bluuebunny/crossref_metadata_2025 huggingface dataset:
CR23P DOES POOR BOWEL PREPARATION AND POLYPECTOMY INCREASE THE RISK OF METACHRONOUS COLORECTAL CANCER?
Authors: Tiong L. U. , Hollinton P.
Published: April 2009

Introduction:   Colorectal cancer is the 3rd most common cause of cancer deaths in Australia. Some studies recently reported disturbing rates of metachronous colorectal cancer occurring early after curative treatment of the index tumour. Poor bowel preparation and polypectomy during colonoscopy may increase the risk of metachronous cancer, by causing cancerous lesions to be missed and tumour seeding respectively. This study examines these two factors in association with the timing of metachronous recurrence.

Methods:   This is a retrospective audit utilising a database of all patients undergoing surveillance colonoscopy at Flinders Medical Centre and Repatriation General Hospital. Patients were identified using the database, with subsequent case note review. Patients with familial disorders or disease recurrence at anastomotic sites within 12 months were excluded. This audit has been approved by the Ethics and Research Committee of both hospitals.

Results:   Colorectal cancers were identified in 569 patients, of whom 15 (2.6%) had metachronous cancers. There were 10 men and 5 women with average age of 74 years. Bowel preparation was categorised as good (7 patients), moderate (1 patient) and poor (1 patient). Quality of bowel preparation was not available for 6 patients (4 had no comments documented and 2 had colonoscopies performed elsewhere). Of the 4 patients who had biopsy of polyps found during the initial colonoscopy, 1 developed metachronous cancer in the same area at 60 months.

Conclusion:   Poor bowel preparation may contribute to missed lesions presenting as early metachronous cancers. Seeding into polypectomy sites does not appear to be a problem.
CR04 *DOUBLE BLIND RANDOMISED CONTROLLED TRIAL OF THE INFLUENCE OF GLUCOCORTICOIDS ON POST‐OPERATIVE RECOVERY FOLLOWING COLECTOMY
Authors: Zargar Shoshtari K. , Sammour T. , Kahokehr A. , Connolly A. B. , Hill A. G.
Published: April 2009

Introduction:   Post‐operative fatigue (POF) is an important indicator of recovery after major surgery. Recent data have suggested a relationship between the post‐operative peritoneal cytokine response and development of POF. Glucocorticoids decrease the production of cytokines and thus we hypothesised that administration of dexamethasone to patients undergoing colonic surgery may decrease peritoneal cytokine production and POF.

Aim:   To assess the influence of 8 mg of pre‐op IV Dexamethasone on peritoneal cytokine and POF in patients undergoing elective colonic surgery. Method: In a double blinded RCT, 70 consecutive patients undergoing elective, open colonic resection were administered 8 mg I.V. Dexamethasone or saline (Placebo) prior to surgery. All patients were treated within a structured Enhanced Recovery After Surgery program.

Results:   After exclusions there were 31 patients in the Placebo group and 29 in the Dex group. At baseline there were no differences in the age, ASA, BMI or CR‐POSSUM scores. Dexamethasone was associated with a significant reduction in Interleukin‐6 (IL‐6) and IL‐13 in the peritoneum and IL‐6 and IL‐8 in plasma. Subsequently, patients in the Dex group had lesser POF and fatigue impact scores at days 3 and 7. Patients in the Dex group had less post‐op nausea and vomiting. There was no significant increase in complications.

Conclusion:   Preoperative Dexamethasone administration is associated with a significantly diminished post‐operative pro‐inflammatory reaction which is associated with clinical benefits in POF and its impact. This intervention may be an effective method of improving outcomes for patients undergoing major colonic surgery within a multimodal enhanced peri‐operative care pathway.
ES01 PARATHYROID CANCER: IS THERE AN EPIDEMIC?
Authors: Delbridge L. W. , Suliburk J. , Sidhu S. , Sywak M.
Published: April 2009

Background:   Parathyroid cancer has hitherto been regarded as an exceedingly rare tumour. Most surgeons have never seen a case, nor is it classified as a separate entity on many Cancer registries. Diagnosis has been difficult with few clear histological criteria. It has also been difficult to manage as, if not completely resected progressive, potentially fatal, hypercalcaemia is likely to ensue. The aim of this study was to examine the current incidence and management of parathyroid cancer.

Patients and Methods:   This is a retrospective cohort study with data obtained from the University of Sydney Endocrine Surgical Unit database from 1959 to 2008.

Results:   Over the first four decades, only two cases were ever diagnosed (0.5 cases/ decade), however the last decade has seen 22 cases treated (40X increase – p < 0.001). This is only partly explained by the increase in parathyroid surgery overall (259 cases/ decade in the first period vs. 2,335 cases in the last decade – a 9X increase). In half the recently diagnosed cases, a confident diagnosis was facilitated by parafibromin and PGP9.5 immunohistochemistry, or a family history of hyperparathyroidism jaw‐tumour syndrome (HPJT). In all the recent cases long‐term normocalcaemia has been achieved with surgical excision and/or calcimimetic therapy (Cinacalcet).

Conclusions:   The increased incidence of parathyroid cancer is probably due to a number of factors including the increase in parathyroid surgery associated with the minimally invasive approaches, improvements in histopathological criteria, and recognition of familial disease. The availability of calcimimetics has enabled hypercalcaemia to be appropriately managed in the long‐term.
ES11 *10 YEAR HISTORY OF OVER 1000 CONSECUTIVE MINIMALLY INVASIVE PARATHYROIDECTOMIES (MIPS) WITHOUT INTRAOPERATIVE PTH AT A SINGLE INSTITUTION: LESSONS LEARNED
Authors: Suliburk J. W. , Sywak M. S. , Sidhu S. B. , Delbridge L. W.
Published: April 2009

Purpose:   Minimally invasive parathyroidectomy (MIP) has become the procedure of choice to treat primary hyperparathyroidism. The role for intra‐operative parathyroid hormone measurement (IOPTH) is controversial. Some experts indicate that IOPTH is a requirement for MIP while others feel it not needed. We reviewed a 10 year history of MIP at a single institution without use of IOPTH to determine reasons for failure.

