bluuebunny/crossref_metadata_2025 huggingface dataset:
HP19 RE‐OPERATION FOR DYSPHAGIA AFTER CARDIOMYOTOMY FOR ACHALASIA
Authors: Grotenhuis B. A. , Wijnhoven B. P. L. , Myers J. C. , Jamieson G. G. , Devitt P. G. , Watson D. I.
Published: April 2007

Purpose  Although laparoscopic cardiomyotomy is considered to be the treatment of choice for achalasia, there is no consensus about how persistent or recurrent dysphagia after myotomy should be treated. In this study we evaluated our experience with re‐operation following previous cardiomyotomy.

Methodology  From a prospective database, all patients were identified who underwent a re‐cardiomyotomy for persistent or recurrent dysphagia between 1992 and 2006.

Results  19 patients (6 female, 13 male) underwent a re‐operation: 7 for persistent and 12 for recurrent dysphagia. The mean time interval between both cardiomyotomies was 81 months. Different operative approaches for reoperations were used, depending on surgeon’s preference and the technique used for the first operation. In 12 patients, the alternative body cavity to that used for the first operation (thoracic versus abdominal) was used for access in the revision operation. This was associated with a shorter operation time (90 vs.128 minutes). An incomplete myotomy or scar tissue were the most common causes of failure identified. Mean hospital stay was 4 days. Mean follow‐up after the revision operation was 3.6 years. 89% of patients had an improvement in symptoms, and the mean satisfaction score (0–10) was 7.

Conclusion  Re‐operation for persistent or recurrent achalasia achieves a satisfactory outcome in most patients. Using the alternative body cavity to that used in the original procedure facilitates minimal access techniques, and gives easier access to the operative field.
HP20 OESOPHAGECTOMY FOR TUMOURS AND DYSPLASIA OF THE OESOPHAGUS AND GASTRO‐OESOPHAGEAL JUNCTION: EXPERIENCE OF A SINGLE SURGEON
Authors: Epari K. P. , Cade R. J.
Published: April 2007

Purpose  Neoadjuvant therapy, radical lymphadenectomy and treatment in high volume centres have been proposed to improve outcomes for resectable oesophageal tumours. The aim of our study was to review the outcomes of oesophagectomy performed by a single surgeon with a moderate caseload where surgery was the principal treatment and a conservative lymphadenectomy was performed and compare them with current literature.

Methodology  The study comprises 125 consecutive cases of attempted oesophagectomy performed by a single surgeon (RC) from 1993–2006. Data has been recorded in a prospective database maintained and updated by the surgeon.

Results  Endoscopic ultrasound was used in staging 69% of patients. Only 23% patients received neoadjuvant therapy. Resection rate was 97%. There were 121 oesophagectomies performed with a complete R0 resection in 82%. In‐hospital mortality was 0.8%. Clinical anastomotic leak occurred in 1.7%. Median length of stay was 14 days. Overall median and 5 year survival were 46 months and 47%. Stage specific 5 year survival was stage 0 100%, stage I 71%, stage II 41% and stage III 21%. Isolated local recurrence occurred in 8%. Dilatation was required in 15 patients and 3 stents were placed.

Conclusion  A moderate volume surgeon with specialist training can achieve a low mortality and anastomotic leak rate with good survival outcomes. Surgery remains the principal treatment for resectable oesophageal tumours. The role for neoadjuvant therapy and radical lymphadenectomy is controversial and remains to be clearly defined. Accurate preoperative staging with endoscopic ultrasound is important for selection of patients, determining therapy and comparison of results.
HP21 ACUTE PRESENTATION OF GASTRIC CANCER IS ASSOCIATED WITH A WORSE PROGNOSIS
Authors: Lo A. S. N. , Bartlett A. , Siu M. , Poole G.
Published: April 2007

Purpose  Some patients with gastric cancers develop acute complications and present acutely. It has been proposed that this group of patients have a worse prognosis. This paper describes the management of acute and elective gastric cancer patients at South Auckland Health.

Methods  Patients were identified by electronic searching patient records from 2000 to 2006, and obtaining data pertaining to patient demographics, mode of presentation, management and outcome.

Results  Two‐hundred and thirty eight patients were identified, of which 120 (50%) had an acute presentation. Patient demographics were similar in both groups, except for acute patients were older (77 years compared to 64 years; p < 0.001). Gastrointestinal bleeding and vomiting were more common in patients that presented acutely, 46% and 39% respectively, compared to 19% and 14% respectively in the elective group (p < 0.001). Fifty‐six percent of all patients underwent an operation; 36% had a curative resection, 11% palliative resection and 9% had an operation for the purpose of staging. Curative resection was undertaken more commonly in patients that presented electively (47%) than those that presented acutely (24%; p < 0.001). After curative resections, the median survival for acute patients was 30.3 months, with a 3 year overall survival rate of 41.6%, compared to 72% for elective patients (p < 0.0001).

Conclusions  We have shown that 50% of patients with gastric cancer develop complications leading to an acute presentation. Only a minority of these patients are able to undergo resection with a curative intent, and consequently these patients have a poorer survival.
HP23 USE OF ANTI‐REFLUX MEDICATION AFTER ANTI‐REFLUX SURGERY
Authors: Wijnhoven B. P. L. , Lally C. J. , Kelly J. J. , Myers J. C. , Watson D. I.
Published: April 2007

Purpose  It is thought that a substantial number of patients who undergo anti‐reflux surgery use anti‐reflux medication post operatively, despite no objective evidence of reflux. This study aims to determine the prevalence and underlying reasons for anti‐reflux medication usage in patients after anti‐reflux surgery.

