bluuebunny/crossref_metadata_2025 huggingface dataset:
LOCALLY ADVANCED BREAST CANCER: IS SURGERY WARRANTED FOLLOWING CHEMOTHERAPY?
Authors: Kent Alison L. , Eaton Michael , Marshall Nicholas , Humeniuk Vladimir
Published: January 2008

Various methods of management of locally advanced breast cancer have been proposed, including combinations of chemotherapy, surgery. radiotherapy. immunotherapy and hormone manipulation. This retrospective study evaluated the effectiveness of chemotherapy in the management of locally advanced breast cancer in pre‐ and perimenopausal women by examining the pathology of the mastectomy specimens. Sixteen women who on initial clinical examination had breast cancers measuring 5 cm or greater underwent chemotherapy prior to surgery. Four women were also treated with radiotherapy prior to surgery. All 16 women underwent msstectomy and axillary clearance. All specimens showed residual tumour in the mastectomy specimen or the regional lymph nodes. Chemotherapy is useful in reducing tumour burden to allow surgical resection, but does not produce centripetal shrinkage of tumour, nor sterilize the breast of cancer. In this small series. the addition of radiotherapy also failed to clear the patient of tumour. Wide surgical excision including the original tumour margins is thus required to achieve locoregional control. Until chemotherapy and radiotherapy regimens can be proved to sterilize the breast of tumour, we caution against the use of any surgery less than total mastectomy if optimal local control is to be achieved for locally advanced breast cancer in pre‐ and perimenopausal women.
INDICATIONS FOR LAPAROSCOPIC PELVIC LYMPH NODE DISSECTION IN THE STAGING OF PROSTATE CANCER
Authors: Patel Manish I. , Katelaris Philip M.
Published: January 2008

Laparoscopic pelvic lymph node dissection is increasing in popularity, in the absence of validated surgical indications. This retrospective study was performed to identify those patients who would benefit from laparoscopic pelvic lyrnphadenectomy. The case notes of 50 patients who underwent bilateral open pelvic lymphadenectorny with frozen section examination were reviewed. The patients were staged clinically as having A2 (16), B1 (20) and B2 (14) prostate cancer. Except for the two patients who had macroscopically involved pelvic lymph nodes at operation, all proceeded to total prostatectorny. Six patients were found to have positive pelvic nodes. Of the six, four patients were clinical stage B2, one was B1 and one was A2. The Gleason score of two of these six patients was greater than seven. The prostate specific antigen (PSA) levels correlated more with high turnour volume (i. e. grade C) rather than with D1 disease. Frozen section at the time of lyrnphadenectomy had a false negative rate of 2 of 6. We conclude that laparoscopic pelvic lymph node dissections (LPLND) should be performed where there is a high likelihood of nodal disease, viz. bulky tunours, poorly differentiated histology and a high PSA reading. We consider that such selective use of LPLND optimizes its diagnostic utility while minimizing its unnecessary application.
UNDERSTANDING THE OBJECTlVE STRUCTURED CLINICAL EXAMINATION
Authors: Rothman Arthur I.
Published: January 2008

A number of factors have contributed to the relatively rapid development and growth of the Objective Structured Clinical Examination (OSCA) as a viable and popular assessment tool. Among these was an increased need, expressed both by training institutions and certifying and licensing bodies, for valid performance‐based assessment approaches. That this need became apparent at a time when concern and interest in performance‐based assessment in education generally was growing, was fortuitous and contributed to the developments in medical education. In medical education important consequences were the growing interest and expertise in two distinct areas, the psychometrics of performance assessment and the use of standardized (simulated) patients in the teaching and assessment of clinical skills. Collaboration between people working in these two areas greatly facilitated the rapid development and refinement of the OSCA. Currently, there appears to be general acceptance of the legitimacy of this assessment approach. Research now seems to be directed at resolving remaining important technical problems (e. g. standard setting); the design and implementation of large scale national and regional certifying and licensing examinations are the primary current development challenges. There is a large and still growing body of related literature and many presentations about this assessment approach are given at medical education conferences.
TECHNIQUE AND RESULTS OF LAPAROSCOPIC CHOLEDOCHOTOMY FOR THE MANAGEMENT OF BILE DUCT CALCULI
Authors: Robinson G. , Hollinshead J. , Falk G. , Moulton J.
Published: January 2008

Laparoscopic choledochotomy has been performed in 50 patients to remove common bile duct calculi demonstrated on routine operative cholangiography at the time of laparoscopic cholecystectomy. The patients ranged from 16 to 91 years old. One patient died, giving a mortality of 2%. At postoperative T‐tube cholangiography, retained stones were demonstrated in three patients (6%) with all stones being removed using a choledochoscope via the T‐tube track. Laparoscopic common bile duct exploration via a choledochotomy is a feasible and effective method to manage common bile duct calculi demonstrated during laparoscopic cholecystectomy.
FALSE POPLITEAL ANEURYSM AFTER FEMORAL EMBOLECTOMY
Authors: Nguyen H. H. , Chleboun J. O.
Published: January 2008

An unusual case with delayed presentation of a false popliteal aneurysm following transfemoral embolectomy is reported. It highlights that arterial embolectomy, despite its well‐established merits. may have major complications.
CELLULITE OWING TO AEROMONAS HYDROPHILIA: TREATMENT WITH HYPERBARIC OXYGEN
Authors: Mathur Manu N. , Patrick William G. , Unsworth Ian P. , Bennett Felicity M.
Published: January 2008

