Phillips A. , Flint R. , Delahunt B. , Kilmartin P.
Published: April 2009

Objective:   To determine whether serum antioxidant capacity measured by the electrochemical technique of cyclic voltammetry (CV) could resolve differences in severity of the inflammatory disease acute pancreatitis.

Methods:   Experimental animal study using male Wistar rats. Group 1 (baseline), immediate euthanasia with no surgical interventions; Group 2 (sham), identical surgical procedures to the pancreatitis groups but no intraductal infusion; Groups 3–5, acute pancreatitis induced by intraductal infusion of 3%, 4% or 5% sodium taurocholate respectively. Terminal blood and pancreatic tissue samples for CV, biochemistry and histology were collected at 12 h (Groups 2–5).

Results:   There was a significant positive correlation of the first serum cyclic voltametric peak current maxima (CVi1) with pancreatic histological severity (Spearman r = 0.51, p = 0.007) as well as with a number of other markers of systemic disease severity, notably bicarbonate (r =−0.57, p = 0.002), base excess (r =−0.65, p < 0.001) urea (r =−0.68, p < 0.001) and calcium (r =−0.60, p = 0.008). CVi1 was superior at indicating the severity of the disease state compared to a standard method of total antioxidant capacity measurement.

Conclusions:   CV was found to be a simple, technique that could differentiate between the physiological and histological severities of acute pancreatitis. Further clinical studies are now justified to determine if point‐of‐care CV offers prognostic and treatment‐monitoring advantages for severe acute inflammatory illnesses within the critical care setting.
GS23P ACHIEVING QUALITY IN COLONOSCOPY: BOWEL PREPARATION TIMING AND PROCEDURAL TECHNIQUE
Authors: Owen G. N. , Athreya P. J. , Wong S. W. , Douglas P. R. , Newstead G. L.
Published: April 2009

Background:   Colonoscopy is the gold standard for investigating pathology of the large bowel. Numerous factors influence the efficacy of bowel preparation for colonoscopy. Inadequate bowel preparation can lead to missed pathology. Timing of preparation, timing of procedure and patient bowel habit may have an influence on the quality of the preparation. The aim of this study was to investigate the quality of cleansing of sodium picosulphate with different administration schedules and to evaluate whether patient's prior bowel patterns influenced quality of cleansing.

Methods:   325 patients were interviewed prior to colonoscopy to evaluate prior bowel habit and timing of preparation administration. The quality of preparation was then assessed during colonoscopy. Further patient factors evaluated included patient tolerance, compliance and adverse reactions to preparation. Procedural factors evaluated included quality of cleansing and circular muscle hypertrophy. Procedure total time, caecal intubation time and withdrawal times were also recorded. A 5‐point scale was used to assess quality of cleansing.

Results:   The quality of cleansing for individual bowel segments was worse for afternoon procedures (p < 0.05 for all segments), and for patients with prior constipation (p < 0.05 for transverse and descending segments). No correlation was found between the quality indicators (total duration, caecal intubation time, withdrawal times), colon length, circular muscle hypertrophy or presence of diverticula for cleansing quality.

Conclusion:   The quality of cleansing is significantly improved when bowel preparation is taken the day prior to colonoscopy. In addition patients with prior constipation demonstrated poorer cleansing.
GS25P BURNOUT IN AUSTRALASIAN YOUNGER FELLOWS
Authors: Sammour T. , Benson S. , Neuhaus S. J. , Findlay B. , Hill A. G.
Published: April 2009

Purpose:   Burnout is the state of prolonged physical, emotional, and psychological exhaustion characteristic of individuals working in human service occupations. This study examines the prevalence of burnout among Younger Fellows of the Royal Australasian College of Surgeons (RACS), and its relationship to demographic variables.

Methodology:   In March 2008, a survey was sent via email to 1,287 Younger Fellows. This included demographic questions, a measure of burnout (Copenhagen Burnout Inventory), and an estimate of social desirability (Marlowe‐Crowne Social Desirability Scale – Form C).