Methodology  A questionnaire (13 questions) on the usage of anti‐reflux medication was sent to 1016 patients from a prospective database of anti‐reflux surgery patients.

Results  852 patients (84%), (437 males & 415 females with a mean age 58 yrs) returned the questionnaire. Mean follow up was 5.9 yrs after surgery. A single or combination of medications was being taken by 319 patients (37%): 82% proton pump inhibitors, 9% H2‐blockers and 34% antacids. 54 patients (18%) had never stopped taking medication, whereas 261 patients (82%) re‐started medication at a mean of 2.4 yrs after surgery. Persistent or return of the same or different symptoms was the reason for taking medication by the vast majority (85%), whereas 15% were asymptomatic or had other reasons for medication use. A response of symptoms to the medication occurred for 30% of the patients, whereas 64% noticed some improvement. Postoperative 24‐hour pH studies (while off medication) were abnormal in 17/62 patients (27%) on medication and in 5/73 patients (6%) not taking medication.

Conclusions  Anti‐reflux medication is frequently taken by patients for symptoms after surgery, despite normal pH profiles in the majority. Strategies need to be employed to lower the inappropriate use of medications after surgery and to further evaluate the mechanisms underlying postoperative symptoms, which are non‐responsive to anti‐reflux medication.
HP25 LAPAROSCOPIC SLEEVE GASTRECTOMY FOR MORBIDLY OBESE PATIENTS
Authors: Ou Yang S. O. , Loi K. , Jorgensen J. , Talbot M.
Published: April 2007

Background  Obesity surgery is been endorsed as the only effective method of weight reduction in morbidly obese patients. Laparoscopic Roux‐en‐Y gastric bypass (LRYGBP) is been used as the most effective procedures in our centre. However LRYGBP also conveys high risk of peri‐ and postoperative complications on obese patients. Laparoscopic sleeve gastrectomy (LSG) is been employed first‐stage procedure as a risk reduction strategy. The aim of this study was to report the short‐term outcomes of LSG, its effect on risk reduction and resolution in co‐morbidities.

Methods  We prospectively investigated 92 patients who underwent LSG between July 2004 and February 2006 and completed our data collection through 3‐ to 6‐monthly follow up and/or patient questionnaire. Data collected included demographics, degree of weight reduction, postoperative complications, and changes in co‐morbidities.

Results  Median BMI was 52.03 kg/m2 (33–82). 56% patients had a BMI >50 kg/m2. The median postoperative excess weight loss (EWL) was 45% with 35.49% at 6 months, 49.07% at 12 months, and 55.75% at 18 months. 39% of patients had resolutions in Diabetes Mellitus type 2, 56% had resolutions in dyslipidaemia, 28% in hypertension, 66% in obstructive sleep apnoea. Complication rate of 7.5% and three patients necessitated surgical intervention. There was zero mortality.

Conclusion  LSG minimizes postoperative complication rates significantly on high risk patients and achieves effective short‐term weight loss with resolutions in co‐morbidities. Additional studies are required to evaluate LSG as a stand‐lone procedure.
HP26 PSEUDO‐ACHALASIA FOLLOWING A SLIPPED LAPAROSCOPICALLY PLACED ADJUSTABLE GASTRIC BAND: A CASE REPORT
Authors: Al‐Mozany N. , Booth M.
Published: April 2007

Purpose  To demonstrate that laparoscopic adjustable gastric banding may promote oesophageal dilatation or interfere with oesophageal motility.

Methodology  We report a case of a 67 year old female with a complex medical history who developed secondary achalasia from a slipped laparoscopic adjustable gastric band for weight loss. This led to recurring episodes of aspiration pneumonia requiring multiple admissions at North Shore Hospital, Auckland, New Zealand.

Results  A decision was made to remove the gastric band, five years after its initial insertion. At one month follow up, she was swallowing normally and oesophageal manometry had returned to normal.

Conclusion  Oesophageal dysmotility is sometimes seen in patients who have bands that are adjusted too tightly or in whom the band has slipped. This can lead to serious complications if unrecognized and incorrectly treated. Oesophageal symptoms in patients with adjustable bands must be considered secondary to the band until proven otherwise ie removal of the band or complete deflation.
HP27 MORTALITY, MORBIDITY AND 2 YEAR SURVIVAL FOLLOWING OESOPHAGECTOMY – DUNEDIN EXPERIENCE
Authors: Popadich A. , Elliott T. B.
Published: April 2007

Purpose  Oesophagectomy is associated with considerable morbidity, mortality and poor survival of patients who have undergone oesophagectomy for oesophageal carcinoma. Numerous studies have examined the impact of hospital volume on early mortality, most demonstrating a strong inverse relationship between operative mortality and hospital case volume. This study looks at the morbidity, mortality and 2‐year survival of patients following oesophagectomy at Dunedin hospital, a low volume centre, and comparing it to high volume centres.

Methods  A retrospective analysis of all patients who had elective oesophagectomy between 1995 and 2004. Otago Surgical Audit database, patient management system database (OraCare) as well as operating theatre database were used.

Results  40 patients were identified, which had either transhiatal or Ivor‐Lewis procedure. 50% had pre‐op chemotherapy and 33% pre‐op radiotherapy. 65% had adenocarcinoma, 10% squamous cell carcinoma and 15% had Barrett’s with severe dysplasia. The mortality at Dunedin was 5%. Complications were: respiratory 37.5%, leak 10%, wound 22.5%, oesophageal stricture 2.5% and chylothorax 2.5%. Median length of stay was 15 days (11–94). Median survival of patients with oesophageal carcinoma was 26 months. Median survival of node negative patients was 34.5 months and node positive patients 14 months.

