bluuebunny/crossref_metadata_2025 huggingface dataset:
Preadmission processes may improve length of stay for colorectal surgery
Authors: Monagle John , Waxman Bruce , Abourizk Steven , Sparrow Maryanne , Shearer Bill
Published: December 2004

Background:  The preadmission process (PAP) is known to reduce length of stay prior to surgery, but there are few data on its effects on postoperative stay. The aim of the present study was to test the hypothesis that a PAP may reduce postoperative length of stay as well as the preoperative length of stay.

Methods:  An audit of admission and discharge times for patients having major colorectal surgery was undertaken to determine the impact of the preadmission process at Dandenong Hospital. One hundred and two elective patients were identified over a 12‐month period.

Results:  The 71 patients admitted through the preadmission process had a 10.7‐day average length of stay compared to 18.4 days if the patients were admitted directly by the surgeon. The reduction in length of stay was contributed to by 4 days less preoperatively and 4 days less postoperatively. Thus the benefits from a preadmission service can be realized both at admission and discharge. The nature of this impact of preadmission requires further investigation.

Conclusions:  The PAP will reduce preoperative length of stay. Utilization of a PAP also appears to reduce postoperative length of stay and may reduce postoperative complications. Further investigation is required to determine the exact nature and extent of these PAP benefits.
Hilar benign biliary strictures: need for subclassification
Authors: Sikora Sadiq S. , Srikanth Gadiyaram , Sarkari Anuj , Kumar Ashok , Saxena Rajan , Kapoor Vinay K.
Published: December 2004

Background:  A uniformly accepted classification allows an accurate comparison of results and formulation of a standardized treatment plan. Suggested herein is a subclassification of Bismuth type III post‐cholecystectomy benign biliary strictures (BBS).

Methods:  Fifty‐seven patients (41%) with Bismuth type III and eight patients (6%) with type IV BBS out of a total of 139 patients with BBS were analysed retrospectively. Strictures were subclassified as type IIIA where the confluence was healthy and type III B where the roof of the confluence was healthy and right and left ductal continuity was maintained, although the floor of the confluence was scarred.

Results:  Of 57 patients with type III BBS, 44 were subclassified as type IIIA and 13 as type IIIB. Statistically significant dif­ferences were observed in the mean operative blood loss (317 vs 635 mL, P = 0.004; 317 vs 606 mL, P = 0.006), blood transfused (0.8 vs 2.2 units, P = 0.0007; 0.8 vs 2.0 units, P = 0.0008), and duration of surgery (3.8 vs 5.1 h, P = 0.002; 3.8 vs 5.6 h; P = 0.0004) between type IIIA and IIIB, and between type IIIA and IV strictures, respectively. There were no differences in the operative parameters between type IIIB and IV strictures. There was no difference in the overall morbidity (18% vs 15% vs 25%) and septic complications among the three groups. At a mean follow up of 36.4 months, 87%, 91% and 100% of patients had excellent/good outcome in type IIIA, IIIB and IV, respectively.

Conclusions:  Type III biliary strictures need to be subclassified, based on whether the floor of the confluence is healthy or scarred because it influences the degree of operative difficulty and morbidity. Type IIIB BBS behave like and should be classified with type IV strictures for uniformity of result evaluation.
Maintaining surgical standards beyond the city in Australia
Authors: Green Anthony
Published: December 2004

Many Australians, by choice or necessity, live and work in rural Australia. In the past broadly trained general surgeons and appropriately trained general practitioner (GP) surgeons provided much of the surgical management. Recently very few rural GPs have been trained in surgery and there is a shortage of specialist surgeons in many rural parts of Australia. Outreach surgery can assist in the provision of some surgical services but it is not as effective as an on‐site surgical presence. The challenge for the Royal Australasian College of Surgeons Rural Surgical Training Programme is to provide an ongoing supply of well‐trained surgeons in general surgery and the other specialties to provide adequate surgical services to rural Australians. This will be best achieved by having adequate numbers of surgeons resident in rural areas with appropriate outreach specialist services, and training and support of the procedural GPs in the smaller centres.
Antireflux surgery for Barrett's oesophagus
Authors: Lord Reginald V. N.
Published: December 2004

Barrett's oesophagus is usually the result of severe reflux disease. Relief of reflux symptoms is the primary aim of treatment in patients with Barrett's oesophagus who do not have high‐grade dysplasia. Some studies with medium‐term (2−5 years) follow up show that antireflux surgery can provide good or excellent symptom control, with normal oesophageal acid exposure, in more than 90% of patients with Barrett's oesophagus. Antireflux surgery, but not medical therapy, can also reduce duodenal nonacid reflux to normal levels. There is no conclusive evidence that antireflux surgery can prevent the development of dysplasia or cancer, or that it can reliably induce regression of dysplasia, and patients with Barrett's oesophagus should therefore remain in a surveillance programme after operation. Some data suggest that antireflux surgery can prevent the development of intestinal metaplasia (IM) in patients with reflux disease but no IM. The combination of antireflux surgery plus an endoscopic ablation procedure is a promising treatment for patients with Barrett's oesophagus with low‐grade dysplasia.
Differences in the surgical admissions to hospital between the indigenous and non‐indigenous populations of Australia
Authors: Ishak Maged
Published: December 2004

Background:  The overall rate of admission to hospital for indigenous Australians is in general much higher than that for the non‐indigenous Australians. However, this result is not uniform for surgical and medical admissions. Previous studies in the Northern Territory have suggested a cultural aversion to surgery among indigenous Australians. In the present study the current data of admission to hospital are analysed to explore the pattern for surgical procedures in the indigenous population and to determine whether the disparity between indigenous and non‐indigenous populations still exists at this later period.

