bluuebunny/crossref_metadata_2025 huggingface dataset:
Occurrence conditions of hyperpycnal flows, and their significance for organic‐matter sedimentation in a Holocene estuary, Niigata Plain, Central Japan
Authors: Yoshida Mamiko , Yoshiuchi Yuka , Hoyanagi Koichi
Published: April 2009

River floods influence sedimentary environments and ecosystems from the terrestrial to the deep‐marine. This study documents the occurrence conditions of hyperpycnal flows generated by river floods and related organic‐matter sedimentation for Holocene sediments of the Niigata Plain, Central Japan, based on detailed sedimentary facies, total sulfur and total organic carbon content, diatom assemblages and organic‐matter composition. Holocene sediments of the Niigata Plain consist of sand, mud and gravel that were deposited in estuarine and fluvial systems during a sea‐level rise (15 000–6800 years BP) and stillstand (after 6800 years BP) following the Last Glacial Maximum. Hyperpycnites are present in the upper part of the estuarine lagoon sediments. The depositional age is considered to be about 5000 years BP. The hyperpycnites comprise two successions of a top fining‐up unit and a basal coarsening‐up unit, and include abundant terrigenous organic matter and freshwater diatoms. A large volume of freshwater is inferred to have flowed into the lagoon during deposition of the upper part of the lagoon sediments. In consequence, hyperpycnal flows may have readily formed in the lagoon, because the halocline was weak. The hyperpycnal flows also produced a layer of concentrated terrigenous organic matter in the uppermost part of the hyperpycnites. The abundant organic matter on the estuarine floor is inferred to have produced anoxic bottom conditions owing to oxidative decomposition by benthic bacteria.
Regional distribution of TDP‐43 inclusions in Alzheimer disease (AD) brains: Their relation to AD common pathology
Authors: Kadokura Ai , Yamazaki Tsuneo , Lemere Cynthia A. , Takatama Masamitsu , Okamoto Koichi
Published: April 2009

Initially, trans activation responsive region (TAR)‐DNA‐binding protein 43 (TDP‐43) was considered to be a disease‐specific component of ubiquitin‐positive and tau‐negative inclusions in the brains of patients with frontotemporal lobar degeneration with ubiquitin‐positive inclusions (FTLD‐U) and amyotrophic lateral sclerosis (ALS); however, it is now widely known that this protein also abnormally accumulates in neurons in other neurodegenerative diseases. On the basis of observation mainly in the medial temporal lobe, TDP‐43‐immunoreactive neuronal inclusions have been detected in 20–30% of Alzheimer disease (AD) brains. However, it is controversial whether these cases represent a combined disease, that is, mixed AD/FTLD‐U. To address this issue, it is necessary to obtain more knowledge on the region‐specific distribution of TDP‐43 immunoreactivity and also about its relationship to AD common pathology. Here, we describe abnormal TDP‐43 immunoreactivity in the medial temporal lobe in 5/16 AD patients (31%). Most of the depositions were cytoplasmic inclusions, mainly located in the subiculum and parahippocampal gyrus and rarely in dentate granular cells of the hippocampus. TDP‐43‐positive inclusions and senile plaque/neurofibrillary tangle distribution were not always identical, and intracellular colocalizations of TDP‐43 and phospho‐tau were also infrequent. The cases showing TDP‐43‐positive inclusions in the medial temporal lobe also showed abnormally highly dense TDP‐43 immunoreactivity in the frontal, but not in the parietal and occipital cortices. Intracellularly, TDP‐43‐positive inclusions were highly ubiquitinated and colocalized with p62 immunoreactivity as well. Our findings suggest that abnormal TDP‐43 deposition and AD pathology (formation of senile plaques and neurofibrillary tangles) might occur independently. However, taken together with the results of previous reports, the distribution of TDP‐43 immunoreactivity in the hippocampus and frontal cortex in AD appear to be varying. We consider that it is still too early to determine that the TDP‐43 accumulation is a part of AD pathology or result from a completely independent pathology.
Creutzfeldt‐Jakob disease with an M232R substitution: report of a patient showing slowly progressive disease with abundant plaque‐like PrP deposits in the cerebellum
Authors: Shimizu Hiroshi , Yamada Mitsunori , Matsubara Nae , Takano Hiroki , Umeda Yoshitaka , Kawase Yasuhiro , Kitamoto Tetsuyuki , Nishizawa Masatoyo , Takahashi Hitoshi
Published: April 2009

Patients with genetic Creutzfeldt‐Jakob disease in which arginine is substituted for methionine at codon 232 (M232R) of the prion protein gene (CJD232) have been described in Japan, and a recent study has revealed the presence of two clinical phenotypes: a rapidly progressive type (rapid‐type) and a slowly progressive type (slow‐type). Although the former is known to show pathologic features similar to those of classical CJD, the neuropathology of the latter still remains unclear. We report the autopsy findings of slow‐type CJD232 of 37 months' duration in a 73‐year‐old man who had methionine homozygosity at codon 129 of the prion protein gene (129MM). His initial symptoms included agraphia and memory disturbance, followed by relatively slowly progressive dementia. Myoclonus and akinetic mutism became evident 5 and 23 months after disease onset, respectively. The electroencephalogram revealed periodic sharp wave complexes at 7 months before death. The neuropathologic features were partly reminiscent of those of MM2‐cortical‐type sporadic CJD, showing spongiform change of the large confluent vacuole type, neuronal loss with gliosis, and coarse, perivacuolar prion protein deposits, which were later shown to consist of protease‐resistant type 2 prion protein, in the cerebral cortex and striatum. It was of considerable interest that not only was the medial thalamus severely involved, but also that the cerebellar cortex showed loss of Purkinje cells and abundant plaque‐like prion protein deposits. These findings are not a feature of MM2‐cortical‐type sporadic CJD. Whether or not the M232R substitution, in combination with the genetic polymorphism and the molecular type of pathological prion protein, really participates in the development of CJD232 and its different phenotypes awaits further studies.
Characteristics of elderly people using the psychiatric emergency system
Authors: Sawayama Enami , Takahashi Megumi , Arai Hisatoshi , Nakajima Keisuke , Kano Akiko , Sawayama Toru , Miyaoka Hitoshi
Published: April 2009

