bluuebunny/crossref_metadata_2025 huggingface dataset:
HP30P XANTHOGRANULOMATOUS CHOLECYSTITIS: A CLINICOPATHOLOGICAL STUDY FROM A TERTIARY CARE HEALTH INSTITUTION
Authors: Shenoy R. , Rodrigues G. S. , Rao A.
Published: April 2009

Background:   Xanthogranulomatous cholecystitis (XGC) is an unusual and destructive form of chronic cholecystitis and is indistinguishable from other forms of cholecystitis.

Objectives:   To review the demographic and clinical aspects of XGC; to study the possibility of preoperative diagnosis and to identify the causes for difficult surgery.

Materials and Methods:   Cases histopathologically diagnosed as XGC over a period of six years from October 1999 to September 2005 were included in the study.

Results:   A total of 615 patients underwent cholecystectomy out of which 33 (5.2%) were diagnosed to have XGC. USG showed gallbladder wall thickening in 19 (57.5%) cases and gallstones in 32 (96.9%). Thirty (90.9%) underwent open cholecystectomy. Gallbladder could be removed totally in 25 (75.6%) cases whereas five (15.2%) had to undergo partial cholecystectomy and in one patient, only cholecystostomy could be performed due to dense adhesions. Laparoscopic cholecystectomy was attempted in 11 patients but successful only in two patients with a conversion rate of 81.8%. Postoperative wound infection was seen in five (15.1%) patients and one (3%) had minor biliary leak which was treated conservatively. Histologically, XGC was associated with malignancy in one (3.03%) patient. There was no mortality.

Conclusion:   Clinical presentation of XGC was indistinguishable from chronic cholecystitis. USG reveal only non‐specific findings of calculi and thickened gall bladder wall. Hence preoperative diagnosis is unlikely. Cholecystectomy was usually difficult owing to dense adhesions of gallbladder and Calot's triangle. Conversion rate of laparoscopic cholecystectomy is higher. Morbidity associated with surgery is significant.
HP04 *THE IMPACT OF PRE‐OPERATIVE SERUM CREATININE ON SHORT‐TERM OUTCOMES AFTER LIVER RESECTION
Authors: Armstrong T. , Welsh F. K , Wells J. , Chandrakumaran K. , John T. G. , Rees M.
Published: April 2009

Background:   The aim was to determine whether raised pre‐operative serum creatinine increased the risk of renal failure after liver resection.

Method:   Data was studied from 1535 consecutive liver resections. Outcomes in patients with normal pre‐operative creatinine (<124 µmol L<συπ>−1) (Group 1) was compared to those with elevated pre‐operative creatinine (>125 µmol L<συπ>−1) (Group 2).

Results:   The median age of the 1446 (94.3%) patients resected in Group 1 was 62 years compared to 67 years in the 88 (5.7%) in Group 2 (p < 0.0001). Similarly this latter group had double the number of patients who were ASA 3 or 4 (34.1% versus 15.2%, p = 0.00004). Overall, the incidence of post‐operative renal failure requiring haemofiltration was low (0.9%) but significantly more patients in Group 2 (5.7% versus 0.6, p = 0.0007). In addition, patients in Group 2 were more likely to suffer acute kidney injury post‐operatively (18.2% versus 4.3%, p < 0.0001). Although there was no difference in mortality, patients in Group 2 had higher post‐operative morbidity (37.5%) than Group 1 (21.7%, p = 0.0006), with the incidence of cardiorespiratory complications being higher in Group 2 (25.9% versus 8.9%, p = 0.0025).

Conclusions:   Renal failure following liver resection is rare but patients with an elevated creatinine preoperatively are at increased risk of both renal and non‐renal complications. This information informs both the consent process and provision of post operative care.
HP05 *THE PROTEOME OF MESENTERIC LYMPH DURING ACUTE PANCREATITIS AND IMPLICATIONS FOR TREATMENT
Authors: Mittal A. , Phillips A. , Middleditch M. , Rugeiro K. , Loveday B. , Windsor J. A.
Published: April 2009

Background:   Mesenteric lymph has been implicated in the development of organ dysfunction in acute pancreatitis and critical illness. The protein fraction of mesenteric lymph is thought to contain toxic factors. However, we do not have a complete description of the mesenteric lymph proteome during acute pancreatitis.

Aim:   The aim of this study was to identify significant changes in the mesenteric lymph proteome during acute pancreatitis.

Methods:   Mesenteric lymph was collected from sixteen male Wistar rats randomised to Group 1 (n = 8) sham control and Group 2 (n = 8) with taurocholate induced acute pancreatitis. The lymph was subjected to proteomic analysis using iTRAQ(tm) and liquid chromatography–tandem mass spectrometry.

Results:   245 proteins including 35 hypothetical proteins were identified in mesenteric lymph. There was a significant increase in the relative abundance of 8 of the 245 proteins in acute pancreatitis conditioned mesenteric lymph, and 7 of these were pancreatic catabolic enzymes (pancreatic amylase 2, pancreatic lipase, carboxypeptidase A2, chymotrypsinogen B, carboxypeptidase B1, cationic trypsinogen, ribonuclease 1).

