bluuebunny/crossref_metadata_2025 huggingface dataset:
ES24P TOTAL THYROIDECTOMY AND POST OPERATIVE HYPOCALCAEMIA: A REVIEW OF OUR PRACTICE AT THE LAUNCESTON GENERAL HOSPITAL
Authors: Lloyd D. , Jacob A. O. , Nguyen H. , Thwe A. , Lee F. , Young A.
Published: April 2009

Traditionally subtotal thyroidectomy has been the preferred operation for benign thyroid diseases such as Grave's disease and multinodular goitre. Towards the end of the 21st century total thyroidectomy has been the operation of choice. However there have been concerns that there is likely to be a larger percentage of patients to suffer from temporary and permanent hypocalcaemia. At the Launceston General Hospital total thyroidectomy has been preferred operation. There has not been an audit previously however anecdotally we do not perceive a high rate of complication. This study was a retrospective analysis of patient data from January 1996 to June 2008. The records for all patients that had undergone a total thyroidectomy for either malignant or benign disease at Launceston General Hospital was collected and reviewed. A total of 159 patients had undergone a total thyroidectomy from January 1996 to June 2008. The operations were performed by 12 different surgeons, however 4 surgeons performed the bulk of the operations (80%). The median age of patients was 54. 82% (130) of the study group were female. 89% (141) of the cases were performed for benign disease of the thyroid. 18% (29) patients had a post‐op calcium level less than 2.0. 7 (4.4%) of patients required long term supplements, however 4 out of the 7 had total thyroidectomies for malignant disease. Total thyroidectomy for benign disease of the thyroid is an operation associated with low mortality and morbidity. Hypocalcaemia is a problem that is encountered with this type of operation. Our results show that we have an acceptable rate of hypocalcaemia post total thyroidectomy, hence an appropriate operation for benign disease of the thyroid.
ES25P TUMOUR HISTOLOGY DOES NOT PREDICT RESPONSE TO LAPAROSCOPIC ADRENALECTOMY IN CONN'S SYNDROME
Authors: Sywak M. S. , Suliburk J. W. , Chou A. S. , Sidhu S. B. , Gill A. J.
Published: April 2009

Introduction:   Primary aldosteronism (Conn's syndrome) due to an aldosterone producing adenoma is a frequent cause of surgically correctable hypertension. It is unknown exactly which patients will have improved blood pressure (BP) control following resection. This study was undertaken to determine if histology correlated to post operative BP control in Conn's adenoma patients. We hypothesized that degree of zona glomerulosa hyperplasia would predict response to surgery.

Methods:   The University of Sydney Endocrine Surgery Database was queried for 20 consecutive patients who did and 20 consecutive patients who did not have improved BP control following surgery for Conn's Syndrome. Histology was reviewed to identify presence and degree of zona glomerulosa hyperplasia as well as dominate adenoma cell type: glomerulosa (G), reticularis (R) or fasciculata (F). Responders were defined as taking no BP medication or reduction of more than 2 medications 3 months after surgery. Student's t and Fischer's Exact tests were used to determine significance (p < 0.05 significant).

Results:   20 responders and 13 non‐responders had histology available for review. Age and sex between groups were not significantly different. Glomerulosa hyperplasia was present in 65% and 77% of responders and non‐responders respectively (p = 0.7). Percentage cell type in responder tumours: 0% G, 35% F, 0% R, 65% mixed. Percentage cell type of non‐responders, 0%G, 38% F, 0% R, 62% mixed with no significant difference in cell type between groups.

Conclusion:   Tumour histology does not influence clinical outcome following resection of Conn's adenomas. Improvement in BP following resection is unlikely related to local tumour characteristics.
ES26 I‐131 AND SURVIVAL IN DIFFERENTIATED THYROID CANCER
Authors: Allison R.
Published: April 2009

Data from the Queensland Cancer Registry and our Multidisciplinary Thyroid Cancer Clinic indicate that thyroid cancer incidence is increasing. This is particularly in well differentiated tumours in women. Whilst some of the increase may be due to ascertainment, there appears to be a genuine increase. The cause for this is unknown. Surgery for the primary and nodal disease remains the mainstay of treatment. Adjuvant treatment with I‐131 for ablation of remnants and treatment of unresectable disease is the next echelon of treatment. From 1980 to 2007 the Thyroid Cancer Clinic at the Royal Brisbane and Women's Hospital saw 3061 patients. The overall 15 year disease specific survival is 86%. However, if we look at the well differentiated cohort of papillary follicular and Hurthle cell tumours, the 15 year disease specific survival rises to 90%. This is based on 2377 patients. Significant survival variables are sex (Females – 93%, males – 79% – 15 year survival), age (0–44 – 98%, 45–59 – 94%, 60–69 – 70%, 70+ 36%), for T stage only T4 is significant, for M stage M0 is 91% and M1 is 62%, nodal status shows a non‐significant trend N 0 – 93%, N positive – 84%.Our practice, in line with international guidelines, is to offer adjuvant treatment with I‐131 for tumours above 15?mm, to consider treatment on risk factors between 10–15?mm and not to treat tumours under 10?mm. Despite these good results, patients would benefit from a better ability to define a good prognosis group in whom we could avoid treatment and also identify the worst prognosis group in whom to escalate treatment.
ES03 GOITRE SURGERY IN AFRICA
Authors: Wetzig N. R.
Published: April 2009

Purpose:   To highlight details and difficulties of management of large goitres in the developing world.

Method:   This paper presents a retrospective review of patients undergoing surgery for large goitre at the HEAL Africa Hospital (Health, Education, Action, Leadership) in Goma, Democratic Republic of Congo.