Methodology:   This study is a retrospective review of the University of Sydney Endocrine Surgery Database from May of 1998 to August of 2008. The database was queried for MIPs performed as well as for failed operations. Patient record analysis was completed to determine the reason for failure of the operation.

Results:   1020 MIPs were performed with 23 (2.2%) failures. 1 patient was found to have benign familial hypercalcaemia, 5 were lost to follow up. Of the remaining 17 patients, average age was 62, and 76% were female. Reasons for failure in these patients were: 10 patients (59%) found to have double adenomas, 3 (17%) patients with hyperplasia and 4 (24%) patients with single gland disease missed at initial operation. All 17 were cured on repeat exploration. Of these 11 (65%) had repeat Sestamibi scans that correctly localized remaining hyperfunctioning gland(s).

Conclusion:   MIP can be performed safely without the need for IOPTH. The most common cause of failure after MIP is an occult double adenoma. Given that repeat Sestamibi scan correctly identifies persistent disease consideration can be given to MIP as a choice of procedure for repeat operation.
ES17 *RESULTS OF SUTURELESS TECHNIQUES VS CONVENTIONAL VESSEL LIGATION FOR TOTAL THYROIDECTOMY
Authors: Chang L.‐Y. , Suliburk J. , Sidhu S. , Delbridge L. , Sywak M.
Published: April 2009

Aim:   Advanced vessel sealing devices provide an alternative to conventional ligation techniques. Studies into sutureless thyroidectomy (ST) suggest advantages with reduction in operative time, but most were inadequately powered to explore differences in postoperative complications which should be approximately 1%. This study is designed to compare the outcomes of ST and conventional thyroidectomy (CT) for recurrent laryngeal nerve (RLN) injury, permanent hypoparathyroidism and haematoma formation.

Method:   A cohort study of consecutive patients undergoing total thyroidectomy using conventional vs. sutureless techniques was performed. ST was performed using either Ligasure Precise or Harmonic Focus devices. The primary outcome measures were postoperative haemorrhage, permanent RLN injury and hypoparathyroidism. Secondary outcome measures were operative time, temporary hypoparathyroidism and vocal cord dysfunction.

Result:   From January 2007 to December 2008, 1449 consecutive patients underwent total thyroidectomy. Of these 725 underwent CT and 724 were performed using ST. The mean operative time was significantly lower in the ST group (44.2 vs. 57.3 min. p = 0.032). There was no difference in postoperative haematoma incidence between groups 0.8% CT vs. 0.7% ST, p = 0.89. The permanent hypoparathyroidism rate was not significantly different between groups 1.2% CT versus 0.4% ST, p = 0.08. There was no difference in the incidence of permanent RLN injury 0.2%CT and 0.4%ST, p = 0.31.

Conclusion:   Sutureless total thyroidectomy using advanced vessel sealing technology is safe and efficient and has complication rates equivalent to conventional techniques.
ES19P ARE THE GUIDELINES SET BY THE AUSTRALIAN ENDOCRINE SURGEONS AES06/01 GROUP VALID?
Authors: Moore E. M. , Sanders K. M. , Guest G. D. , Watters D. A. K.
Published: April 2009

Background:   Recent guidelines published by the Australian Endocrine Surgeons AES06/01 Group recommend a parathormone (PTH) measurement >1.0 ρmol/L drawn 4 hrs following total or completion thyroidectomy predicts those patients not requiring treatment (92.6% sensitivity, 70.7% specificity). This study evaluated the ability of single PTH and calcium levels in the early prediction of which patients need treatment for hypocalcaemia and so facilitating earlier discharge.

Method:   Clinical details and pathology results of patients undergoing total or completion thyroidectomy from 2001–2008 were retrieved electronically. PTH and calcium levels at 6–8 hrs and at 18–24 hrs were assessed by Receiver‐Operating Characteristic curve analyses.

Results:   180 patients (151 females, 29 males) underwent total (145) or completion (35) thyroidectomy; 66 required postoperative calcium supplements. A PTH measurement drawn at 6–8 hrs post‐surgery ≤1.1 ρmol/L identified all patients requiring treatment (100% sensitivity), ruling out 86% of patients not requiring treatment. A PTH measurement ≤1.1 ρmol/L drawn at 18–24 hrs predicted those patients requiring treatment (91% sensitivity, 93% specificity). Calcium measurements at 6–8 hrs (81% sensitivity, 51% specificity) and 18–24 hrs (80% sensitivity, 68% specificity) proved poor predictors. There was no benefit in plotting a calcium slope over the first postoperative day (73% sensitivity, 65% specificity).

Conclusion:   In our series a PTH of <1.1 ρmol/L at 6–8 hrs was the most accurate at identifying those patients requiring calcium supplements to enable earlier discharge from hospital. These results are certainly consistent with the recently published AES guidelines and validate their findings.
ES22P PARAFIBROMIN IMMUNOHISTOCHEMISTRY ENABLES THE LATE DIAGNOSIS OF PARATHYROID CANCER
Authors: Suliburk J. W. , Sidhu S. B. , Sywak M. S. , Delbridge L. W.
Published: April 2009

Background:   Until recently the diagnosis of parathyroid cancer has been based upon difficult to interpret criteria and traditional indicators of malignancy such as mitotic activity and cellular atypia are unreliable. It is estimated that up to 50% of parathyroid carcinomas with biologically malignant behaviour may be considered benign. The aim of this study was to examine the impact of parafibromin immunohistochemistry (PI) on achieving a late diagnosis of parathyroid cancer.