Results:   The sample comprised 278 participants – an overall response rate of 21.6%. Females exhibited higher levels of personal burnout and work‐related burnout, but no significant difference in patient‐related burnout. Younger Fellows in hospitals with less than 50 beds reported significantly higher patient‐related burnout levels. An equal work division between public and private practice resulted in higher work‐related burnout than concentration of work in one sector. Younger Fellows working more than 60 hours per week reported significantly higher personal burnout than those who worked less than this. There was no significant correlation between age, country of practice, surgical specialty and any of the burnout subscales.

Conclusion:   Female surgeons, surgeons that work in smaller hospitals, those that work more than 60 hours per week, and those with practice division between the private and public sectors, are at a particularly high risk of burnout. Further enquiry into potentially remediable causes for the increased burnout in these groups is indicated.
GS27P COLONOSCOPY PATIENT SATISFACTION SURVEY: A COMPARISON OF ANAESTHETIC DELIVERY
Authors: Waliuddin A. R. , Smith S. , Morris O.
Published: April 2009

Purpose:   Anaesthesia delivery for colonoscopy within HNEAHS is either by an Anaesthetic driven propofol or an Endoscopist supplied sedation service (usually midazolam and fentanyl). The aim of this project is to compare patient satisfaction with respect to these two different modalities of anaesthetic delivery.

Methodology:   All patients undergoing colonoscopy between 1/9/2008 and 30/12/2008 in two endoscopy units (that utilised different sedation services) were surveyed with respect to their pain, recall and satisfaction regarding their anaesthetic delivery.

Results:   263 out of a potential 735 patients consented prospectively to participation in the survey. Patients undergoing Anaesthetic driven propofol experienced less pain during colonoscopy than those who had Endoscopist supplied sedation (VAS 0.05/10 vs. 1.34/10, p < 0.0001). There was also significantly less recall during the procedure with propofol, and a significantly higher rate of satisfaction with the anaesthetic driven propofol service. There was no difference with respect to recall of events or pain following the procedure.

Most importantly a higher proportion of patients who had Anaesthetic driven propofol would either be willing to undergo the procedure again when compared with patients having Endoscopist supplied sedation (99% vs. 95%, p < 0.05), or recommend it to others (100% vs. 92%, p < 0.005).

Conclusion:   An Anaesthetic driven propofol service for colonoscopy provides superior patient satisfaction when compared to Endoscopist supplied sedation.
GS31P FACTORS INFLUENCING MEDICAL ONCOLOGY REFERRALS IN DUKES’ C COLONIC CANCER
Authors: Lu C.T. , Stephens J. H. , Rieger N. A.
Published: April 2009

Introduction:   Colorectal cancer (CRC) is one of the most common malignancies worldwide including Australia. Adjuvant chemotherapy improved survival in patients with Dukes’ C CRC. Yet, not all Dukes’ C CRC are referred to medical oncology and subsequently received adjuvant chemotherapy.

Purposes:  

To analyse factors influencing referral to medical oncology in patients with Dukes’ C Colonic cancer in our institutions.

Methods:   Prospective database on patients underwent resection for CRC, was collected at our institutions between 1991 to July 2007. Univariate and multivariate analysis of factors including demographic, institution based, timing of surgery, complications and length of hospitalisation on the pattern of medical oncology referral. P value of 0.05 or less was considered to be significant.

Results:   466 patients were identified to have Dukes’ C colonic cancer, 251 (53.9%) females and 215 (46.1%) males. 272 (58.4%) were referred to medical oncology. Univariate analysis revealed Age, Sex, ASA grade, underwent resection in private hospitals and underwent elective resection were statistically significant associated with medical oncology referrals. Age, underwent elective resection and underwent resection in private hospitals were the independent factors on multivariate analysis. The probability of medical oncology referral in those underwent elective resection was 63% vs. 41% in those underwent emergency resection, similarly 69% in those underwent resection in private hospitals vs. 50% in public hospitals.

Conclusion:   Referrals to medical oncology for adjuvant chemotherapy in Dukes’ C colonic cancer were more likely in younger patients, underwent elective resection and underwent surgery in private hospitals.
GS33P IS AN APGAR SCORE FOR SURGICAL PATIENTS USEFUL?
Authors: Levi E. , Nasis L. , Chiu D. , Chu K. , Grigg M. J.
Published: April 2009

Purpose:   The Apgar score for neonates is well established. Gawande et al (1) recently reported a validated Apgar score for surgery derived for intraoperative parameters (blood loss, lowest heart rate, lowest mean arterial pressure). They studied elective general and vascular surgical patients and demonstrated predictive capability in terms of major complications and death within 30 days. The aim of our study was to determine if the Apgar surgical score was valid and useful in an Australian hospital setting.

