bluuebunny/crossref_metadata_2025 huggingface dataset:
PR09 INFECTION RATES IN IMPLANT BASED BREAST RECONSTRUCTION
Authors: Friederich L. J. , Corrigan E. B.
Published: April 2007

Infection is a potentially devastating complication of Breast Reconstruction Surgery.

We retrospectively reviewed primary implant based breast reconstruction cases over a six year period at a tertiary Plastic Surgery Unit in Perth to determine both infection and explantation rates, as well as patient and operative factors which may contribute to this risk.

First and subsequent reconstructive stages were included in the study with the majority of patients having had their second stage procedure. All cases were followed up for a minimum of six months post operatively.

185 implants were placed into 88 patients with an overall infection rate of 7.6% and an explantation rate of 4.3%. Most (86%) of these infections occurred following the first staged procedure.

Factors which may impart a greater risk of infection included smoking, increased Body Mass Index, shorter duration of wound drains and larger implant size.

Multiple antibiotic regimes of varying duration were noted, however there was no significant difference between the infected and non‐infected groups.

Of note, documentation was found to be poor, particularly regarding implant and pocket preparation, drain sites and their subsequent daily drainage and time of removal.

Formal protocol and/or a dedicated Breast Reconstruction database may prove useful in further audit and surveillance with the aims of identifying and decreasing patient and operative risks.
SE01 THE EMERGING ROLE OF SIMULATION IN SURGICAL TRAINING
Authors: Traynor O.
Published: April 2007

Traditionally, surgical trainees have acquired their technical skills whilst working in the operating theatre alongside more senior surgeons in an apprenticeship model. Recently, changes in surgical practice have challenged this traditional approach, including reduced working hours, decreased availability of operating theatre time, increased cost of operating theatre time and increasing complexity of surgical procedures. Most importantly, public opinion is increasingly resistant to having patients used as teaching material. Moving forward in the 21st century, we need to develop a new model of technical skills acquisition. Surgical simulation offers a means of practicing surgical skills in a laboratory environment with no risk to patients. Simulators range from simple bench models, which are relatively inexpensive, to high tech virtual reality simulators. The Royal College of Surgeons in Ireland has developed a syllabus for operative surgery which is based on simulation and all trainees attend the National Surgical Training Centre on a regular recurrent basis, six times each year, for concentrated skills training. Simulation allows the standardisation of teaching technical skills and, most importantly, standardisation of assessment of technical skills. Furthermore, simulation offers trainees “permission to make mistakes”– a valuable learning exercise. Our trainees are assessed in the laboratory setting and must demonstrate proficiency before moving to the next stage of training (proficiency based progression). Simulation has played a key role in this process.
SE11 DEVELOPMENT OF A PERSONAL SKILLS PROGRAMME FOR SURGICAL TRAINEES
Authors: Traynor O.
Published: April 2007

It has been estimated that only 25% of the important events which take place during the surgical procedures are related to technical skills and that 75% relate to human factors such as decision‐making / judgement, error management, communication, team work and leadership. Despite compelling evidence that human factors play a vital role in clinical outcome, surgical training has not traditionally included a systematic approach to human factor training. At the Royal College of Surgeons in Ireland we have developed a formal programme of human factor training, Human Factors in the Surgical Arena. This programme is based on a clearly defined syllabus. All surgical trainees (>450) attend the National Surgical Training Centre three times each year in groups of 30 for a full day of training according to the syllabus. Learning occurs in conjunction with trainees in anaesthesia and postgraduate nursing and the focus is on the team approach to patient care. Through small group discussions, role playing and realistic clinical scenarios, trainees explore the various human factors which come into play in surgical clinical practice. Trainees are given assignments which are designed to bring what they have learned in the classroom back to the workplace. The programme aims to give trainees “previously learned responses” to a wide range of clinical situations so that when they encounter such situations in real life, they will know how to utilise the resources available to optimise the outcome for their patients.
SE13 ACCURACY, ACCEPTANCE AND COMPLIANCE IN THE USE OF A WEB BASED AUDIT TOOL – RESULTS OF PHASE 1
Authors: Khurana S. , Orford J. , Preen D. , Logan J. , Gera P. , Jackson C.
Published: April 2007

Background  Patient privacy related concerns are thought to be a major impediment to the use of modern web‐based database systems in clinical audit and multi‐centre research. Most new electronic health record systems are ‘opt out’ models in which all patients are included within the system by default.1

Aim  The aim of the first phase of this ‘multi’‐centre study is to assess the level of community acceptance of an ‘opt in’ model in which individual parents are given a choice of having their child’s medical information stored on a customised, highly secure, commercially available web‐based data management system.

Materials and methods  Parents/guardians of all children presenting with any of a pre‐determined set of conditions are invited to complete a questionnaire after reading an information leaflet. The questionnaire is designed to correlate community attitudes to web‐bases electronic health records with factors such as expected duration of requirement for health services, availability of mobile phone and internet services, usage of other web based services as well as parental demographics.

Results  The recruitment rate of ‘eligible’ parents has been 100% so far. Overall, 64.5% have responded in favour of a web based databank, 17.5% were unsure and 17.5% not in favour of a web based databank. 90% of parents with children requiring ‘medium’ and ‘long’ term follow up were definitely in favour.