Conclusions:   This is the first comprehensive description of the proteome of mesenteric lymph during acute pancreatitis. The striking presence of pancreatic catabolic enzymes in the mesenteric lymph, and the absence of other candidate proteins, provide incentive to explore the role of these proteases in the development of multiple organ dysfunction and provide a rationale for further studies to explore a potential therapeutic role for enteral anti‐protease therapy in acute pancreatitis.
HP06 *TRENDS IN THE MINIMALLY INVASIVE MANAGEMENT OF NECROTIZING PANCREATITIS: A SURVEY OF AUSTRALIAN AND NEW ZEALAND SURGEONS
Authors: Loveday B. , Rossaak J. , Mittal A. , Phillips A. , Windsor J. A.
Published: April 2009

Purpose:   Minimally invasive techniques to manage infected pancreatic necrosis have been recently developed, and changes in their pattern of use are not known. This study aimed to determine, in Australia and New Zealand the trends in the role of minimally invasive techniques to manage infected complications of necrotizing pancreatitis; and barriers to using minimally invasive necrosectomy.

Methodology:   In 2007, members of the Australian and New Zealand Hepatic Pancreatic and Biliary Association were surveyed. Participant demographics and necrotizing pancreatitis caseload were determined. The role of percutaneous catheter drainage and minimally invasive necrosectomy in the management of pancreatic abscess, pseudocyst and necrosis were scored on Likert scales, comparing 2002 with 2007. Barriers to using minimally invasive necrosectomy were scored.

Results:   The response rate was 49% (44/90). Between 2002 and 2007, percutaneous catheter drainage became more important as primary (p = 0.05) and secondary (p < 0.01) treatment for pancreatic abscess, and prior to minimally invasive necrosectomy for abscess, pseudocyst and necrosis (p < 0.01). Minimally invasive necrosectomy became increasingly important as primary treatment for infected necrosis (p < 0.01), and had been used by 47% of respondents. The greatest barriers to using minimally invasive necrosectomy were lack of training and experience, and the anatomical position and complexity of the target lesion.

Conclusion:   Minimally invasive techniques are becoming increasingly important to manage pancreatic abscess, pseudocyst and necrosis. Further evidence is required to determine the best techniques for treating each form of infection associated with necrotizing pancreatitis.
HP07 THE EFFECT OF OBESITY ON THE OUTCOME OF LAPAROSCOPIC ANTIREFLUX SURGERY
Authors: Chisholm J. A. , Jamieson G. G. , Lally C. J. , Devitt P. G. , Game P. A. , Watson D. I.
Published: April 2009

Purpose:   Obesity has long been considered to be a predisposing factor for gastroesophageal reflux. It is also thought to predispose patients to a poorer clinical outcome following antireflux surgery. This study examined the effect of body mass index (BMI) on clinical outcomes following laparoscopic antireflux surgery.

Methodology:   Patients were included if they had undergone a laparoscopic fundoplication, their pre‐surgical BMI was known, and they had been followed for at least 12 months after surgery. The clinical outcome was determined using a structured questionnaire, and this was applied yearly after surgery. Patients were divided into 4 groups according to BMI: normal weight (BMI < 25), overweight (BMI 25–29.9), obese (BMI 30–34.9) and morbidly obese (BMI > or = 35). The most recent clinical outcome data was analysed for each BMI group.

Results:   481 patients were studied. 103 (21%) had a normal BMI, 208 (43%) were overweight, 115 (24%) were obese, and 55 (12%) were morbidly obese. Mean follow up was 7.5 years. Conversion to an open operation and requirement for revision surgery were not influenced by preoperative weight. Operating time was longer in obese patients (mean 86 vs. 75 min). Clinical outcomes improved following surgery regardless of BMI.

Conclusion:   Preoperative BMI does not influence the clinical outcome following laparoscopic antireflux surgery. Obesity is not a contraindication for laparoscopic fundoplication.
IF01 AUSTRALIAN DEFENCE FORCE EDUCATION PROGRAMS
Authors: Sharwood P. F.
Published: April 2009

The deployment of military surgeons and anaesthetists has been a feature of the commitment of the ADF to the health and well being of their deployed soldiers. The tradition goes back to the 1870's and in the Boer War, the first Australian Victoria Cross was one by a deployed surgeon, Neville Howse VC. The first Australian killed in action in WW1 was Dr Pockley, deployed to German New Guinea in 1914. Throughout the two world wars, the Korean War and the Vietnam War, the ADF has sent medical personnel, often with minimal training, to assist with the wounded and ill. More recently, deployment involves a complex training schedule, initially selecting and training medical officers to be members of our military forces, then along with all deployed personnel, they must undergo force preparation training. They must be competent with weapons and able to handle them safely. Medical personnel must be familiar with the cultural background of the areas to which they deploy and as well the political structure of the area. Rules of engagement must be understood, not only with respect to the military mission, but the medical mission as well. Having this preparation, and maintaining an up to date vaccination schedule, makes it easy for these trained personnel to join in non‐military deployments to disaster areas with minimal additional instruction.
IF02 WHAT IS PREPAREDNESS?
Authors: Sharwood P. F.
Published: April 2009

Preparedness for deployment involves a complex of tasks which cannot be performed overnight. Generally deployment for a military or humanitarian mission involves the medical personnel to be prepared to go yesterday. This involves a raft of thoughts and actions which cannot be done overnight.

Preparedness involves be able simply to drop what one is doing and walk out. This needs mechanisms to protect, not only your own practice, but there needs to be consideration taken of your colleagues as well, particularly if you desire to go again! Many patients understand when their doctor or health practitioner suddenly disappears to aid in a crisis, but there are always some who feel aggrieved to have their problems left to a locum or perhaps left entirely until the practitioner returns.

Preparedness involves having your business affairs in place should there be an adverse outcome involving your physical or social well being. Do you have the correct insurance cover? Is your business vulnerable without your immediate presence?

Preparedness involves additional medical, social and environmental skills which most have not previously experienced.