Results:   Dr Neil Wetzig has been involved in training African doctors in goitre surgery since 2003. In northern parts of D R Congo a very high incidence of large goitre exists. Published estimates range from 48–85% and it is suggested that four million people in the north of Congo have large goitres. The types of cases encountered will be discussed, along with the likely causes of endemic goitre, including dietary factors in this community, and the social effect of having a large goitre. Patients undergoing surgery at “HEAL Africa” have a mean age of 44 years, a mean duration of goitre of 7 years and they are predominantly euthyroid range. 88% are female. The difficult circumstances in which this surgery is performed, with poor lighting, poor power supply, poor instruments and limited resources, for example limited suture material, will also be outlined. Details will be presented of the teaching that has been conducted for local Congolese doctors, including surgical aspects of these large African goitres, in particular one case of a huge four kilogram recurrent goitre with skin erosion occurring in a 20‐year‐old woman. This experience of very large goitre in Africa is unique for surgeons from developed countries, and the techniques used are of importance to all thyroid surgeons.
ES04 *DIAGNOSTIC LOBECTOMY IS NOT ROUTINELY REQUIRED TO DIAGNOSE THYROID CANCER IN NODULES GREATER THAN OR EQUAL TO 4CM IN SIZE?
Authors: Raj M. D. , Grodski S. , Yeung M. , Serpell J.
Published: April 2009

Purpose:   The current gold standard for determining malignancy in thyroid nodules >4 cm is diagnostic lobectomy, regardless of the fine needle aspirate cytology (FNAC) result. This is based on the reportedly high false‐negative rates of FNAC (>10%) in large thyroid nodules. The purpose of this study was to determine if routine removal of thyroid nodules >4 cm is best clinical practice. We hypothesize that ultrasound guided FNAC is as effective as diagnostic lobectomy in detecting malignancy in these patients.

Method:   We conducted a cross sectional study of 225 consecutive patients with thyroid nodules >4 cm between 1994 and 2008 who all underwent surgical excision. We assessed the efficacy of preoperative FNAC alone in detecting malignancy in this group compared to surgical excision.

Results:   225 patients in the study underwent surgery. 162 patients had preoperative FNAC performed. Male to female ratio was 1:3. Overall incidence of thyroid cancer was 9.6% (16/165). The sensitivity of preoperative FNAC alone in identifying thyroid cancer was 81% and specificity was 62%. False negative rate for FNAC was 1/16 (6%). Positive predictive value of FNAC was 22% (13/60), with negative predictive value of 99% (90/91). Likelihood ratio for positive FNAC result was 2.13.

Conclusion:   The incidence of carcinoma in thyroid nodules less than 4 cm is low. Preoperative FNAC is highly sensitive and specific in detecting thyroid cancer even in nodules less than 4 cm in size. Effective management of these patients can be confidently carried out based on the preoperative FNAC result alone, without the need for diagnostic lobectomy.
ES07 *EXTRA‐ADRENAL PHEOCHROMOCYTOMA: IS THE “RULE OF 10” STILL APPLICABLE?
Authors: Imisairi A. H. , Hisham A. N.
Published: April 2009

Background:   The “rule of 10” is often used to described pheochromocytomas, with 10% extra‐adrenal, 10% malignant, 10% extra‐abdomen, 10% bilateral as well as 10% are found in patients who do not have hypertension and 10% are familial.

Objective:   To review the extra‐adrenal pheochromocytomas in our center and to establish whether the “rule of 10” is still applicable.

Methods:   Retrospective data were collected on all patients diagnosed to have extra‐adrenal pheochromocytomas (EAP) from January 1998 to December 2007 at our institution.

Results:   Over the last 10 years a total of 48 patients were diagnosed to have pheochromocytoma in our centre and 10 (20.8%) were documented to have EAP. The clinical presentation of 6(60%) patients was classical of pheochromocytoma with hypertension, headache, and palpitation, 2 (25%) patients had epigastric pain, 1(12.5%) with progressive weight loss and 1 (12.5%) with pregnancy induced hypertension. The EAP in all 10 patients were localized with CT scan or MRI. The anatomic locations of the EAP were as follows: 40% in the organ of Zuckerkandl, 30% adjacent to the adrenals, 20% along the renal vessels and 10% at the pre‐sacral area. All patients were explored via the anterior transperitoneal approach and histopathological report confirmed 9 (90%) were benign and 1(10%) malignant EAP.

Conclusion:   Our series demonstrates a higher incidence of 20.8% for EAP and 40% of them do not have hypertension. In addition, none of them had extra‐abdominal lesion. Therefore the study does not correlate with the “rule of 10” except the incidence of malignant EAP.
GS10 LAPAROSCOPIC APPENDICECTOMIES: THE LEARNING CURVE, RBWH EXPERIENCE
Authors: Patel B. M. , O’rourke N. A.
Published: April 2009

Introduction:   Laparoscopic appendicectomy has become the procedure of choice for acute appendicitis at our hospital. It provides ideal training in a variety of laparoscopic techniques. It is both safe for patients and good for the community by improving the skills of surgical trainees.

Methods:   We reviewed the prospective audit of one junior registrar's first 150 consecutive cases of laparoscopic appendicectomy, after supervision for the first five cases.