Methods:  Admission data for all acute public and private hospitals in New South Wales (NSW) for the 6‐year period 1989−1995 are used for this analysis.

Results:  It is shown that when adjustments have been made for the differing age composition of the two populations in NSW, the medical admission rate for the indigenous population is approximately double that for the non‐indigenous population. In contrast, the non‐indigenous admission rate for surgical procedure is approximately 1.3 times the indigenous surgical admission rate. In addition, while approximately one‐third of non‐indigenous admissions are for surgical procedure, this proportion is only one‐sixth of the indigenous admissions. Indigenous people are more likely to be admitted for emergency surgery rather than planned surgery. and while approximately 25% of the surgical admissions in the indigenous population are through emergency, this proportion is only 14% in the non‐indigenous population.

Conclusions:  It seems that the disparity between admission patterns for indigenous and non‐indigenous populations still exists in NSW at this later period, particularly in rural areas. There appears to be a need to find ways to overcome a possible bias within the indigenous population against surgery. It is possible that medical treatments are being substituted for surgical procedures.
Improving the evidence base in surgery: sources of bias in surgical studies
Authors: Young Jane M. , Solomon Michael J.
Published: December 2004

Clinical epidemiology, which is concerned with the application of epidemiological principles to patient care, provides the scientific basis for evidence‐based medicine. The present paper reviews the epidemiological concepts of selection bias, measurement bias and confounding in surgical research and discusses ways in which these sources of bias can be minimized in surgical studies.
Dupuytren's disease or Cooper's contracture?: Kenneth Fitzpatrick Russell Memorial Lecture
Authors: Thurston Alan
Published: December 2004

In his position as curator of the Cowlishaw collection of historical medical books in the Library of the College, Kenneth Russell prepared the definitive catalogue of the collection. This catalogue is comprehensive and for almost all entries there is an annotation that demonstrates his meticulous attention to detail and the love of the book collection that he managed to secure for the College. It is from this catalogue that I have chosen two books in particular that bring together two great surgeons of the turn of the 19th century.

Although he was a pupil of the great John Hunter, the young Astley Cooper possessed good manners and a gift of oratory of which the Scot, his teacher, was devoid. After his apprenticeship with Henry Cline senior, Cooper came to share the podium with Cline at Guy's and St Thomas’ hospitals and the two dominated surgical teaching in London for some 22 years, until Cline's retirement in 1811. It was the latter who was first to recognize the true nature of the condition now known as Dupuytren's disease. Later, in 1822, Cooper wrote a detailed description of the contracture of the palmar aponeurosis and recommended fasciotomy as being curative. His book A Treatise on Dislocations and Fractures of the Joints, which contains this description of Dupuytren's contracture, is held in the Cowlishaw Collection.

On the other side of the English Channel, M. le Baron Dupuytren repeatedly misquoted Cooper and stated that Cooper believed that the disease was incurable. In his famous lecture given to the staff of the Hôtel Dieu in Paris on 5th December 1931, he admitted to having seen 30 or 40 cases over 20 years of practice. It seems likely that he was not aware of the true cause of the condition before 1831 when he treated his first case. This lecture, along with others, are recorded in his Leçons Orales de Clinique Chirurgicale, a copy of which is also to be found in the Cowlishaw Collection.
Fine needle aspiration in the management of benign thyroid cysts
Authors: Smith Marty D. , Serpell Jonathan W. , Morgan Joanna L. , Cheng Michael S. P.
Published: December 2004

Background:  Resolution of cystic thyroid lesions after aspiration occurs in 8−45% of cases, the remainder require treatment for residual tumour or recurrent cysts. The aim of this study was to identify patient characteristics that predict cyst recurrence to enable these patients to undergo early surgery.

Methods:  A retrospective analysis of 123 patients with benign thyroid cysts that were suitable for conservative management was undertaken. Demographic, clinical, ultrasound and fine needle aspiration cytology data were collated for patients who underwent surgery or were managed conservatively. Univariate and multivariate analyses were performed to identify factors predictive of cyst recurrence.

Results:  Of the 123 patients, 43 underwent surgery consequent on cyst recurrence or persistent symptoms after aspiration, and 80 were treated by aspiration alone. There were 17 males and 106 females, of mean age 45.5 years. The mean cyst size was 27 mm. Those undergoing surgery had a significantly greater mean cyst size (P = 0.001). The only factor predicting cyst recurrence on univariate analysis was absence of follicular cells on initial aspiration (P = 0.005). Multivariate analysis confirmed absence of follicular cells as an independent characteristic predicting recurrence, the odds ratios for recurrence was 3.18 (95%CI 1.39−7.29).