We investigated the differences between elderly and under‐65‐year‐old patients using the psychiatric emergency system. The following characteristics were more common in elderly patients than in younger patients: organic mental disorder, mood disorder, dementia, disturbed consciousness, no excitation, physical complications, no history of visiting a psychiatrist and no history of hospitalization. In addition, significantly more elderly patients with mood disorder attempt suicide.
BT02 LAPAROSCOPIC SLEEVE GASTRECTOMY AS A SINGLE‐STAGE BARIATRIC PROCEDURE
Authors: Sammour T. , Hill A. G. , Singh P. , Ranasinghe A. , Babor R. , Rahman H.
Published: April 2009

Purpose:   Laparoscopic sleeve gastrectomy is increasingly being recognised as a stand‐alone procedure in bariatric surgery, with long term follow‐up data now emerging. We present our early experience patients with a mean BMI in the super‐obese range.

Methodology:   Retrospective review of laparoscopic sleeve gastrectomies performed by two surgeons at Middlemore Hospital, between March 2007 and July 2008.

Results:   One hundred and one patients were identified, with a mean age of 42.7 years (95% CI 40.9–44.5). Maori and Pacific Islanders made up 31% of the patient subset. Patients had a mean BMI of 50.2 kg/m2 (95% CI 48.8–51.7), and 45 patients were super‐obese. They had a median hospital stay of 2 days (1–7 days), and a mean follow‐up of 6.0 months. Mean excess BMI loss (excluding patients with a major complication) was 46% (95% CI 43.3–48.7). 64% of diabetics and 37% of hypertensives showed in an improvement in medication requirement. There was a major complication rate of 8%, including 3 staple line leaks (one of which required laparotomy), 2 staple line bleeds (one requiring laparotomy), 1 infected haematoma, and 1 critical stricture. There were no deaths.

Conclusion:   Laparoscopic sleeve gastrectomy has achieved satisfactory weight‐loss results with an acceptable complication rate in the short to medium term.
BT03 SILASTIC RING MINI GASTRIC BYPASS FOR MORBID OBESITY: THE NEW ZEALAND EXPERIENCE
Authors: Wong K. C. , Booth M.
Published: April 2009

Purpose:   The laparoscopic mini gastric bypass (LMGB) is purportedly a technically simpler, yet equally effective operation to the laparoscopic Roux‐en‐Y gastric bypass as treatment for morbid obesity. This study reports the early results of LMGB in a major New Zealand bariatric centre.

Methodology:   Clinical data was prospectively collected on all patients undergoing LMGB over a two year period.

Results:   142 patients were studied. 77% were females. Mean age was 43.8. Pre‐operative mean body weight and body mass index (BMI) were 121.3 kg and 45.4 kg/m2 respectively. Mean BMI at one and two years follow up had decreased to 27.35 and 25.72 kg/m2 respectively. 83% of patients reported obesity associated co‐morbidities pre‐operatively. Post‐operatively, 78% of patients reported a reduction in medication requirement. All surgery was performed laparoscopically. There were no anastomotic leaks and zero mortality. 8% of patients required further operations for complications or revision to a Roux‐en‐Y gastric bypass. 20% of patients required subsequent endoscopic interventions, the majority for investigation of vomiting and/or pain. 22% of patients required re‐admission. 14% of patients reported new onset reflux or worsening of pre‐existing reflux after LMGB. 82% of patients reported increased exercise capability post LMGB. 54% of patients required vitamin supplementation.

Conclusion:   LMGB achieves significant weight loss and resolution of obesity related co‐morbidities with a low short term complication rate. LMGB should be considered as a safe and simple surgical option for morbid obesity.
BT04 LAPAROSCOPIC REVISION OF GASTRIC BAND SURGERY
Authors: Bardsley S. , Hopkins G.
Published: April 2009

Aim:   To identify the outcome of laparoscopic revision of gastric band surgery with respect to percentage of excess weight lost (%EWL).

Methods:   Analysis of a prospective database was performed and %EWL was plotted with respect to time from initial procedure and also time from revision procedure.

Results:   All revision operations were performed laparoscopically. There were no patient deaths, but two serious complications. Percentage Excess Weight Loss after replacement of the band because of prosthetic failure or dysphagia was 57% at an average follow up of 19 months. For repositioning of the band due to slippage, the %EWL was 72% at an average of 15 months follow up for those who had the existing band repositioned, and 42% at an average of 23 months follow up for those who had a new band repositioned.

Conclusion:   Revision laparoscopic gastric band surgery is a safe option for patients, and results in good %EWL at an average follow up period of 19 months.
BS10 POST‐SURGICAL CARE IN BREAST CANCER – PROCESS MAPPING CURRENT MODELS IN AUSTRALIA
Authors: Giles C. , Buckingham J. , Delaney G. , Pearce A. , Wilcoxon H. , Zorbas H.
Published: April 2009

Purpose:   Evidence collated by National Breast and Ovarian Cancer Centre (NBOCC) suggests that recent reductions in length of stay (LOS) following early breast cancer surgery are influencing the care women receive. Process mapping (PM) identifies steps involved in a patient's pathway. This project utilises PM to identify successful components and gaps in current models related to LOS and highlight opportunities to improve the post‐surgical (PS) care of women with breast cancer in Australia.