Methods:   This is a case series with data obtained from the University of Sydney Endocrine Surgical Unit database. PI was performed on the cases identified.

Results:   Three patients were identified where an initial diagnosis of parathyroid adenoma had been made but where subsequent PI enabled a late diagnosis of parathyroid carcinoma. The mean age and sex distribution of the three patients at initial diagnosis was 38.3 years, M : F 2:1 (range 29–57); mean delay in diagnosis was 22 years (range 7–30). There were no statistically significant differences in patient age, sex distribution, serum calcium, and tumour weight between the three patients in the series and all other patients who have undergone parathyroidectomy for primary hyperparathyroidism. At follow‐up, one patient appears cured with a normal serum calcium, one has permanent hypoparathyroidism, and one has persistent hypercalcaemia with control of serum calcium by Cinacalcet therapy.

Conclusions:   Diagnosis of parathyroid cancer may well be missed due to lack of clear histological criteria. PI in selected cases of parathyroid tumours will enable the accurate diagnosis of parathyroid carcinoma.
ES23P SURGICAL AUDIT OF INADVERTENT PARATHYROIDECTOMY DURING TOTAL THYROIDECTOMY: INCIDENCE, RISK FACTORS, AND OUTCOME
Authors: Janakiraman R. , Paul M. J. , Thomas D. A , Selvan B. , Nair A. , Samuel P.
Published: April 2009

Objectives:  

To assess the incidence, risk factors and clinical relevance of inadvertent parathyroidectomy during thyroidectomy.

Design:  

Retrospective study.

Setting:  

Tertiary care hospital and post‐graduate teaching institute.

Subjects & Methods:  

Patients who underwent total thyroidectomy between 2004 and 2006 (three years) in a general surgical unit with a special interest in endocrine surgery were included in the study. Medical records were accessed for patient demographic data, diagnosis, operative details, histopathology reports, postoperative hypocalcaemia and the total duration of hospital stay.

Results:   Inadvertent removal of parathyroid glands occurred in 12.9% of cases. Removed parathyroids were intra‐capsular / intra‐thyroidal in 44.6% of cases. Female sex, malignancy and central neck dissection were found to be risk factors. These patients had an increased incidence of temporary and permanent biochemical hypocalcaemia but the hospital stay was not prolonged.

Conclusion:   In our study, inadvertent parathyroid excision accounted for increased morbidity. Steps should be taken to preserve more parathyroid glands by improving surgical technique (magnification) and auto‐transplantation of parathyroid gland if necessary.
ES06 *A STUDY OF NORCHOLESTEROL SCINTIGRAPHY VERSUS COMPUTED TOMOGRAPHY IN THE LATERALISATION OF HYPERFUNCTIONING ADRENAL LESIONS
Authors: Sanli E. , Tan C. K. , Sidhu S. B. , Sywak M. S.
Published: April 2009

Purpose:   Norcholesterol adrenal scintigraphy (Norchol) and computed tomography (CT) are frequently utilised in the investigation of hyperfunctioning adrenal lesions. In primary hyperaldosteronism where venous sampling has been unsuccessful and in Cushing's syndrome these modalities may help in the lateralisation of adrenal pathology. The aim of this study is to compare the accuracy of Norchol scintigraphy with that of high resolution CT in the lateralisation of hyperfunctioning adrenal tumours.

Methodology:   A prospective study comparing Norchol with CT was performed. Patients with primary hyperaldosteronism and failed venous sampling underwent evaluation with Norchol scintigraphy and 64 slice multidetector CT. Patients with adrenal Cushing's syndrome were also included and similarly evaluated. Imaging results were correlated with histopathology and clinical outcome after surgery.

Results:   In the period 2004 to 2007, 23 patients underwent Norchol and CT assessment. 20 patients had laparoscopic adrenalectomy and median follow up was 1 yr. Of these 10 had hyperaldosteronism with failed venous sampling and 10 had Cushing's syndrome. In patients with primary hyperaldosteronism Norchol correctly lateralised pathology in only 60% of cases compared to CT which was correct in 70%. In patients with Cushing's syndrome both Norchol and CT were 100% accurate in detecting the site of cortisol excess.

Conclusion:   In hyperaldosteronism with failed venous sampling Norchol scintigraphy offers no advantage over high resolution CT for lateralisation of pathology. In Cushing's syndrome both Norchol and CT are highly accurate and equivalent.
ES08 MICRORNA MICROARRAY ANALYSIS OF HUMAN ADRENOCORTICAL TUMOURS
Authors: Soon P. S. , Tacon L. , Yeh M. W. , Clifton‐bligh R. , Robinson B. G. , Sidhu S. B.
Published: April 2009

Purpose:   A dilemma in the management of adrenal tumours is differentiating between benign and malignant tumours. Adrenocortical adenomas (ACAs) are common while adrenocortical carcinomas (ACCs) are rare. ACCs also have poor prognosis with limited treatment options. MicroRNAs (miRs) are non‐coding, 20–22 nucleotide RNAs which have been implicated in tumorigenesis. The aim of this study was to use microarray analysis to identify miRs which play a role in the pathogenesis of ACCs and have the ability to discriminate between ACCs and ACAs as well as to serve as therapeutic targets.

Methodology:   RNA from 6 normal adrenal cortices, 27 ACAs and 22 ACCs were hybridised to Exiqon mirCURYTM LNA Arrays version 10.0.