Aeromonas hydrophilia, a Gram‐negative facultative anaerobe, is a rare cause of cellulitis. We review the literature and report a case of Aeromonas hydrophilia cellulitis which failed to respond to the conventional management of surgical debridement and antibiotics. Hyperbaric oxygen therapy was used successfully to control the infection. As far as we are aware this is the first case in world literature of Aeromonas hydrophilia cellulitis treated with hyperbaric oxygen.
TESTICULAR TORSION
Authors: Koh K. B. H. , Dublin N. , Light T.
Published: January 2008

A retrospective review of 80 patients who underwent scrotal exploration for presumed testicular torsion is presented. Of these, 67 patients were found to have torsion, and the testicular loss rate was 51%. Patients who experienced delays in scrotal exploration of more than 24 h from onset of symptoms had a testicular loss rate of 71 %. These delays arose from both hesitation in seeking medical treatment and misdiagnoses. It is emphasized that an acute scrotum in a child or in an adolescent should be explored early to exclude torsion.
HYPOSPADIAS: RESULTS OF TREATMENT IN 18 YEARS OF PAEDIATRIC SURGICAL PRACTICE
Authors: Wright J. E.
Published: January 2008

This is a review of hypospadias surgery in a provincial surgical practice over 18 years. A total of 347 boys were seen with hypospadias, of whom 209 were operated upon. These operations consisted of 69 Durham Smith de‐epithelialized double‐breasting two‐stage procedures, 45 meatal advancement and glanuloplasty procedures, 27 hemi‐circumcisions with or without meatotomy, 24 single stage repairs for distal hypospadias without chordee, 23 operations for chordee without hypospadias. 15 modified Mathieu single stage procedures and six miscellaneous procedures. The complication rate, particularly for fistulae formation in 17%, was unacceptably high. Some causes of fistulae were identified; these included delayed absorption of chromic catgut sutures and stitch abscess. Stricture occurred less frequently, but one case was severe enough to require complete revision of the urethroplasty. In early operations a coronal meatus was the norm and six patients required advancement procedures.
PAEDIATRIC LARYNGOTRACHEAL RECONSTRUCTION: MELBOURNE EXPERIENCE AT THE ROYAL CHILDREN'S HOSPITAL
Authors: Berkowitz R. G.
Published: January 2008

A retrospective study was carried out to evaluate the outcome following laryngotracheal reconstruction (LTR) performed in 15 children for the treatment of severe laryngotracheal stenosis between 1989 and 1993. The age ranged from 18 months to 19 years with all but one patient being tracheostomy‐dependent. The trdcheostomy tube was successfully removed in 12 children who remain free of obstructive symptoms at follow up. One patient was successfully decannulated but required repeat tracheostomy 8 months later for intermittent severe supraglotticlpharyngeal obstruction. There were two failures, with one of these undergoing repeat LTR with successful decannulation. Surgery was complicated in one child by aspiration which improved spontaneously. These findings suggest that LTR is a safe and effective procedure for the management of severe paediatric laryngotracheal stenosis.
A METHOD FOR THE TREATMENT OF URETERIC COMPLICATIONS FOLLOWING RENAL TRANSPLANTATION
Authors: Insall Robert L. , Bell Roger , Hutchison Brian G. , Haywood Edward F. , House Anthony K.
Published: January 2008

Over an 8 year period, 117 renal transplants (97 cadaveric and 20 living related) were performed at the Sir Charles Gairdner Hospital, Perth, Western Australia, Australia. Ureteric complications following renal transplantation occurred following seven transplants (6%). The technique of using a multiply fenestrated vesicocutaneous stent/drain to manage this problem is described. This was uncomplicated in all cases with the exception of one case in which the stenvdrain was removed early because of blockage and sepsis, but most importantly on no occasion was the graft lost. We therefore recommend this technique for the management of this complication, whether early or late. We observed a disproportionate number of ureteric complications in living related transplants, a feature not described previously.
EFFECTS OF VESICOCOLIC ANASTOMOSIS ON THE PROLIFERATION OF COLONIC MUCOSA IN A RAT MODEL
Authors: Edwards W. H. B. , Whitehead R. H.
Published: January 2008

The effects of diverting the urinary stream into a defunctioned segment of the distal colon has been studied in a rat model. Distal rat colon was defunctioned using the Hartmann's procedure and a vesicocolic anastomosis was performed 14 days later. The distal colon was harvested after 10 days following the administration of a vinblastine mitotic block either 1 or 3 h before death. Both the mean crypt cell proliferation and the crypt length were increased significantly in the colonic mucosa exposed to urine when compared with the control defunctioned colon or to the functional unexposed proximal colon. An active fraction was obtained from human urine by elution from a diethylaminoethyl sepharose column using 1 mol/L NaCl. This fraction was administered intraluminally to defunctioned rat colons using Alzet miniosmotic pumps. In these animals the crypt cell production rate was significantly increased compared with the control animals. Although the crypt length did not increase significantly in these animals the atrophy normally seen in defunctioned colonic mucosa did not occur. The identity of the active molecule in this urine fraction is still being determined.
A RARE COMPLICATION OF PECTORALS MAJOR RUPTURE
Authors: Pai V. S. , Slmison A. J. M.
Published: January 2008

Pectoralis major rupture is an uncommon injury. Only 85 cases have been reported in the literature. Rupture may be partial or complete. The treatment of partial rupture is conservative, whereas in cases of total rupture surgical repair is advocated, particularly in young active patients. Complications are few. We describe a case of infection of the haematoma following a partial rupture. To the best of our knowledge it is the first case to be reported in the English literature.
PILONIDAL SINUS: MANAGEMENT OBJECTIVES
Authors: Stephens F. O. , Stephens R. B. H.
Published: January 2008