Methodology:   Nine Australian hospitals were selected for high level PM using seven criteria; public/private, metropolitan/regional, services (diagnostic, treatment and follow up), surgical caseload, patient management protocols, multidisciplinary care, information and support. PM includes a workshop with the multidisciplinary team and consumers, as well as interviews with key clinical informants from the PS care pathway.

Results:   PM results in a series of flowcharts of the PS pathway. These inform a report on current models of care and their successful aspects, together with stakeholder perceptions. Differences between public/private and metropolitan/regional facilities are highlighted, along with the impact of different delivery models on the provision of information, clinical and supportive care for women.

Conclusion:   PM allows a representation of the impact of LOS on women's PS care, and the extent to which information, clinical and supportive care are available within current models. These results, combined with other NBOCC collated data (including AIHW statistics, surveys of women and breast care nurses, and literature reviews) will inform recommendations on new delivery models.
BS12 SURGICAL OUTCOMES IN NEO‐ADJUVANT CHEMOTHERAPY FOR INFLAMMATORY AND LOCALLY ADVANCED BREAST CANCER EOVER 5 YEARS OF SINGLE INSTITUTION EXPERIENCE
Authors: Dean T. L. , Pitcher M.
Published: April 2009

Purpose:   Examination of short and long term surgical outcomes and degree of pathological response in breast cancer patients who have undergone neo‐adjuvant chemotherapy surgery at Western Health from March 2003 – December 2008.

Methods:   retrospective analysis of prospectively maintained breast cancer database as well as examination of medical records, pathology and radiology reports. 28 of the 535 patients in the database met criteria for inclusion.

Results:   26/28 underwent mastectomy and axillary dissection +/− immediate reconstruction.

Pathological response – 7.1% had no residual disease, 10.7% had in situ disease only. A reduction in maximum diameter of > 50% was found in 35.7%. 18.8% were minimally or unresponsive.

The degree of clinical response did not correlate reliably with degree of pathological response.

Wound infection was seen in 100% smokers and 19% non‐smokers.

4 patients had evidence of metastatic disease at presentation. 5 of the remaining 24 (20.8%) developed distant metastases.

4/28 suffered loco‐regional recurrence during the study period.

4/28 patients died from their disease, 50% of whom had extensive metastases at diagnosis.

Follow up range 6–69 months, average follow up 32 months.

We found a relationship between post neo‐adjuvant chemotherapy AJCC stage and survival.

Conclusions:   Neo‐adjuvant chemotherapy prior to surgery allows good local control and safe reconstruction in locally advanced and inflammatory breast cancer. Smoking cessation should be encouraged prior to surgery to decrease post operative morbidity due to wound complications. Continued follow up of this group would allow examination of and 10 year outcomes.
BS03 UPDATES FROM RACS NATIONAL BREAST CANCER AUDIT
Authors: Malycha P. L.
Published: April 2009

RACS National Breast Cancer Audit (NBCA) began in 1998 when a Standing Committee of the House of Representatives indicated that RACS should establish it post haste.

It started as a paper based audit using Windows Access in the College Office in Adelaide in 1998 and has grown into a web based audit under the management of ASERNIPS.

It now has 80,000 patients enrolled and is beginning to close the audit loop by analyzing relevant key performance indicators (KPI).

These indicators are the percentage of patients treated with breast conserving surgery referred for radiotherapy (>85%), the percentage of patients prescribed or referred for hormone therapy for ER+ patients (>85%), the percentage of patients undergoing axillary surgery for invasive breast cancer (KPI > 90%) and the percentage of patients who underwent breast conserving surgery undergoing no axillary surgery (>90%).

New KPIs are being added and data tidied.

The current numbers and analysis as well as plans for the audit will be presented.
BS04 WHAT IS THE PLACE OF OFFICE ULTRASOUND IN A BREAST SURGEON'S PRACTICE
Authors: Bennett I. C.
Published: April 2009

In almost every area of surgery specialty, ultrasound is being increasingly utilized and incorporated into daily clinical practice by surgeons. This has been facilitated by advances in ultrasound technology which have seen the development of many high quality small portable ultrasound units, often in the format of a laptop, and which are extremely user friendly. Office ultrasound is particularly applicable and relevant for the breast surgeon who is able to use this technology to enhance his assessment of and streamline the management of breast patients. Breast ultrasound should be considered an extension of the physical examination and can often be used to provide immediate reassurance for symptomatic women. Office ultrasound enables the breast surgeon to undertake fine needle aspiration biopsies, core biopsies and even vacuum assisted biopsies. It also enables the better pre‐operative assessment of breast cancer patients and it may help in decision‐making regarding optimal surgical management. It can also be a useful tool in the management of breast abscesses through repeated aspirations. There is a distinct learning curve and surgeons who are starting out using this technology need to appreciate their own limitations. In the near future, ultrasound‐guided ablation or excision of breast lesions using modalities such as radio‐frequency cautery will become routine, and may be performed as office‐based procedures. It is important that breast surgeons incorporate ultrasound into their practice to remain relevant to the management of women with breast disease.
BS06 INDICATIONS FOR SENTINEL LYMPH NODE BIOPSY IN PATIENTS WITH A PRE‐OPERATIVE DIAGNOSIS OF DUCTAL CARCINOMA IN SITU
Authors: Jones B. J. , Buckingham J. M.
Published: April 2009

Purpose:   Ductal carcinoma in situ (DCIS) is non‐invasive so the use of sentinel lymph node biopsy (SLNB) in patients diagnosed with DCIS is questionable. DCIS has the potential to progress to invasive cancer, so SLNB would be useful in staging disease in patients at higher risk of invasion. This study aims to identify pre‐operative characteristics of DCIS that are predictors of invasive disease and thus provide a guide as to when to use SLNB.