Conclusion  Prognosis for patients with node‐positive disease continues to be poor despite oesophagectomy. The complication rates and in‐hospital mortality at Dunedin are similar to high volume centres. This study shows that patients undergoing oesophagectomy at low volume hospital do not have increased risk of operative mortality.
HP03 A NOVEL AND SAFE DEVICE FOR HEPATIC PARENCHYMAL TRANSECTION DURING LIVER RESECTION: THE GYRUS PLASMAKINETIC PULSED BIPOLAR COAGULATION FORCEPS
Authors: Tan J. T. H. , Hunt A. S. , Delriviere L. , Mitchell A. W. S.
Published: April 2007

Introduction  The Gyrus PlasmaKinetic bipolar coagulation device has been described for use in most types of abdominal surgery. However, its use in liver resection has, to date, not been described. This study has been conducted to evaluate the safety and efficacy of the Gyrus PlasmaKinetic bipolar coagulation device during the parenchymal transection phase of both open and laparoscopic liver resections.

Materials and Methods  A retrospective review was undertaken of 30 consecutive liver resections using the Gyrus Plasmakinetic pulsed bipolar coagulation device. The study period was from July 20, 2005 to November 1, 2006. Post‐operative morbidity, mortality, and need for blood transfusion were measured.

Results  There were 18 males and 12 females. The average age was 54.8 +/− 13.8 yrs, with a range of 29 to 87 yrs. There were 27 open procedures and 3 laparoscopic procedures. Of these, there were 13 major resections (greater or equal to 3 segments) and 17 minor resections (<3 segments). Six patients had histopathological confirmation of cirrhosis in the adjacent liver. Average operation time was 263.1 +/−117.2 min. Length of stay had a median of 9 days. 16 patients (53.3%) did not require any blood transfusion. There was no difference in the proportion of patients receiving a blood transfusion between the cirrhotic and non‐cirrhotic groups (p = 0.46). There were no post‐operative deaths. 6 patients (20 %) had significant post‐operative complications.

Conclusion  The Gyrus PlasmaKinetic system is safe and efficacious for use in hepatic parenchymal transection when used together with Argon beam coagulation and other more traditional haemostatic strategies in both cirrhotic and non‐cirrhotic livers.
HP32P OESOPHAGEAL PH PROFILE FOLLOWING PARTIAL AND TOTAL LAPAROSCOPIC FUNDOPLICATION
Authors: Wong A. S. Y. , Myers J. C. , Jamieson G. G.
Published: April 2007

Purpose  In Barrett’s oesophagus, it may be that total abolition of reflux will give maximal protection against the development of malignancy. It is not known whether a laparoscopic partial fundoplication gives the same degree of acid reflux control as a Nissen fundoplication. This study was undertaken to answer that question.

Methodology  A retrospective analysis of a prospectively followed cohort of patients who had undergone laparoscopic fundoplication as a part of clinical trials that required patients to return for routine oesophageal pH testing within 6 months of surgery. Parameters studied were percentage time pH < 4 and total number of reflux episodes compared against wrap types.

Results  A total of 167 patients had routine post‐operative oesophageal pH testing, of which 123 had had laparoscopic Nissen fundoplication and the remaining 44 had partial wraps. The total number of reflux episodes was significantly different between the full and partial wrap types (p = 0.026), with a median of 4 refluxes for full wrap and 6 for partial wraps. However, there was no significant difference in the percentage time pH < 4 between wrap types (p = 0.08). In patients with two post‐operative pH studies done at least 5 years apart, there was no significant difference in the parameters both within and between wrap types over time.

Conclusion  Although there was a significant difference in the number of reflux episodes between a full wrap and a partial wrap, it is hard to see this as biologically or clinically significant. Furthermore none of the other parameters showed a statistically significant difference. This study does not support the view that a total fundoplication gives more effective reflux control than a partial fundoplication.
HP33P LAPAROSCOPIC ANTI‐REFLUX SURGERY IN THE ELDERLY
Authors: Grotenhuis B. A. , Wijnhoven B. P. L. , Watson D. I.
Published: April 2007

Purpose  Elderly patients can experience refractory symptoms of gastroesophageal reflux disease (GORD) with or without a large para‐oesophageal hernia (POH). The aim of this study was to analyse the outcome of laparoscopic anti‐reflux surgery in patients older than 70 years.

Methodology  Patients were identified from a prospective database, which documents patients who underwent anti‐reflux surgery between 1992 and 2006. Pre‐operative symptoms and investigations, operative details and post‐operative outcome were analyzed.

Results  226 patients (mean age 76 yrs; 77 males,149 females) were included. In 92 patients GORD and in 134 patients a large POH was the primary indication for surgery. Nissen fundoplication was performed in 90 (40%), 90 anterior in 70 (31%), Dor in 59 (26%), Toupet in 1 (0.4%) and no fundoplication was performed in 6 patients (3%). Conversion rate was 10%. There were more intra‐operative complications in the large POH group than in the GORD group (8% vs. 1%; p = 0.03), operation time was longer (109 vs. 78 minutes; p < 0.001), and mortality post‐operatively was higher (1.5% vs. 0%; p = 0.24). Overall short‐term re‐operation rate was 6% and did not differ between both groups. Mean follow‐up was 3.7 years. The symptom scores for heartburn and dysphagia improved significantly in both groups with subjective outcome in the POH group being slightly better. Overall mean satisfaction score (0–10) was 8.2. The GORD patients used significantly more reflux‐medications post‐operatively (40% vs. 21%; p = 0.007).