Results:   14 miRs were significantly upregulated while 9 were significantly downregulated between ACCs and ACAs. Several miRs which have previously been reported to be associated with other cancers and act as regulators of genes such as EGFR, PTEN and RAS were found in our group of significantly differentially expressed miRs. One of the significantly downregulated miRs is located in a 10.4 megabase common minimal region of loss on 17p13 which we have previously delineated in ACCs. In addition, one of the 14 significantly upregulated miRs was located in an intron of IGF2, a gene frequently overexpressed in ACCs compared to ACAs.

Conclusions:   In this study, we found miRs which were significantly differentially expressed between ACCs, ACAs and normal adrenal cortex, indicating that miRs are involved in the pathogenesis of adrenocortical tumours and have the potential to serve as diagnostic markers and therapeutic targets.
GS01 HERNIA REPAIR: ARE WE THERE YET?
Authors: Mccallum M.
Published: April 2009

Herniae have been documented since ancient times, but the era of modern hernia treatment is accepted as starting with the surgery of Bassini. Suture repairs of various types then dominated the treatment of hernia until the era of mesh repair championed by Stoppa and Lichtenstein.

Surgeons feel that mesh repairs have revolutionized hernia surgery. Have the mesh repairs really made such a difference? There is evidence that all is not as it seems! Published recurrence figures don't seem to withstand close scrutiny.

One of the trendy terms in herniology is the “myo‐pectineal orifice”, while many hernia specialists pay lip service to this concept, very few available hernia operations address this problem.

The latest area of interest in the world of hernia surgery is the area of post‐hernia groin pain, either neuralgic or non‐neuralgic. There are studies showing an incidence of chronic groin pain following anterior repairs of 30% or more, and yet these operations are the most common hernia operations in the world!

Keith in 1924 first postulated the concept of herniosis and was criticized. However there is a large volume of convincing evidence that herniae are manifestations of a metabolic disorder. They are associated with abdominal aortic aneurysm and possibly with such diverse conditions as diverticular disease, cholelithiasis, and perhaps haemorrhoidal disease.

Are we there yet? The answer is certainly no. However research into the metabolic problem of hernia development means that we are surely closer than we have ever been before.
GS13 SPOT MARKING FOR LAPAROSCOPIC COLECTOMIES
Authors: Smith S. R. , Cao C.
Published: April 2009

Purpose:   Mechanical Bowel Preparation (MBP) is often used by surgeons for patients undergoing Laparoscopic Colectomy (LC) due to the concern that small lesions normally palpable at open surgery may not be seen at the time of laparoscopic surgery. This study sought to determine whether preoperative marking of the colonic primary at the time of colonoscopy with Spot® could overcome this concern.

Methodology:   All patients suitable for a LC had Spot® marking performed at their colonoscopy. One millilitre of Spot® marking was injected submucosally in 3 positions around the circumference of the lumen at least 5 cm distal to the lesion. The first 100 LC performed by the surgeon for lesions were audited for the purpose of this study, and MBP was not used while all patients received preoperative immunonutrition.

Results:   Overall mortality was 0%. The anastomotic leak rate was 2% (1 reoperation, 1 low output fistula). Conversion rate was 23%. Spot® marking was successfully identified at laparoscopy in all 100 cases. No cases were converted as a result of failure to identify the marking, however 1 case required an extension in the final incision due to the fact the Spot® marking had been placed proximal to the lesion. Anastomoses were performed “across” the Spot® marking on 3 occasions with no untoward effect.

Conclusion:   Spot® marking is a safe and effective way to mark lesions in the colon in order to facilitate LC without the need for MBP.
GS20 *ADVERSE EVENTS IN GENERAL SURGERY
Authors: Kalogeropoulos G. , Watters D. , Brereton S.
Published: April 2009

Background:   The rate of adverse events occurring in Australian hospitals is reported to be up to 12–17%. Adverse events need to be identified, reported and responded to if the system of health care is to be improved. The purpose of this study was to determine the rate and nature of adverse events (unintentional harm arising as a result of healthcare) in general surgery in the Geelong Hospital.

Method:   A review was conducted of adverse events in the hospital incident reporting system (Riskman) and general surgical audits between 2004 and 2008. Adverse events were categorised according to severity (1–4) and the hospital response to these events noted.

Results:   There were 888 adverse events arising in 12801 general surgical admissions (6.93%). Their severity assessment codes (SAC) were: catastrophic (0.15%),; major (0.40%),; moderate (2.22%),; and minor (4.30). Some of the complications reported in surgical audits were also adverse events, the major ones being mortality (0.74%), unplanned reoperation (1.27%) and unplanned readmission (1.46%). Identification and tracking of these enabled implementation of system changes. These included a colorectal outcome reporting, PreVENT program (for DVT prophylaxis), review of colonoscopy initiatives, bedside tracheostomy care, and an electronic system to respond to pathology results (TR3).

Conclusion:   The adverse event rates occurring in general surgery at the Geelong Hospital were lower than those previously reported in the literature and may reflect a general improvement in the quality of care during the last decade if these rates are applicable to other hospitals. The hospital response to adverse events has resulted in significant sustainable system changes.
HP12 *ACTUAL 5‐YEAR SURVIVORS FOLLOWING OESOPHAGECTOMY AND PREDICTORS OF SURVIVAL
Authors: Hirst J. , Smithers M. , Gotley D. , Martin I. , Thomas J. , Barbour A.
Published: April 2009

Purpose:   Oesophagectomy remains the mainstay of curative treatment for localised oesophageal cancer. Despite this there is a paucity of data reporting actual 5 year survivors following oesophagectomy. This study was undertaken to identify and characterise actual 5 year survivors who underwent oesophagectomy.