Methodology:   This study is a consecutive series of 374 patients that underwent SLNB, of whom 37 patients had a preoperative diagnosis of DCIS, treated by one surgeon between July 2001 and February 2008. The association between pre‐ operative clinical and pathological factors and a post‐operative diagnosis of invasive disease were analysed. Associations between final pathological diagnosis of DCIS or invasive disease and treatment parameters were also analysed.

Results:   Of the 37 patients, 13 (35%) were found to have invasive disease post‐operatively. Analysis revealed that an initial suspicion of microinvasion, larger mammographic size, younger age, diagnosis with core biopsy, nipple discharge and presence of necrosis had statistically significant association with a post‐operative diagnosis of invasive cancer. Only patients with invasive disease had positive SLNs. Analysis of treatment with mastectomy or conservative surgery showed a link between mastectomy and a palpable lump.

Conclusion:   SLNB is recommended for staging disease in patients with a pre‐operative diagnosis of DCIS who also have characteristics suggestive of invasive disease
BS07 MEDIUM‐TERM OUTCOME OF SCREEN‐DETECTED DCIS TREATED WITH WIDE EXCISION ALONE
Authors: Fong J. Y. , Kurniawan E. D. , Windle I. , Rose A. K. , Mann G. B.
Published: April 2009

Purpose:   The optimal treatment for ductal carcinoma in situ (DCIS) remains controversial. Randomised trials have shown a 50% reduction in local recurrence (LR) with the addition of radiotherapy (RT) to Wide excision (WE) with no difference in overall survival. We used our database to assess the outcome of patients with screen‐detected DCIS treated primarily with WE only.

Methodology:   All patients with DCIS detected through NorthWestern BreastScreen in Melbourne, Australia from 1988–2005 were identified. Demographic, pathological and outcome data were collected from BreastScreen databases, Medical Record review and the National Death Registry.

Results:   490 patients were diagnosed with DCIS without invasive cancer. 3 opted out of the study. 46 were treated with mastectomy, and 45 were lost to follow‐up, leaving 396 patients for analysis. 5‐year breast cancer specific‐survival was 99.2%, and 5 year overall survival was 96.3%. There were 78 local recurrences, with a 5‐year LR rate of 15%. Factors potentially associated with LR including grade, size, margin status and age were analysed. No significant associations on Univariate or Multivariate analysis were found (p = 0.32–0.83). No sizeable subgroup with a very low risk of LR could be identified.

Conclusion:   Our study confirms that treatment of screen‐detected DCIS with WE alone is associated with excellent breast cancer specific survival and a moderate rate of LR. We were unable to identify associations with low recurrence rate, nor subgroups with minimal recurrence risk. Decisions regarding RT must balance inconvenience and side effects of RT with higher LR rate.
BA02 THE IMPACT OF LASER DOPPLER IMAGING (LDI) ON TIME TO GRAFTING DECISION
Authors: Kim L. , Ward D. , Holland A. J. A. , Lam L.
Published: April 2009

Purpose:   Early definitive treatment of burns gives optimal results by reducing the risk of developing hypertrophic scar. LDI has been shown to assist in predicting burn wound outcome with good accuracy, optimising clinical management. This is particularly beneficial in paediatric burns where the predominant type is scald injury, known to be heterogeneous in thickness. This study was sought to determine whether LDI has led to earlier decision making for grafting.

Methodology:   Patients who underwent grafting procedure at a single paediatric institute, a state referral centre for all major paediatric burns, between June 2006 and December 2007 formed the basis of this study. Time of burn injury to time of decision making for grafting procedure was calculated in days for both patients that had LDI imaging and those patients not scanned.

Results:   50% of 196 patients underwent LDI. Comparatively, there was no significant difference in type, body surface area percentage and microbiology swab results. The mean time from the date of injury to decision making for graft procedure was 8.9 days in those patients scanned by LDI and 11.6 days in group diagnosed on the basis of clinical observation alone. This trend for earlier decision for grafting in the LDI group was statistically significant (p = 0.01).

Conclusion:   There was a significant reduction in time to grafting decision in the LDI group. This would potentially reduce length of hospital stay, number of visits and facilitate planning of surgery. Earlier diagnosis of burn depth may enhance parental satisfaction by allowing greater opportunities for discussion of potential surgery and improving long term outcome.
BA03 THE IMPACT OF THE NATIONAL BURN SERVICE MODEL ON WAIKATO REGIONAL BURNS UNIT IN NEW ZEALAND
Authors: Yang A. S. , Moaveni Z.
Published: April 2009

New Zealand moved to a centralised national service model for the management of severe burn patients in 2006. Waikato Hospital is one of three regional burns centres within this framework, in which complex burns (greater than 30% total body surface area; burns to hands, face, and perineum; extremes of age) are transferred to the National Burn Centre in Auckland. Whilst a national burns service potentially improves outcomes in these severely injured patients, valid concerns have been raised regarding the maintenance of the regional centres’ ability to care for major burns in case of a disaster scenario where national resources may be stretched thin.