Conclusions  Greater involvement of patients and clinicians may overcome one of the major impediments in the use of web based audit tools.
SE14 COMPETENCY MODELS AND POLITICALLY MANAGING THE SURGICAL PROFESSIONS
Authors: Canter R. J.
Published: April 2007

This presentation examines the nature of surgical competency and the drift towards what might be termed “models of competence”, the advantages and disadvantages of such a model, from where has this model arisen, and the concerns the professions frequently sense but have trouble articulating about what is happening.

The development of simple checklist competency models arguably arises out of a combination of skill remix, appealing to simple ‘assembly lines’ models of healthcare delivery, and a behaviouralist model of management control. Awareness of the broader political context in which all of this is played out helps to make sense of what is happening as surgery becomes ‘de‐professionalised’ and reduced to a technical activity. The development of simple competency models has the capacity to destroy the very thing it seeks to define so that there is genuine concern that an organisational model of healthcare delivery, so effective in industry, may be inappropriate to a profession.

The presentation takes a ‘simple’ surgical case and, as the case unfolds, shows how the ‘technical’ process of clinical surgical decision‐making is actually very complex indeed, so complex that the literature on the subject struggles to define it at all. As one generation of surgeons passes down its skills to the next generation, how are we to define clinical decision‐making and judgement? What are the implications for surgical training? How do we respond to being ‘deprofessionalised’?
SE19 CAN THE TRAINEE OPERATIVE LOGBOOK BE USED AS AN ASSESSMENT TOOL OF THE LEVEL OF SUPERVISION PROVIDED BY TRAINING CENTRES?
Authors: Mcbride C. A. , Beasley S. W.
Published: April 2007

Purpose  Specialist trainees and the specialty boards of the College of Surgeons expect that levels of supervision will not remain static during training. As training progresses the level of supervision will change, from an assistant role and direct supervision towards independent practice with consultation available as required. The Summary of Operative Experience may provide a de facto measurement of this.

Methodology  Assessment of the surgical logbook of an individual trainee to document the changes in the level of supervision that occur during a training term, the factors that influence it, and the degree of variation between posts.

Results  Upon arrival at a new institution supervision for most cases is direct. For minor and intermediate surgery that supervision is rapidly relaxed once it has been confirmed the trainee has acquired and demonstrated the required skills. In areas of complex surgery (such as neonatal surgery) there is a clear progression observable over the training period. In the early part of the term the trainee is assisting in complex surgery, with the surgeon supervisor operating. By the end of the term those roles may have reversed, but there are significant variations between posts.

Conclusion  It is possible to use the operative logbook as an indicator of the supervision provided by training centres to trainees. This could provide one mechanism to enable specialty boards to confirm that supervision for trainees is appropriate to their needs as they progress through their training. It also allows an indirect measure of the quality of the post for specialty training.
SE20 THE ANATOMY OF COMPLICATIONS IN THE UPPER LIMB
Authors: Luo D. Y. W. , Tai E. , Lim T. S. , Stokes B. , McMenamin P.
Published: April 2007

Complications in clinical medicine and surgery may arise from an inadequate knowledge of topographical anatomy. Consequently, a thorough understanding and knowledge of topographical anatomy is one of the major pillars in the training of many surgical and medical disciplines. In Western Australia, we have found that even simple procedures done on the ward by junior medical staff can result in a complication due to a lack of understanding of anatomy. For example, procedures such as intravenous cannulation at the wrist may result in superficial radial nerve injuries and debilitating neuromas.

The authors, with the support of The Office of Safety and Quality in the Department of Health have put together a teaching DVD which focuses on the applied anatomy of the upper limb, with a focus on procedures involving the peripheral vascular system. This DVD emphasizes vascular and related topographical anatomical features prior to introducing the viewers to procedures like intravenous cannulation, peripheral lines, peripherally inserted central cannulas and central venous lines. It thus raises awareness of possible complications that may arise from these procedures which can be avoided from understanding the anatomy.

The amount of topographical anatomy taught in medical school has been reduced compared to 30–50 years ago. This has been necessary to accommodate the increase in knowledge in other pre‐clinical, para‐clinical and clinical sciences. This DVD is a timely reminder of the importance of a sound knowledge of anatomy for those practitioners required to perform invasive procedures. We hope that this will be a prototype for further teaching material produced in collaboration with The Department of Health.
SE03 ANATOMY IN THE VIRTUAL WORLD
Authors: Dobbins C. , Kanhere A. , Maddern G. J.
Published: April 2007

Background  Recently, the use of 3‐dimensional virtual reality anatomy teaching tools has generated interest. Although they would appear to have the potential to revolutionise the way in which anatomy is taught, further evaluation is required. The aim of this study was to evaluate the use of 3‐dimensional virtual reality as a tool for teaching anatomy to basic surgical trainees.

Methods  Basic surgical trainees from The Queen Elizabeth Hospital and Flinders Medical Centre in South Australia were invited to participate in an anatomy teaching session. Liver and pancreas anatomy were the topics covered during the session and these were taught using either standard or virtual reality teaching techniques. Participants were asked to evaluate the two modalities by way of multiple choice examination, pre and post session evaluation forms and commenting on their preferred teaching modality.

Results  16 participants were involved in the study. 1 of 16 participants preferred teaching with standard techniques. 14 out of 16 participants found teaching with virtual reality to be either good or very good. The number who thought their knowledge of anatomy had improved with either technique was similar (7 out of 16 with virtual reality, 6 out of 16 with standard techniques). Post teaching session test results showed similar improvements with both teaching modalities.