Preparedness involves maintaining physical and mental fitness to withstand adversity and being able to avoid becoming a casualty yourself. Cultural sensitivity and ability to live in less comfortable surroundings as well as being well covered by appropriate and up to date vaccination schedule.

Preparedness involves one's family who must be prepared to step up and do those activities around the house that you would normally do.

Preparedness requires prior preparation and planning, or one will experience poor performance.
ML04P WHERE THE MEDICAL AND LEGAL FRATERNITIES CONVERGE AND DIVERGE
Authors: Kapila S. , Kapila H. B.
Published: April 2009

The medical fraternity is regularly requested by lawyers and insurance companies to assess a level of impairment of an injured person. The purpose of this assessment is to assist and provide some guidelines for lawyers and insurance companies to make a reasonable and accurate punitive level of compensation to the injured person.

The medical assessment aims to define the level of impairment once “maximum medical improvement” has been reached. This assessment should be determined solely on objective findings. Doctors should not determine disability (alteration of an individual's capacity to meet personal, social or occupational demands) or a handicap (the impairment which substantially limits one or more of life's activities) which are subjective findings.

The decision in Cummins v G James Safety Glass Pty Ltd 1994 of the NSW Workers Compensation Court, as it was then, highlights where the medical and legal fraternities converge and diverge. In this case, Burke CCJ opined, “the concept of permanent loss of efficient use is not concerned solely with the physiological or anatomical restrictions of movement. It is a much wider concept. It is concerned with use.” His Honour awarded the worker on the basis of disability rather than impairment. The decision was subsequently followed in Leanne Lukacic v Vickarni Pty Ltd t/as Chester Jakes Pharmacy 4 February 2005, where the Appeal Panel considered and accepted the earlier decision of Burke CCJ.

The role of the Medical fraternity is to assess impairment. This case sets the precedence for focus on disability and allows for plaintiff lawyers to apply for punitive compensation for patients who have no objective signs.
MS01 BOMBS AND BLAST: PRIORITIES AND MANAGEMENT OPTIONS
Authors: Rosenfeld J. V.
Published: April 2009

Bomb blast victims have combinations of penetrating, blunt and burn injuries. The more severely injured patients often arrive with hypotension, active haemorrhage, multiple extremity injuries, torso trauma, respiratory compromise, hypothermia, acidosis and traumatic brain injury. The ‘ABCs’ must be performed rapidly. Uncontrolled haemorrhage is a major cause of mortality in these patients. Tourniquets are useful for large extremity wounds with brisk haemorrhage. Whilst resuscitation and triage proceed on the multiple patients, priorities need to be determined for radiology, and theatre based on trauma surgeon triage and resources available. The injuries of the individual patient then need to be prioritised based on the urgency and predicted duration of the surgery and how this will affect overall theatre availability. Patients with head and neck and/or torso trauma should have a CT prior to surgery. Damage control surgery is an essential strategy for all specialties. Prolonged surgery and surgery which is not life‐saving may have to be postponed. The most urgent surgery is to stop severe haemorrhage. Protocols for massive transfusion should be available. There should be a low threshold for tracheostomy in severe head and neck trauma and burns. Simultaneous surgery by multiple teams of surgeons is preferable when there are multiple life threatening injuries eg simultaneous craniotomy, laparotomy and vascular/orthopaedic limb repair. Multiple returns to theatre will be common and must also be accommodated in planning. Australian trauma centres should plan and prepare to receive mass casualties from a bomb blast terrorist event.
MS02 WHY MILITARY SURGEONS SAVE MORE LIVES?
Authors: Rosenfeld J. V.
Published: April 2009

The mortality of battle injuries has reduced progressively since World War II (WWII) and is now approximately 10% in the Iraq and Afghanistan war which is at the lowest level ever recorded. This is a remarkable achievement considering the severity of the blast injury and the mass casualty environment. There are many reasons for the reduction in mortality which will be presented. Blast injury results in poly‐trauma with penetrating trauma, blast injury and burns. ‘Blast lung’ and ‘blast brain’ increase the severity of injury and the complexity of management. This severe multiple trauma produces gross physiological compromise and requires trauma care of the highest order in order to save lives and reduce morbidity. The superb trauma system in Iraq has evolved to deliver immediate expert care at the point of injury, rapid road or aero‐medical evacuation (AME), early initial wound (damage control) surgery at a forward operating base, then further resuscitation more specialised damage control surgery at the major field hospital which is a Level 1 Trauma Centre. There have also been advances in critical care and damage control resuscitation and surgical techniques and in the ongoing management of severe burns. When stabilized, the patients are transported with ongoing intensive care to Germany and then to the US. Such severe trauma is infrequently encountered in the civilian sector but there are many lessons in how these casualties are managed in a military trauma system which inform the management of blast injury, poly‐trauma and mass casualties in the civilian sector.
MS04 PERIOPERATIVE OUTCOMES FROM ADF OPERATIONS IN AFGHANISTAN
Authors: Neuhaus S. J. , Rosenfeld J.
Published: April 2009

Background:   Surgical audit is a requirement of the Royal Australasian College of Surgeons (RACS) and a normal part of surgical practice. Peri‐operative audit on deployed operations has recently been introduced into the Australian Defence Force (ADF). From 2008 three Australian surgical teams have deployed to Uruzgan province in Afghanistan to provide resuscitative surgical capability within a Dutch NATO forward hospital facility. During this time a trial of a computer based audit programme ADF SurgAssist was undertaken.