Methods:   Elective and emergency surgical procedures over a 31‐day period were prospectively studied. The anaesthetic and surgical teams were not aware of the Apgar score. The postoperative course of each patient was reviewed. Primary outcome measures were death or major complications; secondary measures were ICU admission and inpatient length of stay.

Results:   790 patients were studied and the Apgar score calculated. No correlation was found between Apgar score and complications or death within 30 days. Only 20 (2.5%) had a score of less than 4, and in this group there was 1 death and 6 patients with complications. There were no unplanned ICU admissions. Inpatient length of stay was not shown to be significantly longer in those with lower scores. The Apgar score did not correlate with ASA status. Patients undergoing Caesarean section tended to have poor Apgar scores but excellent outcomes.

Conclusion:   Using the surgical Apgar would not have altered the management of any patient in the study e.g., planning ICU admission etc. and therefore we are unable to recommend its introduction as a routine measure.
GS37P SELECTIVE MAGNETIC RESONANCE CHOLANGIO‐PANCREATOGRAPHY (MRCP) IN GALLSTONE PANCREATITIS MAY MISS CHOLEDOCHOLITHIASIS
Authors: Srinivasa S. , Sammour T. , Mcentee B. , Davis N. , Hill A. G.
Published: April 2009

Purpose:   Patients with Gallstone Pancreatitis (GP) have a high risk of choledocholithiasis. MRCP has been recommended by some as the investigation of choice to diagnose choledocholithiasis. This study examines the diagnostic value of selective MRCP in GP.

Methodology:   Retrospective audit of all presentations of GP between Jan 2001–December 2007 at Middlemore Hospital. Demographic data, clinical presentation, biochemical, radiological findings and outcomes were reviewed. Data were analysed using univariate analysis and chi‐squared test.

Results:   There were 339 cases of gallstone pancreatitis with 243 females and a mean age of 52 years. Overall, 95 cases of choledocholithiasis‐ as confirmed by ERCP/ Intra‐Operative Cholangiogram (IOC) – were diagnosed. The indications for MRCP in this study were heterogeneous. 117 patients underwent MRCP within a median of 4 days of admission with 15 (13.7%) showing choledocholithiasis. There was no significant difference in time to MRCP between positive and negative groups. ERCP/IOC confirmed 13/15 stones within a median of 2.5 days. MRCPs, however, missed 8 cases of choledocholithiasis subsequently demonstrated on ERCP/IOC where clinical suspicion remained after a negative MRCP. MRCP sensitivity was 62.0, specificity 97.9. The Positive Likelihood Ratio was 6.5, Negative Likelihood Ratio was 0.1. PPV was 86.7, NPV was 92.0. 222 patients followed different clinical pathways with 82 Common Bile Duct (CBD) stones diagnosed by ERCP/IOC.

Conclusion:   Choledocholithiasis is common in GP. Selective MRCP is highly specific in GP but may not be sensitive enough to exclude choledocholithiasis in this context.
GS39P THE UNDIFFERENTIATED PRESACRAL MASS: A NERVOUS TUMOUR
Authors: Kaplan E. D. , Rozen W. M. , Murugasu A. , Sitzler P.
Published: April 2009

Background:   Presacral lesions often present late because of non‐specific presenting symptoms and imaging findings that are difficult to interpret. We present the clinical scenario and review of the literature.

Methods:   A plexiform neurofibroma presenting as a presacral mass is described, with the difficulties in diagnosis and investigation explored.

Results:   CT and MRI are useful imaging modalities in the diagnosis of an undifferentiated presacral mass and certainly contribute to eliminating some differential diagnoses and exploring characteristics of the lesion, but ultimately the need for a histological diagnosis and surgical excision is highlighted.