In spite of a number of ingenious operative and non‐operative techniques in the management of pilonidal sinus no single technique can be relied upon to prevent recurrence of this benign yet troublesome condition. Once thought to be a congenital condition it is now appreciated that pilonidal sinus is most often an acquired condition due to accumulation of tough, bristly hair penetrating the skin, or local hair growing into a skin crevice, pit or abnormal follicle. The most common site is the upper natal cleft but the condition may occur in other sites especially where there is a crevice or irregularity of skin surface with pressure or suction applied to that region. Most surgical procedures have been designed to eradicate the existing sinus and the crevice in which hair tends to accumulate. However, without the presence of hair there can be no pilonidal sinus and, in the past, little attention has been given to preventing the re‐accumulation of hair in the troublesome site; hence the risk of recurrence. Management objectives should be directed not only at eradicating the obvious lesion present but also to preventing recurrence of the aetiological factors: especially the re‐accumulation or re‐growth of hair.
CROHN'S DISEASE IN THE HUNTER VALLEY REGION OF AUSTRALIA
Authors: Anseline Paul F.
Published: January 2008

Between 1967 and 1991, 130 patients underwent surgery for Crohn's disense at The Royal Newcastle Hospital, New South Wales, There were more patients in recent years, which suggested an increased incidence of the condition (2.1/100 000/per year). The clinical profile and recurrence rate were similar to other studies. However, a greater proportion of patients required surgery for chronic small bowel obstruction and fulminant colitis compared with patients in other countries.
THE LONGER TERM RESULTS OF INTERNAL ANAL SPHINCTEROTOMY FOR ANAL FISSURE
Authors: Usatoff V. , Polglase A. L.
Published: January 2008

This study details the results of a retrospective analysis of 98 patients who underwent lateral subcutaneous internal sphincterotoiny for the treatment of fissure in ano. Data with particular emphasis on patient satisfaction and anorectal control were collected by postal questionnaire. Minimum follow up was 15 months with an average of 41 months. Ninety‐seven percent of patients indicated that they were moderately or very satistied with the outcome of the procedure and 90% claimed symptomatic improvement with this being sustained in 69%. Eighteen per cent of patients noted ongoing new problems with minor impairment of anorcctal control. Despite these symptoms, 90% of this group were also moderately or very pleased with the outcome and 72% had resolution of their symptoms which was sustained in more than two‐thirds of cases. It is concluded that lateral subcutaneous internal sphincterotomy is well tolerated and the majority of patients are more than moderately pleased with the outcome. There was however a significant incidence of minor impairment in anorectal control but this did not detract from the perceived success of the procedure.
TRANSFUSION DOES NOT INFLUENCE PATIENT SURVIVAL AFTER RESECTION OF COLORECTAL CANCER
Authors: Molland G. , Dent O. F. , Chapuis P. H. , Bokey E. L. , Nicholls M. , Newland R. C.
Published: January 2008

Two recent reviews reached opposing conclusions regarding the apparent detrimental effect of peri‐operative blood transfusion on patient survival after resection of colorectal cancer. However, both studies agree that the influence of confounding variables has not been controlled adequately in most studies. The present study is based on 433 patients who had a curative resection for colorectal cancer between 1984 and 1989 and whose details and follow‐up information were recorded in the Concord Hospital Colorectal Cancer Registry, Sydney. The association between peri‐operative transfusion and patient survival after resection of colorectal cancer was examined taking into account 20 other prognostic variables. A proportional hazards regression model showed that transfusion did not have a statistically significant independent effect on survival after controlling for the patients' poor general condition, the complexity of the surgery and the occurrence of postoperative complications.
RECTAL NECROSIS FOLLOWING ANTERIOR RESECTION OF THE RECTUM
Authors: Hubler M. , Isbister W. H.
Published: January 2008

Acute ischaemic colitis is a well recognized complication following abdominal aortic surgery. It may occur spontaneously in older patients and is probably due to diffuse or localized obliterative arterial disease. In contrast, acute ischaemic proctitis is a rare clinical problem. It is caused by an acute surgical or thromboembolic interruption of the major blood supply and or collateral circulation of the rectum. Minor ischaemia may result in superficial mucosal ulceration whereas a major ischaemic episode will result in rectal necrosis with perforation. Acute rectal necrosis has not been reported as a complication following anterior resxtion of the rectum. This paper details a patient who developed necrosis of the rectum and the anal canal following anterior resection of the rectum for cancer of the recto‐sigmoid junction.
VERTICAL BANDED GASTROPLASTY FOR MORBID OBESITV: WEIGHT LOSS AT SHORT AND LONG‐TERM FOLLOW UP
Authors: Ramsey‐Stewart George
Published: January 2008

A standardized vertical banded gastroplasty (VBG) was carried out by the one surgeon on 60 consecutive morbidly obese patients. All patients were followed at 4 week intervals for 1.5 years. Long‐term follow up was carried out at medians 5.7 and 9.6 years. All patients had significant weight loss at 1.5 years. However, at long‐term follow up, despite an apparently intact gastric restrictive procedure, only 40% of patients had maintained their weight loss. Sixty per cent had regained significant weight and 31% had returned to or were above their pre‐operative weight level.
THE EFFECT OF FINASTERIDE ON PROSTATE VOLUME, URINARY FLOW RATE AND SYMPTOM SCORE IN MEN WITH BENIGN PROSTATIC HYPERPLASIA
Authors: Nacey John N. , Meffan Patrick J. , Delahunt Brett
Published: January 2008