Results:   150 patients underwent laparoscopic appendicectomy over a period of 27 months. Ages ranged from 14 to 72 with a mean of 28. A standard 3 port technique was used, utilizing mostly suture loops, or occasionally linear staplers to tackle the appendix base. Of 124 patients with confirmed appendicitis, 44 (35%) had perforated, possibly reflecting delay in access to operating theatre in a busy public hospital. Despite this, only two post operative abscesses occurred, and both resolved after percutaneous drains. Hospital stay ranged from 2–7 days (Mean 2, Median 3.5 days). Senior surgical assistance was required in only two patients, once for laparoscopic repair of a serosal tear, and once for conversion for an inflammatory mass subsequently shown to be a carcinoma. Analysis of the cohort in three groups of fifty: early, mid, and late in the series demonstrated a statistically significant improvement in both operative time and diagnostic accuracy.

Conclusion:   Laparoscopic appendicectomy is the ideal training operation. After some initial supervision the trainees can perform surgery unsupervised and gain experience in a wide variety of surgical techniques. Clinical acumen and operative times improve with experience.
GS11 SEEING IS BELIEVING: A NEW WAY OF LOOKING AT HISTOPATHOLOGY RESULTS
Authors: Guest G. D. , Watters D. A. , Green R. , Bourke J. , Ward R. , Plueckhahn D.
Published: April 2009

Purpose:   A sentinel case of missed rectal malignancy resulting in a poor outcome for a patient prompted a search for a process that ensures adequate follow up of all significant histopathology results. This paper aims to quantify the problem of inadequate histopathology follow up and develop an electronic tool and review process to ensure the patient's results are acted upon appropriately.

Methodology:   A Histopathology audit was undertaken at the Geelong Hospital between 2002 and 2006. Patients where inadequate follow up had occurred were identified. The situation for these patients was rectified and the risk quantified. An integrated electronic tool was then developed including a minimum data set. A review process was then tested to ensure adequacy of future follow up.

Results:   6.3% (120/1912) of histopathology results in a 5 year period had been inadequately followed up. No further adverse outcomes were identified but each case was a potential time bomb for the patients who were not scheduled for clinical review (3.8%) or a recommended procedure (2.5%). A process of follow up has now been implemented and a minimum data set, procedure and electronic audit tool developed to assist with this process.

Conclusion:   Failure of adequate follow up of histopathology is a potential pitfall in any large health system. One such failure led to a disastrous outcome and a comprehensive audit suggested 6.3% of patients in the last 5 years were also at risk. We have established a review process we believe is reliable and developed an electronic tool to facilitate this process.
GS14 UPPER GI EMERGENCIES FOR GENERAL SURGEONS – BLEEDING PEPTIC ULCER
Authors: Kendall B. J.
Published: April 2009

Peptic ulcers (PU) are the most common cause of upper gastrointestinal bleeding. They result in significant costs both to the patient and the health care system. Despite a decrease in the prevalence of H. pylori infection, the incidence of bleeding PU has not reduced.

Resuscitation of the patient with a bleeding PU remains the foundation of management. Upper gastrointestinal endoscopy has evolved from initially a diagnostic tool to now also being a therapeutic modality. The endoscopic stigmata of a visible vessel or active bleeding have been validated as indicators of a high risk of adverse outcomes. Multiple endoscopic techniques have been developed to treat bleeding PU with these stigmata. The most effective and commonly used are thermal contact therapy (heater probe or bipolar electrocoagulation) and endoscopic clipping. They are each used either as monotherapies or combined with adrenaline injection. These techniques have been shown to reduce the rates of rebleeding, surgery and mortality.

Early studies showed no benefit from the use of H2‐receptor antagonists in patients with bleeding PU. In contrast, proton pump inhibitors (PPIs) given after endoscopic haemostatic therapy as a bolus and then a subsequent 72 hr infusion, have been shown to significantly reduce the rates of rebleeding,, surgery and mortality compared to placebo.

In summary, endoscopic techniques combined with pharmacological treatment with PPIs significantly improve outcomes in patients with bleeding PU with high risk endoscopic stigmata. These methods are widely available and are essential in the optimal modern management of bleeding PU.
GS16 *MARKERS OF MUCOSAL AND TRANSMURAL INTESTINAL DAMAGE
Authors: Evennett N. J. , Cerigioni E. , Hall N. J. , Pierro A. , Eaton S.
Published: April 2009

Purpose:   To investigate intestinal fatty acid binding protein (iFABP) and smooth muscle actin (SMA) as markers of mucosal and transmural intestinal damage, respectively, in both rat intestinal ischaemia reperfusion injury, and in human necrotising enterocolitis (NEC).

Methodology:   Plasma was collected from anaesthetized rats that underwent intestinal ischaemia reperfusion (IIR) injury and from control rats undergoing sham laparotomy. In a separate study, plasma and urine was collected from infants with NEC, and from control infants with non‐abdominal diagnoses. iFABP was measured in urine and plasma using a commercially available ELISA. SMA was detected in plasma using a western blot technique. Results are median [IQR] and compared by Mann‐Whitney test unless otherwise stated.

Results:   Animal model: Plasma iFABP was significantly higher in the IRI group compared with control group (IRI 32.4 [29.2] ng/ml vs. control 3.8 [3.3] ng/ml; p < 0.01). SMA became detectable in IRI plasma during reperfusion (p < 0.01 compared with pre‐ischaemia, Wilcoxon Signed Ranks test), but never in the control group.

Human NEC Study:  

Urinary iFABP was significantly higher in the NEC group (2.1 [3.9] pg/nmol) compared to controls (1.1 [0.7] pg/nmol, p, < 0.05). Furthermore plasma and urinary iFABP correlated with extent of intestinal damage at laparotomy, and decreased with NEC resolution. SMA was detectable in the plasma of infants with multifocal or panintestinal NEC, but in neither focal nor non‐operative disease.