Conclusion:  The present study suggests consideration of early surgery for patients with thyroid cysts with absence of follicular cells on initial cytology.
Fine‐needle aspiration cytology of thyroid nodules: how useful is it?
Authors: Morgan Joanna L. , Serpell Jonathan W. , Cheng Michael S. P.
Published: December 2004

Background:  Thyroid nodules are common and the principal method of diagnosis is fine‐needle aspiration cytology (FNAC).

Methods:  To determine the value of FNAC in the diagnosis of thyroid nodules, thyroid cytology of 253 patients with definitive histology after surgery was analyzed from 1992 to 2002. FNAC was correlated with histology and the sensitivity, specificity and likelihood ratios were calculated. The method of FNAC and number of non‐diagnostic aspirates were noted. The frequency of thyroid cancer was investigated in male and females who presented with a solitary thyroid nodule.

Results:  The overall sensitivity of FNAC detecting thyroid neoplasia was 55.0%, specificity 73.7% and accuracy 67.2%. Likelihood ratios indicate that a ‘malignant’ or ‘suspicious for malignancy’ cytology dramatically increase the pretest probability of thyroid neoplasia. There were no false positive ‘malignant’ FNAC. Ultrasound guided FNAC had a significantly lower non‐diagnostic rate compared to freehand FNAC (P < 0.02). Of 22 males, 22.7% who proceeded to surgery for their solitary nodule had thyroid carcinoma compared with 11.9% of 167 females (P = 0.02).

Conclusions:  FNAC was essential to management in this series of patients. ‘Malignant’ or ‘suspicious for malignancy’ cytology are absolute indicators for thyroidectomy. FNAC should be undertaken with ultrasound guidance and if possible with a pathologist in attendance to assess sample adequacy. We recommend a high index of suspicion of thyroid cancer in the male patient who presents with a solitary nodule. If solitary nodules are to be observed, repeat FNAC should be undertaken because of the high false negative rate.
Early development of the vascular laboratory in Australia
Authors: Harris John P.
Published: December 2004

Vascular surgeons were involved in the early development of the vascular laboratory in Australia, extrapolating experience gained overseas, introducing the methodology and training programmes and later determining qualifications and standards. Common themes emerged in a review of individual surgeons’ involvement, notably their early commitment, ingenuity in overcoming financial and political barriers and the close working relationship that developed between them and their vascular technologists. Vascular surgeons are now a minority player in vascular imaging but retain important leadership roles. If the next generation of vascular surgeons is to retain their involvement in the vascular laboratory, there are inherent capital costs they need to meet and administrative skills necessary to complement clinical expertise to deliver optimum vascular surgical care. Just as endovascular skills are now being introduced into the traditional armamentarium, experience in the vascular laboratory must be consolidated in vascular fellowship training ­programs. This has implications for manpower, resources and training.
Training and skills for breast surgeons in the new millennium
Authors: Rainsbury Richard M.
Published: December 2004

Breast surgeons are learning to adapt to an evidence‐based, guideline‐directed and outcome‐orientated culture as key members of the multidisciplinary team. Recent data has confirmed the central role of surgery in preventing recurrence, improving survival and reducing risk, and rising scrutiny is raising the standards of breast cancer treatment. Specialization is increasing in breast surgery as a result of foreshortened training, greater patient demand and increasing trainee expectations and breast surgeons are learning new skills. The balance of the breast surgeon's skill‐base reflects personal preferences and professional networks, local needs and geographical ­constraints, and current developments in advanced surgical training curricula. Modern training programmes need to recognize these needs, supporting interprofessional cross‐specialty training initiatives and encouraging professional development. Trainees and ­trainers will need to acquire new skills in diagnostic, targeted, oncoplastic and prophylactic procedures through a variety of new training initiatives. Breast surgery is standing on the threshold of change, and breast surgeons must develop new strategies, new skills and new alliances to strengthen their role in this expanding specialty.
Is capitonnage unnecessary in the surgery of intact pulmonary hydatic cyst?
Authors: Bilgin Mehmet , Oguzkaya Fahri , Akçali Yigit
Published: December 2004

Background:  Hydatid disease, a parasitosis, is still an important health problem in Turkey. Surgery is the choice of treatment for pulmonary hydatid cyst. In this study, cystotomy and capitonnage were compared to cystotomy.

Methods:  Fifty‐nine patients with 70 pulmonary intact hydatid cysts were surgically treated between 1993 and 1999. There were 11 females and 48 males (range 4−58 years). Cystotomy and closure of bronchial openings were performed in all patients. The patients were divided into two groups. In Group A (n = 32 patients, n = 38 cysts), the cavity was closed (capitonnage), and in Group B (n = 27 patients, n = 32 cysts) capitonnage was not performed. The patients treated by other surgical methods (pericystectomy, lobectomy, and others) were not included in this study.