This study was designed to determine the efficacy of the 5α‐reductase inhibitor finasteride (Proscar, MK‐906) in men with reduced urinary flow rates and symptoms of urinary outflow obstruction secondary to benign prostatic hyperplasia. Forty‐five men were randomized to one of three groups receiving either placebo, 1 mg/day or 5 mg/day tinasteride for the first 12 months of the study period. At the end of this period all men received 5 mg/day finasteride for a further 2 years. Efficacy was determined by measurement of prostate volume, maximum urinary flow rate, and symptom score using a modified Boyarsky assessment. Prostate volume reduced by 20 and 27%. respectively, for those on 1 and 5 mg after the first year. At 3 years the volume had reduced by 43%. This reduction in prostate volume was associated with an improvement in maximum urinary flow rate by 50% (1 mg), and 35% (5 mg) at 1 year, and 36% at 3 years. The total, obstructive and non‐obstructive symptom scores decreased (improved) for patients on 1 and 5 mg tinasteride, with the total score reducing by 33% from baseline at year 3. The results demonstrate that finasteride causes a modest but signiticant clinical improvement in men with urinary outflow obstruction secondary to benign prostatic hyperplasia.
THE GENERAL VERSUS REGIONAL ANAESTHESIA DEBATE: TIME TO RE‐EXAMINE THE GOALS
Authors: Blake D. W.
Published: January 2008

New justification for the use of regional anaesthesia, either alone or in combination with general anaesthesia, has been provided with reports of some unexpected influences on outcome. A reduction in the incidence of postoperative thrombotic episodes and vascular graft occlusion is strongly suggested in patients with generalized vascular disease. Application of a variety of drugs, including local anaesthetics, opioids and adrenergic agonists, in the region of the spinal cord reduces afferent input during surgery and also the metabolic stress response. Evidence is increasing that this multi‐modal approach to anaesthesia has important consequences in the spinal cord which result in modification of the postoperative requirement for analgesia. Prernedication with opioid and other analgesics may also enhance this pre‐emptive effect. New general anaesthetic and analgesic drugs are available that are more suited to these combined techniques. They have shorter duration of action so that plasma concentration can be rapidly adjusted to match a variable surgical stimulus.
DORSAL TRANSSCAPHOID PERILUNATE DISLOCATION THROUGH AN ISOLATED SCAPHOID NON‐UNION
Authors: Lam Peter , Baddeley Steve
Published: January 2008

An unusal case of a traumatic dorsal transscaphoid perilunate dislocation occurring through an isolated scaphoid non‐union is presented. This set of circumstances has not, to the authors' knowledge, been described previously.
RETROPERITONEAL MALIGNANT FIBROUS HISTIOCYTOMA CAUSING PROFUSE BLEEDING PER RECTUM
Authors: Sim P. H. , Pathmanathan R. , Jalleh R. P.
Published: January 2008

A case is reported of retroperitoneal malignant fibrous histiocytoma (MFH) invading into the colon, causing fresh bleeding per rectum. It illustrates the difficulty encountered in the pre‐operative diagnosis of this condition, especially in a patient with an atypical presentation of profuse lower gastrointestinal bleeding.
THE ROYAL AUSTRALASIAN COLLEGE OF SURGEONS AND TRAUMA CARE*
Authors: Trinca Gordon W.
Published: January 2008

This presentation is an account of the involvement of the Royal Australasian College of Surgeons in trauma care over the past 25 years. In October 1969 a 3 day seminar was held at the College entitled ‘The Management of Road Traffic Casualties’. This was in response to an increasing demand for the College to combat the devastating effects resulting from road traftic accidents. By the mid‐60s road trauma in Australia and New Zealand, as seen in other fully motorized countries, had reached epidemic proportions. Those directly involved in the care of surgical emergencies were aware of the frequency and severity of road trauma which was striking all sections of the community. Unlike the USA. Australia was not troubled by a high incidence of penetrating injuries due to guns and knives.
HEPATIC ARTERY CHEMOTHERAPY FOR COLORECTAL LIVER METASTASES
Authors: McCall John L. , Jorgensen John O. , Morris David L.
Published: January 2008

Fifty per cent of patients with colorectal cancer develop hepatic metastases but only a minority are candidates for potentially curative surgical resection. Hepatic artery chemotherapy (HAC) has been used to treat patients with non‐resectable metastases confined to the liver. Although response rates to HAC have been shown to be higher thnn response rates to systemic chemotherapy. the advantage in ternis of survival has been dehated. Furthermore. HAC requires surgical catheter placement which adds to the cost and morbidity of treatment. There have now been eight prospective randomized trials of HAC vs intravenous chemotherapy and/or supportive therapy. The present paper analyses the results of these trials with particular reference to survival. Surgical morbidity. treatment‐related toxicity and cost nre also discussed.
BONE SCANNING IN THE MULTIPLY INJURED PATIENT
Authors: Frawley P. A. , Mills J. A. , Murton F. , Ware R.
Published: January 2008

A prospective study was undertaken to evaluate the role of radionuclide bone scanning in the management of patients with multiple injuries. During a 7 month period, 14 patients with multiple injuries underwent a bone scan in order to identify occult skeletal injuries. All of the patients had new injuries diagnosed. The majority of new injuries occurred either in a limb in which an injury had already been diagnosed at presentation. or in the chest. Such findings are consistent with previously published data. Infrequently, there was a change in management of the patients in this series following the bone scan.
V‐Y ADVANCEMENT HAMSTRING MYOCUTANEOUS ISLAND FLAP REPAIR OF ISCHIAL PRESSURE ULCERS
Authors: Cope C. , Barry P. , Hassall M. , Barnett R. , Richards M. , Vandervord J.
Published: January 2008