Conclusion:   FABP and SMA are markers of mucosal and transmural intestinal damage, respectively, and may offer clinically relevant information in the diagnosis and management of severe intestinal disease.
GS17 *THE VALUE OF EARLY CT IN BOWEL OBSTRUCTION
Authors: Morris B. P. , Turner R. , De costa A. , Gleeson J. , Slack T.
Published: April 2009

There is increasing use of CT in intestinal obstruction to delineate those patients requiring expeditious surgical intervention from those in whom conservative management is appropriate. We sought to assess the accuracy of CT in predicting those patients for whom conservative management would suffice. A mixed prospective‐retrospective series had 75 patients with a clinical diagnosis of intestinal obstruction and a CT performed within 24 hours of hospital admission. Patients were excluded if there was an immediate indication for surgery eg peritoneal irritation or shock. A positive diagnosis was defined as suitability for conservative management based on CT absence of an obstructing lesion and/or progression of contrast. A negative diagnosis was defined as a high‐grade obstruction, signs of strangulation or a lesion requiring operation eg volvulus or tumour. Sixty‐two cases (82.7%) had a history of abdominal surgery. Forty‐one (54.7%) underwent operative intervention during their index admission. Diagnostic accuracy measures for CT in predicting successful conservative management were: sensitivity 91.4%, specificity 77.5%, positive predictive value 78% and negative predictive value 91.2%. In those with prior abdominal surgery, these results were 96.7%, 71.9%, 76.3% and 95.8% respectively. CT is highly effective in detecting bowel obstruction cases that do not require operation and also in predicting those cases that actually do. These measures are slightly improved when selecting patients with previous abdominal surgery. CT scanning may therefore be incorporated into a diagnostic algorithm for acute bowel obstruction. Future studies may benefit from more standardised assessment criteria and cost‐effectiveness analyses.
GS18 *PROTEOMIC CHANGES IN MESENTERIC LYMPH SECONDARY TO HAEMORRHAGIC SHOCK
Authors: Mittal A. , Phillips A. , Middleditch, K. Ruggiero M. , Loveday B. , Windsor J. A.
Published: April 2009

Background:   Biologically active factors produced by the intestine and transported by the protein fraction of mesenteric lymph are thought to contribute significantly to the development of distant organ failure in haemorrhagic shock. Despite the likely relevance of the protein composition of mesenteric lymph conditioned by haemorrhagic shock, there is no detailed description of its proteome. The aim of this study was to provide the first comprehensive description of the proteome of haemorrhagic shock conditioned mesenteric lymph.

Methods:   20 male Wistar rats were randomized to either control or haemorrhagic shock group. Mean arterial pressure was reduced to 30 mmHg in the shock group for 90 minutes followed by resuscitation and mesenteric lymph collection for another 90 minutes. Proteomic changes in mesenteric lymph due to haemorrhagic shock were identified using LC‐MS/MS.

Results:   245 proteins were identified in mesenteric lymph, including 35 hypothetical proteins. 60 of the 245 proteins had a significant increase in their relative abundance in the haemorrhagic shock group vs. sham group. Potentially toxic pancreatic enzymes had increased abundance in post‐shock mesenteric lymph. In addition, a bioinformatics approach allowed for the identification of key pathways relating to defence and metabolic responses. A number of potentially important proteins were also identified as targets for future research in hemorrhagic shock: peroxiredoxins, 14‐3‐3 zeta/epsilon, calmodulin, cofilin, and profilin.

Conclusions:   This study not only provides the first comprehensive list of protein changes in the haemorrhagic shock conditioned mesenteric lymph, but also provides rational for future research.
GS02 **INGUINAL HERNIA REPAIR WITH UHS – A SINGLE SURGEON REVIEW
Authors: Hatch J. A. , Tan P.
Published: April 2009

Purpose:   Inguinal hernia repair is a common operation with much focus in recent times on improving morbidity. The use of mesh repair has greatly decreased reoccurrence rates and focus turns towards improving postoperative groin pain. This review examines the use of UHS in inguinal hernia repair and relation with postoperative groin pain.

Methods:   A retrospective audit of consecutive cases over one year (telephone and mailed questionnaires) was conducted. The recently validated IPQ (inguinal pain score) was used. A review of files and operative reports was also undertaken. Cases undergoing bilateral repair, or other operations simultaneously were excluded.

Results:   59 patients (61%) participated in the audit, with a mean follow up of 11 months (range 5–16). 4 minor wound complications occurred. Higher pain scores appeared to correlate preoperatively with age and workers compensation status. Postoperative pain scores and limitation to functional status were low, and trended towards lower values in the UHS (ultrapro hernia system) repair group compared to the group who underwent repair with PHS (preceding week pain scores respectively –UHS repair, mean 1.22, (95%CI 1.07–1.38); PHS 1.76, (95%CI 1.11–2.43)). The average time until pain disappeared in the groin was within one month (IPQ score of 1.27). For those patients still experiencing any pain, (14 of 59; 23.7%) it occurred on average, once per week for minutes to hours and was at a level that could be ignored.

Conclusion:   Inguinal hernia repair with UHS appears to be a safe procedure with minimal complications and a favourable postoperative chronic pain profile.
GS21 *ENHANCED RECOVERY PROGRAMS (EPR) – IS IT APPROPRIATE IN A TERTIARY REFERRAL CENTRE AND COMPLEX COLORECTAL SURGERY?
Authors: Cooke F. J. , Ballal M. , Entriken F. , Aitken J. R. , Hodder R. J.
Published: April 2009

Introduction:   Enhanced Recovery Programs (EPR) have been shown to reduce mortality, morbidity and length of stay. Can similar results be produced in tertiary centres with the presence of complex colorectal cases?