Methods:   A prospectively maintained database identified 526 patients who underwent oesophagectomy from 1987 to 2008. Patients were followed for a minimum of 5 years or until death. Clinico‐pathologic factors associated with 5 year disease‐specific survivorship were analysed. Median follow‐up for all patients was 40 months.

Results:   Median disease specific survival (DSS) was 32 months. Neoadjuvant therapy was administered to 248/526 (47%). There were 95/526 (18%) actual 5‐year survivors. On multivariate analysis, 5‐year survivors were significantly lower T stage, N stage and less likely to have received blood transfusion compared with patients who died less than 5 years after surgery. There were 76/526 (14%) patients with positive margins and of these 6 patients were 5 year survivors. Amongst 5‐year survivors, 41 (43%) had neoadjuvant therapy. Of the 95 5‐year survivors, 14 (14%) subsequently died of oesophageal cancer. The prognostic factors for DSS after 5 years were dysphagia or odynophagia at presentation. Stage was no longer a prognostic factor after surviving to 5 years.

Conclusion:   No single clinico‐pathological variable negated survival to 5 years. Prognostication in 5 year survivors is difficult, but odynophagia and dysphagia at presentation are still active as prognostic factors after 5 years. The majority of 5‐year survivors can be considered cured of oesophageal cancer.
HP14 EVOLVING MANAGEMENT OF HIGH GRADE DYSPLASIA IN BARRETT'S OESOPHAGUS
Authors: Duong C. P. , Smithers M. , Thomas J. , Gotley D. , Martin I. , Barbour A.
Published: April 2009

Background:   High grade dysplasia (HGD) in Barrett's oesophagus is a pre‐cancerous condition, where oesophagectomy eliminates the risk of malignancy but can incur significant morbidity. Endoscopic therapies and expectant surveillance have been increasingly adopted. Given that the timing of malignant transformation cannot be predicted, the optimal treatment for HGD is unclear and is evolving. This study aims to evaluate the outcome of a cohort of patients with HGD in Barrett's oesophagus.

Methodology:   There were 84 patients with biopsy‐proven HGD treated at our institution between 3/1992 and 12/2008 documented prospectively onto a database. Records were reviewed for patient characteristics, presence of occult cancer, treatment and outcomes including operative mortality and morbidity, and malignant transformation.

Results:   The primary treatment was oesophagectomy in 48 patients, endoscopic mucosal resection (EMR)/ablation in 18 and observation in 18. Following oesophagectomy, 19 (40%) had an occult invasive carcinoma. Following endoscopic therapy, (median FU 36 months), 2 patients were diagnosed with cancer requiring resection. In those patients observed, due to co‐morbidity or patient's choice, (median FU 74 months) 9 (50%) developed malignancy leading to resection (6), EMR (1) and radiotherapy (2). Following resection there was 1 death (2%) with 34 patients (62%) having a complication.

Conclusion:   Resection of HGD is a curative treatment but post‐operative morbidity is not insignificant. Medium term outcome data for endoscopic therapies is encouraging but patients need long term careful follow‐up. Patients with HGD need to be fully informed of the different treatment options and their limitations.
HP21P HIGH‐FREQUENCY GASTRIC ELECTRICAL STIMULATION FOR THE TREATMENT OF GASTROPARESIS: A META‐ANALYSIS
Authors: O’grady G. , Egbuji J. U. , Du P. , Cheng L. K. , Pullan A. J. , Windsor J. A.
Published: April 2009

Purpose:   High‐frequency gastric electrical stimulation (GES) is a relatively new treatment for medically‐refractory gastroparesis. There have been a number of clinical studies using a surgically‐implanted stimulator (Enterra, Medtronic, Minneapolis). A meta‐analysis was performed to evaluate the evidence for improved outcome.

Methodology:   A literature search of major medical databases was performed for the period January 1992 to August 2008. Studies involving an implanted high‐frequency GES device were included and reported a range of clinical outcomes. Studies of external, temporary and/or low frequency GES were excluded.

Results:   Of 13 included studies, 12 lacked controls and only one was blinded and randomized. Following GES, patients reported improvements in total symptom severity score (3/13 studies, mean difference 6.52 [CI: 1.32, 11.73], p = 0.01), vomiting severity score (4/13, 1.45 [CI: 0.99, 1.91], p < 0.0001), nausea severity score (4/13, 1.69 [CI: 1.26, 2.12], p < 0.0001), SF‐36 physical composite score (4/13, 8.05 [CI: 5.01, 11.10], p < 0.0001), SF‐36 mental composite score (4/13, 8.16 [CI: 4.85, 11.47], p < 0.0001), requirement for enteral or parenteral nutrition (8/13, OR 5.53 [CI: 2.75, 11.13], p < 0.001) and 4‐hour gastric emptying (5/13, 12.7% [CI: 9.8, 15.6], p < 0.0001). Weight gain did not reach significance (3/13, 3.68 kg [CI: –0.23, 7.58], p = 0.07). The device removal or reimplantation rate was 8.3%.

Conclusion:   Results show substantial benefits for high frequency GES in the treatment of gastroparesis. However, caution is necessary in interpreting the results, primarily due to the limitations of uncontrolled studies. Further controlled studies are required to confirm the benefits of high‐frequency GES.
HP27P META‐ANALYSIS OF GLYCERYL TRINITRATE USE IN ERCP: EFFECTS ON TECHNICAL SUCCESS OF CANNULATION AND RATE OF POST‐ERCP PANCREATITIS
Authors: Maddock L. A.
Published: April 2009

Background:   ERCP is a technically challenging procedure. Glyceryl Trinitrate [GTN] has been shown to reduce sphincter of Oddi pressure. Several randomized controlled trials have sought to assess the clinical effect of GTN in ERCP. The objective of this study is to assess in a meta‐analysis the benefit of routine GTN use in ERCP in cannulation success and post‐ERCP pancreatitis.