Conclusion  Anti‐reflux surgery in patients of 70 yrs and older is safe. Patients with a large POH encounter more complications but this does not compromise symptomatic outcome.
HP35P THE NATURAL HISTORY OF GALL STONE VS ALCOHOL INDUCED‐SEVERE PANCREATITIS IN WESTERN SYDNEY
Authors: Yen A. , Rose T. , Langcake M. , Hollands M.
Published: April 2007

Gall stones (GS) and alcohol (EtOH), are the two commonest causes of pancreatitis, potentially leading to different outcomes. A retrospective review was undertaken of patients admitted with pancreatitis attributed to these two causes, hypothesising that GS pancreatitis carries a worse prognosis. Patients admitted to Westmead Hospital between 2000 to 2005, were audited using PiMS database, entering key words pancreatitis, and greater than 14 days stay. Data obtained from Westmead Hospital’s pathology database, CERNER, and medical records, were recorded regarding demographics, diagnosis, severity of pancreatitis, radiological indices, length of stay (including ICU/HDU), surgical interventions, complications and mortality. A Glasgow score (1) was assigned to each case. Initially of 57 cases reviewed, there was an equal incidence of pancreatitis between genders (28 M;29 F). There was a higher proportion of GS pancreatitis in females (75%), and a higher incidence of EtOH pancreatitis in males (n = 7) compared to females (n = 2). On average, GS pancreatitis scored a higher Glasgow score (2.28). Complications occurred more often in males and the GS pancreatitis population. The data from this pilot project suggested GS pancreatitis leads to a worse outcome compared to EtOH pancreatitis. Case note review has been ongoing and the combined data will be presented. The study provides a foundation for expanding this database to include other factors, such as ethnicity and weight, in comparing the outcome of GS and EtOH pancreatitis. As well a prospective study has been designed that may help predict the outcome of these two types of pancreatitis.
HP37 PROGNOSTIC FACTORS IN OESOPHAGEAL CANCER: NUMBER OF LYMPH NODES AND EXTRACAPSULAR LYMPH NODE INVASION – AN INTERIM ANALYSIS
Authors: Thompson S. K. , Ruszkiewicz A. R. , Jamieson G. G. , Wijnhoven B. P. , Watson D. I. , Devitt P. G.
Published: April 2007

Purpose  Controversy exists over the 2nd edition of the TNM staging system introduced by the American Joint Committee in Cancer in 1988, and revised in 2002. Prognostic pathological factors such as the number of positive lymph nodes and any extracapsular lymph node invasion may refine this current staging system and optimize patient treatment.

Methodology  All patients who underwent surgical resection for oesophageal cancer were identified in a prospectively‐maintained database. Patients without invasive adenocarcinoma or squamous cell cancer were excluded. Pathology slides were reviewed by a single pathologist. Survival data was calculated using Kaplan‐Meier curves, and prognostic factors were examined using the log rank test.

Results  235 surgical specimens met inclusion criteria, and 95 specimens have been reviewed so far. The 5‐yr overall survival rate was 43% (median 31.4 months). Subdividing pN‐stage into 1–2 positive nodes and >2 positive nodes showed significant differences in 5‐yr survival between both groups: 41% vs. 6.0%, respectively (P = 0.0003). Similarly, including absence and presence of extracapsular lymph node invasion into our pathology review showed significant differences in 5‐yr survival: 40% vs. 7.8%, respectively (P < 0.01). A negative circumferential margin, and the absence of both vascular and perineural invasion were also found to significantly improve survival rates.

Conclusions  The number and characteristics of metastatic invasion of lymph nodes should be included in current oesophageal cancer staging systems. Clinicians will then have more accurate prognostic information, and treatment can be better tailored to patients’ needs.
HP38P MANAGEMENT OF TRAUMATIC PANCREATIC INJURY
Authors: Warwick A. M. , Goonewardene K. , Burton P. R. , Usatoff V. , Evans P. M.
Published: April 2007

Background  Trauma to the pancreas is a challenging area both in initial diagnosis and longer‐term management. The retroperitoneal location makes clinical diagnosis of injury difficult and delayed diagnosis has morbid complications.

Methods  A review of patients with a diagnosis of traumatic pancreatic injury was performed, over a period of five years, from 2002 to 2006. We assessed the type of injury that occurred in the pancreas after both blunt and penetrating trauma; the diagnosis and timing of pancreatic injury; the need for operative/radiological intervention; and the complications of these injuries. Specifically patients with complex injuries were evaluated and these cases were critically reviewed.

Results  We identified 45 of cases of pancreatic trauma, aged 16–85, with a mean ISS of 27.8. Minor injury to the pancreas was found in 29 patients, and 16 patients had severe trauma to the pancreas, either major laceration or transection. Four particularly complex cases were identified, two of which required a Whipple’s procedure following gunshot wounds involving the pancreatic head. Two patients with abdominal crush injuries required multiple interventions.