Conclusions  The 3‐dimensional virtual reality teaching method was very well received by participants and is at least as good as standard teaching techniques. The use of 3‐dimensional virtual reality may offer a more interesting and useful option for anatomy instruction.
SE04 BIO‐REALITY SURGICAL TRAINING MODELS
Authors: Murphy D. L.
Published: April 2007

Purpose  To create valid, re‐vascularized tissue models for surgical training.

Method  Re‐established pulsatile flows were created in selectively cannulated arteries of the cadaveric tissues, being developed as training models. Venous flow was also re‐established for some teaching models. Manual pump techniques were used to produce a pulsatile flow through these blood vessels.

Results  Selected examples have been developed and used in Advanced Surgical training. Video examples to be displayed include Models for renal, vascular, micro‐vascular and cardiac surgery.

Conclusion  The ideal surgical training model needs pulsatile vessel preparations for many training circumstances.

A bio‐reality, pulsatile surgical training model has been developed. It has application as a penultimate model for surgical skills training.
SE05 THE PRIVATE HEALTH SECTOR: A POTENTIAL SURGICAL TRAINING GROUND? – A STUDY OF THE PERCEPTIONS OF PATIENTS
Authors: Wun L. P. S. , Wong L. M. , Shaw J. , Heriot A. , Keck J. , Vellar D.
Published: April 2007

Purpose  The need for more accredited advanced surgical training positions has been identified by the Royal Australasian College of Surgeons. This study aimed to explore the perceptions of a sample of patients on surgical education and training in a private hospital setting.

Methodology  This is a prospective study where patients undergoing elective surgery in a private hospital were recruited over a 6‐week period. A Likert Scale questionnaire was used to assess patient perception on choice of private healthcare, the role of the surgical resident in a private hospital and surgical training within a private hospital environment.

Results  Sixty‐eight patients were recruited. Choice of surgeon was the most important reason for having private health insurance (59%). Almost all (97%) patients supported surgical training within a private hospital. There was support for a surgical trainee to liaise with the consultant surgeon about their care (95%), to perform minor procedures on the ward (91%) and assist the consultant at surgery (86%). Patients supported options for the trainee to perform part (73.4%), the majority (50.0%) and the entire operation (40.6%) under supervision of the consultant surgeon.

Conclusion  A representative group of patients surveyed supported surgical training within a private hospital environment. The increasing demand for surgical training within the public environment necessitates the consideration of additional training resources such as the private healthcare system. It appears that the private health sector could be explored as a potential avenue for provision of surgical education and training.
SE06 DOCTORS AND POWER; OR THE TRUE STORY OF SURGERY TOLD FOR THE VERY FIRST TIME!
Authors: Canter R. J.
Published: April 2007

This presentation aims to discuss two ideas in particular; the ‘biomedical’ paradigm of evidence based medicine and ‘power’ in the medical encounter, to link them together to examine, and hopefully disturb, some basic assumptions that exist in medical decision‐making. To keep the talk firmly rooted within the bounds of real life, all the ideas will be illustrated by reference to a simple surgical procedure and basic science experiments with a frog.

The gold standard for knowledge in medicine are ‘facts’ generated by a randomized,double‐blind controlled trial, so called level 1 evidence. By drawing on the ideas postulated by the philosopher David Hume, the presentation will argue that such ‘facts’ do not fully comply with the requirements of causality, question the appropriateness of such a reductionist biomedical model in a world of complexity, raise questions about their generalisability and illustrate the tendency for the model to marginalize certain types of information.

As is often quoted, ‘knowledge is power’ so what power framework can be used to shed light on the medical encounter and the way medical ‘facts’ are used. How do doctors handle their power? Is this a question any of us ask of ourselves? By utilizing various contemporary models of power I hope to show how the ideas put forward by the French philosopher Michel Foucault and the English philosopher Steven Lukes can shed light on how we use our power in the medical encounter, and in turn how establishment power is used to manage the medical profession.
SE08 STUDENTS PERSPECTIVES OF A SURGICAL EDUCATION PROGRAM
Authors: Hillis J. , Dodds A. , Collins J. P.
Published: April 2007

Background  The purpose of the undergraduate surgical education program is to prepare students for their internship and eventual vocational practice. It is also an opportunity to sow the seeds of a possible career in surgery.

Methods  In order to understand students’ perspective of their surgical program and the various factors which might impact on their learning, and the possibility of their choosing a career in surgery, a structured questionnaire was given to the 2006 cohort of final year medical students at the University of Melbourne.

Results  Responses were received from 260 of the 285 students (91%). Bedside teaching, small group tutorials and clinical skills workshops were regarded as the most appropriate methods for learning surgery, with bedside teaching and the operating theatre (when surgeons were willing to teach) considered to provide the greatest learning opportunities. The most significant barriers were lack of anatomy teaching and lack of formal surgical teaching and difficulties accessing surgeons willing to undertaking teaching. 25% did not feel adequately prepared for the surgical components of their internship. 32% were considering a career in surgery and lifestyle factors and poor experience with surgeons were given as some of the reasons for lack of interest in surgery. Increase in anatomy teaching throughout the course, and more bedside and formal teaching were considered the most significant ways to improve the course.