Methods:   A comprehensive literature search was conducted using online databases PubMed, Medline and Cochrane database of randomised controlled trials. Studies included had to be randomised controlled trials of GTN use as in ERCP. The outcomes of interest were cannulation success and/or rate of post‐ERCP pancreatitis.

Data Collection and Analysis:   Seven Randomised Controlled Trials were identified. Data was analysed using Cochrane Collaboration Review Manager software. Each study was weighted in accordance with its size and event rate. Outcome of interest from each study and pooled results had Risk Ratio and 95% confidence intervals calculated.

Results:   A total of six studies and 1321 patients were analysed for effect on cannulation success. A pooled Risk Ratio of 0.66 [95% CI 0.43–1.01] represents a relative risk reduction of 34%, though not statistically significant. Four studies and a total of 854 patients were analysed for rate of post ERCP pancreatitis. A pooled Risk Ratio of 0.56 [95% CI 0.37–0.85] represents a significant relative risk reduction of 44%.

Conclusions:   GTN administration in ERCP reduces the rate of post ERCP pancreatitis and may have a small benefit in cannulation success.
ML01 SURVIVING THE GLOBAL FINANCIAL CRISIS: THE OUTLOOK IS DISTURBING FOR MEDICAL INDEMNITY
Authors: Coman W.
Published: April 2009

The world is faced with a recession. We can see three disturbing trends: (1) Insurers expect an increase in the number and size of claims, particularly in insurance, such as MI. (2) Investment returns will be lower as a result of lower interest rates and weaker equity markets. (3) All companies face reduced access to funding, as lenders become more reluctant to lend money.

To survive these forces, insurers need to be well capitalised and to have effective risk and governance practices in place. No insurers will be immune to the adverse trends listed above. There are some specific issues facing MI insurers: (1) There is emerging evidence that the tort law reforms in MI are being watered down in interpretation, which would cause medical indemnity claims to increase rather than decrease in the future. (2) MI claims are long‐tail in nature, so it is critical that the insurer is strong enough that it will still be around when the claims need to be settled. (3) Because MI claims can be very large, it is important that the MI insurer holds adequate reinsurance, which is the principal way that insurers spread the risk that they take on.

By their very nature, insurers are risk takers. However, risk must be properly managed. A good risk management approach forms a useful checklist for anyone seeking review of their insurer: (1) Active and effective underwriting ensures that an appropriate premium is charged for the risk being underwritten. (2) Use of pre‐eminent reinsurers ensures that policyholders can be confident that their claims can be paid.

A low‐risk, absolute‐return investment strategy, with minimal exposure to equities, avoids adding risks. 3A strong track record and a listing on the ASX make it easier to raise further capital if so required.
ML03P CLINICAL HANDOVER: A NATIONAL AUDIT OF PRACTICE IN NEW ZEALAND HOSPITALS
Authors: Jenkins B. A.
Published: April 2009

Purpose:   When the responsibility for care of any patient passes from one doctor to another, there must be a systematic and structured transfer of relevant information. This clinical handover must be performed well to ensure patient safety is protected. The audit's aim was to gain a snapshot of morning handover practice in New Zealand hospitals and to compare this to the inaugural audit of 2007.

Method:   An eleven point questionnaire was sent to resident doctors across New Zealand. One questionnaire per handover on a specified date was to be completed and returned. Questions were related to the physical and technical support of handover as well as quality and integrity of the information handed over. This information was analysed and compared to the results of the initial audit.

Results:   Seventy–five questionnaires across 16 District Health Boards (DHBs) were returned. In 2007 there were 190 across 18 DHBs. Across the two years, data has been collected for all NZ DHBs bar one. Most questions recorded an improvement overall, with the most dramatic improvement being handovers that were completed without interruptions for non–urgent tasks (9% 2007, 86% 2008).

Conclusion:   This snapshot audit shows an overall improvement in the practice of handover. The full results have been tabled to the NZ Resident Doctors’ Association – DHB Memorandum of Understanding (MOU) Collaborative Committee to contribute to developing supporting national guidelines for handover. A further audit is planned for 2009 to continue assessment.
NS02 THE USE OF WW(TM) VENTRICULAR PORT FOR NEUROENDOSCOPY – A NOVEL DEVICE AND TECHNIQUE
Authors: Akil H. , Symons W. , Wickremesekra A.
Published: April 2009

Purpose:   Peel‐away sheaths are widely used to facilitate the intracranial/intraventricular introduction of neuro‐endoscopes. They can be very cumbersome and can cause minor bleeding from the split edges of the sheath. We report on our experience of a WW(TM) ventricular port that we developed at Wellington Hospital.

Methodology:   The stainless‐steel port is made to fit the 6 mm and 3 mm rigid and flexible neuro‐endoscopes. The port has an outer sheath and inner introducer with a central open channel at length from 1 to 7 cm. The proximal end has a fine adjustable stabilizing screw hat that sits on the outer table of the skull at the margins of the Burr hole. The port is inserted through a Burr hole to tap the ventricle and when cerebrospinal fluid is exiting the central channel, the introducer can be withdrawn and the neuro‐endoscope passed into the ventricle.

Results:   We have been using this port for the past 4 years for 32 selected cases (25 ETVs, 4 arachnoid cysts, 2 colloid cysts and 1 septum pellucidum fenestration), and have not experienced device related complications. The port has the advantages of atraumatic insertion, stability on the skull, fine adjustability of length, repetitive withdrawal/insertion of the neuro‐endoscope through the port and a central channel for CSF tapping.