Methods:   All patients undergoing surgery by the Australian surgical team were included. Data was collected prospectively and entered onto a computer based audit system. Data fields included the Minimum Data Set recommended by the RACS, modified to the battlefield environment.

Results:   (Data from the 3rd rotation will included but is not yet available). A total of 199 operative procedures were undertaken over a discontinuous 12 week period. The majority of cases (>90%) reflected emergency or subsequent management of conflict related trauma. The most common procedure performed was exploration and debridement following explosive or gunshot injury followed by delayed closure or grafting. 11% required orthopaedic fixation. Australian personnel constituted 11% of all operations performed. Paediatric (<16 years) cases accounted for 31%. Follow‐up information is limited but three in‐hospital deaths were reported.

Conclusion:   Whilst still under development, ADF SurgAssist has demonstrated its utility in the battlefield environment. This is the first time verifiable peri‐operative outcome data has been obtained during ADF operations and represents the ADF's ongoing commitment to best surgical practice.
MS05 EFFECT OF LANDMINES AND UNEXPLODED ORDNANCE ON CHILDREN VERSUS ADULTS OF CAMBODIA
Authors: Bendinelli C.
Published: April 2009

Aim of these study is to compare the impact of explosive remnants of war on children as compared to adults. Methods: Consecutive series of patients acutely wounded by antipersonnel landmines, antitank landmines, or unexploded ordnances (UXO) treated at “EMERGENCY NGO” Surgical Centre, Cambodia. Paediatric patients (<16 years‐old) were compared to adults in terms of: female ratio, evacuation time, ordinance type, injury pattern, number of operations, transfused patients, hospitalization, mortality and residual disability. Results: From October 2003 to January 2006, 805 war wounded patients were admitted. Patients injured from more than 24 hours (n°443) or discharged against medical advice (n°8) were excluded. Among 356 included cases, 94 were children (26.4%). Females were more common among children (31.9% versus 11.8%). 61.7% of children were injured by UXO, whereas 72.1 of adults were victims of antipersonnel landmines. Antitank mines victims were uncommon in both groups. The majority of adults (49.2%) were injured to lower limbs, whereas 50.0% of children were injured to upper limbs, face, and torso. Random wounds, typical of an explosion in vicinity, were observed in 32.9% of children and 18.7% of adults. Number of transfused patients (23.0% versus 7.2%), mortality (6.3% versus 1.5%), and incidence of blindness and maimed upper limbs were higher in children compare to adults. All differences were statistically significant (P < 0.05). Evacuation time, number of operations, and days of hospitalization did not statistically differ. Conclusions: Following armed conflicts antitank mines, antipersonnel landmines, and UXO pose long term risks to population. Children are commonly injured and sustain the most severe injuries.
NS01 TECHNICAL ADVANCES IN MINIMALLY INVASIVE INTERBODY FUSION FOR THE TREATMENT OF LUMBAR RADICULOPATHY
Authors: Mannion R. J. , Nowitzke A. M. , Wood M. J.
Published: April 2009

Introduction:   Posterolateral pedicle screw fixation with interbody fusion is a popular technique to treat degenerative lumbar spine disease with radiculopathy, particularly in the presence of foramenal stenosis and/or lumbar spondylolisthesis. Recently, minimally invasive techniques have been developed with which to achieve the same surgical goals as open surgery, offering the patient the potential for less post‐operative pain and a quicker recovery.

Methodology:   64 consecutive patients between 2005 & 2008 were treated with minimally invasive interbody fusion and percutaneous pedicle screw fixation with navigation (Stealth, Medtronic). Following removal of the disc contents, the interbody cage(s) were inserted with iliac crest bone graft +/− BCP in the first half of the series, and local bone graft and BMP in the latter half.

Results:   Our current technique includes a number of key changes which have evolved to overcome specific difficulties and as technology has advanced. We now perform the procedure using CT‐guided navigation for pedicle screw insertion and muscle splitting minimally invasive tube surgery for decompression and interbody fusion for all but a small number of cases at L5/S1 where the lumbosacral angle precludes access through a tube. A number of improvements have been introduced with regard to – radiation exposure; interbody fusion technique; navigation with fluoroscopy versus CT, and methods to encourage fusion including the use of BMP.

Conclusions:   Minimally invasive interbody fusion is an attractive alternative to open techniques, with less post‐operative pain and quicker recovery for the patient. The pros and cons of minimally invasive versus open techniques will be discussed.
NS03 RISK FACTORS FOR NON‐UNION IN THE NON‐OPERATIVE MANAGEMENT OF TYPE II DENS FRACTURES
Authors: Lewis E. J. , Liew S. , Dowrick A.
Published: April 2009

Purpose:   Despite the publication of numerous studies, controversy regarding the non‐operative treatment of type II dens fractures remains. The halo‐thoracic vest (HTV) and cervical collar are the most commonly used devices. We sought to compare the outcomes of patients managed with these devices in terms of risk factors for non‐union and the rate of associated complications.

Methodology:   This study was a retrospective review of adult patients with type II dens fractures treated non‐operatively at a level 1 trauma centre between 2001 and 2007. Patient records and imaging studies were reviewed. Union was defined as stable fibrous union or bony union, measured at 3 months. A p‐value of <0.05 was considered statistically significant.

Results:   Sixty‐seven patients were included. Thirty‐five patients were treated using a HTV and 32 with a collar. The proportion of patients with stable union at 3 months was 60% for the HTV group versus 35% for the cervical collar group (p = 0.10). Non‐union was found to be associated with increased time in HTV or collar (p = 0.011) and a mechanism of injury involving a low fall (p = 0.008). Clinically significant complications of HTV had a ten‐fold greater prevalence than those of the collar (60% versus 6%).