Conclusion  Surgical education is at a crossroads and the findings of this study have important messages for preparing the future workforce and will be discussed.
SH01 MY COUSIN ERNEST
Authors: Arnot R. S.
Published: April 2007

My cousin Ernest was born into an Anglo‐Irish Protestant family on 15 February 1874. My Quaker grandmother was his second cousin. Shackleton did not follow his father into medicine, but went to sea at the age of 16, and accompanied Scott to the Antarctic on the Discovery expedition in 1902. He went on to lead three Antarctic expeditions, and has been hailed as one of the world’s greatest leaders. In all his travels he is acclaimed as never having lost a man, and a fellow explorer once said of him –‘for a dash to the Pole give me Amundsen, but if I am in a devil of a hole and want to get out, give me Shackleton every time’.

Recently his techniques of leadership have become widely disseminated in business, the military and many other walks of life and have been described as ‘Shackleton’s Way’. And yet paradoxically, Shackleton never led a group larger than 27 and he failed to reach nearly every goal he ever set.

I will also discuss the Endurance expedition of 1914–16, which is one of the most spectacular disasters of all time.
SH12 HISTORY OF SURGERY IN NEW GUINEA 1921–1942
Authors: Watters D. A. K.
Published: April 2007

New Guinea was governed by Australia under Mandate from the League of Nations. Information was obtained through review of personnel files in the National Archives, interviews with former residents or family members and from biographies. It was a time when surgery in the separate territories of Papua and New Guinea was conducted by general doctors who were selected often on availability, stability and knowledge of tropical medicine. The two territories had different pay scales and different staffing arrangements. A mix of missionaries, mercenaries and madmen were recruited. These were wild days, plantations and gold rushes, when mavericks such as Errol Flynn were on the loose. It was often alleged surgical incompetence that determined whether someone was regarded as suitable or not. Doris Booth, a nurse and the first white woman prospector, set up a hospital on the Goldfields in 1926. Some MO’s did only a few months filling positions of “desperate need” whilst others, such as ET Brennan, Backhouse, Dickson and Sinclair made significant contributions. By 1927 Raphael Cilento (1924–29) was Director of Public Health with 9 Medical Officers stationed in Rabaul (2), Kavieng, Madang, Manus, Aitape, Morobe with one travelling and one relieving medical officer. Europeans were treated at the Namanula hospital and natives at the Rapindik Native Hospital (est 1930) at Matiep. Theodore Braun arrived as a Lutheran missionary doctor in 1935 and proved to be a highly competent surgeon. The period ends with the Japanese bombing of Rabaul in 1942 and the controversial evacuation of Dr Alex Price and others from Kieta, Bougainville, aboard the Bilua.
SH02 THE BIRTH OF VASCULAR SURGERY IN AUSTRALIA
Authors: Mellick S. A.
Published: April 2007

During and after the Napoleonic wars surgeons in Europe, Britain and America ligated peripheral arteries for symptomatic aneurysms. It is not generally known that five surgeons performed similar operations in early colonial Australia.

Andrew Gibson ligated the femoral artery in 1827 and William Bland the innominate in 1832 and 1837, all in Sydney. Edward Bedford ligated the carotid artery in Hobart in 1837 having apparently previously ligated one popliteal artery in a patient in 1835 and his other popliteal in 1837. Colin Buchanan of Port Stephens tied the femoral artery of a patient in Stroud in the Hunter Valley in 1847, possibly the first major operation performed under general anaesthesia in Australia; and somewhat later Frederick Milford in Sydney ligated the femoral artery in St Vincent’s Hospital in 1869, again under general anaesthesia.

None of these isolated cases was included in an extensive review article in 1847 by G W Norris of Philadelphia, who recorded no less than 118 ligations of the external iliac and femoral arteries between 1796 and 1842, with an overall mortality of 33 (28%). Bland’s operation in 1832 escaped his scrutiny despite its being reported in The Lancet Volume I 1832/3.

It is timely that the work of these pioneer ‘vascular’ surgeons and their place in the history of vascular surgery in Australia be acknowledged.
SH03 SLAVERY, SERPENTS, SPELLS & SURGERY: DR ETIENNE RUFZ DE LAVISON IN MARTINIQUE
Authors: Robson K. J.
Published: April 2007

Martinique, an island in the archipelago of the Lesser Antilles, and today a d???rtement of France, was throughout the 19th century a much‐feared outpost of the French empire. “This is a region”, wrote one early commentator, “where the land is shaken by earthquakes, the towns turned upside down by hurricanes, the air poisoned by yellow fever, and the different social classes in a perpetual state of hostility”. The healthcare needs of Martinique?s diverse population were shouldered by a small mix of military surgeons, civilian doctors and local healers.

In 1804, Etienne Rufz de Lavison was born to Creole nobility in St Pierre, Martinique’s thriving, cosmopolitan former capital. Sent to mainland France at the age of 13, Rufz studied medicine in Paris before returning to St Pierre, where he spent 20 years as a clinician, scientist and prolific historian. A man of astonishing intellectual curiosity, with a self‐confessed ‘mania for writing’, Dr Rufz’s publications encompass local surgical techniques, the yellow fever epidemics, snake bites, plantation and slave health, ethnology, island flora, and the effects of climate. An innovative practitioner, he was a pioneer of anaesthesia on the island. Dr Rufz was also a leader in health politics; he inaugurated Martinique’s public hygiene campaigns, led the vaccination committee, established the colony’s first psychiatric hospital, and became mayor of St Pierre.