The aim of this study was to look at the impact the change to a national service model has had on the management of burns in the regional unit.

Patients with burns admitted to the Waikato Hospital between January 2005 and December 2008 were included in this retrospective review. Patient notes and hospital coding data were analysed including total body surface area of burns, theatre visits and operating time for change of dressings as well as debridement and grafting, length of ICU stay and total length of hospital stay until discharge. A comparison of results pre‐ and post‐centralisation of major burns care are presented and implications for regional hospitals are discussed.
BA06 BURN INJURIES SECONDARY TO LPG WHEN REFUELLING VEHICLES
Authors: Pearce F. E. , Vandervord J.
Published: April 2009

Purpose:   To highlight the danger of reverse thermal burns secondary to exposure to LPG when refuelling vehicles.

Methodology:   Review of patient medical records and the burns data base

Results:   Over a 12 month period 4 people have presented to RNSH Severe Burns Unit after sustaining a reverse thermal burn injury while refuelling their vehicle with LPG. The burn was primarily to the first web space of the dominant hand. Other areas were also involved. TBSA was <10% for each case. The burn ranged from superficial partial thickness to full thickness. One patient required surgical intervention.

Conclusion:   Due to the increasing price of petrol, LPG has become a popular cheaper alternative fuel. There is a lack of public awareness regarding this type of burn and petrol station employees lack first aid knowledge in the acute setting. These small burns can be severe, requiring surgical intervention with prolonged periods of impairment and time off work.
CR17 PARASTOMAL HERNIA
Authors: Petersen D. J.
Published: April 2009

Parastomal hernia can be a difficult clinical scenario to manage and a significant technical challenge to repair. The reported incidence of parastomal hernia formation varies depending on type of ostomy created. Reported rates vary between 6% for loop ileostomy and 48% for end colostomy. Indications for repair include parastomal or abdominal pain, obstructive symptoms and appliance failure. Techniques for repair include direct closure of parastomal defects, mesh repair and relocation. These techniques will be presented for discussion.
CR18P A PROSPECTIVE STUDY ON THE INFLUENCE OF A FAST‐TRACK PROGRAMME ON POST OPERATIVE FATIGUE AND FUNCTIONAL RECOVERY AFTER MAJOR COLONIC SURGERY
Authors: Zargar Shoshtari K. , Paddison J. S. , Booth R. J. , Hill A. G.
Published: April 2009

Introduction:   Enhanced Recovery After Surgery (ERAS) programmes have demonstrated significant reduction in hospital stay for patient undergoing colonic surgery, however their impact on long term outcomes such as Post Operative Fatigue (POF) has not been fully established. Aim: To assess the impact of an ERAS programme on POF and recovery following elective open colonic surgery.

Method:   In a prospective study, 26 consecutive patients undergoing open colonic surgery under a conventional care plan were compared to 26 consecutive patients in an ERAS programme.

Results:   Demographic and clinical characteristics were comparable at baseline. The median duration of total hospital‐stay (4 v 7 days p < 0.001), rates of urinary‐tract infections (p = 0.028) and ileus (p = 0.042) were significantly smaller in the ERAS group. Postoperatively, POF significantly increased in both groups. However peak POF score was significantly lower in the ERAS group (p = 0.001). In the first 30 days after surgery, Fatigue Consequence scores were also significantly smaller in the ERAS group. Overall, the total fatigue experience (p = 0.035) and the total fatigue impact (p = 0.005) were significantly smaller in the ERAS group.

Conclusion:   The impact of ERAS programmes may extend beyond the commonly reported short term outcomes and ERAS may accelerate overall recovery and return to normal function.
CR19P A RARE CASE OF MASSIVE GASTROINTESTINAL HAEMORRHAGE: AN IMPORTANT CONSIDERATION IN TRAVELLERS
Authors: Flatman S. J. , Darby J. , Mckelvie P. , Stanley P. , Thiruchelvam D.
Published: April 2009

We report a case of massive gastrointestinal haemorrhage in a traveller who presented to a tertiary hospital emergency department in Melbourne, Australia. An 18 year‐old man from India presented with two weeks of malaise, anorexia, fever and generalised abdominal pain and had massive rectal bleeding on presentation. He underwent computed tomography angiography before urgent laparotomy and ileocolic resection of a bleeding ulcer in the terminal ileum. Blood cultures subsequently grew Salmonella typhi. Histopathology showed multiple areas of ulceration centred on Peyer's patches, transmural mononuclear cell infiltrates and focal non‐necrotizing granulomas. A diagnosis of enteric fever causing massive bleeding from an ulcer in the terminal ileum was made and the Health Department notified. The patient had four weeks of antibiotic therapy and made a full recovery.

Surgery was once thought contraindicated in enteric fever complicated by bleeding, citing a tendency for the bowel to be friable and difficulty locating the site of bleeding in multiple ulcers. Bleeding and perforation occur from necrosis of Peyer's patches. However, evidence shows this is limited to the terminal ileum and proximal colon, allowing directed surgical excision. In the current age of international travel, surgeons must be increasingly aware of relevant diseases that may have had their origins overseas. Enteric fever should be considered in patients with rectal bleeding who are travellers and immigrants from endemic areas with a compatible illness.
CR22P DIGITAL RECTAL EXAMINATION – DO JUNIOR DOCTORS NEED POINTERS IN THE RIGHT DIRECTION?
Authors: Yeung J. M. , Yeeles H. , Tang S. W. , Amin S. , Chapple K.
Published: April 2009

Purpose:   Digital Rectal Examination (DRE) is an essential skill that newly qualified doctors are expected to have, but what are they like in reality?