Conclusion:   Presacral masses are difficult to diagnose, assess and treat. Adequate imaging and histological confirmation are essential in their treatment.
GS04 **MANAGEMENT OF ULTRASOUND DETECTED INGUINAL HERNIA WITH NO CLINICAL CORRELATION
Authors: Chetrit S. R. , Tan P. R.
Published: April 2009

Purpose:   To determine the outcome of patients who had ultrasound detected, but no evidence of clinical correlation.

Methodology:   In a single surgeon practice, all the patients referred by General Practitioners between Aug 2007 to June 2008 with an ultrasound suggesting inguinal hernia, but with no clinical correlation were included. All of them were managed non‐surgically. Telephone interviews were conducted to assess the outcome in 16 out the 19 patients eligible for the study. Median follow‐up was eight months.

Results:   Pain in the inguinal region was the predominant symptom at presentation. Seven patients had become pain free within two weeks of the initial consultation. The remaining 9 patients had residual pain; 5 patients noticed improvement, 1 patient felt no change and 2 patients had other diagnosis made for their symptoms. No patient chose to see another specialist or had an operation for the management of the initial presentation.

Conclusion:   Fourteen out of sixteen (87.5%) patients who had an ultrasound demonstrating the presence of an inguinal hernia, with no clinical correlation, had improvement or resolution of their pain. This study demonstrates the importance of non surgical management in patients with groin pain and ultrasound detected inguinal hernia but with no clinical correlation.
HS10P DYNAMIC EXTERNAL FIXATION FOR COMMINUTED INTRA‐ARTICULAR METACARPAL HEAD FRACTURE OF THE THUMB
Authors: Dhillon R. S. , Baldwin R. , Alkadhi A. , Moaveni Z.
Published: April 2009

Principles of osteosynthesis for intra‐articular fractures dictate anatomic reduction of the fracture fragments to restore articular surface congruity and to allow early active joint motion. Open reduction and internal fixation of small comminuted intraarticular fragments may not be possible and risk devitalizing blood supply to the small fragments. Suzuki et al. described the Pins and Rubber band Traction System (PRTS) for proximal interphalyngeal joint pilon fractures. This method relies on capsuloligamentotaxis to reduce the fracture. We describe the successful use of this device for a severely comminuted fracture of the thumb metacarpal head.

A 52 year old right hand dominant office manager sustained a mechanical fall with an axial compression force onto the right thumb and sustained a closed comminuted intraarticular fracture of the metacarpal head. Given the degree of comminution seen on CT, we elected to treat this with the PRTS although it is for a different indication than that described by Suzuki. We modified the post‐operative rehabilitation regime.

The QuickDASH score was 20/100. The patient had achieved full range of motion (equal to the uninjured side) and full return of function by the 6 week follow up. Six month follow‐up revealed an excellent outcome and repeat radiograph showed preservation of joint space and remodelling of the metacarpal head. This paper discussed the operative and rehabilitation details of this case. We feel that in such cases minimally invasive treatment with dynamic external fixation allows early joint motion and excellent outcomes without inherent risks of open reduction and internal fixation of the small comminuted fragments.
HS02 NON VASCULARIZED CANCELLOUS BONE GRAFT FROM DISTAL RADIUS AND KIRSCHNER WIRE FIXATION AS A TREATMENT FOR CAVITARY TYPE SCAPHOID NONUNIONS EXHIBITING DISI
Authors: Millar M. J. , Kirkham S. G.
Published: April 2009

Purpose:   Cavitary type scaphoid nonunions represent a difficult treatment challenge as they exhibit bone loss, scaphoid shortening, flexion (“humpback”) deformity and dorsal intercalated segmental instability (DISI), creating altered carpal mechanics which may proceed to the degenerative changes of scapholunate advanced collapse of the wrist. We present our technique for these problematic cavitary nonunions and discuss its rationale.

Methodology:   A retrospective analysis was undertaken on a consecutive cohort of 19 patients that were treated by the relatively simple method of (1) excising the nonunion via a volar approach (2) packing the volar defect with cancellous autograft, harvested from the ipsilateral distal radius and (3) holding it out to length with two Kirschner wires and a plaster cast. Wires are removed at 10–12 weeks.