Method:   102 patients were prospectively analysed with a power calculation of 34 being established prior to commencement of the study. The average age was 66.6 (male: female ratio of 1:1).

Data collection included demographics, operative procedure, pain scores, POSSUM scores, American Society of Anaesthiology (ASA) scores, and discharge times. All complications were documented.

Results:   83 cases were open procedures and 19 laparoscopically, (3 were converted intra‐operatively). The majority were anterior resection (47, [46.1%]) and right hemicolectomies (32, [31.3%]).

The average overall discharge time was 11.75 days compared to 15.11 (p < 0.001) prior to commencement of the study in 2005. Anterior resections and subtotal colectomies (14.3 and 13.7 days respectively) had significantly longer lengths of stay compared to right hemicolectomies (10.7 days) [p < 0.001].

56% patients were ASA grade 3 & 4 (50% and 6% respectively). A clear correlation with increasing ASA and discharge time was demonstrated (ANOVA p = 0.0004) with significant exponential rise with ASA greater than 2. POSSUM scoring demonstrated a positive correlation with prolonged hospital stay with increasing scores having worse discharge time.

Conclusion:   In the presence of complex major surgery and tertiary centre referrals an ERP is feasible producing an average saving of 3.36 days. The benefit is however less with increasing ASA and POSSUM Scores. It however still produced an average economic bed stay saving cost of $3700 per patient stay.
GS22 *THE PROVISION OF A DEDICATED ACUTE GENERAL SURGICAL UNIT IMPROVES THE MANAGEMENT OF PATIENTS WITH ACUTE GALL BLADDER DISEASE
Authors: Shackleton S. D. , O’neill C. J. , Shah K. , Wills V. L.
Published: April 2009

Introduction:   The goal of an acute general surgical unit (AGSU) is to improve the management of all emergency surgical admissions including those with acute gall bladder disease. In May 2008, John Hunter Hospital Newcastle implemented an AGSU. Changes to service provision included an in‐house consultant (7 am to 7 pm) dedicated to acute surgery with access to an afternoon operating list most weekdays. This study compares the management of acute gall bladder disease before and after implementation of the AGSU in the setting of an unchanged policy of operative management during the index admission (where appropriate) for acute gall bladder disease.

Method:   An analysis was performed of all patients admitted via the emergency department with biliary colic or cholecystitis. Demographic, clinical management data and complications were compared for the 6 months of June to November (inclusive) 2007 (pre‐AGSU) and 2008 (AGSU).

Results:   In 6 months of 2007, 45 patients were admitted with acute gall bladder disease of which 35 (78%) underwent operative management. By comparison in the same 6 months of 2008, there were 70 admissions, with operative management in 61 (87%). In 2008 average length of stay was 4.24 days (5.07 days in 2007); average time from admission to surgery 34.8 hrs (54.5 hours in 2007, p < 0.05) and, 70.5% of operations occurred between 8 am and 5 pm on a weekday (60% in 2007).

Conclusion:   The provision of an acute gall bladder service is improved within a dedicated acute general surgical unit. This translates to benefits to patients, staff and healthcare economics.
GS24P ACUTE COLONIC PSEUDO‐OBSTRUCTION (ACPO): SURGERY REMAINS AN IMPORTANT TREATMENT OPTION
Authors: Chow Z. Y. , Lee H. S. , Jones I. , Hastie I. , Hayes I. , Shedda S.
Published: April 2009

Purpose:   ACPO often occurs in patients with serious comorbidities and can result in high morbidity and mortality. We aimed to evaluate the current practice of treatment of pseudo obstruction in the era of neostigmine in a single metropolitan hospital.

Method:   A retrospective review of prospective hospital databases was undertaken to identify patients with radiological evidence of pseudo‐obstruction and gather demographic information. Further information was retrieved from patient files.

Results:   133 patients were identified with radiological evidence of pseudo‐obstruction from June 1996 to December 2008. The median age was 68.5 (range 17–95). There were 80 (60%) males. Overall median length of stay was 37 days with a mortality rate of 9%. For conservative treatment or neostigmine (CN), endoscopic decompression (E), surgery (S) groups, the mortality rates were 9.5%, 8.6% and 6.2% respectively, p = 0.36. There were 94 patients in the CN group, 16 (12%) required surgery (S) and 23 (17%) had endoscopy (E), p = 0.36. The median time to diagnosis from admission was 10 days (CN), 0 days (E) and 7 days (S); p = 0.13. The most frequent mode of diagnosis was gastrograffin enema for CN (43), AXR for E (9) and CT abdomen for S (7). It was noted that 44 (33%) patients had unrelated surgery within the last 30 days prior to the current admission. Surgery for complications was required including 7 colectomies (44%) and 5 caecostomies (31%).

Conclusion:   Surgery remains crucial as a treatment modality for pseudo‐obstruction in the era of neostigmine. The majority of operations performed at our institution for pseudo‐obstruction were colectomies, which reflects a high rate of complications in our cohort of patients.
GS26P C REACTIVE PROTEIN IMPROVES DIAGNOSTIC ACCURACY OF ACUTE APPENDICITIS IN EQUIVOCAL CASES
Authors: Thanavinthan thirumalai S. , Wijesuriya R. , Lim S. , Ong S. , Delriviere L. , Mitchell A.
Published: April 2009

Introduction:   The aim of the study was to evaluate whether C reactive protein level (CRP) on admission could aid the diagnostic accuracy of Alvarado score in acute appendicitis.

Patients and methods : 233 patients (males 115, females 118, median age 28 years, range 15–87 years) who underwent appendicectomy were evaluated.