Results:  Prolonged air leak (> 5 days) was found in one patient in Group A, and in four patients in Group B. Atelectasis developed in one patient in Group A, and in three patients in Group B. Additionally, in Group B pseudocystic appearance occurred in two patients and empyema in one patient. The duration of hospitalization was 9.8 ± 2.1 days for Group A, and 12.4 ± 3.2 days for Group B. There was a significant difference between the groups for hospital time (p < 0.01). There was no mortality in either group.

Conclusion:  This study shows that capitonnage is a procedure that should not be easily abandoned, despite the current contrary opinions, because of its low complication rate.
Deep venous valve reconstruction for non‐healing leg ulcers: Techniques and results
Authors: Tripathi Ramesh , Sieunarine Kishore , Abbas Manzoor , Durrani Nazish
Published: December 2004

Background:  The purpose of the present paper was to report clinical and imaging results of a 5 year experience of deep venous valve surgery with evaluation of end‐points at 2 year follow up for the management of non‐healing venous leg ulcers in 137 patients.

Methods:  Between October 1994 and November 1999, 137 patients (169 limbs) underwent deep vein reconstructions for non‐healing venous leg ulcers of clinical, etiological, anatomical, pathological classification (CEAP) C6 class, as a ‘last resort’ treatment. End‐points of the study were post‐valve reconstruction, freedom from leg ulceration, vein valve patency and competency at 2 years. Primary refluxive disease was present in 96 patients (118 limbs). External valvuloplasty was performed in 12 limbs (19 valves) and internal valvuloplasty was performed in 90 limbs (144 valves). External supports were used in 16 limbs (16 valves). Multilevel (2−3) reconstructions were performed in 37 limbs. Forty‐one patients had secondary valvular defects involving 51 limbs. Axillary−femoral vein or saphenofemoral vein valve transplant was performed for 29 patients (35 limbs) and three patients (three limbs), respectively, saphenofemoral venous transposition was performed in three patients (four limbs), and femoral/popliteal vein ligation was carried out in six patients (nine limbs).

Results:  Two year results of external valvuloplasty showed ulcer healing in 50% of limbs with maintenance of competency at only 31% of valve stations. Internal valvuloplasty was the most durable valve repair procedure with 2 year leg ulcer healing rates of 67% and valve station competency of 79%. For secondary incompetence, valve transplants had a significant deterioration in valve patency and competence at 2 years: 58% and 47%, respectively, with 55.3% leg ulcer healing. It was also noted that single‐level repairs or single valve transplants had lower ulcer healing rates than multilevel repairs or valve transplants with multiple valve stations.

Conclusion:  In a 2 year follow up, valvular reconstruction for refluxive disease is effective in healing venous ulcers that defy conservative management and superficial/perforator venous surgery. Furthermore, these procedures appear more promising for primary than for secondary incompetence. Multilevel or multivalve reconstructions yield superior results to single‐level repairs in medium‐term follow up.
Determination of amputation level in ischaemic lower limbs
Authors: Gu Yong Q.
Published: December 2004

Background:  A properly performed amputation can not only be lifesaving for the patient, but may often be a better therapeutic alternative than an ill‐conceived, futile attempt at a vascular reconstruction doomed to fail for lack of adequate recipient vessels. Currently there are no consistent criteria that can be applied before surgery. The purpose of the present investigation was to find a reliable method of determining the best amputation level in an ischaemic lower extremity.

Methods:  In the present study the author has tried to devise a ‘score’ for distal run‐off vessel patency as shown by the preoperative angiogram to determine the most appropriate amputation level. The author has reviewed the level of amputation on ischaemic lower extremities in the vascular surgery unit of the Austin and Repatriation Medical Centre (ARMC) over the last 5 years. Two hundred and two patients have undergone 232 lower extremity amputations at ARMC.

Results:  The author used χ2 corrected testing and found a good correlation between the score and the level of amputation. The lower the score, the higher the level of amputations (χ2 = 289.23, P < 0.005). The author could predict that with a score of <12 a patient would probably need an above‐knee amputation; for a score from 12 to 19, a below‐knee amputation; for a score of 20−25 a forefoot amputation would be sufficient and for a score of>25 a toe amputation would be all that was required.