Results:   Union was achieved in (18/19) 95% of cases, with no complications, in an average of 9.7 (range 8–12) weeks. Carpal mechanics were restored, with an average carpal height index of 1.52 ± 0.07 and an average scapholunate angle of 46 ± 10 degrees. Average follow up was 2.2 years.

Conclusion:   In this subset of patients we believe this technique is less technically demanding than the use of either corticocancellous grafts or various compression screws. Our success equals that of other published techniques, with all patients enjoying a full return to work even in occupations demanding heavy labour. We believe this may also be due to the ability of cancellous grafts to restore carpal height and normal carpal angles, thereby producing a better functional outcome.
HS03 STABILITY OF THE WRIST AND THE RADIAL (LATERAL) COLLATERAL LIGAMENT
Authors: Fahrer M.
Published: April 2009

Purpose:   Most textbooks, including “Terminology for Surgery of the Hand” name this ligament. Ingenious diagrams demonstrate its role in stabilizing the wrist in extreme ulnar deviation. The present study aims to verify this assumption.

Methods:   Eight embalmed cadaveric specimens, dissected to expose the fibrous apparatus on the radial side of the wrist joint were fixed to a stand by the radius and ulna. Constant traction of 2 kg in the ulnar direction was exerted through the base of the third metacarpal. The fibrous elements on the radial side of the joint, ie. the capsule and the strong fibrous sheaths of the tendons of Extensor Pollicis Longus (EPL), Extensor Carpi Radialis Longus (ECRL) and Brevis (ECRB), and of the Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB) were divided in different sequences.

Results:   No real radial (lateral) collateral ligament of the wrist, capable of stabilising it in extreme ulnar inclination was found. Stability was due to the strong fibrous sheaths of ECRL, ECRB, and especially that of APL and EPB.

Conclusion:   This raises questions about the aetiology of de Quervin's disease.
HS09P COMPARISON OF SPEED AND EFFICACY OF SPRAY‐ON VS PAINT‐ON BETADINE FOR SKIN PREPARATION IN HAND SURGERY
Authors: Mafi D. R. , Dhillon R. , Phang L. , Moaveni Z.
Published: April 2009

Purpose:   Human skin contains an abundance of natural micro‐organisms on its surface. Routine surgical practice involves preparation of the operative field with skin cleansing using various agents to reduce risk of post‐operative infection. Betadine is routinely used in skin preparation of the operative field prior to hand surgery. This is a pilot study to compare speed and efficacy of two methods of surgical site preparation (spray and paint) using Betadine.

Methodology:   This study utilized twenty healthy adult volunteers who had Betadine sprayed on one hand and painted on the other. Prior to application of Betadine bacterial skin swabs were taken from two areas on each hand (palm and nails) to identify baseline bacterial counts. The side sprayed and painted alternated with each volunteer. Betadine was applied by a single surgeon. Repeat skin bacterial swabs were taken following skin preparation. The time taken to spray and paint on the Betadine was recorded. Swabs were cultured for 48 hours and then bacterial counts were measured by counting colony‐forming units per plate.

Results:   Application time by spraying was significantly faster than painting, taking less than half the time (p < 0.0001). The application of Betadine by both methods resulted in substantial reduction in bacterial counts. Application via spraying achieved a mean reduction in bacterial counts of 93% compared to 98% achieved by painting (p = 0.12).

Conclusion:   In this pilot study surgical preparation of the hand with Betadine by spraying was significantly faster than painting. Both methods achieved substantial drops in bacterial counts with no significant difference in efficacy being found.
HN04 THE EVOLUTION OF THE WELLINGTON HEAD & NECK AND SKULL BASE SURGERY SERVICE – AN ANALYSIS
Authors: Chong S. J. , Mackinnon C. A. , Davis C. , Armstrong J. A. , Tan S. T.
Published: April 2009

Aims:   To improve our head & neck and skull base surgery service, over the last decade, we have expanded the multidisciplinary head & neck clinics, recruited additional surgeons with appropriate skills, increased resources such as theatre access, and prospective data collection. We have also introduced novel approaches including routine immediate facial reanimation, based on our central philosophy that ‘head and neck surgery is about the quality of life’. The effects of this strategy have been captured by our prospective database established in 2000. This paper demonstrates the impact of these changes upon our service.