Thirty‐seven ischial pressure ulcers were repaired in 27 patients (eight quadriplegic, 19 paraplegic) between 1988–1993 using the V‐Y advancement hamstring myocutaneous island flap. Twenty‐one ulcers (57%) arose de now and 16 were recurrent, with five patients having bilateral ulcers. The average duration of the ulcer was 5 months (range 1–30). All ulcers extended through the deep fascia (clinical grade IV), with the average diameter being 4.7 cm (range 2–10). There were four major flap complications (11%). All but one of the ulcers healed at discharge (97%). Mean follow up was 20 months (range 5–54) in 21 patients (78%), with six patients being lost to follow up. Seven of the 21 (33%) patients developed recurrent ulcers, with four of these having flap re‐advancement with successful healing, and one patient having two re‐advancements. Overall, 18 of the 21 (86%) patients with follow up had healed ulcers at time of follow up.

The V‐Y advancement hamstring myocutaneous island flap is versatile, reliable, easy to perform, has few complications, and can be re‐advanced in the event of recurrence.
VIDEO‐ASSISTED THORACOSCOPIC LOBECTOMY: A WORD OF CAUTION
Authors: Yim Anthony P. , Ho Jonathan K. S.
Published: January 2008

Advances in video‐assisted thoracoscopic (VAT) surgery allow it to assume an increasingly important therapeutic role. Two successful VAT lobectomies (left upper lobe and right lower lobe) were performed in patients with stage I adenocarcinoma. An 8 cm access minithoracotomy for hilar dissection and subsequent specimen delivery was used. Routine mediastinal node sampling was performed thoracoscopically as would be done conventionally. Video‐assisted thoracoscopic lobectomy of the right upper lobe was attempted in another patient but he required emergency conversion to open thoracotomy because of bleeding from mechanical failure of the vascular staple‐cutter. Although VAT lobectomy is feasible technically, attention to detail is important when mechanical devices are used to minimize the chance of malfunctioning. Once disaster occurs the surgeon should be capable of dealing with the consequences.
ENDOSCOPIC TREATMENT OF A GIANT ILEAL CONDUIT CALCULUS
Authors: Bolton Damien M. , Peters Justin S.
Published: January 2008

A giant ileal conduit calculus is an uncommon complication of urinary diversion, with few recent reports present in the English literature. To date all described instances have necessitated treatment by laparotomy. The first reported successful management of such a condition by purely endoscopic means is reported.
A SIMPLE AND EFFECTIVE WAY TO REDUCE POSTOPERATIVE PAIN AFTER LAPAROSCOPIC CHOLECYSTECTOMY
Authors: Jorgensen John O. , Gillies Robert B. , Hunt David R. , Caplehorn John R.M. , Lumley Thomas
Published: January 2008

The aims of this study were to see if laparoscopic cholecystectomy is associated with a similar postoperative pain pattern to gynaecological lapnroscopy and to see whether the use of a suprahepatic suction drain makes recovery from laparoscopic cholecystectomy mnre comfortable. After routine laparoscopic cholecystectomy nnd insertion of a suprahepatic suction drain, patients were randomized to suction or no suction on the drain. The time course of the severity of wound, abdominal and shoulder tip pain was assessed by visual analogue scales administered in the morning and afternoon of the tirst 3 postoperative days. The control group had a high incidence of shoulder tip pain similar to that after gynaecological laparoscopy. Patients in the treatment group reported signiticantly less shoulder tip pain than the control group (O.R.0.16, 95% Cl, 0.06–0.40). There was a tendency for the treatment group to report reduced abdominal and. to a lesser extent, wound pain. The authors recommend suprahepatic suction as a simple and more effective way to improve patient comfort after laparoscopic cholecystectomy.
DEVELOPMENT OF A STAPHYLOCOCCUS EPIDERMIDIS VASCULAR GRAFT INFECTION MODEL IN SHEEP
Authors: Sardelic F. , Peng Y. A. , Fletcher J. P.
Published: January 2008

Staphylococcus epidermidis is an increasingly recognized causative organism of vascular graft infections. To increase our understanding of this problem we have tried to establish Staph. epidermidis vascular graft infection in sheep by direct inoculation.

A 2 cm long, 5 mm diameter polytetrafluoroethylene (PTFE) or a gelatin sealed Dacron vascular graft was inserted into the left carotid artery, At the completion of the operation 1 mL of normal saline containing either 104, 106, or 108 colony forming units (cfu) of a slime producing Staph. epidermidis was inoculated directly onto the graft. After 3 weeks the grafts were harvested in a sterile fashion. Swabs were taken of the perigraft tissues and the external and internal aspects of the grafts; a 3–5 mm segment of the graft was incubated in broth medium and a second segment was ground for 5 min and then incubated in broth medium. Note was made of the presence of abscess formation, anastomotic failure or thrombosis.

Thirteen sheep received a PTFE graft and 14 received a gelatin sealed Dacron graft. Three sheep died immediately postoperatively. The rate of infection was 40% at 104. 67% at 106 and 80% at 108 cfu Staph. epidermidis. In only four cases were all five cultures positive. In nine cases two or less cultures were positive, the majority of these being the broth cultures. Nine other organisms were isolated from nine mixed infections. Nine out of 13 PTFE and seven out of 11 Dacron grafts were infected.