Conclusions  Patients with pancreatic trauma often have other significant injuries and one should have a high degree of suspicion of pancreatic injury in multiply injured patients. Penetrating injury to the pancreas can result in catastrophic injury requiring radical surgery. Blunt injury should be assessed by magnetic resonance cholangio‐pancreatography or at laparotomy. The management of pancreatic trauma is complex and these patients should be managed in a tertiary hospital with involvement by both specialised pancreatic and trauma surgeons.
HP40P A SYSTEMATIC REVIEW AND META‐ANALYSIS OF THE RANDOMISED CONTROLLED TRIALS ON ADJUVANT INTRAPERITONEAL CHEMOTHERAPY FOR ADVANCED GASTRIC CANCER
Authors: Yan T. D. , Black D. , Sugarbaker P. H. , Zhu J. , Petrou G. , Morris D. L.
Published: April 2007

Purpose  The purpose of this systematic review and meta‐analysis was to determine the effectiveness and safety of adjuvant intraperitoneal chemotherapy for patients with advanced gastric cancer.

Methodology  Studies eligible for this systematic review included those in which patients with gastric cancer were randomly assigned to receive surgery combined with intraperitoneal chemotherapy versus surgery without intraperitoneal chemotherapy. The end‐points of the meta‐analysis were overall survival, incidence of recurrence, morbidity and mortality.

Results  Thirteen reports of RCTs were included for appraisal and data extraction. Ten reports were judged fair‐quality and subjected to the meta‐analysis. A significant improvement in survival was associated with hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) alone (HR = 0.60; 95% CI = 0.43 to 0.83; p = 0.002) or combined with early postoperative intraperitoneal chemotherapy (EPIC) (HR = 0.45; 95% CI = 0.29 to 0.68; p = 0.0002). Survival improvement was marginally significant (p = 0.06) with normothermic intraoperative intraperitoneal chemotherapy, but not significant with EPIC alone or delayed postoperative intraperitoneal chemotherapy. Intraperitoneal chemotherapy was also found to be associated with higher risks for intra‐abdominal abscess (RR = 2.37; 95% CI = 1.32 to 4.26; p = 0.003) and neutropenia (RR = 4.33; 95% CI = 1.49 to 12.61; p = 0.007).

Conclusions  The present meta‐analysis indicates that HIIC with or without EPIC after resection of advanced gastric primary cancer is associated with an improved overall survival. However, increased risks of intra‐abdominal abscess and neutropenia are demonstrated.
HP06 PANCREATIC ABSCESS: RESULTS OF A SURGEON’S PROTOCOL
Authors: Smith R. C. , Pender S.
Published: April 2007

A standardized management has been adopted for management of pancreatic abscess, where TPN was used to maintain nutritional status and ICU for maintenance of homeostasis until the junction between the abscess and viable tissue demarcated. Surgical intervention was undertaken if resolution was unlikely after 2 weeks and the patient was deteriorating. This involved a complete sequestrectomy with careful drainage. Flagyl was preferred for prophylaxis when cholangitis was not a factor and gut rest with TPN was used to maintain nutritional status. A review of the results over the last 7 years is presented.

31 (16 male and 15 female) patients required surgical intervention. Their ages ranged from 18 to 88 years with a mean (sd) of 58 (18) years. The aetiology was biliary in 17, alcohol in 11 postoperative in 3 and 2 had other causes. The Apache II scores on admission was 13.8 (5.0) and 14.5 (5.2) preoperatively.

There were 5 deaths (13%) which occurred in patients aged 34, 58, 83, 76, and 78 years. They presented with ApacheII scores of 20, 18, 15, 24, 16 respectively and 3 had significant co‐morbidities. The median hospital stay was 47 (7–132) days. Only 3 patients required a re‐operation for incomplete sequestrectomy. They required TPN for from 7 to 64 days (median 20 IQR 11–32 days).

Conclusion: Delaying surgery until there is good demarcation between the sequestrum and the normal tissue allows for a more aggressive surgical approach even in patients with severe pancreatitis and high ApacheII scores. Age is an important determinant of death but some elderly patients survive this serious illness.
HP09 REFLUX AFTER OESOPHAGECTOMY: CAN A FUNDOPLICATION PREVENT IT?
Authors: Aly A. , Jamieson G. , Watson D. , Devitt P. , Ackroyd R. , Stoddard C.
Published: April 2007

Introduction  Oesophagectomy for oesophageal carcinoma is a major undertaking with a definite morbidity and mortality. Long term survival rates are low and post operative quality of life becomes increasingly important. When the anastomosis is in the thorax, gastro‐oesophageal reflux, particularly volume reflux symptoms are common and may significantly affect quality of life. It is proposed that a fundoplication at the anastomosis may help prevent reflux symptoms.

Aims  The aim of this study was to compare reflux after a fundoplication type anastomosis with a standard anastomosis in patients undergoing Ivor – Lewis Oesophagectomy.

Study Design  Prospective randomised trial utilising standardised symptom questionnaires applied in blinded fashion.

Results  The fundoplication anastomosis was associated with a significant reduction in the incidence of reflux (30% vs 70%) as well as reducing the incidence of severe reflux (7% vs 25%). A total fundoplication was more effective than a partial fundoplication in preventing severe reflux. Disturbance of sleep due to reflux was significantly reduced in the fundoplication group (18% vs 47%) as was the incidence of respiratory symptoms. The fundoplication anastomosis was not associated with an increase in dysphagia.

Conclusion  The fundoplication anastomosis protects patients from the symptoms of reflux after oesophagectomy and improves quality of life particularly with regard sleep disturbance.
ML01 COMPETENCE REVIEWS IN NEW ZEALAND AND THE AFTERMATH
Authors: Blair R.
Published: April 2007

The inquiry into allegations concerning the treatment of cervical cancer at National Womens Hospital in 1987 and 1988 was one of the most significant medical controversies of the 20th century in New Zealand. This event brought the legal and medical professions into close contact, and the legal profession has been involved with further developments in the assessment of medical competence.