Conclusion:   In our experience this novel ventricular port has proven to be a useful adjunctive device for neuro‐endoscopic procedure, and has the potential to be incorporated with image guidance techniques and as well as other intracranial procedures.
PM02 ASSESSMENT OF PAIN IN THE AMA6 GUIDES
Authors: Atkinson R. L.
Published: April 2009

Pain related impairment has been a divisive issue for the editors of the AMA Guides. While the First Edition was published in 1971, it was not until the Fourth Edition (1993) that pain was included. Modifications in the Fifth Edition (2000), Chapter 18, were confusing. The inclusion of the pain chapter is at odds with the editorial principles, based on evidence‐based medicine, validation and interrater physician reliability. The move towards disability in the Sixth Edition ensures the inclusion of Chapter 3 which is now simplified. In the absence of an objective anatomically based impairment assessed under Chapters 4 to 17, the subjective complaint of pain is allocated an impairment to a maximum of 3%. This is based on the written responses to the validated pain disability rating scale. Special pain rating impairments are allocated for migraine, trigeminal neuralgia, chronic regional pain syndrome and spinal cord injury.
PM03 INFECTION REDUCTION STRATEGIES FOR SPINAL CORD STIMULATION AND INTRATHECAL DRUG DELIVERY SYSTEMS
Authors: Turner M. S.
Published: April 2009

Spinal Cord Stimulation (SCS) and Intrathecal Drug Delivery (IDD) Systems have proven efficacy in relieving pain in properly selected patients. One of the devastating complications that can occur with these systems is an infection. An infection usually leads to loss of the device at great expense, increased pain for the patient, loss of the benefit of the device to the patient, and significant expenses for treating the infection. The last 3 years of implant procedures, of a single surgeon at a single institution, both SCS and IDD devices is reviewed. Over 1000 procedures, with breakdown of co morbidities and infection rates for each procedure are identified. Strategies for reduction of infection in implant procedures are discussed.
PR16 A PROSPECTIVE BLINDED RANDOMIZED CONTROLLED TRIAL OF COMMERCIAL VACUUM DRESSINGS VERSUS NON‐MECHANICAL TOPICAL NEGATIVE PRESSURE DRESSING FOR DAY SURGERY LOWER LEG SPLIT THICKNESS SKIN GRAFTS
Authors: Mcardle B. , Stradwick L. , Frank C.
Published: April 2009

Purpose:   To show that ambulatory non‐mechanical negative pressure dressing results in equivalent graft take and survival compared with commercially available mechanical vacuum dressings.

Methodology:   Twenty‐four patients, both males and female, between 18 and 95 years of age in the Australian population requiring skin grafting of the lower limb from July 2008 were randomized consecutively into commercial vacuum assisted ambulatory dressing group, KCI Freedom VAC, [VAC] and non‐mechanical topical negative pressure dressing group using 14 gauge drain [Belovac]. Patients were discharged on the same day of surgery and reviewed at 5 or 6 days post‐operatively. Both groups were treated equally in all other facets of care. The dressings remained intact until outpatient review. A photo of the graft was taken upon removal of the dressing. Graft take/survival was measured from these photographs by an experienced plastic surgeon blinded to treatment group.

Results:   Graft take was found to be equivalent in both groups. All twelve patients in the VAC group were judged to have >95% graft take at five/six days post‐op. In the Belovac group all twelve were judged to have >95% graft take at 5/6 days. The cost for VAC group was $AUD413.50/478.50 [5/6 days] compared to $AUD55.93 for the Belovac dressing group.

Conclusion:   We conclude that non‐mechanical topical negative pressure dressings are equally effective as commercially available VAC dressings in for the treatment of lower limb skin grafts. We recommend that non‐mechanical topical negative pressure dressing is an acceptable, cheap and safe alternative to commercially available dressings for day surgery patient.
PR28P ABDOMINAL WALL MORBIDITY FOLLOWING TRAM BREAST RECONSTRUCTION
Authors: Anesti K. D. , Avery G. , Armstrong J. R. , Tan S.
Published: April 2009

Background:   The lower abdominal wall provides ideal autogenous tissue for breast reconstruction. Pedicled TRAM flap is associated with significant flap complication rates and donor site morbidity especially in bilateral reconstruction. Free TRAM flap, muscle sparing free TRAM and DIEP flaps have been used to reduce abdominal wall weakness.

Aim:   To document abdominal wall function following breast reconstruction using pedicled TRAM, muscle sparing free TRAM, and DIEP flaps.

Methods:   Consecutive patients who underwent breast reconstruction with pedicled TRAM, muscle sparing free TRAM or DIEP flaps were culled from our prospective breast reconstruction database 2004–2007. Each reconstructive technique used was favoured exclusively by individual surgeons within our unit. Patient demographics, the type/timing of reconstruction, and flap and donor site complications were recorded. Abdominal wall function was assessed pre‐operatively and at 6 and 12 months post‐operatively using the Lacote evaluation test. DASH and patient questionnaires were administrated to assess the effect of surgery on daily activities and patient satisfaction.

Results:   s34 pedicled TRAM flaps were performed in 29 (24 unilateral, 5 bilateral) patients. There were 38 muscle sparing free TRAM flaps in 29 (20 unilateral, 9 bilateral) patients and 7 DIEP flaps in 7 patients. Abdominal wall function and complications will be presented.
PR30P DELIVERY OF ACUTE PLASTIC SURGICAL SERVICES IN A TERTIARY CENTRE
Authors: Usmar S. J. , She R. W. , Smith K.
Published: April 2009

Purpose:   To (1) assess the accuracy with which acute plastic surgical caseload is predicted; (2) identify key factors which influence operating times; and (3) determine whether services are delivered in a timely manner.