Methods:   Patients undergoing head and neck surgery were culled from our prospective database 2000–2008 and compared with those treated 1990–1999. Analyses included overall numbers, tumour distribution and stage, the use of free tissue transfer and facial reanimation, complication rates and oncological outcomes.

Results:   Between 2000 and 2008, 682 new patients were evaluated at the head & neck clinics, 59% of whom had Stage III or IV disease, and 56% were squamous cell carcinoma. 182 free tissue flaps and 251 nodal dissections were performed, 156 of which were for nodal metastasis. The recurrence and mortality rates were 23% and 10% respectively.

Conclusions:   Since 2000, our multidisciplinary head & neck and skull base service has expanded in both patient numbers and reconstructive complexity, including routine immediate facial reanimation and a quadruple rate of free flap reconstruction. Future directions are discussed.
HP13 THE EFFECT OF PROVIDER CASE VOLUME ON CANCER MORTALITY: A SYSTEMATIC REVIEW AND META‐ANALYSIS
Authors: Gruen R. L. , Pitt V. , Green S. , Parkhill A. , Campbell D. , Jolley D.
Published: April 2009

Much research has addressed the association between provider case volume and mortality. We systematically reviewed this association in 96 primary studies involving over one million patients with oesophageal, gastric, hepatic, pancreatic, colonic or rectal cancer, among whom over 70,000 deaths were recorded. Most studies addressed the relationship between hospital surgical case volume and short‐term peri‐operative mortality. Few studies have addressed the impact of surgeon case volume or evaluated long‐term survival as an outcome. Common methodological limitations in estimating magnitude of a volume‐related effect were failure to control for potential important confounders, post‐hoc categorisation of provider volume and unit of analysis errors.

We found a large volume effect for most gastrointestinal cancers: with each doubling of hospital case volume the odds of peri‐operative death decreased by 0.1 to 0.23. This effect was apparent for case volumes ranging from fewer than ten to several hundred per year, with no clear threshold levels. We calculated that between 10 and 50 patients per year, depending on cancer type, need to be moved from a ‘low volume’ hospital to a ‘high volume’ hospital in order to prevent one additional volume‐associated peri‐operative death. Despite these findings, a number of large studies found no apparent association between hospital volume and peri‐operative mortality. The heterogeneity of results from individual studies calls into question the validity of case volume as a proxy for care quality, and leads us to conclude that more direct quality measures and the validity of their use to inform policy should be explored.
HP15 TRANSGASTRIC LAPAROENDOSCOPIC RESECTION OF GIST
Authors: Aly A. , Bhatia K. , Sweeney T.
Published: April 2009

Background:   GIST lesions of the stomach are adequately treated by local resection amenable to standard laparoscopic techniques. However approach depends on the position of the lesion as well as its presenting surface. GISTs presenting at the luminal surface, particularly those located near the gastro‐oesophageal junction pose particular difficulty and often require major open surgery. A novel minimally invasive “transgastric laparo‐endoscopic” approach may simplify resection and avoid open surgery.

Aims:   To describe the performance of, and our early experience with, the “transgastric laparo‐endoscopic” approach for luminal gastric lesions.

Method:   The transgastric laparo‐endoscopic technique combines the use of endoscopy and standard laparoscopic instruments used within the lumen of the stomach. Details of six consecutive cases employing this technique were recorded prospectively.

Results:   In 5 of 6 cases, GIST lesions were successfully resected with adequate surgical margin whilst in one patient the technique failed. No complications occurred in successful patients.

Significant benefits of the technique were experienced with respect, access, vision, precision of resection and protection of the gastro‐oesophageal junction. Both proximal and distal areas of the stomach and synchronous lesions were accessed without altering port positions. The technique and important factors contributing to technical difficulty and methods of overcoming them are described in detail and a video is presented.

Conclusion:   This is a potentially useful technique offering significant benefits in approaching awkwardly placed gastric lesions.
HP17P BARRETT'S OESOPHAGUS AND THE SYMPTOMATIC EFFICACY OF FUNDOPLICATION
Authors: Hester C. A. , Barbour A. P. , Smithers B. M. , Menzies B. , Martin I. , Gotley D. G.
Published: April 2009

Purpose:   To examine the efficacy of fundoplication for patients with uncomplicated gastro‐oesophageal reflux disease (GORD) and Barrett's oesophagus (BO) and to compare the outcomes for patients with BO following either Nissen or Toupet fundoplication.