Conclusion:   We were unable to demonstrate any clear advantage or disadvantage of either device. Further investigation of mortality would be beneficial, particularly in the patient group injured with a mechanism involving a low fall which tends to include more elderly patients.
NS04 INTRADURAL EXTRAMEDULLARY TUMOUR REMOVAL USING MINIMALLY INVASIVE TECHNIQUES – INDICATIONS, ADVANTAGES AND DIFFICULTIES
Authors: Mannion R. J. , Nowitzke A. M. , Wood M. J.
Published: April 2009

Purpose:   While minimally invasive surgery offers the potential benefit of less post‐operative pain, a quicker recovery and the avoidance of long‐term instability from multilevel laminectomy, there are concerns over whether one can safely and effectively remove intradural extramedullary tumours in a fashion comparable to open techniques, and whether the theoretical advantages of minimally invasive surgery are clinically significant. Here we review our early experience with minimally invasive techniques for intradural tumours in the thoracolumbar spine.

Methodology:   Eleven intradural thoracic or lumbar tumours in 9 patients were operated upon using a muscle splitting, tube‐assisted para‐median approach with hemilaminectomy to access the spinal canal. Fluoroscopy and navigation were used to determine the surgical level in all cases.

Results:   Satisfactory tumour resection using standard microsurgical techniques was achieved in all but one case through a minimally invasive approach. Surgical time and intra‐operative blood loss were favourable compared to open techniques. There was no post‐operative morbidity in any of these cases although there were 2 cases in the high thoracic spine in which the surgical site was inaccurately placed by 1 level. In one case, the approach was converted to open when the tumour could not be found. In this case there was a post‐operative CSF leak which required re‐admission.

Conclusions:   Intradural tumours can be safely and effectively removed using minimally invasive techniques. The pros and cons of minimally invasive versus open surgery are discussed.
PS01 ECTOPIC NEPHROGENIC RESTS IN CHILDREN: THE CLINICO‐SURGICAL IMPLICATIONS
Authors: Desphande A. V. , Lai hei E. R. , Kellie S. , Arbuckle S. , Cummins G. , Cooke A. A.
Published: April 2009

Purpose:   Ectopic nephrogenic rests (ENR) are rare. The significance of ENR and their role in tumourgenesis is largely unknown, although they have been associated with Extrarenal Wilms’ Tumours (ERWT). We review our experience with the surgical management of ENR and discuss the clinico‐surgical implications of their incidental discovery.

Methodology:   We reviewed the hospital records of patients with histopathologically confirmed ERWT and ENR treated at our hospital over a ten year period.

Results:   Ninety‐five children with WT were identified but only one case of ENR and ERWT. This patient was a fourteen month old boy who was incidentally found to have a mass in the left inguinal canal during orchiopexy. Following histology, a provisional diagnosis of ENR was made. Six months later the child went onto develop an ERWT at the same site. Periodic post surgical follow‐up has been uneventful.

Conclusion:   The discovery of a site of ENR raises two distinct possibilities: either it is an isolated developmental abnormality or, of more clinical significance, the early stages of a neoplastic process. Our experience lends support for the theory that ENR are precursor lesions to the development of WT in ectopic sites. Histopathologically, ENR can be difficult to differentiate from ERWT and this adds to the uncertainty in identifying a natural clinical progression for these lesions and in labelling them as putative pre‐ cursor lesions to ERWT. Children with confirmed ENR should be considered as high risk for the development of ERWT and require long term post – operative follow up.
PS02P DELAYED PRESENTATION OF DUODENAL HEMATOMA AND ACUTE PANCREATITIS FOLLOWING A SEATBELT INJURY
Authors: Siddaiah‐subramanya M. B. , Deambrosis K. , Hopkins R. , Memon B. , Memon M. A.
Published: April 2009

Purpose:   Intramural duodenal hematoma is a rare duodenal injury, usually occurring in association with blunt abdominal trauma. Diagnostic and therapeutic implementations remain controversial. We present a case of delayed onset of such an injury complicated by acute pancreatitis following a MVA.

Methodology:   A 15‐year old male re‐presented to the emergency department four days after involvement as a restrained rear seat passenger in a front‐on collision at 60 km per hour. In the absence of demonstrable external injury or clinical signs of trauma, the patient was discharged home following six hours of stable observation. Over the subsequent four days, he developed increasing abdominal distension and pain for which he represented to the hospital.

Results:   On examination the patient was hypovolaemic and tachycardic with a tense, distended abdomen with few bowel sounds. An abdominal CT demonstrated significant duodenal hematoma. An oral Gastrografin meal study performed six hour later showed complete gastric outlet obstruction. The patient was managed conservatively with a NG aspirations and TPN. He developed high lipase levels a couple of days later suggesting delayed manifestation of pancreatic injury. A repeat CT scan however was negative. A repeat gastrografin meal on day 18 revealed complete resolution of the gastric outlet obstruction.

Conclusion:   This case emphasises the characteristic delayed presentation of duodenal hematoma following a blunt abdominal trauma and associated sequelae of delayed pancreatitis. Total parenteral nutrition and gastric decompression provides an effective conservative treatment of gastric outlet obstruction associated with this injury.
PS03P MASSIVE SKIN NECROSIS FOLLOWING COBRA BITE
Authors: Nor M. T. T.
Published: April 2009

Introduction:   Local necrosis which needed debridement or amputation is common complication of a snake bite. On the other hand, large area of necrosis which need frequent debridement and skin graft is very uncommon.