The quintessential Renaissance man, Dr Rufz upheld the belief that good medical practice requires an understanding not only of disease, but of history, people and the natural world. The story of his life and work offers a vivid portrait of early colonial medicine and surgery.
SH04 BASIL KILVINGTON–SURGICAL SCIENTIST
Authors: Masterton J. P.
Published: April 2007

Basil Kilvington, son of the Rev. James Kilvington, was born in Hartlepool in the North of England on August 6th. 1877. His schooling began in Greenock but in 1888, when he was eleven, the family migrated to Victoria where he attended Camberwell Anglican Boys’ Grammar School which had been founded just two years earlier. He must have been a bright and capable student because in 1893, when barely sixteen, he matriculated in the Faculty of Medicine of Melbourne University and graduated M.B., B.S. in 1898 at aged 21.

He became a resident medical officer at the Royal Melbourne Hospital but retained an interest in teaching and research as a tutor at Trinity College. His academic leaning is reflected in his being awarded M.D. in 1901 and M.S. in 1902. Thereafter he had a distinguished career as both a surgeon and researcher particularly in the field of neurology and nerve regeneration.

When he died in 1947 aged 70 the obituaries by Sir Albert Coates and others all bear fulsome testimony to a remarkable man. Above all he was a thinker and a man of great compassion and gentleness both in his surgical technique as well as his dealings with his fellow man. He was one of the College’s Founding Fathers and perhaps deserves better recognition.
SH05 IMAGES OF FREYBERG
Authors: Beasley A. W.
Published: April 2007

Bernard Freyberg was brought to New Zealand as a two‐year old boy, educated in Wellington, distinguished himself as a swimmer, began a career as a dentist, then sailed to England. He arrived in time to become part of the Royal Naval Division at the outbreak of the 1914–18 war, won his first DSO at Gallipoli, and his VC in France the following year. He became friendly with J M Barrie, who was his best man when he married in 1922.

In the 1939–45 war he commanded the NZ forces in the Middle East and Gallipoli, and was then appointed governor‐general of NZ, his term being extended to six years. This paper traces his career with reference to his portraiture.
SH07 LOCH NESS SAS AND THE FIRST SURGEON IN PARADISE
Authors: Watters D. A. K.
Published: April 2007

Robert Kenneth Wilson was born in Madagascar in 1899, the son of a Scottish missionary doctor. As a boy he was raised by his elder sister and developed a keen interest in natural history. He served in the first world war before studying medicine at Cambridge. He married Gwen Gulliver, an Australian in 1924. They had two sons. In 1926 he gained his FRCSEd and set up practice in London. During the 1930’s he was a court expert in ballistics together with Lord Gerrard Burrard. He wrote a definitive textbook on Automatic Pistols which was published during World War II. In 1933 he took the photo of the Loch Ness Monster which was only admitted to be a hoax in 1992. In 1939 he walked out of his practice, rejoined the Royal Artillery but in 1942 joined the elite SAS. He was decorated in Holland (orange order) and France (croix de guerre) before being parachuted into Borneo with Australian troops in 1945 to serve in Z force with SEMUT 2. In 1950 he went to PNG as the first fully qualified surgeon and was posted to Rabaul (1950–53) and Port Moresby (1953–56). He is remembered by his anaesthetist and nurses as an excellent general surgeon who could turn his hand to anything, though his results with thoracic surgery were probably suboptimal. In addition to surgery he was an expert fisherman and shot. He died in 1969 of oesophageal cancer. He served with distinction in every phase of his life.
SH08 AL‐ZAHRAWI – THE FATHER OF SURGERY
Authors: Ahmad Z.
Published: April 2007

A pioneer in all fields of surgery, Al‐Zahrawi developed numerous original techniques as well as instruments. He published the first ever surgical encyclopaedia entitled “At‐Tashrif”. His way of thinking and practice of surgery inspired many subsequent great surgeons. As a result of his imperious work and contribution to surgery, he has been given the title of ‘Father of Surgery’, and provided yet another beacon of light in the dark ages. In his many papers and manuals, he describes various operations and procedures which had never been recorded before. Some have described him as the first ever plastic surgeon, notably for his attention to and methods of incision, use of silk thread suture to achieve good cosmesis. He describes what is thought to be the first attempt at reduction mammaplasty for the management of gynaecomastia. He gives detailed descriptions of other basic surgical techniques such as cautery and wound management. The aim of this paper is to highlight and remind us of the invaluable contributions made by this remarkable pioneer in the field of surgery, which have acted a preamble for many techniques and procedures used in the field of plastic surgery.
SO01 NEOADJUVANT: RECTAL CANCER
Authors: Robinson B. A.
Published: April 2007

Neoadjuvant therapy is given before surgery to improve resectability, local control and/or survival. Post‐operative radiation therapy for locally advanced rectal cancer has been long accepted, and since 1990 adding fluorouracil (5FU) chemotherapy became the NIH standard. However, trials then showed that pre‐operative radiotherapy followed by surgery improved local control over surgery alone, but had a less consistent effect on overall survival. The German trial (Sauer, NEJM, 2004, 351:1731) showed a 5 year local relapse rate of 6% for pre‐operative chemo‐radiotherapy and 13% for post‐operative chemo‐radiotherapy for T3 or T4 or node‐positive rectal cancer treated by TME. The EORTC 22921 trial (37% had TME) showed a similar reduction in local recurrence whether 5FU/leucovorin chemotherapy was given with pre‐operative radiotherapy, after pre‐operative radiotherapy plus surgery, or both (Bosset, NEJM, 2006, 355:1114). Trials show increased rates of complete pathological remission, increased acute toxicity, but no consistent effects on sphincter preservation rates or overall survival when chemotherapy is combined with pre‐operative radiation.