The rate of graft infection grew with increasing concentration of inoculum. Retrieval of bacteria was greatest when the graft was cultured directly, especially with physical disruption. Infection with additional organisms was common. There was no difference in the infection rate between gelatin sealed Dacron and PTFE.
MINIMAL ACCESS SURGERY OF THE GASTROINTESTINAL TRACT
Authors: Toouli James , Cox Michael R.
Published: January 2008

In the last 5 years, surgery of the gastrointestinal tract has been revolutionized by the application of minimal access techniques. Following initial enthusiasm, which suggested that most abdominal surgery would ultimately be done via this approach, there is now need for appraisal and evaluation of the role of a number of these minimal access techniques when compared with open surgery.

Undoubtedly, the most convincing and total application of minimal access techniques has been in the treatment of gallstone disease. Laparoscopic cholecystectomy is now standard therapy for cholelithiasis and endoscopic sphincterotomy with stone extraction is standard therapy for choledocholithiasis. Where the two conditions co‐exist, operative cholangiography allows for the recognition of stones in the bile duct at the time of laparoscopic cholecystectorny and provides the potential avenue for treatment. Most major centres also would recommend routine operative cholangiography during laparoscopic cholecystectomy for the detection of unsuspected stones and as an extra safety procedure in the early identification of potential bile duct injuries.

The efficacy of laparoscopic appendicectomy and laparoscopic or thoracoscopic treatment of achalasia of the oesophagus also is supported by data from well conducted prospective studies.

Doubt remains regarding the advantage of laparoscopic surgery over other approaches in the treatment of gastro‐oesophageal reflux, inguinal hernias and jaundice due to non‐resectable cancer. For all three of these conditions, prospective trials are underway and the results of these trials should be assessed prior to widespread adoption of the laparoscopic techniques.

The application of minimal access surgery for colorectal procedures, peptic ulcer therapy, liver and pancreatic surgery or surgery of the spleen and adrenal has been demonstrated; however, its ultimate place awaits the further development of instruments and a demonstration of efficacy over open approaches before it can be recommended for use in prospectively conducted comparison trials.
A MISSED BREAST CANCER
Authors: Davis Neville C. , Herron John J.
Published: January 2008

The purpose of this case report is to point out that it is possible to misdiagnose a breast cancer when the classical finding. the mammogram and cytology. are all negative.
SYNCHRONOUS CONTRALATERAL ADRENAL METASTASIS FROM RENAL CELL CARCINOMA: A 7 YEAR SURVIVAL FOLLOWING RESECTION
Authors: Barnes R. D. , Abratt R. P. , Cant P. J. , Dent D. M.
Published: January 2008

Solitary contralateral adrenal metastasis from a renal cell carcinoma is distinctly unusual but aggressive surgical resection alone can produce long‐term survival.
ASSESSMENT OF BLUNT ABDOMINAL TRAUMA
Authors: Woods S. D. S.
Published: January 2008

Computerized tomography (CT) scanning and diagnostic peritoneal lavage have often been seen as competing modalities in the assessment of blunt abdominal trauma. Each has its own strengths and weakness. A judicious use of both modalities can result in improved diagnostic accuracy. An algorithm for their appropriate use is suggested.
HYPOTHERMIA AND SEVERE TRAUMA
Authors: Gunning K. A. , Sugrue M. , Sloane D. , Deane S. A.
Published: January 2008

During the period from May 1992 until April 1993, 108 patients were admitted to Liverpool Hospital with Injury Severity Scores (ISS) > 15. Temperatures had been recorded in 100. Of these, 17 had a core temperature of less than 35°C documented within 24 h of arrival. The hypothermic group presented with more severe injuries and contained a disproportionate number of females. Hypothermia was found to be more common in the winter months, but it was not associated with a delay in reaching hospital from the time of injury. When injuries were ranked by ISS, both hypothermic and normothermic patients were equally likely to have received a blood transfusion; however, the mean number of units of packed cells transfused was greater for the hypothermic group with ISS < 41 than for the similarly injured normothermic group. Two patients in the hypothermic group had sustained bums, and both of these were hypothennic on arrival. All of the hypothermic patients who required surgery developed hypothermia in the operating theatre.
A REPRODUCIBLE MODEL OF CHRONIC REJECTION IN RAT RENAL ALLOGRAFTS
Authors: Jablonski Paula , Baxter Kirsty , Howden Brian O. , Thomas Anita C. , Marshall Vernon C. , Stein‐Oakley Alicia , Thomson Napier M.
Published: January 2008

A reproducible animal model is essential for the study of the pathogenesis of chronic rejection. This study investigates: (i) the optimal pre‐transplant blood transfusion conditions to induce tolerance in a strongly rejecting rat kidney allograft model (Dark Agouti to Albino‐Surgery) and avoiding post‐transplant immunosuppression; (ii) the functional and histological changes that occur in long‐term surviving kidneys and their similarity to chronic rejection; and (iii) the maintenance of tolerance. Prolonged survival occurred after administration of at least two donor blood transfusions with concomitant cyclosporin A (5 mg/kg per day). The time‐span between transfusions appeared to be critical: 4 days was more effective than 2 or 7 days. Ineffective treatment led to death within the first 2 weeks post‐transplant with histological evidence of acute graft rejection. Seventy‐five per cent of long‐term survivors experienced impaired renal function in the first week which improved spontaneously and remained stable in 93% of the surviving animals after 100 days and in 668 after 200 days. The morphology of long‐term allografts was extremely variable from minor to extensive tubular atrophy, interstitial fibrosis, glomerular hypertrophy, focal and segmental glomerulosclerosis and vascular changes. Glomerular hypertrophy occurred in uninephrectomized controls and probably denoted a response to uninephrectomy. Glomerulosclerosis increased with time and was absent in controls. Although chronic damage was evident, the rats remained tolerant to fresh donor skin. Replacement of the original kidney allograft with a fresh donor kidney resulted in 70% survival. These second grafts showed less severe renal dysfunction and morphological damage than the original allografts in the long‐term follow up.
NEOPLASTIC OBSTRUCTION OF THE ABDOMINAL AORTA
Authors: Steffen C. M. , Thursby P. F.
Published: January 2008