Since the inquiry in 1988 the government in New Zealand has moved to provide “further protection to the community”: The appointment of a Health and Disability Commissioner to act as an advocate for the community and changes in legislation. As a result, the self regulating privilege of the medical profession has been lost.

The profession was initially stunned by the outcomes of the National Womens Review, but on the positive side there has been a response by the profession to improve the standards of practice. The department of Continuing Professional Development in the RACS has been a major step forward.

Over the next two days the Medico‐Legal Section will examine our response to competence reviews. The changes over the last twenty years have brought about considerable change in our professional status within the community, but we must continue to address those matters which have resulted in a loss of community trust.
ML03 WORK INJURIES – NOT ALWAYS WHAT THEY SEEM
Authors: Strack C.
Published: April 2007

We all know that work can be associated with health risks and injuries. Assessing whether a patient has a work related injury can be problematic at times, especially with conditions that are common in the general population. This is an area where common basic clinical assumptions and clinical “common sense” may sometimes be at odds with the epidemiological evidence.

Some times the extent to which a condition is reported as being due to work or injury may seem to have more to do with compensation and legal issues rather than work or injury related factors.

Two common conditions, carpal tunnel syndrome and lumbar spondylosis, will be discussed with respect to the extent to which they may, (or may not) be caused by work.
NS10 ANTERIOR APPROACHES FOR THORACOLUMBAR FRACTURES
Authors: Robertson P. A.
Published: April 2007

The anterior approach for surgery in thoracolumbar injuries allows decompression of anterior neural compression, reconstruction of the anterior and middle columns of the thoracolumbar spine, and osteototomy through the vertebral body if there is a need for late correction of deformity. In acute injuries the burst fracture with neurological injury is the ideal indication for anterior surgery and reconstruction. Because of the neural anatomy in the spinal canal at the throracolumbar junction, the injury can involve cord, conus, nerve root and peripheral nerve in either a pure or mixed lesion, with variable prognosis for recovery. The decompression optimises neurological recovery on the basis of animal models and clinical series of late decompression cases. In the last few years there has been a dramatic increase in the reconstruction options that have improved post surgical spinal stability and reduced morbidity from major bone grafting techniques. Anterior vertebral plates, dual rod and screw systems, titanium mesh cages, and now expanding cages facilitate reconstruction and improve stability, however this procedure remains technically demanding with significant morbidity for the patient.
NS11 POSTERIOR APPROACHES FOR THORACO‐LUMBAR FRACTURES
Authors: Inglis G. S.
Published: April 2007

The controversies remain in the management of thoraco‐lumbar fractures. These include who should receive surgical intervention, what constitutes instability of the thoraco‐lumbar spine, should an anterior or posterior approach be used to stabilise thoraco‐lumbar spine fractures, what length of instrumentation should be used and should bracing be utilised?

At the present time there is a paucity of level 1 evidence to support a best practice recommendation for the management of thoraco‐lumbar spine trauma. Various classification systems have been introduced over the last 30–40 years to assist in the decision making process. These include the Holdsworth classification in 1970, the Dennis classification in 1983 and the Magerl AO classification in 1994.

Very recently the thoraco‐lumbar injury classification and severity score has been introduced to try and further assist in the decision making on surgical intervention. The Burwood Spinal Injuries Service has also utilised the double ring concept of spinal instability in decision making. Various fracture patterns including burst fractures, flexion/distraction injuries and complex fracture dislocations, the indications for surgical intervention and the posterior approach to stabilising these fractures will be presented. A short segment posterior fixation with or without fusion for burst fractures and flexion/distraction injuries is recommended. Complex fracture dislocations and neurologically complete patients frequently require longer fixation with short or long fusion depending on fracture comminution and inherent stability. Recent developments with the use of image guided surgery, bone morphogenic protein and the potential for spinal cord regeneration are adding to our ability to deal surgically with thoraco‐lumbar spine trauma.
NS16 RECENT DEVELOPMENTS IN THE TREATMENT OF CRANIOSYNOSTOSIS
Authors: Davis C.
Published: April 2007

For many decades the treatment of single suture craniosynostosis was believed to be primarily for aesthetic reasons. SPECT scanning demonstrates that 70% of cases have cortical perfusion defects adjacent to the synostosis and these defects are corrected after early reconstructive surgery. Meta‐analysis of neurodevelopmental studies demonstrate a three – to five fold increase in the risk for cognitive deficits or learning and language disabilities. It is now widely accepted that surgery is performed for both functional and aesthetic reasons.

Osseodistraction has revolutionized midfacial advancement surgery to overcome maxillary hypoplasia secondary to cranial base synostosis. Our craniofacial program uses external distractors for better vector control, increased facial convexity and to maximize the nasopharyngeal airway dimensions. Case examples will be presented.

Our craniofacial program is one of four world wide using springs for craniofacial remodeling.