Case Report:   We present a case of 11 years old boy with an extensive back necrosis following a snake bite at his right shoulder. The incident happened while the boy is playing in paddy fields with his friends. He complained of pain at bitten subsequently become sleepy and drowsy. However he denied any shortness of breath. He was brought to the hospital and immediately anti‐tetanus toxoid and polyvalent (Antivenom) was given. He was noted to have respiratory distress subsequent morning and was ventilated promptly. Three days later he was referred to our team for extensive back necrosis. Clinical examination revealed normotensive blood pressure with stable pulse rate. Three was low grade fever noted and a snake bite mark at the right shoulder with extensive skin necrosis, estimated about 15% of body surface area. Multiple episodes of wound debridement was done on day 5, day 9 and day 13. Split skin graft was applied over the back and shoulder and he was discharged well on day 35. During follow up, a minimal area which is not cover by good skin however parents refused for another split skin graft.

Conclusion:   Immediate treatment of cobra bite is very crucial in order to save patient's life. Early and extensive debridement of any skin necrosis should be emphasized to warrant patient's survival.
PR10 HELIX SWITCH FOR RECONSTRUCTION OF SEGMENTAL HELICAL RIM/SCAPHA DEFECT: A CASE REPORT
Authors: Farhadieh R. D. , Wong W. , Dickinson G. F. , Ee E. , Morrison W. A. J.
Published: April 2009

A 35 year old man presented to clinic having lost the central two thirds of his left helix and lateral scapha following a human bite. A switch procedure using the root of the opposite helix and adjacent scaphoid cartilage was considered and performed secondarily.

The right helix was harvested with a long pedicle length on the superficial temporal (ST) vessels. The vascular pedicle emerged posteriorly from the graft at its transferred site and was tunnelled under the ear to the preauricular ST vessels for anastomosis. Primary donor site defect was closed with a postauricular flap. Postoperatively leech therapy was commenced on day one for a total duration of 4 days. The patient was discharged and followed up in clinic with no complications.

Ear reconstruction remains one of the most challenging aspects of reconstructive surgery. Here, we report of a novel alternative ear switch procedure for reconstruction of the helical rim.
PR11 *HEAD & NECK CUTANEOUS SQUAMOUS CELL CARCINOMA – UNDERSTANDING THE TUMOUR MICROENVIRONMENT
Authors: Ch’ng S. , Low I. , Brasch H. , Sullivan M. , Davis P. , Tan S. T.
Published: April 2009

Background:   HNcSCC is common in Australasia. Recent advances have led to new paradigms in our understanding of the complex interactions between tumour, stromal and immune cells, and the extracellular matrix. The deranged interplay between tumour and its microenvironment eventually spirals towards irreversibility. The repertoire of gene expression in the tumour becomes increasingly abnormal, and results in metastasis.

Purpose:   To examine the tumour microenvironment including, tumour immunosurveillance, angiogenesis and lymphangiogenesis, and investigate the expression of EGFR, which is fundamental to skin physiology, in HNcSCC.

Methods:   Archived HNcSCC specimens were stratified into groups of primary lesions with and without metastasis. (Immuno) histochemical analysis was performed for the differential parameters of peritumoural mast cell, microvessel and lymphatic vessel densities, VEGF and EGFR expression. The effects of mast cells on cell cycle and apoptotic gene expression were studied using cell co‐culture and cDNA micro‐array. The mechanism of EGFR over‐expression in metastatic HNcSCC and its potential link with HER2 were assessed with fluorescence in‐situ hybridisation.

Results:   Although mast cells demonstrate a tumour inhibitory effect by deregulating the cell cycle and apoptosis in vitro, this observation is not corroborated by study of tissue specimens. Lymphatic vessel density (but not microvessel density or VEGF expression) predicts metastatic potential. 75% of primary HNcSCC that subsequently metastasise over‐express EGFR, with the majority harbouring HER2 polysomy.

Conclusion:   Improved understanding of the tumour microenvironment will hopefully lead to development of novel biologic therapy for HNcSCC.
PR13 INCIDENCE AND SUBSEQUENT NON‐MELANOMA SKIN CANCERS IN CANTERBURY RENAL TRANSPLANT RECIPIENTS –WHAT CAN WE LEARN?
Authors: Mackenzie K. A. , Wells E. , Currie M. , Simcock J. , Lynn K. , Robinson B.
Published: April 2009

Purpose:   The aim of our study was to determine the incidence of non‐melanoma skin cancers (NMSCs) in renal transplant recipients (RTRs) in the Canterbury population and investigate the subsequent history of NMSCs in RTRs.

Methods:   We retrospectively reviewed the hospital notes of 96 RTRs who developed at least one NMSC. Survival analysis was used for the incidence of first NMSC following first renal transplant.

Results:   Of the 384 RTRs, 96 developed at least one NMSC. We identified 4 single predictors of NMSC in RTRs: older age at first transplant (p < 0.0001), transplantation after 1998 (p < 0.0001), male sex (p = 0.002) and initial immunosuppression regime (prednisone, mycophenolate and cyclosporine) (p < 0.0001). The average time from renal transplant to first NMSC presentation was 8.2 years. The ratio of SCC to BCC was 1.2:1. 11% of patients died of metastatic cutaneous SCC. The average number of NMSC was 1.67/year after discovery of the first NMSC. Older age at first transplant (p = 0.009) or at discovery of the first NMSC (p = 0.01) was associated with a higher annual rate of new NMSC. The median time to the discovery of second skin cancer was 2.2 years. Based on survival analysis, 25% of RTR will develop a second NMSC within 10 months of the first NMSC, and 75% by 4.4 years.