Many questions remain. The TROG/AGITG trial compares pre‐operative radiotherapy as a short course (5 Gy X 5♯) or long course with chemotherapy (50.4 Gy plus 5 FU infusion), with accrual just completed. Ongoing phase III trials explore capecitabine, adding other drugs to 5 FU, and post‐operative adjuvant chemotherapy.

Neo‐adjuvant pre‐operative radiation with concurrent chemotherapy, unless contra‐indicated by comorbidity, has become widely accepted for T3 or T4 or node‐positive rectal cancer based on MRI staging. Individual patient care is best planned by a multidisciplinary team.
SO12P COMBINED CYTOREDUCTIVE SURGERY AND PERIOPERATIVE INTRAPERITONEAL CHEMOTHERAPY IN THE TREATMENT OF PERITONEAL MESOTHELIOMA
Authors: Sim J. , Yan T. D. , Morris D. L.
Published: April 2007

Purpose  Australia has the highest incidence of mesothelioma worldwide. Compared with traditional treatments using systemic chemotherapy, the combined cytoreductive surgery (CRS) with perioperative intraperitoneal chemotherapy (PIC) has shown improved survival.

Methodology  Fifteen consecutive patients with peritoneal mesothelioma underwent CRS and PIC at the St. George Hospital, Sydney. Clinical and treatment‐related data were prospectively collected and reported. The morbidity and mortality rates and overall median survival were evaluated to assess the safety and efficacy of CRS and PIC in the treatment of peritoneal mesothelioma.

Results  There were 10 male and 5 female patients. The median age was 55 years old (range 35–72). The median follow‐up was 12 months (range 6–50). Thirteen patients were surveyed regarding asbestos exposure, in which 7 reported a definite asbestos exposure, 3 reported working in high risk occupations and 3 reported minimal exposure risk. The mean operating duration was 9.6 hours. Rate of re‐operation was 7% and mean hospital stay was 23 days. The morbidity and mortality rates were 36% and 7% respectively, with an overall median survival of 86 months (range 1–86). The 1‐, 2‐ and 3‐year survivals were 80%, 69% and 55% respectively.

Conclusion  CRS combined with PIC is a treatment option for peritoneal mesothelioma that confers improved survival, when compared with historical controls using systemic chemotherapy.
SO14P PERIOPERATIVE OUTCOMES OF CYTOREDUCTIVE SURGERY AND PERIOPERATIVE INTRAPERITONEAL CHEMOTHERAPY FOR NON‐APPENDICEAL PERITONEAL CARCINOMATOSIS FROM A PROSPECTIVE DATABASE
Authors: Yan T. D. , Sugarbaker P. H.
Published: April 2007

Purpose  Cytoreductive surgery and perioperative intraperitoneal chemotherapy has expanded its application in the management of peritoneal carcinomatosis from gastrointestinal and ovarian malignancies. An accurate assessment of perioperative outcomes is crucial for integration of this combined procedure into clinical practice.

Methodology  A prospective study of 80 patients undergoing the combined treatment for non‐appendiceal peritoneal carcinomatosis was conducted. Forty‐seven adverse events by 8 organ‐systems were rated from Grade I to IV with increasing severity. Grade I morbidity was self‐limiting; Grade II required medical treatments; Grade III required an invasive intervention; and Grade IV required returning to the operating room or intensive care management.

Results  One patient (1.3%) died postoperatively. Postoperative adverse events affected genitourinary system (38%), haematological system (31%), gastrointestinal system (25%), infection (20%), intravenous catheters status (15%), pulmonary system (14%), cardiovascular system (11%), and neurological system (4%). Thirty‐six patients (45%) experienced 49 Grade III adverse events. Six patients (8%) experienced 8 Grade IV adverse events. More than 4 peritonectomy procedures (p = 0.010), and length of hospital stay of more than 21 days (p = 0.007) were strongly associated with Grade III and/or Grade IV morbidity.

Conclusions  The morbidity and mortality rates after the combined treatment for non‐appendiceal peritoneal carcinomatosis were within the acceptable range of surgical treatments for other gastrointestinal cancers. A standardized prospective database is required for an accurate assessment of perioperative outcomes.
SO16P MULTIDISCIPLINARY CANCER CARE IN AUSTRALIA: AN AUDIT OF CURRENT UPTAKE
Authors: Wilcoxon H. , Evans A. , Goodwin H. , O’Brien J. , Zorbas H. , Luxford K.
Published: April 2007

Multidisciplinary care (MDC) has been shown to improve care and outcomes for cancer patients and is incorporated into national and state/territory clinical practice guidelines, frameworks and plans across Australia. The National Breast Cancer Centre Principles of Multidisciplinary Care provide a flexible framework for the implementation of MDC. However, while there has been a considerable focus on MDC in breast cancer there is anecdotal evidence that the wider uptake of MDC is limited.

The NBCC has undertaken a national audit of MDC activity across five tumour streams: breast, gynaecological, lung, colorectal and prostate cancers. The aim of the audit was to provide a snapshot of MDC activity in Australia across a range of health service delivery settings, to identify areas or gaps where implementation strategies could be targeted to increase MDC uptake. The audit was timed to precede the introduction of a Medicare Benefit Schedule item to support specialists attending MDC meetings.