Methods:   A prospectively collected database identified 2990 patients who underwent either Nissen or Toupet laparoscopic fundoplication for GORD or BO between 1991 and 2008. Pre‐ and post‐operative outcomes were measured using a simplified DeMeester scoring system. The scores were recorded for up to 5 years by the same research nurse and compared using small sample statistics.

Results:   Of the 2990 patients, 390 (13%) had BO and 2600 (87%) had GORD. Preoperatively, the BO group experienced significantly more symptoms of heartburn than did the GORD group (86 vs. 91% p < 0.01). However, both groups responded equally favourably to fundoplication with high patient satisfaction at 5 years (88 vs. 93%, p = NS). There were no statistically significant differences in post‐operative medication and re‐operations rates between the two groups. Nissen and Toupet procedures were both equally effective for patients with Barrett's disease with respect to heartburn and regurgitation. At five years there was an increased occurrence of dysphagia in the Toupet group (17%) compared with the Nissen group (4%, p = 0.01). This may follow from the Toupet procedure being favoured for patients with documented primary oesophageal motility disorder (Toupet 47% vs. Nissen 30%, p < 0.01).

Conclusions:   The symptoms of uncomplicated GORD and BO respond very well to fundoplication. Both the Nissen and Toupet procedures are equally effective in patients with Barrett's oesophagus.
HP18P CHEST PAIN BEFORE AND AFTER LAPAROSCOPIC CARDIOMYOTOMY FOR ACHALASIA
Authors: Wullur C. , Watson D. I. , Bessell J. R.
Published: April 2009

Purpose:   Laparoscopic cardiomyotomy with anterior partial fundoplication usually achieves good outcomes for patients with achalasia. However, some patients continue to experience chest pain after surgery, even when symptoms such as dysphagia have resolved. Previous studies have not investigated this. Hence, in this study we sought to identify the outcome of chest pain following laparoscopic myotomy.

Methodology:   The outcome of chest pain in 157 patients who underwent laparoscopic cardiomyotomy and anterior partial fundoplication was determined. Patients underwent symptom assessment before and after surgery using a standardised questionnaire. This determines evaluated chest pain, and other symptoms including odynophagia, dysphagia and regurgitation, and overall satisfaction with the outcome.

Results:   Chest pain levels were similar across all age groups and sexes before and after surgery. Following surgery, there was a significant reduction in the frequency of chest pain (daily chest pain declined from 27% to 6%). 60% still experienced some degree of chest pain after surgery. Of these, 72% also reported dysphagia, 14% odynophagia, and 35% acid regurgitation (66%, 12% and 23% before surgery).

Conclusion:   Chest pain is common before and after cardiomyotomy for achalasia, and it is frequently associated with dysphagia. Whilst it occurs less frequently after surgery, it will persist in many patients, and this information should be provided to individuals with achalasia who are being considered for surgical treatment.
HP19P EARLY ORGAN SPECIFIC MITOCHONDRIAL DYSFUNCTION SEEN DURING EXPERIMENTAL ACUTE PANCREATITIS
Authors: Mittal A. , Phillips A. , Hickey A. , Loveday B. , Windsor J. A.
Published: April 2009

Background and Aims:  

Multiple organ dysfunction syndrome (MODS) is the main cause of death in severe acute pancreatitis. Primary mitochondrial dysfunction is now thought to play a central role in the development and progression of organ failure in critical illness. The aim of this study was to investigate mitochondrial function in seven tissues during early acute pancreatitis in two experimental rodent models.

Methods:   Twenty‐eight male Wistar rats were studied. Group 1 (n = 8), saline control; Group 2 (n = 6), caerulein induced acute pancreatitis; Group 3, (n = 7) sham surgical controls; Group 4 (n = 7), taurocholate induced acute pancreatitis. Animals were euthanased at 6 h from the start of the experimental protocol and mitochondrial function was assessed in the heart, lung, liver, kidney, pancreas, duodenum and jejunum. Mitochondrial function was assed using a substrate and inhibitor protocol on the Oroboros machine.