Conclusions:   NMSCs, especially SCCs are not a minor inconvenience of transplantation. We have quantified the clinical challenge of skin cancers in the RTR population and the particular subgroups at increased risk of developing skin cancers. We hope the size of the health burden of skin cancers carried by our RTRs will raise the awareness of this serious problem.
PR14 IMPROVING DISSECTION OF PERFORATORY ARTERIES
Authors: Ting J. W. , Morsi A.
Published: April 2009

Perforator flaps such as the deep inferior epigastric artery (DIEA) perforator flap is used increasingly for breast reconstruction. This is often preferred to traditional transverse rectus abdominis musculocutaneous (TRAM) flaps where sparing of muscle significantly reduces the risk of abdominal wall weakness. Perforators however are often small (diameter of less than 1 mm) and travel substantial longitudinal and transverse distances within the rectus abdominus muscle. Some surgeons therefore, may find the DIEA perforator flap technically more difficult to dissect than the traditional TRAM flap. Pre‐operative CT angiography (CTA) plays an integral part in mapping the size and location of these perforators. We describe a simple intra‐operative technique, commonly used in plastic and ophthalmic surgery, which is invaluable in assisting the surgeon in the dissection of these perforators. This technique has been performed successfully on over 12 patients in the last 2 years.
PR19 ABDOMINAL COMPARTMENT SYNDROME IN BURNS PATIENTS: FROM DIAGNOSIS TO FOLLOW‐UP
Authors: Chan Q.
Published: April 2009

Acute increase in intra‐abdominal pressure is a known complication of patients undergoing burns resuscitation. It can progress rapidly in the absence of primary abdominal pathology, causing multiple organ dysfunction. This is known as secondary abdominal compartment syndrome (ACS). Intravascular fluid replacement and decompressive laparotomy form the standard management practices for ACS. Despite these measures, survival rates of secondary ACS in burns patients remain extremely poor. The medical records of four severely burnt patients are reviewed. All four patients underwent decompressive laparotomy. Three patients had either vacuum‐assisted closure therapy or a Silastic bowel bag inserted and temporary abdominal wound closure was gained using an absorbable synthetic mesh. There was one survivor. Early recognition and alternatives to standard therapy may result in possible decrease in mortality figures. However, the poor outcome may be intrinsic to the severe burn injuries rather than a reflection of current practices. Patients that survive open laparotomy face a new set of complications on road to recovery that are often ignored.
PR20 USE OF LOCAL PERFORATOR FLAPS IN PARTIAL MASTECTOMY DEFECTS
Authors: Brakovsky Y. , Buccimazza I.
Published: April 2009

Purpose:   To demonstrate various possibilities of local pedicle perforator flaps use (mainly L‐ICAP and also A‐ICAP, LoTP and TAP flaps) for different types of partial mastectomy defects .Specific modifications are proposed to enhance aesthetic outcomes of these procedures. To determine suitability of these flaps as a method of choice for selected patients.

Methodology:   On‐going study – to‐date 17 patients. Patients with breast cancers suitable for breast conserving surgery but with post‐resection defects too large to be reconstructed with parenchymal flaps. Immediate reconstructions in all patients. Choice of flap dictated by site /size of the defect and the availability of local perforators (confirmed preoperatively by Doppler probe). Modifications are devised to maintain /re‐create aesthetic units of the breast. Detailed documentation including patients’ oncologic data and pre‐, intra‐ and post‐ operative photographs as well as follow‐up photographs after completion of radiation therapy.

Results:   These include: patients satisfaction, aesthetic results (using a panel of independent observers), complications, lessons learned and suggestions.
PR21 PLANNING GLUTEAL ARTERY PERFORATOR FLAPS FOR BREAST RECONSTRUCTION WITH PREOPERATIVE IMAGING
Authors: Grinsell D. G. , Rozen W. M.
Published: April 2009

Background:   While autologous breast reconstruction is frequently sought, donor sites providing versatility in volume with low donor site morbidity other than the abdominal wall are limited. Gluteal artery perforator flaps have been described in this role, however variations in individual vascular anatomy have resulted in the difficult planning of flaps, and particularly selection of whether superior or inferior gluteal artery perforators should be utilized.

Methods:   Five consecutive patients underwent a gluteal artery perforator flap for breast reconstruction. Preoperative imaging of the gluteal artery vasculature was undertaken with computed tomographic angiography (CTA). Both superior and inferior gluteal artery perforators were mapped on imaging, and the dominant system selected preoperatively. The anatomical basis, operative technique and outcomes are discussed.

Results:   In all cases, CTA was able to demonstrate individual vascular anatomy, and select the optimal perforators supplying the gluteal integument. Either a superior gluteal artery perforator (SGAP) or inferior gluteal artery perforator (IGAP) flap was planned, and undertaken successfully in each case. There was a 100% flap survival, with low donor site morbidity.

Conclusion:   With the use of preoperative planning, selection of either an SGAP or IGAP flap can be reliably made based on individual vascular anatomy. With low donor site morbidity and good aesthetic outcomes, gluteal artery perforator flaps are a good option in cases where the abdominal wall is not appropriate.
PR22 *THE STACKED DIEP FLAP FOR BREAST RECONSTRUCTION: A RELIABLE OPTION FOR COMPLEX CASES WITH THE USE OF PREOPERATIVE IMAGING
Authors: Rozen W. M. , Grinsell D.
Published: April 2009

Background:   Autologous reconstruction with the deep inferior epigastric artery (DIEA) perforator (DIEP) flap is increasingly utilized for breast reconstruction. However, situations arise in which the DIEP flap is not an appropriate option, including the presence of a midline abdominal scar or an inadequate volume of abdominal tissue. While other donor sites may be considered, the stacked DIEP flap, in which the perforators of both hemi‐abdominal walls are utilized in a single vascular pedicle, provides a safe technique to utilize the integument of both hemi‐abdominal walls.