Obstruction of major arteries by neoplastic tissue is rare. 1 A case of symptomatic obstruction of the distal abdominal aorta by metastatic carcinoma of the cervix, presenting 6 years after initial diagnosis, is described.
THE SURGICAL TREATMENT OF BRACHIAL PLEXUS INJURIES
Authors: Tonkin M. A. , Eckersley J. R. T. , Gschwind C. R.
Published: January 2008

Background: Brachial plexus injuries cause a devastating loss of function in the arm. The aim of this study was to review the results of surgical treatment of patients with brachial plexus injuries.

Methods: Forty‐seven patients were reviewed. Five patients did not undergo surgery. Forty‐two patients had exploration and 38 had primary surgery with neurolysis, nerve graft or neurotization or a combination. Four patients had other reconstructive surgery primarily. Secondary reconstructive surgery consisted of joint fusions and tendon transfers to enhance or replace the primary surgery.

Results: Nerve grafting achieved 62% Medical Research Council (MRC) grade M3 or better. Intercostal neurotization (ICN) of the musculocutaneous nerve (MCN) for elbow flexion achieved M3 or better in 69% of patients.

Conclusions: Primary nerve reconstruction, combined with joint fusions and tendon transfers, provides a worthwhile return of function to many patients. We advise early exploration (i. e. within 2 weeks when possible) for patients with complete C5‐T1 lesions or C5, 6, 7 lesions in conjunction with high energy injuries. In order to obtain optimal results patients with brachial plexus injuries should be referred to appropriate units as early as possible.
SURGICAL CONSIDERATIONS IN THE HARTMANN'S PROCEDURE
Authors: Chua C. L.
Published: January 2008

Background: The present study examines the surgical outcome of the Hartmann's and Hartmann‐type procedures, the problems with the remnant rectal stump and the issues related to the colorectal anastomosis as well as the differences in patient outcome. Methods: One hundred and five consecutive patients (mean age 66) were evaluated. Surgical morbidity and mortality were analysed with regard to the colorectal pathology and the type of rectal stump remnant. The surviving patients were reviewed according to whether they had second‐stage anastomosis.

Results: In 65% of cases there were obstructed or perforated malignancies and in 16% complicated diverticular diseases. The peri‐operative mortality and morbidity were 11.4% and 24%. respectively. Seventy‐two patients had intraperitoneal rectal stumps and stump blowout occurred in three intraperitoneal and one extraperitoneal remnant stumps. Local tumour recurrence (four) and diversion proctitis (three) were diagnosed in the rectal stump among asymptomatic patients. When the second‐stage reversal of Hartmann's procedure was considered (35 cases), twice as many were performed for diverticular and other benign conditions as for tumour cases.

Conclusions: Although there is a good anatomical basis for advocating extraperitoneal rather than intraperitoneal stumps, in practice the stump blowout rate is not statistically significant (3%vs 4.1%). However, the chances of regaining normal rectal function are much better for benign disease (68%vs 32%—Fisher's exact test, P= 0.004). Complications from second‐stage re‐anastomosis are not determined by timing of the closure, provided the septic episode has subsided.
BIZARRE PAROSTEAL OSTEOCHONDROMATOUS PROLIFERATION: A REVIEW OF SEVEN CASES
Authors: Smith N. C. , Ellis A. M. , McCarthy S. , McNaught P.
Published: January 2008

Background: Bizarre parosteal osteochondromatous proliferation (BPOP) is a rare tumour‐like condition mostly affecting the tubular bones of the hands and feet. Although it recurs in 50% of cases after local excision, it is a form of heterotopic ossification and its behaviour is otherwise benign. The present study describes seven cases of BPOP collected by the Bone Tumour Registry of New South Wales.

Methods: Clinical data, radiographs and histological specimens collected by the Bone Tumour Registry of New South Wales were examined, and further clinical data were sought from the referring doctor where necessary.

Results: Six males and one female aged 18 to 37 years (median 30 years) presented between 1988 and 1995. There were three cases involving the hands, three involving the feet and one involving the distal humerus. Initial treatment was by local excision in all cases. There was local recurrence in three cases. The initial diagnosis was wrong in five of the seven cases. Radiologically, BPOP appears as a well‐defined tumour arising directly from the bony cortex, without periosteal reaction or change to the underlying bone. Histologically, a large amount of hypercellular cartilage shows maturation to trabecular bone, which frequently contains spindle cells in the intertrabecular spaces.

Conclusion: BPOP is a rare, locally recurrent but otherwise benign condition of bone which must be distinguished from more sinister lesions such as parosteal osteosarcoma and chondrosarcoma.
THE NEW AGE OF LIVER TRANSPLANTATION
Authors: Sheil A. G. R.
Published: January 2008