A random sample of 420 hospitals, stratified by state/territory, hospital type (public/private) and geographic area (metropolitan/regional) were invited to nominate hospital staff to participate in a telephone survey about MDC activity for each of the five tumour streams. The survey investigated both practical and qualitative aspects of MDC practice based on the Principles of Multidisciplinary Care. Within two states the survey was administered through collaboration with state‐based health departments.

The national data was analysed by tumour stream, hospital type and geographical area. Key results and outcomes relevant to surgeons will be presented.
SO02 SYNOPTIC REPORTING OF BREAST IMAGING: AN OPPORTUNITY TO IMPROVE BREAST CANCER CARE
Authors: Mann B. , Zorbas H. , Goodwin H. , Nehill C.
Published: April 2007

A scoping study of breast imaging reporting in July 2006 by the National Breast Cancer Centre (NBCC) revealed that synoptic reporting has not been widely implemented in Australia. The 2002 NBCC publication Breast imaging: a guide for practice recommended the use of a breast imaging synoptic report.

A synoptic report contains a summary of essential information in a checklist format with standard language, descriptions and classification system (i). Synoptic reporting may improve the content and completeness of reports, reduce the risk of misinterpretation of findings, improve communication between referring clinicians and radiologists and facilitate the transfer of information to databases for quality improvement activities and audit (i).

A breast imaging synoptic report helps clinicians and patients by assisting in tracking individual lesions, ensuring the inclusion of mammographic and ultrasound characteristics of lesions, offering one classification per lesion and a combined imaging diagnosis.

As a result of the scoping study, the breast imaging synoptic report has been revised by a multidisciplinary working group to ensure acceptability and applicability to radiologists, referring clinicians and end users. A number of strategies have been identified to assist the implementation of the revised NBCC breast imaging synoptic report and standard classification system.

Surgeons as referrers and end users, play an integral role in advocating and promoting the use of synoptic reporting in breast imaging.

(i) National Breast Cancer Centre. Breast imaging: a guide for practice. Camperdown, NSW: National Breast Cancer Centre, 2002.
SO03 CRITICAL ANALYSIS OF TREATMENT FAILURE FOLLOWING COMPLETE CYTOREDUCTIVE SURGERY AND PERIOPERATIVE INTRAPERITONEAL CHEMOTHERAPY FOR PERITONEAL DISSEMINATION FROM APPENDICEAL MUCINOUS NEOPLASMS
Authors: Yan T. D. , Bijelic L. , Sugarbaker P. H.
Published: April 2007

Purpose  The objective of this data analysis was to study treatment failure after complete cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) for peritoneal dissemination from appendiceal mucinous neoplasms.

Methodology  Prior to June 2006, 402 patients with peritoneal dissemination from appendiceal mucinous neoplasms underwent complete cytoreduction and PIC at the Washington Cancer Institute. Patient characteristics, pathologic features and treatment‐related data were obtained from a prospective database. Survival analyses were performed using Kaplan‐Meier method and Cox Regression model.

Results  After a median follow‐up of 66 months, the 5‐ and 10‐year overall survival rates for the entire 402 patients were 90% and 85%, respectively. The 5‐ and 10‐year progression‐free survival rates were 70% and 67%, respectively. Disease progression was the only independent risk factor for a reduced overall survival. One hundred and eleven patients (28%) developed progressive disease. Of these, 98 patients underwent second‐time and 26 patients third‐time CRS and PIC. Complete cytoreduction after repeat surgery was the only independent prognostic factor for an improved survival. The most common sites of treatment failure were on the small bowel and in the pelvis.

Conclusions  The present study reported the patterns of treatment failure after complete cytoreduction and demonstrated that a disease‐free state is important for long‐term survival in peritoneal dissemination from appendiceal mucinous neoplasms. Repeat complete cytoreduction should be pursued when possible and is associated with an improved overall survival in patients with recurrent disease.
SO05 THE NATURE OF NEARBY LYMPHATICS DICTATES WHETHER A VASCULAR ENDOTHELIAL GROWTH FACTOR‐D (VEGF‐D) INDUCES TUMOR LYMPHATICS AND METASTASIS
Authors: Shayan R. , Karnesis T. , Achen M. G. , Mann G. B. , Stacker S. A. , Taylor G. I.
Published: April 2007

Purpose  Tumors secreting VEGF‐D or VEGF‐C proteins exhibit increased lymphatic vessel density and lymph node spread (1), however tumor depth and anatomical location also influence metastasis in some tumors. It is unclear whether tumor lymphatics mirror one of the normal lymphatic subtypes or if they form an independent phenotype, and how this may vary in different anatomical locations. We aimed to study lymphatics induced in a VEGF‐D+ tumor model (1), xenografted in different locations, to better understand the vessels that facilitate tumor spread.

Methods  We analysed lymphatics formed in mouse skin wounds and tissue from VEGF‐D+ or VEGF‐D‐ tumors in the ear or flank, using immunohistochemical lymphatic marker LYVE‐1 and confocal imaging of fluorescent‐labelled antibodies.