Methods:   Newly qualified doctors were asked to complete a questionnaire. Their responses to clinical scenarios, diagnosis of anal conditions as well as confidence in DRE were assessed.

Results:   90 (52 F, 38 M) newly qualified doctors responded to our questionnaire (response rate of 90%). 69 (77%) of doctors have never felt a rectal tumour, many felt uncomfortable diagnosing anal and rectal cancers and two thirds of respondents had only performed up to ten DREs before graduation. Although 78 (87%) had been taught how to perform a DRE, a third of doctors were not confident in performing this examination, and the vast majority (91%) did not have their findings checked by a senior colleague. Seven (8%) doctors do not routinely perform a DRE in a patient presenting with rectal bleeding; reasons included that there was no time to perform the examination, it was unfair to subject the patient to multiple examinations or that there was no chaperone to do the examination. 74 (82%) of doctors felt that better training at an undergraduate level would improve their confidence and abilities. In comparison with other forms of examination, these same doctors were less comfortable with PV and testicular examinations but most confident in groin hernia examinations.

Conclusion:   DRE is an important skill but despite being taught at medical school, many newly qualified doctors felt that they lacked confidence in this. More attention to developing this competency should be included in the junior doctor inductions.
CR24P DOES PRE‐OPERATIVE DECISION MAKING UNDERLIE THE INCREASED RATE OF POSITIVE CIRCUMFERENTIAL RESECTION MARGINS FOLLOWING ABDOMINOPERINEAL EXCISION
Authors: Hernon J. M. , Stebbings W. S. , Sargen K. , Wharton R. Q. , Kapur S. , Speakman C. T.
Published: April 2009

Introduction:   A positive circumferential resection margin (CRM) is associated with local recurrence and poor oncological outcome. Studies highlight that positive CRMs occurs more often following abdominoperineal excisions (APER), compared to anterior resections (AR). However a bias towards performing APERs in patients with locally advanced tumours, or down staging prior to sphincter preserving surgery may underlie the difference.

Aims:   Determine (1) positive CRM rates following APER and low ARs (2) if pre‐operative decision making accounts for the difference.

Methods:   The last 100 low AR and 100 APERs within our unit were reviewed. Data collected included 1) Tumour distance from the anal verge, 2) Pre‐operative staging (CT / MRI) (Early stage cancers T1‐2N0, Intermediate stage – T3N0‐1, and Advanced stage – CRM threatened by tumour or involved nodes) 3) Neo‐adjuvant therapy use 4) positive CRMs.

Results:   One hundred Low AR were performed Between Jan 2008 – June 2004, while 100 APER were performed between Jan 2008 – Jan 2003. Average tumour distance from anal verge: APERs 3.4 cm vs. AR 5.2 cm. There was no significant difference in the pre‐operative stage (Early 28 vs. 27, Intermediate 51 vs. 58, and advanced 21 vs. 15), or the use of chemo‐radiotherapy (APER 9 vs. AR 13). There was a significant increase in CRMs in the APER group 15 vs. 7.

Conclusion:   A positive CRM occurred twice as often following APERs vs. low AR. This difference could not be accounted for by early cancers undergoing AR, or the use of down staging chemo‐radiotherapy.
CR29P LYMPH NODE YIELD IN COLORECTAL CANCER RESECTIONS
Authors: Wakeman C. J. , Chandra R. , Yu V. , Mclean C. , Wale R. , Bell S.
Published: April 2009

Purpose:   This study was designed to determine whether blue dye injections in the resected specimen increased lymph node yield and ease of identification of lymph nodes in the resected specimen.

Methods:   A prospective randomized control trial was performed on all colorectal cancer patients undergoing surgery at the Alfred Hospital for the calendar year of 2008. Specimens were randomised to either receiving or not receiving patent blue V dye. All specimens were pathologically examined in a standardised manner. The number of lymph nodes identified in the specimen was recorded, both containing and not containing blue dye. All specimens were soaked in Carnoy's solution, and re‐examined for additional lymph nodes.

Results:   67 patients randomized, 33 patients received blue dye and 34 patients received no blue dye. In the Blue dye group the median number of blue nodes identified was 4, and the median number of all nodes pre Carnoy's was 11. In the blue dye group the median combined post Carnoy's lymph node count was 15. In the non‐blue dye group the median number of lymph nodes pre Carnoy's was 12, the median combined post Carnoy's lymph node count was 16. The percentage of specimens having less than 12 nodes was 37% in the blue dye group and 27% in the non‐blue dye group.

Conclusion:   The injection of patent blue dye did not increase the lymph node count or the percentage of specimens has less than 12 lymph nodes.
CR31P MULTIDISCIPLINARY MEETINGS IN COLORECTAL CANCER – DO THEY MAKE A DIFFERENCE?
Authors: Holmes M. J. , Guest G. D. , Watters D. A.
Published: April 2009

Purpose:   The aim of this study is to make an objective assessment of whether multidisciplinary meetings (MDM) improve the management of patients requiring surgery for colorectal cancer as this has never been examined.

Methodology:   This retrospective study analyzed patients from the Geelong Hospital mandatory Colorectal Database between 1/1/2006 and 31/12/2007. MDM were implemented on 3/10/2006. To be included in the study patients had to have had an operation for colorectal adenocarcinoma. Each patient's management was determined to have conformed, or not conformed, to meet the best practice guidelines according to the 2005 Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer. Those patients who had been discussed in an MDM were compared with those pre‐MDM to ascertain if there was any difference in patient treatment.