The advent of cyclosporin A for immunosuppression (IS) in liver transplantation (LTx) in the early 1980s heralded a new age for LTx, resulting in widespread application, rapidly expanding indications, relaxation of restrictions in donor selection and advances in the preservation of liver grafts and management of LTx operations. Liver transplantation, together with the transplantation of other organs (kidney, pancreas, heart, heart‐lung, intestine), became possible. In Australia, around 125 LTx (22% in children) are performed each year. Indications are: primary sclerosing cholangitis; primary biliary cirrhosis; auto‐immune hepatitis; chronic viral hepatitis; biliary atresia; metabolic disorders; fulminant hepatic failure (FHF); alcoholic cirrhosis; and malignancy (cancer, CA). Since 1965, 810 patients underwent LTx and 70 (9%) re‐Tx. Patient survivals at 1, 5 and 9 years post‐Tx are 80, 74 and 66%, respectively. Patients with primary diseases that recur in the LTx (hepatitis B and CA) do less well following LTx, with 5‐y‐ear survival rates of 55 and 40%. respectively). Recent developments include: increasing the availability of donor organs by the use of living donors, ‘split’ cadaveric donor (CD) grafts, ‘marginal’ and non‐heart‐beating CD grafts and xenografts; expanding the indications for LTx; development of effective liver support systems for patients with FHF; the treatment of diabetics with liver failure with islet Tx (at the time of LTx); more effective immunosuppression; and methods to diminish recurrent disease in LTx. Some understanding of the unique ‘tolerogenic’ capabilities of the liver has come with the recognition of ‘two‐way microchimerism’. The satisfactory 5–9 year outcomes for patients underline the cost‐effectiveness of LTx.
DIFFERENCES IN PATTERNS OF CARE OF PROSTATE CANCER, NEW SOUTH WALES, 1991
Authors: McCredie Margaret , Bell Jane , Lee Alice , Rogers John
Published: January 2008

Background: In this time of uncertainty about the benefits of earlier diagnosis for prostate cancer and the optimal choice of treatment in various clinical scenarios, we addressed the hypothesis that two groups in the population, namely country dwellers and migrants from non‐English‐speaking countries, were less likely to be offered new methods of diagnosis and treatment for prostate cancer.

Methods: Incident cases of prostate cancer in 1991 were identified through the population‐based New South Wales Central Cancer Registry. For 73% of eligible cases information relating to diagnosis, staging and treatment was abstracted onto a checklist from clinical records in urologists' consulting rooms and in public hospitals.

Results: Transrectal ultrasound and prostatic biopsy were used for diagnosis significantly more often in urban than in rural cases while the reverse was true for transurethral resection of the prostate. Intravenous pyelography, ultrasound (other than transrectal) and bone scans were performed for staging more frequently in urban than rural cases. Rural cases were more likely to be treated with anti‐androgens than urban cases and less likely to be given luteinizing‐hormone releasing hormone (LH‐RH) agonists. The pattern of use of various diagnostic and staging procedures for 1991 rural cases resembled that for urban men diagnosed with prostate cancer in 1986 rather than that for 1991 urban cases.

Conclusions: At least in part, these urban‐rural differences could be explained by the fact that some patients in the country would have been treated by general surgeons rather than urologists. The patterns of care for non‐English‐speaking migrants resembled those for the Australian‐born and for English‐speaking migrants.
A MODIFICATION OF SINGLE STAPLED COLORECTAL ANASTOMOSIS USING THE TRANSANAL INSERTION DEVICE (TAIS)
Authors: Hoffmann D. C. , Young J. F. , Sweeney J. L. , Hunter R. A. , Moore J. W. E.
Published: January 2008

A modification of single stapled colorectal anastomosis utilizing a reusable stapler head (transanal insertion device [TAIS]) is described. This modification minimizes the time that the proximal bowel is open by allowing early placement of the circular stapler head, and minimizes the risk of rectal injury that may be associated with the passage of a circular stapling device without the head in situ.
HORSESHOE KIDNEY WITH BILATERAL SINGLE SYSTEM ECTOPIC URETERS
Authors: Khong P. L. , Peh W. C. G. , Mya G. H. , Chan K. L. , Saing H.
Published: January 2008

A horseshoe kidney, associated with bilateral single system ectopic ureters in a 9‐month‐old boy, is reported. The right ureteric orifice was located near the midline of a deformed trigone while the grossly dilated left ureter inserted into the posterior urethra. Imaging defined this rare combination of urological anomalies prior to surgical treatment.
THIRTY YEARS EXPERIENCE WITH HEART VALVE SURGERY: ISOLATED MITRAL VALVE REPLACEMENT
Authors: Bessell Justin R. , Gower Georgina , Craddock David R. , Stubberfield John , Maddern Guy J.
Published: January 2008

Background: Thirty years have elapsed since the commencement of open‐heart surgery in South Australia. A retrospective study was performed to evaluate mortality and complication rates and to identify factors associated with poor outcomes in all patients who underwent prosthetic mitral valve replacement during this period.

Methods: Questionnaires and personal contact have been used to generate a combined database of pre‐operative and postoperative information and long‐term follow‐up on 938 patients who underwent isolated prosthetic mitral valve replacement at the Cardio‐Thoracic Surgical Unit of the Royal Adelaide Hospital between 1963 and 1993.

Results: Complete survival follow‐up data were obtained for 92% (865) of the patients. The Starr‐Edwards valve was used in 95% (891) of the patients, a Bjork‐Shiley prosthesis in 2.5% (23) of the patients, and only 24 (2.5%) other valves were inserted. The hospital mortality rate for the 30‐year period was 4.7%. The mean age of the patients who underwent surgery was greater in each of the three successive decades. A long‐term survival advantage was observed for patients with mitral stenosis, however, survival was significantly shorter for patients with higher New York Heart Association (NYHA) functional classifications and for patients in pre‐operative atrial fibrillation. Pre‐operative dyspnoea was significantly improved following mitral valve replacement. The rates of postoperative haemorrhagic and embolic complications were low by comparison with other published series. Conclusion: Mitral valve recipients do not regain a normalized life expectancy, but risk factors that determine long‐term survival can be identified pre‐operatively to aid appropriate patient selection.