Methodology:   Data was collected prospectively for 200 patients presenting acutely to the Auckland Regional Plastic, Reconstructive and Hand Surgery Unit between 26 November and 22 December 2008. Recorded variables included procedure type, predicted and actual theatre time, level of surgeon and anaesthetist experience and triage category.

Results:   Of the 200 patients enrolled in the study, 9 were excluded due to incomplete data. Average time spent in the operating theatre was 81 minutes. This was over‐estimated on the pre‐operative booking form by 17% (R = 0.65, p < 0.001). The intra‐operative time was significantly longer when the procedure was performed by a consultant surgeon compared to a trainee (mean = 115 min versus 76 min, p < 0.001) or when regional anaesthesia was used (median = 116 min versus 72 min, p = 0.02). Intra‐operative time was not affected by anaesthetist seniority (p = 0.18). The procedure was correctly identified on the pre‐operative booking form in 75% of cases. Only 59% of cases were performed within their allotted triage time.

Conclusion:   Acute Plastic Surgical Services were not delivered in a timely manner for a significant number of patients. This occurred despite a consistent over‐estimation of theatre time requirements. Methods for improving service efficiency need to be investigated, with a view to reducing the social and economic cost of delays.
PR33P GIANT NON‐MELANOMATOUS SKIN CANCERS: THE CONSEQUENCE OF NEGLECT
Authors: Moore E. C. , Tulloch S. J.
Published: April 2009

Giant non‐melanomatous skin cancers (GNMSCs) are extremely rare and slow growing. They are grossly disfiguring and present unique management dilemmas.

We examined five cases of these unusual tumours and present a literature review of the risk factors inherent in epidemiology, patient demographics and the clinico‐histopathological characteristics.

Five patients with GNMSCs admitted to the Alfred and Dandenong Plastics Surgery Departments over a ten year period were reviewed.

GNMSCs are more frequent on the scalp in men. Lower socioeconomic status and infrequent medical review are also characteristic of these tumours. Histology can be unusually varied with aggressive features in keeping with their higher metastatic potential.

Health promotion by means of vigilant surveillance and prompt specialist referral could prevent extensive surgical efforts later in the course of disease.
PR34P HEAD AND NECK FREE FLAP RECONSTRUCTION IN THE ELDERLY POPULATION – WAIKATO EXPERIENCE
Authors: Neary F. A. , Moaveni Z.
Published: April 2009

The main indication for free flap reconstruction in the head and neck is malignancy. As the world's population ages, we will be presented with more elderly patients with head and neck cancers requiring free flap reconstruction.

However, the older population does have a significantly higher incidence of multisystem disease which can cause some concern when considering a potentially long and complex surgical procedure. Do these co‐morbidities translate into actual risk regarding flap success and post‐operative mortality?

This presentation reviews our ten year experience with microvascular reconstruction in the elderly at Waikato Hospital, New Zealand. A synopsis of key considerations in improving success rates in this type of surgery will also be offered.
PR44P SURAL ARTERY FLAP: A GOOD OPTION FOR LEG DEFECTS
Authors: Mahadik P. J. , Yadav P. S. , Quazi G. A. , Shankhdhar V.
Published: April 2009

Introduction:   Leg defects are a real burden as regards to both, morbidity and hospital stay for the patients. Flaps based on the superficial sural system are good options and would substitute complex free flaps.

Methodology:   The study was undertaken over a period of 1 yr (May2007–Apr2008).We studied 17 patients with defects resulting after excision of SCCs, melanomas etc form the age group of 28–70 yrs. They were reconstructed with a proximally or a distally based sural artery flap. The right/left leg ratio was 1:0.7.

Results:   There was no flap loss and the average hospital stay was 8 days. (6–14 days) The average operative time was 2 hrs 20 min (1.5–3 hrs).Minor complications occurred in 2 patients.

Conclusions:   Sural artery flaps are reliable and can be safely used for variety of defects ranging from knee to the foot. They have a very low risk of complications and are easy and quick to do.
PR49P THE INCIDENCE OF NON‐MELANOCYTIC SKIN CANCER IN NORTH QUEENSLAND: A RETROSPECTIVE REVIEW OF HISTOPATHOLOGY IN 2006
Authors: Mickelburgh M. J. , Birch T. F. , Rowe D.
Published: April 2009

Purpose:   The aim of the study was to determine the incidence of non‐melanocytic skin cancer (NMSC) in Northern Queensland.

Methodology:   All histopathology confirming non‐melanocytic skin cancer (NMSC) during 2006 that was examined by the pathology department at Cairns Base Hospital and private pathology services were collated to determine the incidence of NMSC in this population. Using this data, information including type of NMSC (squamous cell carcinoma, basal cell carcinoma or intraepidermal carcinoma) sex, age at histological diagnosis and anatomical location were deduced. This information was then used to calculate the incidence of the types of NMSC in North Queensland as well as the age and sex distribution to ascertain those most at risk. Population statistics were provided by the 2006 census.

Results:   The overall incidence of NMSC in Northern Queensland was 1356 per 100?000 people in 2006. Males had a greater incidence of non‐melanocytic skin cancer overall. When the data was adjusted into age‐standardised populations consistent with the 2006 census data the group found to be most at risk in both sexes were those over 65. The incidence of BCCs in males was 5.1%, SCC 2% and IEC 0.38%. In females the incidence was slightly lower, BCC 2.3%, SCC 1.31% and IEC 0.36%.

Conclusion:   North Queensland, Australia, has a high incidence of NMSC. The group in this study identified most at risk are men greater than 65 years of age. The burden of disease in this instance is not insignificant and further attention must be drawn to the need for greater public awareness on the incidence of skin cancer in this region.

NB: Data from one of the private pathology service in QLD is still awaiting inclusion in the paper.