Methods:   Patients were categorized in to 3 groups retrospectively based on the Alvarado score. Group I: score 7–10 (n = 154), Group II: score 4–6 (n = 66), Group III: score < 3 (n = 13). Negative (NPV) and positive predictive values (PPV) of CRP which was performed at the time of admission was calculated.

Results:   Overall, 169 of 233 (72.5%) had histopathological confirmation of acute appendicitis. In Group I it was 134 patients (87%), Group II: 35 patients (53%) and none of patients in Group III. NPV and PPV for Group I was 29.6% and 85.5%, Group II was 65% and 80% respectively.

Conclusion:   The CRP level improves the predictive value of diagnosing acute appendicitis in the equivocal group of Alvarado 4–6. Patients in this group with a normal CRP should be further investigated before proceeding to appendicectomy.
GS28P DOES THE USE OF DEDICATED RANSON'S CRITERIA IMPROVE PATIENT OUTCOME?
Authors: Chakraborty J. K. , Jivan Y. , Subramanya M. S. , Smith B. , Memon B. , Memon M. A.
Published: April 2009

Purpose:   Early identification of the disease severity in acute pancreatitis and focused management based on Ranson's criteria has shown to improved patients’ outcomes in many trials. We introduced Ranson's criteria at Ipswich Hospital in 2007 and compared the patients’ outcome using historical controls.

Methodology:   A retrospective chart analysis was undertaken on patients diagnosed with acute pancreatitis at Ipswich Hospital between 2006 and 2007. Ranson's criteria and treatment protocols were introduced in January 2007 and data was collected prospectively. Data was assessed for the length of hospital stay, ICU admission, transfers to tertiary centres, morbidity and mortality.

Results:   33 patients were admitted with acute pancreatitis in 2006 compared to 76 patients in 2007. Ranson's criteria were not formally assessed in any patient prior to 2007. However, 88% of patients had Ranson's criteria scored with strict adherence to the treatment protocol since 2007. 13 patients were scored as severe (greater than 3) in 2007 compared to none in 2006. 6% of patients developed pneumonia compared to 14% in 2007. Length of stay was 5.5 days in 2007 versus 4.87 days in 2006. Five ICU admissions and 4 transfers to tertiary centres occurred in 2007 compared to one transfer with no ICU admissions in 2006. There was no mortality in 2006 compared to 2% in 2007.

Conclusion:   Use of Ranson's criteria enables us to tailor our treatment of acute pancreatitis. It is a clinically useful tool and strict adherence leads to quick severity stratification, improved management and better use of health care resources.
GS29P EFFECT OF IMMUNE‐ENHANCED SUPPLEMENTED FORMULAS IN PERIOPERATIVE OUTCOMES: A META‐ANALYSIS
Authors: Osland E. , Khan S. , Hossain M. B. , Memon M. A.
Published: April 2009

Purpose:   Providing enteral supplements containing ‘immunonutrition’ has been proposed to decrease postoperative complications and duration of hospital stay for elective surgical patients. This meta‐analysis was undertaken to elucidate the potential benefit of providing immune‐enhanced nutrition in surgical patients.

Methodology:   A search of Medline, Embase, Science Citation Index, PubMed and the Cochrane Database identified all RCTs comparing the use of perioperative immunonutrition with standard nutrition provision in elective adult surgical patients between 1990 and 2008. The variables analysed included mortality, total complications, infective complications, anastomotic leak and length of hospital stay.

Results:   21 distinct studies were identified that met inclusion criteria involving 2135 patients (immunonutrition n = 1100; standard nutrition n = 935). The provision of immunonutrition was shown to be associated with significant reductions in the incidence of total postoperative complications (OR 0.50, 95% CI 0.37, 0.69, p < 0.0001), postoperative infective complications (OR 0.47, 95% CI 0.37, 0.60, p < 0.0001), anastomotic breakdown (OR 0.43, 95% 0.25, 0.75, p = 0.003), and the duration of hospital stay (WMD −2.95, 95% CI −4.01, −1.88, p < 0.0001) when compared to standard nutritional provision. No differences were seen between interventions with relation to mortality (OR 0.90, 95% CI 0.41, 1.97. p = 0.8).

Conclusion:   Provision of immunonutrition in preference to standard nutrition was associated with clinically significant decreased length of hospital stay, reduction in the development of postoperative complications including those of infective origin and anastomotic breakdown but has no impact on mortality.
GS30P EFFECTIVENESS OF A STANDARD TEACHING PROGRAMME FOR MEDICAL STUDENTS ACROSS MULTIPLE CLINICAL TEACHING SITES
Authors: Wheeler B. R. , Yu T.‐C. , Wright M. , Hill A. G.
Published: April 2009

Introduction:   Surgical teaching for clinical medical students is often undertaken across multiple clinical campuses. There are concerns heterogeneity of clinical experience may result in heterogeneity of learning outcome achievements. To avoid this, we have utilised standardised learning materials and tutorials across four hospital campuses.

Methods:   Using a feedback questionnaire, clinical experience from assigned hospitals was collected, including a question on influence of clinical experience on future career choice. This was analysed for inter‐hospital differences. Clinical experience was also assessed by analysis of individual student portfolios. Students were administered a centralised standardised formative Objective Structured Clinical Examination (OSCE) during rotations. We analysed OSCE results from 2005 to 2008 for internal reliability and correlation with final written examination grades on a hospital‐by‐hospital basis.

Results:   Analysis of student feedback results and portfolios identified inter‐hospital differences in clinical experience. Students indicated that clinical experiences had influence on decision to pursue future surgical careers. The OSCE had a good level of internal reliability (Cronbach's‐alpha 0.62–0.75). No significant inter‐hospital difference in OSCE results was found using one‐way analysis of variance. OSCE results had strong correlations with final examination grades.