Conclusion:  The use of a scoring system dependent on the preoperative angiogram to assess the run‐off vessel situation provides a practicable and direct way to help predict the level of amputation in an ischaemic lower extremity. However, it is not totally reliable and should be used as one of the factors to be considered when an amputation is required.
Case for postoperative surveillance following colorectal cancer resection
Authors: Worthington Tim R. , Wilson Tom , Padbury Robert
Published: December 2004

Over 4 years have elapsed since the first National Health and Medical Research Council (NHMRC) guidelines were published for the management of patients after potentially curative resection of colorectal cancer. New information has now been published indicating that more intensive follow up than was originally recommended might provide a survival benefit for patients. This new information should be considered when formulating new NHMRC guidelines. In particular, meta‐analyses of published individual trials have suggested a survival advantage that was not evident in the individual studies. There have been significant developments in chemotherapy with new individual agents and use of agents in combination that have proved far more effective than previous protocols. The therapeutic effect of these developments is the downstaging of some patients with metastatic disease, which was previously unresectable, to undergo resection. Furthermore, there is now some evidence that palliation of patients with advanced disease is more effective if commenced before the development of symptoms and this needs to be considered in the assessment of the benefits of follow up. There have been limited studies of cost‐effectiveness, but international analyses suggest that the costs associated with more intensive follow‐up regimes are within the accepted cost parameters associated with the management of many other conditions.
Anatomy of the pudendal nerve and its terminal branches: a cadaver study
Authors: Schraffordt Steven E. , Tjandra Joe J. , Eizenberg Norman , Dwyer Peter L.
Published: December 2004

Background:  This study documents the anatomy of the pudendal nerve, which has a major role in maintaining faecal continence. Unexpected faecal incontinence can develop following perineal surgery even when the anal sphincters are not damaged. In addition, injury to the pudendal nerve might be encountered during pelvic procedures such as a sacrospinous colpopexy.

Methods:  An anatomical study on 28 cadavers was conducted to examine the course of the pudendal nerve and its branches in the perineum.

Results:  In five of the 28 cadavers dissected (four male, one female), a nerve plexus was found within the ischiorectal fossa in close proximity to the anal sphincters. The plexus received contributions from interconnecting branches of the inferior rectal and perineal nerves to innervate the external anal sphincter. In 11 of the 28 cadavers (five female, six male) an additional nerve arose from the medial aspect of the pudendal nerve at the level of the sacrotuberous and sacrospinous ligaments. This nerve continued distally and gave several branches to the perineum and the levator ani muscle.

Conclusion:  A sound knowledge of the anatomical variations of the pudendal nerve and its branches is essential for all surgeons operating in the perineal region.
Intracorporeal ribbon gauze in laparoscopic surgery
Authors: Bariol Simon V. , Heng Chin T. , Lau Howard M.
Published: December 2004

Good haemostasis optimizes laparoscopic visibility and performance. The use of suction reduces pneumoperitoneum and collapses the operative space, and the resulting fall in intra‐abdominal pressure can increase the rate of bleeding. Therefore, other methods of improving laparoscopic visibility need to be investigated. In the present report we describe the effectiveness of a 20−40‐cm length of 3‐inch ribbon dressing gauze when introduced into the peritoneal cavity via a 10−12 mm laparoscopic port. Current results indicate that intracorporeal ribbon gauze can be used successfully during laparoscopic procedures as a suction filter, to assist haemostasis, to facilitate dissection and to provide atraumatic organ retraction.
Management of colorectal cancer patients in Australia: the National Colorectal Cancer Care Survey
Authors: McGrath Daniel R. , Leong David C. , Armstrong Bruce K. , Spigelman Allan D.
Published: December 2004

Background:  The National Colorectal Cancer Care Survey was undertaken to determine the management patterns for individuals newly diagnosed with colorectal cancer in Australia.

Methods:  Between 1 February and 30 April 2000, all new cases of colorectal cancer registered at each Cancer Registry within Australia were entered into the survey. This generated a questionnaire that was sent to the treating surgeons. Chi‐squared and logistic regression analyses were used to determine levels of statistical significance for the various comparisons of interest.

Results:  Of 2383 surgical questionnaires generated, 2015 (85%) were completed. A total of 1911 patients (95% of those who responded to the questionnaire) had an operation. Of the 86 guidelines for the management of colorectal cancer published by the National Health and Medical Research Council, the survey allowed for comparison between 18 of these, which covered a spectrum of surgical management. Thromboembolic prophylaxis was given to 1843 patients (96.4%) undergoing surgery. Prophylactic antibiotics were commonly used, but there appear to be issues regarding the best regimen to use. Curative resections were carried out in 1563 patients (81.8%), with anterior resections being the most commonly performed procedure. Adjuvant therapy was regularly used, but not all eligible patients were offered such treatment.

Conclusion:  With the considerable resources required to develop clinical practice guidelines, studies like this are essential to monitor the impact of the guidelines. To ensure that the guidelines are in line with current evidence, regular reviews of the guideline recommendations are required.
Being CLEAR: evaluation of a module to teach critical appraisal to surgeons
Authors: Toouli James , Stanton Peter
Published: December 2004

The CLEAR (critical literature evaluation and research) module was developed to meet an identified need in both trainees and Fellows for the basic tools to allow them to plan research projects and evaluate research papers. This paper describes briefly the way in which the module was developed and presents results of participant evaluation of the mature product, which indicate a high level of satisfaction.
Damage control laparotomy in the Australian military
Authors: Neuhaus Susan J. , Bessell Justin R.
Published: December 2004