Results:   Significant mitochondrial dysfunction was present in the pancreas, lung and jejunum in the models of acute pancreatitis compared to control groups. The heart, liver, kidney and duodenal mitochondria were unaffected.

Conclusion:   This study found an early inhibition of mitochondrial function present selectively in the lung and jejunum during acute pancreatitis. Subsequent failure of these two organ systems is implicated in the morbidity and mortality associated with severe acute pancreatitis and MODS. These findings suggest that early mitochondrial dysfunction occurs selectively in certain organs remote from the pancreas as a key event during early pancreatitis. Further research is now needed to evaluate the use of early mitochondrial specific therapies in early acute pancreatitis.
HP20P EVALUATION OF SEPTIC COMPLICATIONS IN PATIENTS UNDERGOING BILIARY SURGERY FOR GALL STONES IN A TERTIARY CARE TEACHING HOSPITAL OF SOUTH INDIA
Authors: Rao A. , Rodrigues G. S.
Published: April 2009

Background:   One of the aetiologies of gall stone formation is infection and bile is a good media for micro‐organisms to grow. Acute cholecystitis and spillage of bile intra‐operatively can lead to sepsis and postoperative complications. An attempt to study the nature of organisms and their antibiotic sensitivity is important to take appropriate steps.

Methods:   This prospective study was conducted over a period of two years (from July 2005 to July 2007) in a tertiary care teaching institute in South India. Bile samples of 100 patients undergoing biliary tract surgery were collected and cultured for aerobic and anaerobic bacteria. Patients were divided into two groups which included 84 cases who underwent laparoscopic cholecystectomy and 16, open cholecystectomy. All the patients received prophylactic antibiotic.

Results:   Bile culture was positive in 8 cases. Two cases developed postoperative wound infection; however in these bile culture was sterile. No significant postoperative complications were observed in any of the group apart from 1 case that developed intra abdominal abscess along with wound infection requiring re‐exploration. Six cases developed postoperative fever that subsided on its own.

Conclusion:   The overall rate of septic complications following biliary surgery was extremely low. Present study does not show any correlation between infected bile and septic complications that is in accordance with the published literature and highlights the fact that good surgical technique and judicious use of prophylactic antibiotics are two major factors for lower incidence of septic complications, if any, after biliary tract surgery.
HP23P LAPAROSCOPIC LARGE HIATAL HERNIA REPAIR – IMPACT ON RESPIRATORY FUNCTION AND QUALITY OF LIFE
Authors: Zhu J. C. , Becerril G. , Falk F. L.
Published: April 2009

Purpose:   This study is to examine the impact of laparoscopic repair of large hiatal hernias on patient's respiratory function and quality of life.

Methodology:   From 2004 to 2008, 30 consecutive patients with large paraesophageal hernias defined as >50% of stomach in the intrathoracic cavity with a minimum follow‐up of 2 years were included in this study. All the patients had formal respiratory function test 1 week prior and 3 months after their laparoscopic hiatal hernia repair. The patients had to rate their symptom severity and complete a quality of life questionnaire (GIQLI) preoperatively and then at 3‐month, 6‐month and thereafter yearly intervals postoperatively.

Results:   There were no hospital mortality and the morbidity rate was 10%. In 26 patients with preoperative dyspnoea, 22 had complete resolution while the remaining 4 had experienced improvement in dyspnoea severity postoperatively. The mean dyspnoea severity index reduced from 2.4 to 1.3(p < 0.001). Overall, there was 1%, 3% and 3% postoperative increase in FEV1, FVC and DLCO values for the whole group, none of which reached statistical significance. For the patients with resolution or improvement of their dyspnoea after the laparoscopic repair, no significant changes in their respiratory function parameters were demonstrated. The GIQLI score improved from a preoperative value of 85.7 to 107.9 postoperatively (p < 0.001).

Conclusion:   We failed to show a significant change in patient's respiratory function despite a clearly demonstrated improvement of their respiratory symptoms. Alternative reasons for the reduction of dyspnoea severity should be sought. Laparoscopic hiatal hernia repair is also a safe procedure that can lead to better patient quality of life.