This technique was pioneered by Professor Claes Lauritzen in Sweden in 1997. The provision of a low grade continuous force that causes ongoing biomechanical remodeling in the postoperative period is a novel therapeutic modality in craniofacial surgery. It has allowed minimalization of the extent of surgery without compromising clinical outcomes. This paper summarizes the experience with the first 100 consecutive cases in Sweden and the first 18 cases in New Zealand. We will discuss the way clinical experience has led to an evolution of the way springs are currently incorporated into clinical use. We have shown the use of this technique to be safe and in selected situations to offer significant advantages over other current methods of treatment.
NS17 SURGERY REMAINS THE TREATMENT OF CHOICE FOR AVMS?
Authors: Morgan M.
Published: April 2007

The reported annual risk of haemorrhage for conservatively managed AVMs varies from less than 1% to more than 33% depending on the combination of the presence or absence of some of the following variables: haemorrhagic presentation, presence of aneurysms, the presence of exclusive deep venous drainage, and a deep location was deep. Over time, the acquisition of wear‐and‐tear associated pathologies increases the risk of haemorrhage for those that initially present with a low haemorrhage risk. It is likely that the long‐term risk is in excess of 50% over 20 years. The combined morbidity and mortality from haemorrhage is 50%.

Once an AVM has been diagnosed there are four treatment options to be considered to eliminate the risk of haemorrhage. Surgery, focussed irradiation, embolisation or a combination of treatments. Consideration needs to be given to both the likelihood of haemorrhage risk elimination and the time to achieving this goal and morbidity of the procedure.

Surgery for Spezler Martin grades less than 3 have close to 100% likelihood of cure and a risk of treatment morbidity less than 5% of surgery for the vast majority of cases. This result is unlikely to be approached by other modalities. For grades above 2 AVMs when the nidus is less than 3 cm, without feeding artery aneurysms or recent haemorrhage and has lenticulostriate supply, focussed irradiation is likely to be the treatment of choice. But for all other AVMs surgery remains the only reliable curative option. Combination treatments are ineffective in reducing the risks except when embolisation precedes surgery.
NS02 UPDATE ON CEREBRAL VASOSPASM
Authors: Dorsch N. W. C. , Murray M.
Published: April 2007

Purpose  To review the incidence of vasospasm after cerebral aneurysm rupture, and compare the results with a previous review.

Methodology  An online search of articles from 2001 to 2006 with “cerebral vasospasm” as key words.

Results  From 75 studies involving 10717 SAH patients, delayed ischaemia was reported in 3257, or 30.4%. In a previous review of 32188 reported cases up to the early 1990s, the incidence was 32.5% (1). Those data excluded patients treated with calcium antagonists, which on the other hand were used in at least 3600 of the present 10717.

Therapeutic possibilities include endothelin antagonists. In a trial of clazosentan the incidence of angiographic vasospasm was reduced, but outcome was unchanged. A controlled trial of MgSO4 showed delayed cerebral ischaemia in 24% of controls and 17% treated, and a 23% risk reduction for poor outcome. In two studies of statins there was significantly less DID in treated groups, and a 75% reduction in death rate with pravastatin treatment. Results of these and other trials, including implantation of slow‐release pellets, lamina terminalis fenestration and variations of CSF drainage, will be presented in detail.

Conclusions  Promising therapeutic options for vasospasm are under study, but there is still no universally effective treatment. The incidence of delayed ischaemia has not changed much over the decades, but the clinical impression is that the problem of vasospasm is less now than 20 to 30 years ago. This may be due to improved fluid management – patients are usually treated with at least mild hypervolaemia rather than the considerable dehydration that was the norm in the 1960s and 70s.
NS03 EXPERIENCES IN JAVA
Authors: Dorsch N. W. C. , Dorsch B. L.
Published: April 2007

Over the last four years we have spent three periods of a month or more doing voluntary work in Indonesia, mainly at the principal public hospital in Bandung, the capital of the West Java province. There are in Indonesia a similar number of neurosurgeons to Australia for over 10 times the population, a situation like much of the developing world. Three large training centres are attempting to redress the balance. At Bandung there are usually 40 or more training residents for a unit with about 60 neurosurgical beds. Our air fares are subsidised by the US based Foundation for International Education in Neurological Surgery, and accommodation by the local unit.

There is a vast amount of neurosurgical material, half or more of it trauma. Road conditions are not the best, and seat belt and helmet laws basic and often not observed. In the absence of folate supplements in pregnancy, neural tube defects are common and often quite gross. Tumours are usually very large before coming to treatment, and vascular work is in its infancy, although more progressed in the private system. Examples of all these pathologies will be presented. Rehabilitation is at a level similar to Sydney 40 years ago. On our last visit, in May–June 2006, we spent a week in Jogjakarta some days after the earthquake there, dealing mainly with a large backlog of spinal injuries. There is one spinal unit in Indonesia, several hours flight away in the capital, Jakarta.

We have found the people uniformly very pleasant and friendly, and appreciative of our efforts. We are always well looked after and feel perfectly safe. We can thoroughly recommend this kind of work in our region, for any age but perhaps more so for those winding down towards retirement.
NS07 CHRONIC SUBDURAL HAEMATOMAS AND ANTICOAGULATION OR ANTI‐THROMBOLYTIC THERAPY
Authors: Amato D. P. , Rust T. , Kiemer N. , Erasmus A.
Published: April 2007

Purpose  The use of anticoagulant therapy as a causative agent in the development of chronic subdural haematomas (CSDH) was investigated. We suspected a high incidence of anticoagulant therapy or anti‐thrombotic therapy in patients who presented with CSDH.

Methodology  Retrospective analysis of charts of eighty‐one cases of CSDH admitted to the neurosurgical unit of the Royal Hobart Hospital (RHH), Tasmania, Australia, over a 5‐year period were reviewed. A database of neurosurgical procedures performed at RHH was examined to retrieve these patients undergoing surgery for CSDH. We found that anticoagulant therapy was used by a significant percentage of CSDH patients.