Damage control laparotomy (DCL) is a physiological approach to the management of selected critically injured patients where the surgical technique is directed at minimising the metabolic insult, rather than restoring anatomic integrity. DCL consists of an abbreviated initial laparotomy that is limited to control of haemorrhage and contamination, intra‐abdominal packing, and temporary closure. Secondary resuscitation continues in the intensive care unit for 24−48 h until normal physiology has been restored. The subsequent reoperation involves removal of the packing with definitive repair and closure. Using this approach 50% of civilian patients who would previously have died undergoing a definitive trauma laparotomy will survive. Doctrinal change in Australia has yet to enshrine a strong focus on restoration of key physiological variables as a major objective in treatment of all wartime casualties. Yet the philosophy of damage control is uniquely suited to the Australian military environment. However, transition of DCL to the military setting has to take account of operational constraints. The most important unresolved issue is how to provide adequate postoperative intensive care. An evacuation capability incorporating critical care transport teams needs to be present, as the patient must reach definitive care within 48 h.
Effects of pneumoperitoneum with or without colostomy on rat colonic anastomotic healing
Authors: Özgün Hedef , Boylu Sükrü , Çevikel Mehmet H. , Yenisey Çigdem , Erpek Hakan , Çulhaci Nil , Demirkiran Ahmet E.
Published: December 2004

Background:  Elevated intra‐abdominal pressure and colostomy have adverse effects on colonic anastomoses. The aim of the present study was to investigate the effects of laparoscopic colon surgery with and without diverting colostomy on healing of colonic anastomoses in an experimental model.

Methods:  Thirty‐six male rats were divided into three equal groups: group 1, control (colonic anastomosis and anaesthesia for 180 min only); group 2, 180 min pneumoperitoneum and colonic anastomosis; and group 3, similar to group 2 with a proximal colostomy. On day 7, bursting pressures, tissue hydroxyproline and nitric oxide concentrations and histopathological inflammation scores were determined and compared.

Results:  Mean bursting pressures were higher in the control group than the two pneumoperitoneum groups (P = 0.0003). Mean tissue hydroxyproline concentrations showed no difference (P > 0.05). Mean tissue nitric oxide concentrations were significantly increased in the control group (P = 0.0013). Histopathological scores demonstrated increased inflammatory response in group 3 compared to the controls (P = 0.0009).

Conclusion:  Pneumoperitoneum delays collagen maturation and impairs anastomotic strength in the colon. Following pneumoperitoneum, performance of a diverting loop colostomy to protect the anastomosis will not have additional detrimental effects on anastomotic healing.
Evidence supports adjuvant radiotherapy in selected patients with rectal cancer
Authors: Gibbs Peter , Chao Michael W. , Jones Ian T. , Yip Desmond
Published: December 2004

Background:  Much recent data have been published on the risk of local recurrence (LR) following curative surgery for rectal cancer and the impact of adjuvant radiation therapy (RT). With improvements in surgical technique apparently reducing the risk of LR, the relevance of older data upon which the current recommendations for adjuvant RT are based has been questioned.

Methods:  A focused review was undertaken of the published literature on the risk of LR following surgery for rectal cancer and the impact of adjuvant radiation. In particular the authors attempt to define how accurately the risk for an individual patient can be predicted, trends in reported LR rates over the time period of randomized trials, and the relevance of changing surgical and RT techniques.

Results:  Many of the perceived differences in published results can be explained by variations in study entry criteria, length of follow up and data recording. Comparisons between studies are most accurate when defined subsets of patients, such as those with stage III disease, followed for the same period of time, are considered. In parallel with improvements in surgical technique, which may have reduced the risk of LR, modifications to RT delivery have resulted in recent series not reporting an increased mortality in those patients treated with modern RT techniques.

Conclusion:  All of the available evidence supports the use of adjuvant RT in selected patients with rectal cancer. Ongoing studies will better define individual patient risk and the risk–benefit ratio of adjuvant RT.
Anal sphincter function and integrity after primary repair of third‐degree tear: uncontrolled prospective analysis
Authors: Rieger Nicholas , Perera Shevy , Stephens Jacque , Coates Donna , Po Darren
Published: December 2004

Background:  The purpose of the present paper was to determine the anatomical integrity and functional effect of a tear to the anal sphincter in women after vaginal delivery.

Methods:  A prospective review of third‐ and fourth‐degree vaginal tears over a 3 year period at Lyell McEwin and Queen Elizabeth Hospitals, Adelaide. Obstetric details were obtained from the records. All were counselled by a continence advisor and offered consultation with a colorectal surgeon. The integrity of the anal sphincter was assessed by endoanal ultrasound.

Results:  During the study period there were 6875 vaginal deliveries. There were 89 women (1.3%) who had a third‐ or fourth‐degree tear. Fifty‐one (57%) agreed to participate. Primiparity (67%), episiotomy (49%), forceps delivery (29%) and instrumental delivery were common in women sustaining a tear. Symptoms of anal incontinence (mild) or faecal urgency were described in 23 women (45%). Except for three women with an anovaginal fistula none required surgery for the management of faecal incontinence. A sphincter defect was seen in 27 women (53%) on endoanal ultrasound. The presence or absence of a sphincter defect was not significantly associated with symptoms but a trend was suggested (χ2 = 3.21; P = 0.07).