Methods:   Five consecutive patients underwent a stacked DIEP flap for breast reconstruction. Preoperative imaging with computed tomographic angiography (CTA) of the abdominal wall was undertaken, with each DIEA, its branching pattern, and all musculocutaneous perforating branches mapped using three‐dimensional software reconstructions. The anatomical basis, operative technique and outcomes are discussed.

Results:   In all cases, CTA was able to demonstrate individual vascular anatomy, and guide planning for a stacked DIEP flap. Unique anatomy between individuals required a range of variations in flap anatomy, with the contralateral DIEA, SIEA, or perforators each used to perfuse the contralateral hemi‐abdominal wall. There was a 100% flap survival, with no donor site morbidity reported.

Conclusion:   The stacked DIEP flap is a safe and reliable technique for augmenting the perfusion of the abdominal wall in cases where the single pedicle DIEP flap is limited. The anatomical basis of the flap can be planned preoperatively with CTA, facilitating faster operating times and good outcomes.
PR23 *AN ULTRASONOGRAPHIC AND CLINICAL EVALUATION OF RECTUS MUSCLE FUNCTION – FOLLOWING DIEP AND MUSCLE‐SPARING TRAM BREAST RECONSTRUCTION
Authors: Fullarton A. C. , Ngan N. C. , Armstrong J. , Tan S. T.
Published: April 2009

Background:   An advantage of breast reconstruction with a deep inferior epigastric perforator (DIEP) flap compared with the standard or muscle‐sparing transverse rectus abdominis muscle (TRAM) flap is preservation of the entire rectus muscle. However this purported advantage has not been fully evaluated.

Aim:   This study evaluates rectus muscle morphologically and clinically following unilateral breast reconstruction with DIEP and muscle‐sparing TRAM flaps.

Methods:   The rectus muscle was examined ultrasonographically in 20 patients, at least 18 months after following breast reconstruction. Rectus muscle thickness was measured at three points along its length when relaxed and when contracted; the un‐operated side was used as a control.

Results:   Rectus muscle at or below the umbilicus was thinner after muscle‐sparing TRAM but was unchanged after DIEP reconstruction. However, its contractility (measured as a ratio of contracted and relaxed muscle thickness) was unchanged by either operation. Clinically, there is no difference in abdominal wall function between the two types of operation.

Conclusion:   The purported advantage of DIEP flap over muscle‐sparing TRAM breast reconstruction, with regard to abdominal wall integrity, requires further investigation.
PR24 POST OPERATIVE MONITORING IN 23 MICROVASCULAR FREE‐FLAP OPERATIONS UTILISING THE IMPLANTABLE DOPPLER FLOW SYSTEM
Authors: James D. W. , Langley S. J.
Published: April 2009

Purpose:   The Cook‐Swartz Implantable Doppler has been used to provide continuous feedback on the vascular status of free flaps and has been reported to improve flap salvage. We review our experience of this device, its efficacy and suitability for ongoing use in free flap monitoring.

Methodology:   All patients who were monitored following free flap reconstruction using the Cook Swartz Implantable Doppler in two Hospitals in Christchurch, NZ were retrospectively reviewed from its first use in December 2006 to December 2008.

Results:   In total 43 probes were used on 23 flaps (4 buried, 7 intraoral) in 21 patients (range 17–83 yrs). The probes were placed on the artery in all cases and the vein in 21 cases. 21 (91.3%) flaps survived. 20 flaps had reliable Doppler signals. Overall there were 2 flap failures (8.7%) and these were not salvageable. There were no technical difficulties with application or removal of the probes and it was well received by junior medical/nursing staff. It provided peace of mind to surgeons performing free flap surgery outside the base hospital (6 cases).

Conclusion:   The implantable Doppler probe is a useful tool in monitoring free flaps where clinical evaluation is difficult especially when flaps are buried. Our current experience supports its ongoing use as a free flap monitoring tool at our institution.
PR25 TRAINING EXPERIENCE WITH BREAST REDUCTION AND OTOPLASTY
Authors: Avery G. J.
Published: April 2009

Aim:   To identify the experience, expectations and accessibility of breast reduction and otoplasty for current trainees and how this compares to the experiences and expectations of current practising Plastic Surgeons.

Methods:   All New Zealand advanced Plastic Surgery trainees and vocationally registered Plastic Surgeons in New Zealand were emailed or posted a questionnaire regarding their experience performing otoplasty and breast reduction surgery. Trainee questionnaires were repeated at an interval of three years. Participants were asked to quantify the number of procedures trainees should perform to become proficient and their view as to whether conditions exist at present to achieve this. A review of the number of cases performed within the four Plastic Surgery units was also undertaken.

Results and Conclusions:   Training in Plastic Surgery has no quotas for any procedures as exists in other specialty programs. This means that with changes in waiting list pressures and health priorities there is no safeguarding of procedures for trainees or the community alike. The results of these questionnaires will be presented in an attempt to formalise current opinion on these important issues. The Plastic Surgery community has an obligation to provide a service to the community and also to train its future providers and hence has a responsibility to be actively involved in addressing these topical and important issues.