Results/Conclusions  In the patient group presenting to our unit the risk of developing a CSDH was at least 42.5 times higher in warfarinised patients and also increased for patients on aspirin, although the risk could not be quantified.
NS08 ARE CHRONIC SUBDURAL HAEMATOMAS MORE COMMON ON THE LEFT THAN ON THE RIGHT?
Authors: Kathiravel Y. , Weerakoddy Y. , Macfarlane M. R.
Published: April 2007

Purpose  Subdural haematomas (SDHs) – acute, subacute and especially chronic subdural haematomas (CSDHs) are common lesions encountered in a neurosurgical service.The diagnosis, aetiology, management and prognosis of SDHs including CSDHs are well documented but there few reports documenting the laterality of SDHs and particularly of CSDHs.

Methodology  We analysed all the cases of SDHs (that were operated on and those managed conservatively) that presented to the neurosurgical service at Christchurch Hospital between 1st January 1996 and 30th June 2006.

We present the number of cases of acute, subacute and CSDHs as well as the age, gender and sides of distribution of the SDHs.

Results  Of the 413 patients, 275 (66.6%) were male and 138 (33.4%) were female. They presented with 450 cases of acute, subacute, and CSDHs. The age range for all SDHs was 3 months to 95 years, with the mean age 50.9 +/− 25.8 years for acute SDH, 65.4 +/− 19.8 years for subacute SDH and 68.9 +/− 19.7 years for CSDHs. There were 150 (33.3%) acute SDHs, 38 (8.4%) subacute SDHs and 262 (58.2%) CSDHs. There was a male predominance in the acute SDH group (72.7%), equal gender distributionin the subacute SDH group and a male predominance in the CSDH group (65.3%). The majority (82.1%) of SDHs were unilateral. CSDHs were more frequent on the left side, with 57.2% of cases compared with 42.7% on the right, this being statistically significant (p = 0.03). Neither the acute nor the subacute SDHs manifested this pattern. In this paper, we discuss the likely reasons why CSDHs have a left‐sided predilection.
PS01 RESCUE HYPOTHERMIA REDUCES ILEAL INJURY IN EXPERIMENTAL INTESTINAL ISCHAEMIA AND REPERFUSION
Authors: Stefanutti G. , Pierro A. , Parkinson E. J. , Smith V. V. , Eaton S.
Published: April 2007

Aim  Moderate hypothermia is beneficial when applied throughout intestinal ischaemia‐reperfusion (IR). However, therapeutic intervention is usually possible only after ischaemia has occurred. The aim of this study was to evaluate the efficacy of hypothermia as a rescue therapy for intestinal IR.

Methods  Adult rats were ventilated via a tracheostomy and underwent either intestinal ischaemia‐reperfusion (60 min superior mesenteric artery occlusion, and 120 min reperfusion) or sham operation. Rats in the hypothermia groups were maintained at normothermia (36–38°C) throughout ischaemia, and were cooled at the beginning of reperfusion until reaching target temperature (moderate hypothermia: 30–32°C). Four groups (n = 8 each) were studied: 1) control normothermia; 2) IR normothermia; 3) control hypothermia; 4) IR rescue hypothermia. The degree of histological injury in terminal ileum was assessed on a semi‐quantitative scale (1 = low; 5 = high) by three blinded observers. Data (median [IQ range]) were compared by Kruskal‐Wallis test with Dunn’s post‐test.

Results  Intestinal IR at normothermia caused severe injury to the ileum (4.5 [4–5]) compared to both normothermic (2 [1.5–2], p < 0.01 vs. IR normothermia) and hypothermic controls (2 [1.5–2], p < 0.01 vs. IR normothermia). However, rescue hypothermia offered considerable protection from IR injury, so that intestinal architecture was partly preserved (3 [2.5–4], p = n.s. vs. control normothermia; p = n.s. vs. control hypothermia).

Conclusions  Moderate hypothermia reduces the extent of tissue injury following intestinal ischaemia, even when applied as a rescue therapy. It could be considered as a possible therapy in clinical conditions associated with intestinal IR.
PS15 PAEDIATRIC GUN SHOT INJURIES IN NEW ZEALAND: A DEMOGRAPHIC ANALYSIS OF AN AVOIDABLE CAUSE OF SIGNIFICANT CHILDHOOD MORBIDITY
Authors: Skinner A. M. , Hamill J. , Samarakkody U. , Kim E. , Bowkett B. , Beasley S.
Published: April 2007

Purpose  New Zealand has a reputation for an outdoors lifestyle that includes hunting and tramping. New Zealanders own over a million guns and these are widely distributed throughout the rural and urban communities. Although its gun laws are not liberal, children still suffer gun shot injuries. The aim of this study was to examine the injuries children receive from firearms in New Zealand, their circumstances and long term morbidity.

Methodology  A retrospective review of all children admitted to the four New Zealand paediatric surgical hospitals (at Auckland, Hamilton, Wellington and Christchurch) with gun shot injuries over 10 yr period 1996–2005 was undertaken. Data were compared with published literature from elsewhere.

Results  Overall, the incidence of gunshot injuries in New Zealand is low compared with many other developed countries. The majority are caused by air rifles. Most are superficial but some may lead to long term morbidity.

Conclusions  Although New Zealand gun laws require air rifle owners to be over 18 yrs of age, children often are victims of air rifle misuse, particularly in urban areas. Mortality is rare, but some children suffer long term morbidity. Our data may enable preventative measures to be better focused.