Results:   182 patients had surgery for colorectal cancer. In the period where an MDM was available, 46% (53 of 116) patients were discussed in an MDM and all conformed to best practice guidelines. Of the 130 patients where no MDM review occurred, 98.5% conformed to best practice guidelines. This was consistent in both the pre MDM period (98.5%) and MDM available period (98.4%).

Conclusion:   The implementation of MDM at Geelong Hospital has marginally improved management of colorectal cancer. Few clinicians would dispute the benefits of such meetings but where an already high standard of care exists it is difficult to objectively demonstrate these improvements. We support using MDM but look to the less tangible benefits such as improved consistency and coordination of care, communication between health professionals and educational opportunities that MDM provide.
CR35P THE NATIONAL HEALTH SERVICE COLORECTAL CANCER SCREENING PROGRAMME; ITS EFFECT ON THE WORK LOAD OF COLORECTAL SURGICAL UNITS
Authors: Hernon J. M. , Stebbings W. S. , Sargen K. , Wharton R. Q. , Kapur S. , Speakman C. T.
Published: April 2009

Introduction:   The NHS Bowel Cancer Screening Programme (NHSBCSP) has been running since September 2006. Its impact on the workload of colorectal units has not currently been assessed. Aims: To determine the initial increased in workload resulting from screen detected cancers detected by the NHSBCSP.

Methods:   Cancers detected by the local NHSBCSP were reviewed with respect to: operative intervention, Dukes’ stage, post operative complications, and neo‐adjuvant therapy. Results: Between September 2006 to Jan 2008 100 screen detected cancers were identified. Twenty eight were located in the rectum, 38 sigmoid colon, 2 descending colon, 9 transverse colon, 10 ascending colon, and 13 within the caecum. Of the 100 cases 18 were polyp cancers, 3 of which proceed to a subsequent resection, (2 anterior resections and 1 right hemicolectomy). Of the remaining 82 cases 38 patients had an anterior resection, 26 right hemicolectomy, 5 abdominal perineal resection, 3 sigmoid colectomy and 1 subtotal colectomy. Nine patients had no operative intervention; 5 due to metastatic disease and 4 as a result of patient choice. Thirty five patients had Dukes’ stage A, 31 Dukes’ B, 17 Dukes’ C, and 5 Dukes’ D. There were 8 major post operative complications: 6 anastomotic leaks, 1 colo‐pouch‐vaginal fistula, and one death. Two patients who underwent resections for polyp cancers failed to have the polyp scar removed at the time of surgery.

Conclusion:   The local NHS colorectal cancer screening programme has resulted in a significant shift towards Dukes’ stage A and B cancers at time of presentation. However it has resulted in a dramatic increase in the number of colorectal resections, 76 between September 06 to Jan 2008.
CR37P UNREVERSED STOMAS IN RECTAL CANCER
Authors: Mishra S. , Jones I. T. , Gibbs P. , Shedda S.
Published: April 2009

Purpose:   Approximately 10% of temporary stomas created after low or ultra low anterior resection for rectal cancer remain unreversed. In this study, we aim to determine the reversal rate at our institution and the reasons for stomas remaining unreversed, especially due to anastomotic leaks.

Method:   A retrospective study of patients who underwent surgery for rectal cancer at a single institution between 1st January 2003 and 31st December 2007 was performed. Patients with unreversed stomas were identified and their patient files reviewed.

Results:   230 patients who underwent surgery for rectal cancer were considered. 54 of these had low or ultra‐low anterior resection and a stoma fashioned. 47 (87%) had their stomas reversed (RS), and 7 (13%) had not (US). The RS group were younger, with 30 (63%) males compared to 6 (86%) in the US group. Not surprisingly, the US group were more likely to have surgical complications (72% vs. 28%, p = 0.022). The reasons for non‐reversal were anastomotic leak 2(28%), death 2(28%), metastatic disease 1(14%), medical co‐morbidities 1 (14%), and patient refusal 1 (14%). Of the 2 patients with anastomotic leaks, 1 remained unreversed due to development of stricture at the point of anastomosis, while the other was reversed 8 months later (outside the study period).

Conclusion:   When faecal diversion surgery is undertaken in low or ultra low anterior resection for the treatment of rectal cancer, it is usually reversed during a reasonable period of time. Surprisingly, even in our very small set of patients (7) with unreversed stomas, only 2 were unreversed due to anastomotic leaks.
CR38P VAGINAL DELIVERY COMPARED WITH ELECTIVE CAESAREAN SECTION: THE VIEWS OF PREGNANT WOMEN AND CLINICIANS
Authors: Turner C. E. , Young J. M. , Solomon M. J. , Ludlow J. , Benness C. , Phipps H.
Published: April 2009

Purpose:   Concern about maternal morbidity associated with vaginal delivery (VD) may be driving the increasing trend for elective caesarean section (CS). This study aimed to quantify the risk of morbidity from VD that pregnant women would be prepared to accept before requesting an elective CS, and to compare these views with those of clinicians.

Methodology:   Participants completed a questionnaire to ascertain the maximum level of risk they would be prepared to accept before opting for an elective CS. Utility scores for each complication were calculated, with higher scores (closer to 1) indicating a preference towards VD.