Conclusions:  Third‐degree tear after vaginal delivery was a significant intrapartum event, yet associated only with minimal symptoms (excluding patients with anovaginal fistula) even in the presence of a sphincter defect on anal ultrasound.
Gene therapy in orthopaedic surgery: the current status
Authors: Jüllig Mia , Zhang Wei V. , Stott N. Susan
Published: December 2004

The first successful gene therapy trial was reported in 1991. Since then, successful gene transfer in cultured cells and small animals has been reported by many studies, with achievement of at least transitory high levels of exogenous gene expression. Over 400 clinical protocols for gene therapy have been approved, involving over 4000 patients. However, publication of the results of these gene therapy trials has been limited, with only 80 published reports as of 2002. The majority of clinical gene therapy trials reported so far have been phase I or phase II trials, which are concerned mainly with safety issues and have focused on the treatment of malignancies and other potentially fatal conditions. The death of a patient in 1999 from systemic administration of an adenoviral vector and recent reports of leukaemia in two patients in a clinical gene therapy trial have led to a further re‐evaluation of the safety of gene therapy and the role for gene therapy in clinical practice. This review outlines the current status of gene therapy as it relates to orthopaedic diseases and highlights the areas where progress is still to be made.
Minimal invasive surgery for hip replacement: a new technique using the NILNAV hip system
Authors: Sherry Eugene , Egan Michael , Warnke Patrick H. , Henderson Antony , Eslick Guy D.
Published: December 2004

Background:  Minimal invasive surgical techniques are used for cruciate ligament reconstructions, unicondylar knee replacements and, more recently, for fixation of fractures. This is a report of the first instrumented technique for hip replacement using a 5‐cm incision without the need for a navigation system or X‐rays.

Methods:  It uses the C.F.P stem (LINK) but is universal. It includes jigs for the osteotomy of the neck, a right‐angled reamer and spacers (lollipops) to orientate the acetabular cup to the femoral stem. A case series of 14 patients using this new hip replacement technique (called NILNAV Hip System) is reported.

Results:  The procedure was successfully performed on all seven patients, with reduced postoperative pain and stiffness, and increased quality of life and functional status. All patients were discharged on postoperative Days 1 and 2 with minimal pain and blood loss.

Conclusions:  This new minimal access total hip replacement technique was successfully performed on seven patients. There are several advantages of using this system compared with the more traditional techniques. Such a technique should help reduce morbidity and mortality rates for those patients undergoing a total hip replacement.
Management of gallstone pancreatitis in Auckland: Progress and compliance
Authors: Ong Soo‐Kim , Christie Peter M. , Windsor John A.
Published: December 2004

Background:  Recent advances in the management of acute gallstonepancreatitis include the introduction of laparoscopic cholecystectomy,defining the role of endoscopic retrograde cholangiopancreatography(ERCP) and early cholecystectomy to prevent recurrent pancreatitis.The aim of the present study was to review the current managementof gallstone pancreatitis in Auckland Hospital, compare findingswith a similar study published a decade ago and to determine theextent to which the management is compliant with recently publishedconsensus guidelines.

Methods:  A retrospective review of consecutive patients admittedwith acute pancreatitis during a 39‐month study period was undertaken.Data were recorded regarding demographics, diagnosis, predictedand actual severity of gallstone pancreatitis (index and recurrentattacks), the role of ERCP and computed tomography scanning, thetiming of cholecystectomy (open and laparoscopic), intraoperativecholangiography, duration of hospital stay, complications and mortality.

Results : There were 216 patients admitted with acute pancreatitis,106 of whom had proven gallstones. An ERCP was performed in 62(59%) patients with gallstone pancreatitis but not morecommonly in patients with severe pancreatitis, and common bile duct stoneswere identified in 26% of these patients. Of the 70 (66%)patients who had a cholecystectomy, 56 (80%) had it within3 weeks of admission. Although the proportion of patientswith gallstone pancreatitis who had a cholecystectomy is similarto the earlier study, there has been a significant increase in theproportion of patients having a cholecystectomy during the indexadmission (χ2 = 3.83; P = 0.05).This has resulted in a reduction in recurrent pancreatitis (P < 0.001).Although the overall mortality from gallstone pancreatitis has notsignificantly decreased, it has for patients with predicted severegallstone pancreatitis (P = 0.02).

Conclusion : There has been reasonable compliance with publishedguidelines and some progress in the management of gallstone pancreatitis,particularly in relation to performing timely laparoscopic cholecystectomywith a reduction in the incidence of recurrent pancreatitis. Concernsremain regarding the overuse of diagnostic ERCP in patients withmild pancreatitis.
Comparison of ankle‐brachial pressure index measurements using an automated oscillometric device with the standard doppler ultrasound technique
Authors: Ramanathan Anantha , Conaghan Philip J. , Jenkinson Andrew D. , Bishop Christopher R.
Published: December 2004

Background:  The aim of the present study was to assess the accuracy of an automated oscillometric device (DINAMAP) in measuring ankle‐brachial pressure index (ABPI) in the clinical setting. Results were then compared to those obtained using the standard Doppler technique.