Conclusions:   Heterogeneity of clinical experience across different teaching settings does not translate into heterogeneity in achievement of learning outcomes when teaching materials are standardised. Consistent with previous published data, undergraduate clinical experience may influence future career choices.
GS32P IS ABDOMINAL CT IN ADDITION TO GASTRO‐INTESTINAL TRACT INVESTIGATION SUFFICIENT TO DETECT ALL SIGNIFICANT DISEASE IN PATIENTS PRESENTING WITH IRON DEFICIENCY ANAEMIA
Authors: Hernon J. M. , Fenech M. , Hall N. R.
Published: April 2009

Introduction:   The British Society of Gastroenterology (BSG) guidelines for patients presenting with iron deficiency anaemia (IDA) suggest patients should undergoing upper and lower gastrointestinal tract examination in addition to coeliac serology. Studies suggest that in approximately 20% of patients no diagnosis is made. In these patients subsequent management and risk of underlying malignancy remains unclear. In our unit all patients initially negative following investigation undergo an abdominal CT scan. Aim To determine 1) cancer detection and overall disease detection rates for patients referred with IDA on the cancer pathway 2) Subsequent outcomes of patients with no diagnosis made after initial investigations.

Methods:   Patients referred between Jan 2002 – Jan 2005 were retrospectively reviewed with respect to 1) diagnosis following initial investigations 2) addition diagnosis following abdominal CT 3) Eventual outcome 3 years following presentations.

Results:   111 patients were reviewed. Following initial investigation 12 colorectal and 2 gastric cancers were identified. 63% of patients had a diagnosis following initial investigations. Three patients were diagnosed with underlying malignancy following abdominal CT. 38 patients had no diagnosis, non reattended over a 3 year period with significant pathology.

Conclusion:   BSG guideline investigations with addition abdominal CT is sufficient to detect disease in patients with IDA.
GS34P LAPAROSCOPIC MANAGEMENT OF PRIMARY OMENTAL TORSION: A REGIONAL HOSPITAL EXPERIENCE
Authors: Desai D. J. , Seow H. S. , Ashraf M. , Wagner N.
Published: April 2009

Introduction:   Infarction of the greater omentum is a rare entity representing 0.1% of the total laparotomies performed for acute abdomen.

Materials and Methods:   Prospectively collected data was retrospectively analysed for the last three calendar years from Jan 2006 to Dec 2008. A total of five cases of Primary Omental torsions were identified of which four were managed laparoscopically and one was managed conservatively.

Discussion:  

The cause of Primary (Idiopathic) segmental infraction of the greater Omentum is unknown. The possible mechanisms are arterial micro thrombosis or venous thrombosis secondary to stretching of the Omental veins, and precipitating factors such anomalous arterial supply to the omentum, kinking of vein secondary to increase intra‐abdominal pressure and vascular congestion after large meals have been suggested. Here we present five cases, all males, ranging from ages of 23 to 55 years with a primary presenting complaint of abdominal pain. Only one of these had a previous appendectomy while two had other abdominal surgeries. The working diagnosis was that of an acute abdomen and four of these underwent laparoscopy and Omentectomy. One of them was conservatively managed. Postoperatively there was an immediate relief of pain and the recovery was uneventful with no mortality.

Conclusion:   The aim of this article is to share our experience in the diagnosis and management of this rare condition successfully with minimally invasive laparoscopic surgery in our regional centre, and a brief review of the literature.
GS36P PREOPERATIVE FINE NEEDLE CYTOLOGY AND IMAGING FACILITATES THE MANAGEMENT OF SUBMANDIBULAR SALIVARY GLAND LESIONS
Authors: Taylor M. J. , Serpell J. W. , Thompson P.
Published: April 2009

Purpose:   Lesions of the submandibular gland represent a pleomorphically diverse group making benign and malignant lesions difficult to differentiate from each other. The current series aims to identify the roles of pre‐operative cytology and imaging with subsequent histopathology in the management of these lesions.

Methods:   Between 1998 and 2008 fifty‐four patients, of median age 54 years (range 25–94), were retrospectively identified. Fifty patients underwent fifty‐two surgical procedures involving the submandibular gland. The utility of imaging and cytology was analysed, and the accuracy of cytology correlated with histopathology.

Results:   Pathologies of resected specimens included: sialadenitis; 17 (32%), pleomorphic adenoma; 9 (17%), calculi; 8 (15%), lymphoma; 5 (10%) squamous cell carcinoma; 2 (4%), adenoid cystic carcinoma; 1 (2%) and other; 10 (20%). Twenty‐eight patients (52%) underwent fine needle aspiration cytology/core biopsies; of these 25 proceeded to surgery. Accuracy, sensitivity, and specificity of fine needle aspiration cytology correlation with histology were 88.0%, 71.4%, and 94.4% respectively. Overall, the complication rate was 9.6%.

Conclusion:   This series demonstrates histological outcomes in patients specific to the submandibular salivary gland for which there are few comparative series in the literature. The trans‐cervical surgical approach to submandibular gland pathology is a safe and effective method with minimal morbidity. Combining investigative modalities and cytology optimises the diagnosis and management of submandibular salivary gland lesions.
GS38P THE SAT‐SET COURSE #1: DEVELOPING A TOOL FOR WORKPLACE‐BASED ASSESSMENT OF SURGICAL TRAINEES
Authors: Blackham R. E. , Hamdorf J. M.
Published: April 2009

The SAT SET course is an innovative course designed by the Royal Australasian College of Surgeons in response to a need to meet the challenges posed by the new SET training program. The course aims to teach current Fellows of the College a number of skills and evaluation methods required of surgical supervisors in assessment and performance management. Specifically, the course demonstrates effective use of the Mini‐CEX and DOPS (Direct Observation of Procedural Skills) for initial and mid‐term assessment of trainees; discusses the College's training policies and relevant legal issues such as the appeals process, as well as explaining expectations of their roles as supervisors and trainers.