Results:   122 pregnant women, 84 midwives, 166 obstetricians, 12 urogynaecologists and 79 colorectal surgeons participated. For the evaluated 18 potential complications of VD pregnant women were willing to accept higher risks than clinicians. Pregnant women were least accepting of risks of severe anal incontinence (mean utility score 0.32), emergency CS (0.51), moderate anal incontinence (0.56), severe urinary incontinence (0.56), fourth degree tears (0.59), and third degree tears (0.72) The views of midwives were closest to those of pregnant women. Urogynaecologists and colorectal surgeons were the most risk averse, with 42% and 41% respectively stating they would request an elective CS for themselves or their partners.

Conclusions:   Pregnant women were able to quantify the level of risk they are prepared to accept from a VD before opting for an elective CS being aware of the potential complications of elective CS, and these risks were significantly higher than those accepted by the clinicians involved in their care. Their views are more closely aligned to midwives than to specialist clinicians.
CR09 *LAPAROSCOPIC WASHOUT FOR DIVERTICULITIS
Authors: White S. I. , Frenkiel B. , Martin P. J.
Published: April 2009

Background:   Hartmann's procedure has been the treatment for complicated perforated diverticular disease. Laparoscopic washout with colonic preservation can replace radical resection. Laparoscopic washout is associated with less morbidity, mortality and improved quality of life.

Methods:   An 8‐year retrospective review of 80 consecutive cases of sigmoid diverticulitis warranting emergency surgical intervention (2000–2008). During this time approximately 2000 admissions for diverticulitis were recorded.

Results:   Hinchey grades were I(10), II(26), III(38) and IV(6).Patients age mean 77, median 74. Procedures performed were Laparoscopic washout (34), Hartmann's procedure (34), percutaneous drainage of abscess (5), resection and primary anastomosis (3).Overall mortality was 7% (all in the Hartmann's group). Washout achieved success in 28 of 34 cases without immediate colonic resection. Short‐term failures of washout in 6 were due to perforated cancer (2), faecal fistula formation (2), inadequate washout and ongoing sepsis (2). All failures underwent Hartmann's resection without complication. In long‐term follow up 8 patients developed symptoms of recurrent complicated diverticulitis including (delayed stricture, fistulae and repeat perforation) and underwent sigmoid resection. 8 patients underwent planned resection without experiencing further symptoms. 10 patients were observed without symptoms with mean follow up of 20 months.

Conclusions:   Laparoscopic washout is superior in cases of perforated Diverticulitis with purulent peritonitis(Hinchey III). It is recommended in Hinchey I and II cases, when percutaneous drainage is unhelpful. Hartmann's colonic resection should be reserved for genuine cases of faecal peritonitis (Hinchey IV).
ES10 THE ROLE OF EXTERNAL BEAM RADIATION IN RECURRENT DIFFERENTIATED THYROID CANCER
Authors: Allison R.
Published: April 2009

About 3% of well differentiated tumours either are or will become unresponsive to I‐131. Some of these will be Hurthle cell carcinomas. If surgical resection is not feasible then options are limited.

As with other tumours, local control at the thoracic inlet is highly desirable to prevent strangulation, fungation and dysphagia. Current standard chemotherapy has no well defined role. However, newer agents such as tyrosine kinase inhibitors and angiogenic agents are starting to show promise.

External beam radiation treatment is very effective in establishing local control but the dose required is high in the range of 60 Gy and the target volume is often large. Whilst the acute side effects settle quickly, the late effects of atrophy and fibrosis and possible induction of second malignancy may be considerable. The question is then one of the timing of this intervention, given the growth pattern and the potentially long natural history of these tumours. Treatment delivery has been markedly improved by modern imaging planning techniques. The optimal timing of this intervention mandates close cooperation between oncologists and surgeons.

Extra cervical metastatic disease which is iodine non‐avid or non‐responsive and symptomatic is best palliated by external beam radiation. Often a short course of 20 Gy in 5 fractions may suffice but with oligometastases in structurally important bones a more prolonged course aimed at local control is appropriate. Inoperable primary disease, whilst often iodine avid, rarely responds sufficiently to control the disease and external beam radiation is helpful in providing local control.
ES12 *PRIMARY HYPERPARATHYROIDISM (PHPT) IN CHILDHOOD IS THE SAME DISEASE AS IN ADULTS
Authors: Langusch C. C. , Suliburk J. W. , Sidhu S. , Sywak M. , Shun A. , Delbridge L.
Published: April 2009

Background:   Most management guidelines for PHPT in childhood stress the predominance of familial disease, mandating open four gland exploration to exclude hyperplasia. This study aimed to examine the presentation and pathology of PHPT in children and adolescents, and to review surgical approaches in the era of minimally invasive parathyroid surgery.

Patients & Methods:   This is a retrospective cohort study, with data obtained from the University of Sydney Endocrine Surgical database. The study group comprised all children and adolescents (≤18) undergoing parathyroid surgery. Further information was obtained through individual review of all patients’ medical records.

Results:   19 paediatric patients were operated on for PHPT in the period 1980 to 2008. Of this group, 17 had symptoms of hypercalcaemia. All the symptomatic patients had sporadic parathyroid adenomas, including 16 single adenomas and only 1 double adenoma. In the entire group, only 1 patient had a familial endocrine syndrome with parathyroid hyperplasia, and 1 other patient had parathyroid hyperplasia following prior head and neck irradiation. Both these patients were asymptomatic with the indication for surgery being primarily thyroid related. 4 patients since 2002 have been successfully treated with a minimally invasive parathyroidectomy.

Conclusions:   This study demonstrates that, other than the predominance of symptomatic patients, there is no difference between PHPT in adult and paediatric populations. The majority of young patients actually have a single adenoma, and can therefore be managed in a similar fashion to their adult counterparts, namely with pre‐operative localisation studies aiming to permit a minimally invasive procedure.