Methods:  A prospective comparative study of 50 healthy volunteers was carried out using a standard ward DINAMAP machine, hand‐held Doppler and a 14 cm sphygmomanometer cuff. Three consecutive pressure readings were taken from all four limbs of the volunteers using both Doppler and DINAMAP techniques. The two techniques were carried out by different investigators who were blind to the findings of the other. The ABPI was calculated for each technique and the two techniques were compared.

Results:  There was no significant agreement between the ABPI readings obtained by DINAMAP and those obtained by the standard Doppler technique. There was also a substantial variation in pressure readings produced by the DINAMAP for a given limb as measured by intraclass correlation of the three readings taken.

Conclusions:  There is no role for standard automated oscillometric devices in the calculation of ABPI in the vascular clinic.
The Keystone Design Perforator Island Flap in reconstructive surgery
Authors: Behan Felix C.
Published: December 2004

Background:  A surgical technique for closing skin defects following skin cancer (particularly melanoma) removal is described in the present paper. Its use is illustrated in five patients. The technique has been used in 300 cases over the past 7 years and is suitable for all areas of the body from scalp to foot.

We have coined the term Keystone Design Perforator Island Flap (KDPIF) because of its curvilinear shaped trapezoidal design borrowed from architectural terminology. It is essentially elliptical in shape with its long axis adjacent to the long axis of the defect. The flap is based on randomly located vascular perforators. The wound is closed directly, the mid‐line area is the line of maximum tension and by V‐Y advancement of each end of the flap, the ‘islanded’ flap fills the defect. This allows the secondary defect on the opposite side to be closed, exploiting the mobility of the adjacent surrounding tissue. The importance of blunt dissection is emphasized in raising these perforator island flaps as it preserves the vascular integrity of the musculocutaneous and fasciocutaneous perforators together with venous and neural connections. The keystone flap minimizes the need for skin grafting in the majority of cases and produces excellent aesthetic results. Four types of flaps are described: Type I (direct closure), Type II (with or without grafting), Type III (employs a double island flap technique), and Type IV (involves rotation and advancement with or without grafting). The patient is almost pain free in the postoperative phase. Early mobilization is possible, allowing this technique to be used in short stay patients.

Results:  In a series of 300 patients with flaps situated over the extremities, trunk and facial region, primary wound healing was achieved in 99.6% with one out of 300 developing partial necrosis of the flap.

Conclusions:  The technique described in the present article offers a simple and effective method of wound closure in situations that would otherwise have required complex flap closure or skin grafting particularly for melanoma.
Acute renal failure in the surgical setting
Authors: Carmichael Paul , Carmichael Amtul R.
Published: December 2004

Acute renal failure (ARF) is an unwelcome complication of major surgical procedures that contributes to surgical morbidity and mortality. Acute renal failure associated with surgery may account for 18−47% of all cases of hospital‐acquired ARF. The overall incidence of ARF in surgical patients has been estimated at 1.2%, although is higher in at‐risk groups. Mortality of patients with ARF remains disturbingly high, ranging from 25% to 90%, despite advances in dialysis and intensive care support. Appreciation of at‐risk surgical populations coupled with intensive perioperative care has the capacity to reduce the incidence of ARF and by implication mortality. Developments in understanding the pathophysiology of ARF may eventually result in newer therapeutic strategies to either prevent or accelerate recovery from ARF. At present the best form of treatment is prevention. In this review the epidemiology, pathophysiology, diagnosis, treatment and possible prevention of ARF will be discussed.
Acupuncture anaesthesia in inguinal hernia repair
Authors: Chu David Wa , Lee Daniel Tai‐Yam , Chan Tony Tung‐Fei , Chow Tam‐Lin , Que Manuel Bon‐We , Kwok Samuel Po‐Yin
Published: December 2004

Background:  The present study was undertaken to evaluate the efficacy of acupuncture anaesthesia in inguinal hernia repair.

Methods:  Twelve patients with non‐recurrent inguinal hernia had Lichtenstein mesh repair under acupuncture anaesthesia. Selected acupuncture loci were stimulated with fine needles connected to low frequency current. Supplementary local anaesthetic was given when required.

Results:  Four (33%) patients reported satisfactory analgesic effect throughout the operation without need for additional medication, eight (67%) patients experienced mild discomfort during the operation requiring 1−4 mL of 1% lignocaine injection. Blood pressure and heart rate were stable during the procedure. All patients were able to sit up and resume their diet immediately post­operatively. All but one patient were discharged on day one after the procedure, with no early or late complications reported. Most patients were satisfied with the analgesic effect of acupuncture anaesthesia.

Conclusions:  Acupuncture anaesthesia is a feasible anaesthetic option. It reduces the amount of local anaesthetic required, and thus the associated potential complications. It is effective in pain relief and inhibiting gastrointestinal upset. Postoperative recovery was rapid and complication free.