Results  VEGF‐D+ tumors that were adherent to skin induced abnormal lymphatic structures that promoted lymph node metastasis (89%) and exhibited morphologically abnormal lymphatics; whereas size‐matched tumors that were adherent to the underlying body wall (similar VEGF‐D levels) metastasised minimally (19%, p < 0.001) and contained no morphologically abnormal lymphatics. Analysis of ear wounds and tumors suggested that lymphatics sprout mainly from the ‘pre‐collector’ lymphatic subtype within skin.

Conclusion  Lymphangiogenic growth factors are important but tumor location also plays a role in metastasis. A distinct tumor lymphatic subtype may alsooffer new diagnostic or therapeutic molecular targets.
TN01 HILAR CHOLANGIOCARCINOMA: RADIOLOGICAL DIAGNOSIS, STAGING AND PRE‐OPERATIVE INTERVENTION
Authors: Holden A. H.
Published: April 2007

Hilar intrahepatic cholangiocarcinoma (I‐CAC) accounts for 25% of CAC. Complete surgical resection offers the best possibility of cure but this demands accurate pre‐operative assessment and staging as well as appropriate ancilllary procedures such as selective portal vein embolisation and targeted biliary drainage.

CT (MD‐CT) and MRI are the primary imaging modalities used for the assessment of hilar I‐CAC but despite advances in imaging technology, overall accuracy for assessing resectability of hilar I‐CAC is approximately 60–75% for modalities. Hilar I‐CAC may present as thickening of the biliary wall with infltrative margins or (less commonly) a polypoid intra‐ductal or exophyic mass. The mass typically demonstrates delayed enhancement after contrast as a result of the sclerosis and fibrosis of surrounding tissues frequently seen in CAC. The extent of intraductal tumour spread is more accurately demonstrated with MRI/MRCP but the high spatial resolution of MD‐CT allows possibly more accurate definition of vascular invasion and small lymph metastases. These structures may also be evaluated with pre‐operative laparoscopy. CAC is FDG avid and CT‐PET has a role in detecting nodal and peritoneal metastases.

Selective pre‐operative percutaneous transhepatic biliary drainage (PTBD) of the obstructed hepatic segments in the future hepatic remnant has been shown to improve post‐operative outcomes. Pre‐operative selective portal vein embolisation has been used to promote hypertrophy in patients with marginal remnant volumes. The degree of compensatory hypertrophy is an important predictor of outcome and is dependant on technical procedural success and underlying liver disease.
TN11 RENAL ALLOGRAFT COMPRESSION SYNDROME: A REAL ENTITY
Authors: Heer M. K. , Trevillian P. R. , Stein A. , Grant A. , Sprott P. , Hibberd A. D.
Published: April 2007

Renal allograft compression syndrome (RACS) is being increasingly recognised as cause of early allograft dysfunction.

Aim  To assess the validity of RACS.

Methods  Clinical and laboratory findings used to diagnose RACS included acute allograft dysfunction (+ oliguria), duplex ultrasound demonstrating diminished, or reversed diastolic flow within interlobar and segmental arteries and, biopsy showing absence of acute rejection or toxicity. Final diagnosis was made at urgent laparotomy. Observations of poor allograft colour and perfusion after reopening the retroperitoneum were considered confirmatory for RACS.

Results  Series includes 2 males and 1 female patients. Time elapsed between transplantation and RACS diagnosis was 24–48 hrs. After surgical decompression the allograft perfusion improved visibly in two patients and these cases were then closed with PTFE mesh hood closure. There was no significant improvement observed in the third case that had a renal vein thrombus, which ultimately led to the demise of the graft. Beneficial clinical results were obtained in two cases documented by a sustained decrease in creatinine. Average follow‐up was 9.5 months without any allograft dysfunction.

Conclusions  RACS is a real entity with a potential to cause graft loss. Kidney can be salvaged by urgent surgical decompression and PTFE mesh closure.
TN03 BILIARY STENTING IS ASSOCIATED WITH A REDUCED RISK OF BILIARY ANASTOMOTIC STRICTURE FOLLOWING LIVER TRANSPLANTATION
Authors: Fink M. A. , Wang B. Z. , Muralidharan V. , Christophi C. , Jones R. M.
Published: April 2007

Aim  Biliary complications are a common cause of morbidity following liver transplantation (LT). The risk factors for biliary anastomotic stricture (BAS) are poorly understood. We analysed the risk factors for BAS.

Methods  A respective review of a prospective database of patients who underwent LT between 1988 and 2006 in the Liver Transplant Unit Victoria was undertaken. Forty‐five of 502 (9%) LT carried out during this period were complicated by BAS. These cases were compared with 45 controls who underwent LT immediately preceding the cases. Donor, donor operation, recipient, recipient operation and donor/recipient compatibility factors were assessed. Non‐parametric data analysis was used.

Results  Cases were less likely to have had a biliary stent placed at LT than controls (74% vs 91%, respectively, P = 0.037). The BAS rate in patients who had a stent at LT was 7.3% compared with 25.5% for those who did not (P < 0.001). There was no difference in BAS rate with differences in stent type (infant feeding catheter vs T tube) or size. Although there were statistically significant differences between cases and controls for donor potassium (3.9+/−0.8 vs 4.0+/−0.4 mmol/L, respectively, P = 0.032) and HCO3 (25+/−3 vs 23+/−3 mmol/L, respectively, P = 0.021), the clinical significance of these differences is questionable.

Conclusions  The rate of BAS following LT is higher in patients who did not have a biliary stent placed at the time of LT, though a causative link has not been established.