The course is a forerunner in Australia in active teaching of modern competency‐based assessment tools implemented across a number of disciplines and workplace environments. From its commencement in May 2007 until September 2008, 555 Fellows have participated in SAT SET courses convened in Australia and New Zealand (229 in 2007, 326 in 2008). In addition, 185 SET Supervisor Fellows have attended the course, approximately 40% of all Surgical Supervisors in Australasia.

Our survey aims to test the outcomes of the SAT SET course by the cumulative feedback from Supervisors who have attended the course and follow‐up. Future iterations to improve the course, such as video demonstration of mid‐term assessment, co‐badging of SAT SET courses with hospitals and expansion of resources for facilitators will also be discussed.
GS05 SAFER SURGERY GUIDELINES – EXPERIENCE AT A TERTIARY SURGICAL CENTRE
Authors: Lam J. T. , Heriot A. G. , Lynch C.
Published: April 2009

Introduction:   Although modern surgery is often complex, adherence to simple but critical safety steps have been shown to markedly improve patient outcomes.

Aim:   To review and compare surgical practice at a tertiary surgical centre to recommendations from the WHO Safe Surgery Saves Lives Committee.

Methodology:   Retrospective analysis of all prospectively recorded surgical adverse events over an 18 month period (1st Jan 2007–30th June 2008). These events were compared to the WHO recommendations.

Results:   The tertiary centre practiced all but 3 of the WHO recommendations and 166 surgical adverse events and 23 process failures/near misses were identified. Rate of adverse events was better than the average reported in industrialised nations. Leading adverse events were infection and bleeding/haematoma. Seventeen percent of adverse events identified could have been modified had a ‘sign‐out’ process been followed.

Conclusion:   Implementation of WHO recommendations has the potential to reduce surgical adverse events.
GS06 NUTRITIONAL STATUS OF ACUTE SURGICAL PATIENTS‐PREDICTOR OF HOSPITAL STAY
Authors: Kahokehr A. A. , Sammour T. , Wang K. , Plank L. D. , Hill A. G.
Published: April 2009

Background:   Previous studies have shown that nutritional status affects recovery after elective surgery. The impact of nutritional status in the acute surgical setting has not been well defined.

Methods:   Over a 4 week period consecutive patients admitted for >24 hours under the general surgical service at a tertiary hospital were screened on admission using the subjective global assessment (SGA) nutritional assessment tool.

Results:   Of 332 eligible patients, 310 were screened. Diagnoses at discharge were: Colorectal pathology (28%), Infective (23%), Hepatopancreaticobiliary (15%), upper gastrointestinal (9%), Vascular (5%), trauma (5%), other (15%). 5% had a malignancy diagnosed during their admission. Mean age was 52 years (95% CI 18–84), mean BMI was 28.6 kg/m2 (95% CI 19.2–41.7), and 170 (55%) were female. 48% were deemed well nourished (SGA‐A), 40% had moderate/suspected malnutrition (SGA‐B) and 12% were severely malnourished (SGA‐C). Median (range) hospital stay was 3 (1–20), 5 (1–30) and 7 (2–38) days (p < 0.001 Kruskal Wallis) for SGA category A to C respectively. Cox regression revealed that SGA was an independent predictor of day stay after taking age, malignancy, sex, albumin, lymphocyte and diagnosis into consideration.

Conclusion:   Nutritional status in the acute surgical setting, as measured by a simple clinical tool predicts duration of hospital stay. Admission nutrition screening may be considered in order to determine nutritional requirements of acute surgical patients.
GS07 THE UTILITY OF CT ANGIOGRAPHY IN ACUTE LOWER GASTROINTESTINAL HAEMORRHAGE: A SINGLE INSTITUTION EXPERIENCE
Authors: Mehrotra R. , O’neill C. J. , Smith S. , Draganic B.
Published: April 2009

Introduction:   Lower gastrointestinal haemorrhage (LGIH) is a major health burden. Although for the majority no intervention is required, where conservative management fails, radiological intervention is required to either localise or embolise the bleeding vessels. In recent years CT angiography (CTA) has increasingly been used for localisation. This study assesses the utilisation of this investigation in patients with acute LGIH.

Methods:   A review of all patients admitted to the John Hunter Hospital, Newcastle with acute LGIH was performed and patients undergoing CTA selected. The utility and safety of CTA was assessed as well as a comparison made between positive and negative tests.

Results:   Between January 2005 and August 2008 there were 334 emergency admissions with LGIH of which 79 patients underwent CTA. In 30 (38%) patients, CTA localised an active bleeding site. Of the remaining 49 CTA, other pathology was identified in 8 (10%). Overall mortality was 5% and intervention rate was 9% (4 segmental colectomy and 3 selective angiography). There was no difference in rate of intervention or mortality between the CTA positive and negative groups. Transfusion requirement (4.28 vs. 2.34 units, p < 0.05) and haemodynamic instability at the time of CTA were higher in the positive CTA group.

Conclusion:   LGIH will resolve without intervention in the majority. CTA is safe and a positive test is not indicative of a higher intervention rate but provides a management strategy. We suggest it be performed on patients receiving more than 2 units of packed cells or those with haemodynamic instability.